An international perspective on developing new models of care in the PACS vanguards

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The report Developing new models of care in the PACS vanguards: a new national approach to large-scale change? was commissioned by NHS England as part of a package of support provided to primary and acute care system (PACS) vanguard sites by The King’s Fund. The PACS model is an attempt to bring about closer working between GPs, hospitals, community health professionals, social care and others.

We invited those who have led the development of the PACS model to reflect on the process of being part of the programme, and of trying to bring about complex change in local systems. In this extract from the report Don Berwick offers an international perspective.

When it comes to effective leadership, I put more stock in ‘curiosity and invitation’ than in ‘command and control’. Among the lessons I have learned in three decades in pursuit of improvement, none is stronger than this: the workforce is wise. W Edwards Deming, the great teacher of improvement of the last century, put it more contentiously; he asserted that: ‘We have to bring back the individual. Management has smothered the individual.’ And, elsewhere, that ‘Management does not know what a system is’ (Deming 1986).

That’s a bit harsh, perhaps, but there is a kernel of truth in it. If we really want to improve health care by changing health care, the people who actually do the work day to day will almost always have the best ideas about what is amiss, where the waste is, and what new approaches are worth trying. When they do try out changes, they can learn fastest because they are closest to the action. Leaders who know this will ask the workforce for help and will give them time, space, and permission to innovate. Leaders who try to provide only answers, rather than questions, may squander the biggest resource for improvement that they have: the minds of the people at work.

That is the brilliance of NHS England’s vanguard programme – also known as new care models: inviting the workforce to help. Like any large health care system, the NHS in England has serious problems, such as patient safety hazards, unwanted delays, failures of co-ordination across the continuum of care, unsustainable workloads, and severe budget constraints. Its ambition was clearly articulated in Simon Stevens’s NHS five year forward view, one of the most cogent and patient-centred national health improvement plans of our time. But, manifestly, no ‘top-down’ directives, no design specification from above, could ever bring that good plan into reality. Only the people who do the work could ever make that happen. And they can do that only if they have the latitude to invent and learn.

The vanguard programme was no mere ‘management by objectives’ approach (as in, ‘Get me these results, I don’t care how.’). It was a far more sophisticated invitation for ambitious local systems to think boldly and to get the headroom to innovate and learn for the nation as a whole. It included a potent national infrastructure for shared learning among vanguard sites, for enlisting the help of subject-matter experts, and for celebration of the journey. It seemed to me, properly, far more about release of energy than about central control. And it was big: arguably the largest project on national health care delivery redesign in history, with the possible exception of the Center for Medicare and Medicaid Innovation established with a $10 billion fund in the United States in 2010.

I had the privilege of visiting and talking with many vanguard sites during the three-year programme, and what I saw often thrilled me. In the midst of an NHS period deeply troubled by budget austerity and professional demoralisation, I saw in these vanguards a sense of abundance, empowerment of staff at all levels, authentic involvement of communities, patients, and carers, pride in the learning process, and – in some ways best of all – the emergence of local leaders who often lacked formal authority, but who made up for that in enthusiasm, inclusiveness, and resilience.

The vanguard experiment has important lessons for any large-scale innovation investment, especially in health care.

  • With proper invitation, local leaders will emerge and thrive. Some will be already branded with formal titles and assignments, but more will be good-hearted, creative, courageous, and energetic informal leaders, many of whom will have long nurtured in their minds a powerful new idea that, at last, they will have time, permission, and resources to run with. The harvest can be large.
  • Even small amount of slack can release a large amount of energy.  Most vanguard sites did get some extra budget resources compared with the non-vanguards. Everyone said that the headroom helped, but, in retrospect, these extrinsic sums were remarkably small. The energy supply seemed more to be intrinsic motivation, which multiplied the effect of the marginal slack the programme provided. 
  • Local executive behaviours matter a lot. The most successful vanguards seemed to me to benefit from a virtuous cycle of mutual encouragement, between local executives and boards, who welcomed the exploration and risk-taking of pioneering clinicians and staff, and those risk-takers, who trusted their executives to trust them. The sense of celebration was palpable. As I said earlier, successes came, not from command and control, but from curiosity and invitation.
  • Bold goals can be fuel for change. In a stressed system, the tendency to lower sights is common. The vanguards evinced a very different psychological dynamic, seeking, without apparent trepidation, breakthroughs and unprecedented results. The confidence of local change-agents, especially the emerging, informal leaders, seemed in part to explain this comfort with ambition, as did the permission from formal leaders to try and sometimes fail in order to learn.
  • Measurement can be a friend. The toxicity of the NHS ‘target’ culture is frequently lamented among the NHS workforce and local leaders. The successful vanguards embraced metrics – but as resources for learning, not tools for judgment. And the relevant, helpful metrics were used locally in short ‘plan-do-study-act’ cycles of growth and development. 
  • Spread is difficult – not at all automatic. Perhaps the most informative unfavourable result of the vanguard effort is the general lack of spread throughout the NHS of even the best emerging new models of care. Indeed, even among vanguards working on nearly identical challenges – such as specialty–primary care relationships, home-based care, digital health, and reducing unnecessary hospital days – exchanges of models were viscous and inconsistent. This is a matter worth working on now – hard. I doubt that any form of directive or command from above will produce speedier spread. But I am confident that some new system of support can help.

As the vanguard programme transitions to other forms, including, importantly, integrated care systems, I hope and trust that the lessons of the vanguards will not be lost, either lessons about their now-proven health care delivery redesigns or lessons about the activities, behaviours, and mental models among leaders that best help those innovations emerge from a workforce that, in the final analysis, wants very much to help, and can.

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