Not just another pilot: why the vanguards mean business

29 January 2016

The new care models programme and the vanguards are at the heart of the vision of the future NHS set out by the Five Year Forward View. Samantha Jones has to juggle the demands for urgent solutions to the problems of the NHS with the need to give transformation the time it needs to work, writes Julian Patterson

“The heady mix of policy changes and the people, the emotional intelligence piece and bringing those bits together – that’s what we’re trying to facilitate through the vanguard programme and the care models from a national support perspective.”

The speaker is Samantha Jones, director of the new care models programme. Not for the first time in our conversation, she is trying to draw together the number of different strands she has to keep together to steer the programme she leads in the right direction.

Samantha JonesIt’s “very difficult” she admits, referring not just to the job itself, but to the difficulty of explaining to people who just want to focus on one part of the problem – usually the money part – that it’s not that simple.

The HSJ editor Alastair McLellan said recently that in the HSJ newsroom they joke that Simon Stevens has a 3D model of the NHS that only he can see hovering in front of him wherever he goes. Jones, who works closely with Stevens, appears to have access to the same vision and, like him, has endless patience when it comes to explaining it to those of us that can only see one dimension at a time.

Jones speaks in sentences and generates few soundbites per kilowatt. She apologises for the occasional lapse into jargon. Both of these, in case you're wondering, are encouraging signs.

She knows the official line and sticks to it for the most part, but you don’t get the impression that her words have been written by a twenty-something civil service fast-streamer because she shows every sign of believing them.

These things matter in her job, which as she never tires of saying is not to tell the NHS how to deliver the new models of care envisaged by the Five Year Forward View, but to support them to do it themselves. That means persuading a sceptical service that has come to depend on the top-down style of NHS management it so resents that this time it’s different.

There were and still are those in the NHS who want to be told what to do, and at least as many who believe that behind the apparent freedoms of the new care models programme, NHS England and its partners have a set of templates already drawn up and ready to impose. While it may be true that lower echelons of NHS management may read “model” as “blueprint”, the NHS England planning guidance (December) repeats the Stevens mantra – it’s up to you.

In case anyone should mistake this for an act of reckless hands-off-the-wheel driving, read the guidance, which goes on to say “unless you’re not up to it, in which case it’s up to us,” though not in those exact words. The important thing is that every area has the first shot at getting the local health and care system it wants. Only if the actors in the local system fail to make the most of the opportunity will the centre intervene.

Jones says this is a first. “The planning guidance is very clear, the opportunity to transform as a system around population health is a very, very strong signal as to how this will be delivered in future. I haven’t seen planning guidance that has said that before. There is a big opportunity for people to demonstrate that this is what we want to do as a system.”

“Of course there are going to be different organisational forms, and what we haven’t said is ‘that’s what they are’, because if we say they’re going to look like this, we don’t actually know that’s what they’re going to look like,” Jones says.

There are lots of moments like this, where a cynic might conclude that the new plan is to have no plan, but that wouldn’t be a fair assessment of the story so far.

The new care models programme has to balance national policy aims, the most important of which is to guarantee that the NHS has a future, with the need to plan locally, which is how the right version of the future will be delivered to the right place.

If there was a national planning template that worked everywhere, we’d have found it by now. A country is too large a unit of planning, a CCG is usually too small and always too narrow in scope. Vanguards bring together commissioners, hospitals, primary care, community services, mental health, voluntary sector, social care and others to solve all the problems of the population they serve together.

This involves a number of balancing acts – between national policy and local autonomy, between old and new styles of management, between the reality of discrete services delivered by organisations and the aspiration of whole systems of care, and crucially between the day to day pressures involved in keeping the system running (“sustainability”) and making the creative space to run it in new ways (“transformation”). We’ll come back to that one.

Asked why the vanguard initiative may succeed where countless others before it have failed, Jones starts with the question reforming health secretaries usually try to answer with structural change.

"If you start with organisational form it doesn’t happen, full stop. What we do need to do is support people in the behavioural, the leadership, the system changes.  I was trained for my institutional leadership. I wasn’t changed for my population leadership. We’re saying to people now it’s something completely different,” she says.

Getting away from the idea of vanguards as new organisations is the first step in glimpsing the airborne new model of the NHS in all its virtual glory. That’s not to say that some of the vanguards won’t eventually turn into organisations, just that it’s not necessary the end-point of the programme and it certainly isn’t the starting point.

“It was always going to be an outcome of what the vanguards are doing, but it is not the purpose of doing it,” Jones says.

A second misconception is that this is all and only about vanguards. At almost every mention of the term, Jones is obliged to add “and not just vanguards”.  It’s important to her that vanguards are not seen as special cases. The fifty vanguards are trialling principles that need to work everywhere else – if there is no “spread”, if the vanguards are not followed by subsequent waves of imitators, the programme will have failed.

“Our job is to mainstream all the things that are happening. Otherwise this is just another pilot,” Jones says.

The notion of the vanguards as a temporary phenomenon, a step on the road to transformation rather than the complete project, is helpfully confirmed by the planning guidance. From April 2017, the various initiatives under the broad heading of “transformation” (including vanguards and primary care infrastructure) will be subject to a single application and funding process. The idea is partly to reduce bureaucracy, but there is a bigger game afoot.

The existing system of pushing out money through different funding streams benefits existing organisations but does little to promote the kind of collaborative “system” working that’s vital to the new care models vision. Rather than dole out the “sustainability and transformation fund” (£2.1.4bn in 2016/17) piece by piece, encouraging each organisation to stake its own self-interested claim, the planning guidance will require local organisations to agree plans for a whole population.

In this scenario, local systems should acquire a sense of relativity with transformation judged on its ability to improve sustainability, and sustainability judged on whether it is more than a euphemism for balancing this year’s books. Getting all the providers and commissioners in an area to agree a plan will not guarantee equitable distribution of resources but forcing all the parties to hammer out one deal for extra funding makes more sense than the current free for all. The sanction, provided NHS England is tough enough to apply it, is that if you can’t agree a plan that strikes the right balance between the S and the T, nobody gets any more £.

As the clock counts down on NHS’s five-year plan, now in year two, the pressure on the vanguards to demonstrate their value is immense.  When she took the job, Jones was quick to promise “real-time evaluation” and regular progress reports. There is plenty of vanguard-related news, lots of positive PR, but what does it amount to?

“What we actually said is we wouldn’t be sharing it in three years’ time, we’d be doing it as it happened. We have tried to be as transparent as we can be with what’s coming from the vanguards and using where we can existing metrics, existing evaluation, and also being very honest when we say, actually it’s being developed as it goes,” she says.

The new care models team isn’t ducking the issue. It consulted widely with experts on evaluation and early data from the vanguards is being used to populate a national framework, details of which will be published soon. There is also a dashboard in development to help vanguards measure their progress.

Of course the NHS obsession with evidence and data is a trap of its own making, and one into which suspicious interviewers and commentators fall as easily as policy-makers. It masks a deeper problem, which is that the timescales for transformation are unfeasibly short.

Simon Stevens has been hailed for securing a settlement for the NHS which extends to the end of the current parliament, but that’s still only a little over four years.

“Change does take time,” Jones says. “You don’t start transformation and then it suddenly happens. You don’t say we’re going to do this and we’ll deliver the cultural change by next Tuesday.

“Somebody said to me the other day, ‘Show me the vanguard that has delivered the most efficiencies as a result of being a vanguard.’ Well they have to deliver the normal efficiencies, there are no rule suspensions for the vanguards, these are health and social care systems and voluntary sector working together in the same rules that we have now and on top of that they are required to deliver additional efficiencies by the back-end of 2017/18.

“The vanguards have had access to the bulk of the transformation fund and have been given an opportunity to have 18 months’ worth of investment to give them some space and some time to be able to do that. That’s probably longer than anywhere has ever had, certainly in this country. It may not be long enough in terms of the [degree of change] that people want, but actually we’ve just got to get on and do it.”

While she expects no let-up in the demand for hard evidence of progress, Jones insists that success of the transformation programme will depend on softer factors.

“Whether you’ve led organisations or big change, it’s not abstract. I think the question actually is ‘How do we equip the people that are doing it day to day with the change management skills to keep going when it’s so tough to be able to do so?’” she says.

Jones reels off the list of things that need to change – policy, commissioning and contracting, technology, governance, organisational form, regulation. Some of these are the obstacles the NHS and policy-makers need to remove from the vanguards’ path. Others are obstacles the vanguards will need to move for themselves. “But none of this will happen without the leadership to make it happen, and I don’t just mean leadership at the top of the organisation, it’s across all levels,” she says.

The NHS has had no difficulty attracting leaders to high-profile national roles. A more significant challenge has been to breed leadership closer to the ground. Jones is pinning her hopes on the ability to tap into the natural decision-making and consulting skills of clinicians. “We need to be able to support people like GPs who are makings some really difficult decisions and enable them to do it in a way that isn’t ad hoc,” she says.

As a young NHS manager, Jones credits the now defunct NHS Modernisation Agency with sparking her interest in quality improvement and change, “but one of the downsides was that the service improvement skills were outside the people who were doing it day in and day out”.

Jones rose to become a hospital chief executive and understands how pressing operational concerns get in the way of strategic aspirations. “A year ago, I was worrying about what was happening at 3 o’clock in the morning in A&E, I was worrying about people who were unable to see their GP. I wasn’t thinking today we’re going to think about transformational change.

“We need to be able to equip people to deal with today and think about tomorrow – and that’s incredibly difficult,” she admits.

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