Last reviewed 24 November 2015
In this feature, Healthcare Consultant Thoreya Swage looks at the new models of care — the Vanguard projects — which are a key feature of the NHS’s Five Year Forward View strategy.
In October 2014, NHS England published a strategy called Five Year Forward View which outlined a new vision for the NHS, including a range of models that could deliver better care. The reasons for this five year view included the need to meet the challenges of an ageing population with an increasing number and complexity of long-term conditions in the context of reduced health care expenditure. It was decided that these challenges meant a different approach to health and social care was required, leading to the creation of the Vanguard projects.
What are the Vanguard projects?
Rather than implementing a top-down approach to change, NHS England was keen to encourage a more integrated method of working across health and social care on a local level. The aim of the Vanguards is to test out how to manage the transition to new ways of working and to solve the problems that presented themselves during this time.
The vanguards cover the following five areas.
Primary and Acute Care Systems (PACS) — this is a model whereby many organisations, including general practice, hospital, mental health and community services, come together to provide care for their populations. Through taking responsibility for the health needs of their local registered patients, a PACS can also use a delegated capitated budget. There are nine PACS across the country, most of which bring together GP, hospital and local authority services for a specific population (between 140,000–365,000), either under a single health and social care budget or through better co-ordination of care using digital technology and unified access. Examples include the Isle of Wight’s “My Life a Full Life” programme, and “Salford Together”.
Multispecialty Community Providers (MCPs) — in this model, a number of practices join together into single entities where GPs and other primary care professionals proactively manage patients with complex and continuing needs, utilising digital technologies as well as developing new skills. MCPs may also have a delegated healthcare budget for their registered patients which could include funding for social care. There are 14 MCPs in England which are testing joint working between GPs, social care, therapy, mental health and pharmacy services and, in some cases, the voluntary sector, for populations between 54,000-330,000 in size. Examples include West Cheshire Way, Tower Hamlets Integrated Provider Partnership and Dudley Multispecialty Community Provider.
Enhanced Care Home services (EHCS) — these Vanguards are trying out different models of in-reach support, provided jointly by the NHS and the care home sector, including medical and medication reviews and better rehabilitation. The aim is to reduce the need for hospital admissions. There are six Enhanced Care Home Services Vanguards; examples include East and North Hertfordshire CCG, Gateshead Home Care Project and Sutton Homes of Care.
Urgent and Emergency Care Networks — urgent and emergency care services include care not just in but also outside of the hospital setting, such as general practices, community teams, pharmacists, ambulances, NHS 111, social care and the voluntary sector. In addition, the networks aim to remove the barriers between physical and mental health to enhance the quality of care and to support patients to manage their own conditions through education and other initiatives.
There are eight Vanguards, two of which cover large populations integrating care at scale while the others focus on smaller systems including hospitals, social care and surrounding GP practices. These Vanguards cover populations between 750,000-2.71 million.
Examples include Solihull Together for Better Lives, South Devon and Torbay System Resilience Group and West Yorkshire Urgent Emergency Care Network.
Acute Care Collaborations — these are working partnerships in which local hospitals join together to enhance their clinical and financial viability. This can be through formal shared arrangements across clinical specialisms at different hospitals or through shared back office functions between different sites. This permits a rethink of the traditional models of care, and breaks down institutional boundaries through establishing accountable clinical networks, setting up chains of multiple NHS organisations or creating specialty NHS franchises. The aim is to promote collaboration between acute providers.
Different models being tested include two multispecialty chains and two multi-provider hospital projects, six single specialty franchises — covering ophthalmology, orthopaedics, neurology and spinal care, mental health, women and children’s services and radiology — an accountable clinical network for cancer and two multispecialty networks. The Acute Care Collaborations cover large populations ranging from 850,000 to national reach.
Examples include the Royal Free in London, the Accountable Clinical Network for Cancer and the National Orthopaedic Alliance.
The Primary and Acute Care Systems, Multispecialty Community Providers and Enhanced Care Home Services Vanguards were launched in March 2015, while the Urgent and Emergency Care and Acute Care Collaborations Vanguards were launched in July and September 2015 respectively.
Organisational structures of Vanguards
Different types of organisational structures are emerging as Vanguards develop, including the following.
Joint Venture — this is where GP Federations and local NHS trusts work together to form a lead contractor arrangement for the local population. This body then subcontracts work to primary, acute and mental health services, social care and the voluntary sector.
Foundation Group — in this model, foundation trusts establish a subsidiary company to act as lead contractor to deliver services across primary and secondary care for their population. Primary care has strong input in the design of the care through representation on the subsidiary company board.
Trusts taking over practices and employing GPs directly. This occurs in a situation where practices are no longer sustainable and are not able to develop the services they wish to on their own.
Setting up new organisations to carry out integrated care — for example, the Provider Alliance Network, which delivers the Gateshead Integrated Community Bed and home-based care service.
Implications for primary care
The Vanguards represent a huge change from traditional ways of working and for those within the PACS, MCPs and EHCS, primary care will look very different. This will involve the networking of GP practices, a broader range of services, the development of specialisms, supporting self-care and training of practice staff.
The role and function of the Clinical Commissioning Groups (CCGs) may change as the lead GPs are diverted into redesigning primary and community care with a move away from commissioning. There will be a need to have “backfill” locums to cover the extra work of these GPs.
Much focus needs to be directed on engaging the public, explaining the changes, and on winning over those GPs that remain unconvinced. The latter presents a great challenge as a CCG can function with about a third of willing GPs, but the new models of care will require greater involvement of primary care doctors.
How will the Vanguards be supported and implemented?
NHS England has developed a support package to enable the first wave of Vanguard projects to make the changes they need to, and to build on the best practice that has been established. This package, which comprises eight workstreams, has been designed by Vanguard leaders together with national experts. It includes:
new care model design — enabling Vanguards to develop their local care model
evaluation — this involves the development of metrics to support the evaluation of the Vanguards. The aim is to have “real time” feedback on the impact of the changes on patients, staff and the local population
commissioning and provision of care that is integrated — this is the breaking down of barriers that inhibit integrated commissioning within a local health system
empowerment of patients and local communities — enhancing the way Vanguards work with patients and their communities to develop services
harnessing technology — encouraging Vanguards to consider how digital technology can enhance the delivery of care or deliver in a radically different way. This also includes the sharing of patient information across different organisations
design of the workforce — developing a workforce that is flexible and is centred around patients and local populations
local leadership — Enhancing the Vanguard leadership through local development and learning from international experts
engagement and communications — ensuring that patients, staff and local populations are engaged in the changes that the Vanguards are undertaking and demonstrating best practice in communications.
Local organisations are developing the models of care that best suit their populations and have been allocated some of the resources (nearly £60 million) that have been identified to fund the transformation of the NHS set out in the Five Year Forward View .
It was originally envisaged that planning of the Vanguards would take place during 2015-16, with implementation at the beginning of the following year. However, as the funding did not appear until July 2015, this has delayed planning and subsequent implementation until late 2016-17.
For subsequent years, Vanguards are required to complete business cases or “value propositions” to demonstrate how this funding will be recouped through reduced costs.
Vanguards are expected to demonstrate improvements in the quality of care. Although the metrics can be determined by the Vanguards themselves, they must be agreed with NHS England. The metrics do not need to be current, nationally reported indicators, however, they do need to be easily replicable and progress should be assessed as closely as possible to real time. This is to enable evaluation of the Vanguards as they develop over a three-year span.
Although the spotlight is on the Vanguards identified above, there are other models that are also being tested outside of the programme and there will be an exchange of ideas between the official sites and these projects.
Challenges to implementation
There are a number of challenges to the implementation of the Vanguards.
Information technology — this is a major hurdle as different parts of the healthcare sector and social care have different IT systems, making it difficult to share data.
Information governance — the sharing of personal data across the different health and social care organisations as required by Vanguards is not permitted under current information governance rules. Clear guidance is necessary to solve this.
Greater networking of primary care — GP practices will need to get used to sharing and seeing other practices’ patients as part of a larger primary care network. This will mean a different way of funding practices.
Governance — governance models are being developed as the Vanguards progress. This means that there may be many months before new governance models emerge.
Competition law — by joining together services “under one roof” Vanguards could potentially fall foul of competition law through reducing the choice of services in a locality.
Regulation of the Vanguard models
In recognition of the new ways of delivering care being developed by the Vanguards, the Care Quality Commission (CQC) has indicated that it would change its approach to the regulation of healthcare. Instead of inspecting single bodies, the CQC will examine the quality of care across pathways in further depth and, for the first time, across localities. In support of this, the CQC has begun to undertake a number of thematic reviews addressing various pathways such as urgent care, mental health crisis services, end of life care, care for older people and management of diabetes in the community.
Any new providers planning to register with the CQC will be asked to consider how they will work closely with other organisations to deliver seamless care and will be required to supply evidence at registration in support of this.
While there are many challenges in how the Vanguard sites develop, these new models of care are clearly the way in which the NHS will grow in the future.
The traditional model of care of general practice, hospital care, mental health and social care being provided in separate ways will no longer be appropriate in the 21st century.