Marginal gains secured by new care models offer a glimpse of the future

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In today’s NHS there is an understandable focus on huge and growing financial and operational pressures and their impact on patients. National and local leaders are working overtime to reduce deficits and get back on track in delivering the A&E and referral-to-treatment (RTT) waiting time targets. Front line staff are playing their part in the face of rising demand for care and difficulties in filling vacancies.

Much less visible is the work being done by health care leaders and staff to improve and transform care. I was reminded of this last week in work we are doing with areas involved in the new care models programme in partnership with NHS England and other national bodies. This work is being supported by Professor Don Berwick, who visited two of the vanguards and hosted a meeting of others at the Fund.

Our visit to the Royal Free Hospital was an opportunity to hear about plans to establish a hospital group under the acute care collaboration vanguards. These plans build on the recent merger of the Royal Free with Barnet and Chase Farm hospitals, with the aim of extending the scope of the group to neighbouring hospitals as opportunities arise. A major part of the rationale is to reduce variations in care and to release resources from the duplication of clinical services and back office functions.

Our visit to Barts Health NHS Trust enabled us to learn about work in Tower Hamlets through the multispecialty community provider (MCP), Tower Hamlets Together vanguard (@TH2GETHER). This work extends a longer term commitment in Tower Hamlets to strengthen primary care and to achieve closer integration with hospital services. We heard how integration is being advanced in renal care, with hospital consultants now able to access information about patients in GP records and delivering care more rapidly and effectively through a virtual clinic.

The Fylde Coast vanguard (@YCOPFyldeCoast) in Lancashire (another MCP) reported on its progress at the meeting with Don Berwick here at the Fund. Its innovations include the development of an ‘extensive care’ service for patients with complex needs by a team comprising a consultant, advanced practitioner, care co-ordinator and wellbeing support worker. The service has been tested in four primary care centres and is being rolled out across Fylde Coast. Early indications show reductions in A&E attendance and non-elective admissions as well as in outpatient and elective activity.

All three vanguards are in the early stages of implementation and recognise that most of the hard work lies ahead. They were also keen to share challenges and disappointments encountered along the way. As an example, the Fylde Coast vanguard is working to increase referrals to the extensive care service, to ‘sell’ the service to patients and staff, and to refine criteria for referrals, for example by offering flexibility to refer outside the criteria where appropriate. It is also seeking to build stronger links with the voluntary sector and local authorities.

A common thread in these and other 47 vanguards is the palpable energy and enthusiasm of the staff involved. Even in the context of the well-known pressures bearing down on the NHS, innovation is alive and well as managers and clinicians work together to find better ways of responding to increasing demand for care. The marginal gains being achieved offer the best prospect of the NHS rising to the challenges it faces, if they can be sustained. Small-scale transformation that is shared and scaled up really is more realistic than the unlikely emergence of a big breakthrough in performance.

National leaders can help in four main ways. First, by lending visible support to the vanguards at the same time as dealing with financial and operational pressures. Second, by recognising the time it takes for innovations in care to become established and deliver results. Third, by helping to spread these innovations when they begin to demonstrate results for patients and users. And fourth, by removing policy and regulatory barriers that are getting in the way of progress, as set out in the progress report on the NHS five year forward view we are due to publish later this week.

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Comments

Maj Pushpangadan

Position
consultant geriatrician,
Organisation
BTHFT
Comment date
26 October 2016
Hi Chris

we would love you and your team would come to Bradford and have a look at our work- not a vanguard! but some amazing work- value your opinion

Harry Longman

Position
Chief Executive,
Organisation
http://gpaccess.uk/
Comment date
27 October 2016
The clue is in the title, "Marginal gains secured..." If after two years and the expenditure of countless £millions we can only talk about marginal gains, what's wrong? Only everything. If these ideas were working, the gains would be blindingly obvious. They aren't. It isn't working.

Roger Steer

Position
Director,
Organisation
Healthcare Audit Consultants
Comment date
27 October 2016
You can reduce variations in care by reducing the number of organisations compared.
That doesn't mean that variations no longer exist or are desirable.
"A common thread in these and other 47 vanguards is the palpable energy and enthusiasm of the staff involved."- This is the price paid for getting the money- it doesn't mean that the results are economic or sustainable.
That's what we want to hear about. Why is this so difficult?
Unless as Harry Longman says -It isn't working.

David Oliver

Position
visiting fellow,
Organisation
kings fund
Comment date
29 October 2016
I would draw a very different conclusion to Harry Longman. Marginal gains achieved fairly slowly are what can realistically be achieved as anyone heeding the evidence from research and experience knows. its high time we stopped over-promising massive, unattainable results in a health system already struggling to cope with rising demand in the face of funding and workforce gaps. Even a levelling off in demand or small reductions in bed occupancy or admission rates represent progress. The are only a disappointment to people who are expecting the unattainable and promising what they shouldn't

Richard Ogden

Comment date
30 October 2016
"...in a health system already struggling to cope with rising demand in the face of funding and workforce gaps", should indicate that the need to work "S.M.A.R.T" has past, and a more radical approach needs considering. Cost savings is a myopic, short-term reaction to a long term problem: in fact a problem 68-years in the making. Money saved can not facilitate efficiency, but is as uneconomical as waste itself. To continue using and believing the mantra "more for less" will do for healthcare as the iceberg did for Titanic.

Alan Molineaux

Position
Trainer and Leadership Consultant,
Organisation
Rooted Training
Comment date
24 November 2016
There is not one single answer to the problems faced by the NHS. The Marginal Gains methodology is much misunderstood but offer those facing increased pressure an opportunity to re-evaluate.

I would recommend looking at this further.

Alan Molineaux

Position
Trainer and Leadership Consultant,
Organisation
Rooted Training
Comment date
24 November 2016
There is not one single answer to the problems faced by the NHS. The Marginal Gains methodology is much misunderstood but offer those facing increased pressure an opportunity to re-evaluate.

I would recommend looking at this further.

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