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Vanguard sites: new models of integration in health and social care Vanguard sites: new models of integration in health and social care
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Hard on the heels of the announcement of the devolution of NHS powers in Greater Manchester comes news of the first wave of 29 “vanguard” sites for the new care models programme, heralded last October by Simon Stevens’ Five-Year Forward View for the NHS. These frontrunner sites are meant to lead the way for better integration of health and social care.Hard on the heels of the announcement of the devolution of NHS powers in Greater Manchester comes news of the first wave of 29 “vanguard” sites for the new care models programme, heralded last October by Simon Stevens’ Five-Year Forward View for the NHS. These frontrunner sites are meant to lead the way for better integration of health and social care.
Related: What is the future of health and social care integration? Live discussionRelated: What is the future of health and social care integration? Live discussion
There are three types of model: MCPs (multi-specialty community providers), concerned with moving specialist care out of hospitals and into the community; PACs (primary and acute care system), with single organisations providing hospital, GP and community services; and enhanced health in care homes, with no apparent acronym as yet, butlet’s call it HICH. These models are meant to offer more joined-up care, health and rehabilitation services. Some 5 million people could benefit from the first wave of transformation. There are three types of model: MCPs (multi-specialty community providers), concerned with moving specialist care out of hospitals and into the community; PACs (primary and acute care system), with single organisations providing hospital, GP and community services; and enhanced health in care homes, with no apparent acronym as yet, but let’s call it HICH. These models are meant to offer more joined-up care, health and rehabilitation services. Some 5 million people could benefit from the first wave of transformation.
As Stevens noted in his forward view, there is considerable consensus about what needs to change to improve care and health: “The traditional divide between primary care, community services and hospitals – largely unaltered since the birth of the NHS – is increasingly a barrier to the personalised and coordinated health services patients need.”As Stevens noted in his forward view, there is considerable consensus about what needs to change to improve care and health: “The traditional divide between primary care, community services and hospitals – largely unaltered since the birth of the NHS – is increasingly a barrier to the personalised and coordinated health services patients need.”
Few would argue with this analysis, but while the debate around integration is long-standing, the focus on new care models actually moves things up a gear. Successive governments over at least the last three or four decades have lamented the structural divisions between care and health.Few would argue with this analysis, but while the debate around integration is long-standing, the focus on new care models actually moves things up a gear. Successive governments over at least the last three or four decades have lamented the structural divisions between care and health.
Recurrent attempts since the 1970s to restructure the machinery of joint working, to create new incentives (and sometimes penalties) for collaboration, and to enable enhanced flexibilities for those eager to innovate, all testify to the continued challenge of fragmentation.Recurrent attempts since the 1970s to restructure the machinery of joint working, to create new incentives (and sometimes penalties) for collaboration, and to enable enhanced flexibilities for those eager to innovate, all testify to the continued challenge of fragmentation.
Related: The Manchester experiment is not the way to integrationRelated: The Manchester experiment is not the way to integration
The conclusions from most research point to the importance of both structural and process factors, but also underline the conclusion that too often collaboration and partnership have become ends in themselves, rather than means to wider ends. The Audit Commission, for example, remarked in 2009: “It is difficult to identify the extent to which pooled funds and other joint financing arrangements have directly achieved better value for money or have made a tangible difference for service users ... focus has tended to be on process rather than outcome.”The conclusions from most research point to the importance of both structural and process factors, but also underline the conclusion that too often collaboration and partnership have become ends in themselves, rather than means to wider ends. The Audit Commission, for example, remarked in 2009: “It is difficult to identify the extent to which pooled funds and other joint financing arrangements have directly achieved better value for money or have made a tangible difference for service users ... focus has tended to be on process rather than outcome.”
The latest attempt to achieve better integration and to explore options through the new care models arguably starts from a different standpoint. The central objective is not just closer working, but better integration and coherence around the needs of the patient. This is a qualitative shift in values and objectives.The latest attempt to achieve better integration and to explore options through the new care models arguably starts from a different standpoint. The central objective is not just closer working, but better integration and coherence around the needs of the patient. This is a qualitative shift in values and objectives.
The test of the pilot schemes will be if they are able to achieve a better experience for patients and families. Can they offer more integrated, personalised care that enables people to achieve greater independence? Are they able to avoid hospital admission where possible (and timely discharge where not); to have more treatment closer to home rather than visiting consultants in hospitals, and to postpone or avoid permanent residential care? Of course, making better use of resources and achieving savings will also be priorities.The test of the pilot schemes will be if they are able to achieve a better experience for patients and families. Can they offer more integrated, personalised care that enables people to achieve greater independence? Are they able to avoid hospital admission where possible (and timely discharge where not); to have more treatment closer to home rather than visiting consultants in hospitals, and to postpone or avoid permanent residential care? Of course, making better use of resources and achieving savings will also be priorities.
Many of the pilot schemes are developing in sites that are advanced in their quest for new models of working, and there will be challenges – as with any innovation – in moving from the enthusiasts to mainstream working. Criticisms are also being made by those who see the proliferation of new ways of working as incompatible with the concept of a national health service, and who fear widening the postcode lottery by stealth. It will be important to monitor the impact of the models and evaluate costs and benefits comprehensively.Many of the pilot schemes are developing in sites that are advanced in their quest for new models of working, and there will be challenges – as with any innovation – in moving from the enthusiasts to mainstream working. Criticisms are also being made by those who see the proliferation of new ways of working as incompatible with the concept of a national health service, and who fear widening the postcode lottery by stealth. It will be important to monitor the impact of the models and evaluate costs and benefits comprehensively.
How, for example, are we to assess requirements around equity and universalism while recognising that a “one size fits all” model is unlikely to be personalised or flexible? Whether it makes sense to consider options for health communities with similar characteristics remains to be proven.How, for example, are we to assess requirements around equity and universalism while recognising that a “one size fits all” model is unlikely to be personalised or flexible? Whether it makes sense to consider options for health communities with similar characteristics remains to be proven.
The timing of this development is not ideal. With a general election around the corner there will be plenty of accusations of opportunism. The support for the programme with a £200m transformation fund will be vital.The timing of this development is not ideal. With a general election around the corner there will be plenty of accusations of opportunism. The support for the programme with a £200m transformation fund will be vital.
Related: Devo Manc: five early lessons for the NHSRelated: Devo Manc: five early lessons for the NHS
There will also be some major challenges – not least because the new models threaten well-established ways of working, the relative autonomy of hospital consultants, and operating with delegated budgets across local populations. NHS England describes the new models as potentially offering the “complete redesign of whole health and care systems”.There will also be some major challenges – not least because the new models threaten well-established ways of working, the relative autonomy of hospital consultants, and operating with delegated budgets across local populations. NHS England describes the new models as potentially offering the “complete redesign of whole health and care systems”.
It would be tragic if this latest attempt goes the way of previous efforts and gets bogged down in structural reorganisation and administrative process. It could achieve innovative models of support that integrate care and health seamlessly around the needs of patients.It would be tragic if this latest attempt goes the way of previous efforts and gets bogged down in structural reorganisation and administrative process. It could achieve innovative models of support that integrate care and health seamlessly around the needs of patients.
For the moment it is too soon to judge. But a top-down, centrally driven model of running the NHS must not be replaced by a new model dominated by clinicians and frontline staff. We need one care system that enables genuine partnership with patients, families and wider communities.For the moment it is too soon to judge. But a top-down, centrally driven model of running the NHS must not be replaced by a new model dominated by clinicians and frontline staff. We need one care system that enables genuine partnership with patients, families and wider communities.
This is an edited version of a post published on Melanie Henwood’s blogThis is an edited version of a post published on Melanie Henwood’s blog