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NHS vanguards: redesigning the aeroplane in flight

Will vanguards be able to make significant changes to the configuration of local health and care systems, while sustaining existing services in a difficult environment, with limited spare cash and growing service pressures?

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Last month, the 50 vanguard sites in the New Care Models programme met for a series of events in London to take stock of progress. The majority of the sites – those announced in March 2015 – have now been running for 200 days.

As at previous meetings, the enthusiasm was palpable – this is a group of people who believe their projects can make a difference – but so was the weight of expectation. The intention is for the vanguards to make a major contribution to addressing the NHS’s financial challenges – both through improvements in their local systems and blueprints that can be adopted across the rest of the NHS and social care.

As others have argued, the vanguards face the challenge of ‘redesigning the aeroplane in flight’ – making significant changes to the configuration of local health and care systems, all the while sustaining existing services in a difficult environment, with limited spare cash and growing service pressures.

In his first engagements as an international visiting fellow at The King’s Fund, Don Berwick argued emphatically that this can be done. There are now many examples of local health systems that have transformed the quality of care for their populations, while at the same time working with reduced funding. Last month, the Fund published a detailed report about one of Don’s examples, Southcentral Foundation in Alaska, which moved from four-week waits to same-day appointments in primary care, halved A&E attendance, and dramatically reduced hospital referrals and admissions, while coping with declining funding and fewer doctors and nurses per head of population.

As the vanguards know, improvement of this order of magnitude can only come from far-reaching redesign of local health and care systems. We are looking to the vanguards to develop radically different models of care rather than to make incremental improvements within existing systems. Both Don and Mark Smith (founding chief executive officer of the California Healthcare Foundation) challenged the vanguards to shift the balance of power within their health systems (for example, by asking ‘what matters to service users’ rather than ‘what’s the matter with them’). They encouraged the vanguards to come up with the most innovative and disruptive changes, for example, in the roles of doctors, nurses, patients and carers, the use of technology and where care is delivered.

Many researchers on innovation argue that there are fundamental differences between this type of transformative change and more incremental service improvement. Transformative change is typically led from the top and driven by dedicated project teams, with high levels of engagement with staff and communities to win their support and bring their energy and expertise into the projects. Meanwhile, incremental improvement can, and probably should, be led by frontline teams, drawing on support and expertise from elsewhere when needed (see Chris Trimble’s and Vijay Govindarajan’s research among others).

As we know from Southcentral Foundation and other examples, successful transformation also hinges on having clear objectives, transparent measures and a robust methodology to underpin the improvement effort. As Don Berwick puts it, we need both aim and method. Many of the vanguards have now made considerable progress in defining shared objectives and putting in place dedicated project teams, and are starting to define metrics to measure progress.

If the research is correct, the leaders of local NHS systems face a difficult dilemma: whether to focus their limited resources on supporting the vanguards and similar transformation programmes or to spend their time addressing more immediate financial and operational challenges. One message from last month’s discussions is that senior local leaders need to put transformation on the top of their personal ‘to do’ lists, as the long-term solution to those more immediate operational pressures. The national bodies may need to create a more propitious environment – for example, one where regulatory compliance plays a lesser role – for this to happen.