Chris Ham speaks to Samantha Jones, Director of the New Care Models National Programme, about the opportunities and challenges for the NHS vanguards implementing new models of care.
The King's Fund is working with NHS England and others in the New Care Models team to support vanguards.
CH: So Sam it is one year on since the five year forward view and the Vanguards are making some progress. What are you seeing out there?
SJ: What is really interesting with all of the Vanguards is that the appetite for change and the appetite for delivery of a different type of care model is consistent across all of them. Every single one of them is up for and having some very significantly different types of conversations across the population that they are covering. So I think a few months on, so whatever it is, six months on from when the care models started my reality is very different around the focus that they are taking on the population health.
CH: So if we come down to the patient or the person receiving care, what do you think this is going to mean where it works well?
SJ: Norman who is the 89 year old, actually my father in law which I speak with his permission, is somebody that has had involvement with different parts of the health and social care system consistently over the last five years. And what we are starting to see whether it is Norman or whether it is a younger person, because the Vanguards are approaching things from a population health perspective is they are starting to be able to identify not just the top 1% of their population but the type and the need of their population and individuals like Norman and how care should be wrapped around them across all of the different institutions. So if I use Cumbria or Millom as an example, one of the Vanguards, they have engaged their local population in a very different way for different types of conversation and have shaped the care around people like Norman in a very different way.
CH: And what are the challenges that you have seen? I know it is early days. But are there some barriers to overcome to make a reality of this sort of joined up person centred care?
SJ: Yes. So what the Vanguards have told us and we visited all of the Vanguards and then we played back through the thematic reviews what it is that they said. So some of the challenges are really people not necessarily understanding how long change takes and a real wish to see results very quickly, so those are two challenges. There are some very practical challenges around whether it is technology, whether it is around the system leadership discussions that have been had, whether it is around supporting existing workforce to work in a different way and also recognising changes for the future, or whether it is some of the more technical needing to support the national contract to be developed in a different way so that it supports and incentivises a longer term approach to population health.
CH: There are some barriers at a national level aren’t there that could get in the way of us seeing progress on the ground? How are you working with your national partners on that?
SJ: So although I am employed by NHS England the care model programme and the care models themselves are sponsored by all of the arm’s length bodies. So what that means in practice is that I have tried to develop a blended team through the care models. So we have people from Monitor TDA, we have people from Health Education England actually working within the care model team to support the delivery through the Vanguards, because it is the Vanguards that are delivering not us. What we are doing is identifying which of the appropriate arm’s length body needs to be involved in addressing, whether it is pricing, whether it is around collaboration, procurement, workforce, and making sure that the Vanguards and the wider care models are supported by all of them playing their part in practice.
CH: Part of the challenge is commissions are very busy dealing with the day job, freeing up some of their time to get involved in designing some of these new care models. How encouraged are you by the depth of real clinical engagement in this work?
SJ: So I think there are a number of answers to that. The values of the programme and indeed for the care models generally are around patient engagement and clinical involvement, local delivery through the national team and the national bodies sorting to deliver the change that is very easy to say. But on every interaction we have with the Vanguards and including everything to do with the care models whether it is people from my team or whether it is actually out and about, we have patients and we have clinicians involved in those discussions all the way through to really truly pull out whether what is happening in practice is really what is written on the tin.
The hardest challenge is doing today at the same time as thinking about tomorrow. But if I use a really practical example, I was kindly invited to Wessex LMC last week, there were about 125 GPs in the room and other people from the multi professional team all thinking through...it was about 270 people in total actually, all thinking through how they could in their areas support the delivery of the care models.
CH: If we fast forward three or four years, what will success look like for you?
SJ: So success from a care model perspective will be the majority of the country covered by some form of a “new” care model. Not necessarily a PACS, not a primary and acute care system, not an MCP, but what is right for the local population. Not all of them will be delivering but everybody will be focused on the need of their population. And I think that we will have been able to demonstrate through the Vanguards and wider because it is not just the Vanguards that are delivering the care models of the future. Those bits that are the fundamental building blocks that have to be in place to enable the delivery.
CH: So let’s finally talk about what this means for leaders and leadership. We are talking here about something that is different very often from what we have had before, working across organisational and service boundaries. What do we need of our leaders whether they are in chief executive roles or in clinical roles to make a reality of the Vanguards?
SJ: So I think it is like a reality of the care models actually rather than just the Vanguards. So I was trained to be a leader of an institution, I am a nurse by background. Actually you need to keep the nursing as a background but focus on the population. That is the leadership challenge of the future. And I think that the leadership of the future needs to be comfortable in working in a network of accountability for the population that is served and institution second. So we have spent a lot of time understanding from the Vanguards and wider what is the leadership support that is needed to be able to break down those conversations and break down the narrative so that people are focused on the delivery of population health consistently.
CH: And that is true at the clinical level as well as at the organisational level?
SJ: More importantly in fact. We need to learn from the clinicians. So the clinical model isn’t about institutional boundaries. The clinical model people don’t get ill. When my son is ill he doesn’t get ill just in the GP practice, he uses every single part of the system. And we all know that and we all go yes that is absolutely right, but that is not how the NHS or care systems have been set up.
CH: So very last question. There have been lots of pilots in the NHS before, some people say more pilots in the NHS than in BA, you also talked about the importance of patients and staying the course, how confident are you that national leaders will do that?
SJ: I am optimistic that people understand the need for it. I am optimistic that people understand that change doesn’t happen sitting in Whitehall is the expression. I am also optimistic that...and this is the important point, the Vanguards or the care models have to show delivery.
CH: Sam thank you very much.
SJ: Thank you.
Calling services with different names without changing culture and leaders who deliver them nothing is going to transform. I am happy to hear Sam's passion and her enthusiasm but I still hear locally about bullying leaders, poor clinical engagement and poor governance.
Good to hear Chris Ham asking about clinical engagement but in the ground level I still hear poor clinical engagement and disengaged GPs. This is not going to transform the service.
I wish vanguard every success as without it NHS will not survive for long term. Devomanc and Vanguard are right way forward but they needs good leaders, value based leaders who do everything right for patients and also with good governance and accountability and work together with mutual respect and trust.
One thing which gives me confidence is Sam's leadership. As they proof of the pudding is always in eating. For patients, I don't have any doubt it is the way forward.
As I understand it the Vanguards are the only really comprehensive change programme that will address the £22 billion efficiency gap that the NHS has to find over the next few years. As such I assume that there is the requisite financial modelling of the new patterns of care that are being introduced and tested up and down the land. I hope it was not significant that at no point in Sam's conversation with Chrtis was the grubby issue of financial savings raised as a key question to be addressed. I have an awful feeling that after all the good work and excitement over the 5YFV models of care being developed, the penny will drop that what we end up with has to be afforded and that to everyone's horror the numbers do not add up. I hope to goodness I'm hopelessly wrong - because if I'm not the NHS is in very serious trouble indeed.