Samantha Jones is director of the New Care Models programme, which is part of the NHS Five-Year Forward View. Interview by HPI editor Andy Cowper.
Health Policy Insight: How will you sustain the energy and enthusiasm with which Vanguards were launched as finances tighten?
Samantha Jones: I think the really powerful energy was generated by the Five-Year Forward View, with the direction it set and the care models it articulated being very widely welcomed.
The process of selecting and launching the Vanguards, looking back, was maybe a bit less traditional than how things had been done in the past. We asked clinicians, the voluntary sector, patients and the aspirant Vanguard applicants to choose who should be the first Vanguards.
And that consultation and co-production was important.
There were no secret lists and it wasn't the usual suspects, they chose, and now they share the responsibility for keeping things going and sustaining the energy, as you'd have to in any ‘start-up’.
What I see now is clinicians and other staff from across the range of Vanguards talking and having conversations about improving care: that's where the energy comes from now. Our challenge is to help them continue.
HPI: The Vanguard selection process seems to have launched a few myths about how it worked. What was the reality?
SJ: NHS England and the other Five Year Forward View partners asked for expressions of interests for organisations and partnerships to become integrated primary and acute care systems (PACS), enhanced health in care homes and multispecialty community providers (MCPs). We received 269 applications: the four-page form asked about applicants' vision; what help they'd need to achieved that; and who they planned to work with; and what other support they wanted.
The applications were reviewed by a group of patients, carers, people from the voluntary sector, local government and social care, to assess how they proposed to improve community services and the traditional NHS architecture.
We shortlisted those applicants who met criteria of all four categories. They came to our 'live shows' at the Oval, where they were asked to do a seven-minute presentation without slides, in which they had to 'sell' what they'd be trying to do if selected. It was fascinating to see who brought clinicians and patients, and the videos are up on YouTube (we shared them to show what we want Vanguards to be about).
After the presentations, the people present were asked to vote for who should go forward in the first wave, launched in May 2015.
It was important to have participation and voting that included the applicants all being part of the decisions. Important because the point of this is about a group of people able to make decisions in partnership: having that principle in place during the selection process, rather than after being chosen.
And those who were chosen have the edge of being able to show that they know this work will be hard, but not in a way that should make them (or others in the health and care system) afraid.
And a really important common theme of those selected was that they were able to talk meaningfully to the people who use services.
More recently, when we launched the acute care collaboration Vanguards, we had a huge number of applications to be Vanguards. And the communication theme came out, when a member of public said after a presentation "that's probably all very interesting but I have not a clue what you just said". It's a very powerful point.
There's the energy from people who are prepared to have a go when change will be difficult, with challenges as vanguards approach tricky issues about cross-boundary working and moving to services focused not on single specialties but on whole population health.
The Vanguards need to be supported to be able to make changes, and show that actions speak louder than words. If we think about it, excluding the recent acute care collaborations and urgent and emergency care vanguards, the programme now covers around 9% of England's population: approximately 5 million citizens and a thousand GP practices. That's a significant proportion seeing the investment of time and effort by clinicians and organisations in designing, building and delivering the future care system.
HPI: How are you networking Vanguards, to maximise their learning and effectiveness?
SJ: I see this as one of the most important things for the New Care Models team to support. Practically, each type of new care model - PACS, MCP, acute care collaboration and urgent and emergency care vanguard - regularly meet, and have an external facilitator and coach working specifically to share and discuss their learning. We're starting doing this for the care home Vanguards next.
They meet regularly, as part of which, they exchange and share good practice and sometimes the pain associated with seriously changing things nationally and locally. It's important, when we visit Vanguards, for us to understand what they want from us in terms of support to deliver new care models.
And the learning between Vanguards is equally important: the Isle of Wight went to visit Northumbria, they found they'd been doing some remarkably similar work on their paramedic workforces.
We've also offered to facilitate discussions between other non-Vanguard stakeholders - such as the Royal Colleges. The New Care Models programme has a remit to engage well beyond the Vanguards. At a recent event in Wessex, there were both Vanguards and non-Vangaurds coming together, because local GPs had asked for it. Our job is to give support, not necessarily to organise everything, and to make introductions where it's helpful.
From the start, the way in which we try to work included values-based recruitment and patient engagement in how we work nationally and locally to support the Vanguards. And defining effective (and ineffective) behaviours, with the input of patients, carers, has been a big part of that.
Clinical engagement is also vital. We've had 80 applications to be clinical associates, ranging across the multidisciplinary team, and we've now appointed 16. The NCM clinical associates will have two main functions: to represent multidisciplinary professional expertise and to help with practicalities of designing and constructing the right packages of support around the patient.
The clinical associates will also have an important function in supporting discussions about the new care models outside the Vanguard programme.
HPI: What do you think are the big myths about Vanguards, and the corresponding realities?
SJ: Some people them to think the Vanguards have been around a long time, which we should probably take as a compliment. The facts are that the PACS, care home and MCP Vanguards have been in existence for six months, the acute care collaborations for three months and the urgent and emergency care ones for for five months. That's context, rather than an excuse.
People also seem to think that Vanguards are about either commissioning or provision. In reality, it's about both: they are about health and social care systems. Mid-Nottinghamshire Vanguard includes three district councils, two CCGs and two providers; others cover one CCG but two local authorities and multiple providers. Vanguards aren't about single-institution working: they're about making a reality of significant health and care systems working together.
Another perception seems to be that Vanguards should have revolutionised care in six.
Of course they should be starting to deliver early signs of improvement, and many are: there are great examples in West Cheshire's 'cradle to grave' programme; and Modality in West Midlands, where 60% of GP patients are being seen digitally. Change is already happening, but results will take time.
Our plans for the Vanguards require them to deliver additional efficiencies by the back end of 2017-18. Many are already delivering small-scale but significant numbers of clinical changes to deliver efficiencies already.
Another myth is that Vanguards are just an NHS England thing: our work is broader and supported by all 7 national arms' length bodies - Monitor, and the NHS TDA, NICE, CQC, HEE and PHE.
HPI: Innovation is often disruptive & done by mavericks: how do such people fit into the NHS hierarchy?
SJ: I come at this from a slightly different perspective: to deliver care for the population we serve (whether in Harrogate, Salford or Whitstable), we need a group of system leaders working together. And we know in practice this means that those people have to be able to put their organisational loyalty behind them and do the right thing for patients, even if that may have an impact on their organisation.
So those system leaders need to have that strength of doing the right thing, and the wider system needs to support them. This is important because we know based on evidence and international experience that durable change comes when people feel in control, feel empowered and enabled and see that the case for change talks to their intrinsic motivators. This is not necessarily what's been done in formal, more traditional attempts to change NHS and care systems.
So effective change leaders don't necessarily work against systems in a maverick way: they play to different parts. I'd observe that clinicians in Vanguards (not all of them yet, as there are a range of maturity and perspectives) have told us that they feel able to do things they wanted to do: one said to me 'this is the reason I came into medicine'. And I think that means we are doing something different.
Look at the Millom Alliance (part of the Morecambe Bay vanguard): allied health professionals, working with doctors, nurses and patients. That teamwork's where the difference is being made. Our role is to support the formation of those teams and relationships.
HPI: Is NHS England's internal architecture well aligned to support Vanguards?
SJ: There are real challenges for all national bodies to support delivery of local change: not just NHS England.
We know from international evidence that changes made by local people doing locally appropriate things are what make the difference to patients.
Of course, we have a national N in the NHS, but the Five Year Forward View forced a different kind of conversation and leadership from national bodies. There has been acceptance & recognition by all arms’ length bodies that to deliver the Forward View and new care models will require a different type of approach.
So a different type of regulation for Vanguard systems is required, and this involves reviewing the approach taken by Monitor/TDA and CQC, as well as NHS England. This needs to be something that we’ve really not seen before. National level system leaders are working through what this means, to get the right national framework support. To be honest, regulating systems is very challenging at any level.
HPI: What is the New Care Models theory of change and transmission - and making change stick?
SJ: We need more support for informal networks and information sharing. Early in 2016, we’ll publish a guide to the building blocks from each care model. Local leaders can choose whether to adopt these practical, tangible examples (or not): as well as sharing the work, this is also about demonstrating how change is delivered.
We know that collectively, we need to focus on the ‘what’ – the right contractual policy drivers are very important, but can't get you far without your people understanding how to go about doing change and that includes having difficulty conversations. We need to do more here: not just for the new care models, but in all parts of the NHS in England.
Getting change right means you can’t just focus on the daily work. This is a real challenge nationally because we know the system is under immense pressure, and so we need to refine how we offer our support, and sell the benefits - highlight that changes are improvements. Properly understood, improvement and change are constants: they’re part of the day job, not something separate.
We learn from international and local examples of change. I grew up in NHS management in the time of the NHS Modernisation Agency, which was good at disseminating improvement skills, but I also needed clinical and administrative skills. All three kinds are needed to make change sustainable.
The what and the how of successful change happen through our front-line people. The national conversation needs to recognise this more: getting people enthusiastic about change is every bit as important as managerial leadership and grip.
HPI: You worked as CE in some troubled providers: what did you learn about change from those experiences?
SJ: My biggest learning, as CE and non-CE in challenged organisations, is that you can only do change through the people who deliver care day-in day-out. In those organisations, I spent quite a lot of time discussing what approaches or methodologies were right for change, and how to implement them.
Certainly at West Hertfordshire Hospitals NHS Trust, the approach was to help staff to do the right thing, and to support people to change services to enable that (clearly in ways that were legal and safe). The ‘onion’ daily meetings were a means of doing that. The job of a chief executive is to enable staff.
Change always tends to be slower than anyone wants, but making it gradual and bringing staff with you are how we make it sustainable. All the international evidence suggests that durable change is delivered through people focusing on the health of the organisation delivers results.
I also learnt that the NHS system can be very unforgiving. So it’s really important not to ignore advice from people who’ve done those jobs before. I was lucky that I had experienced people I could talk to, but I had to seek them out.
HPI: Which do you think is the most innovative Vanguard?
SJ: That’s like asking which is my favourite child! There are elements of many Vanguards’ work that we should encourage others to copy, but the common theme is doing the right thing at the right time for the population you serve. Morecambe Bay has very good community and staff engagement; Dudley do massively impressive work with teens and young children. The best stuff is about professionals coming together to work inclusively, not exclusively: Modality do great stuff on this.
My perfect system would draw elements from many Vanguards. That’s honestly not just a political answer: one size does not fit all. A big part of our job is to share their good practice.
HPI: If Vanguards are innovating, some will fail. How are you preparing for that?
SJ: We’re here to try to help Vanguards get on and do things differently. And that’s challenging.
I think we as a health and care system have to get behind them all. There’s a very British approach to first build innovators up, and then tell them all the reasons they’re doing it wrong. When a Vanguard is candid enough to say ‘we got this wrong’, a mature system should not sideline them and laugh at them; it should say ‘thank you for sharing that learning’.
Safety has to be non-negotiable, clearly - legality and safety can never be compromised. In 1996, I was working at the Central Middlesex, and John Pope and his board of executives had been there together for 11 years, and developed this formula: make it legal, make it safe & do the right thing. And if you followed those guides, you had the board’s support.
We as a system need to give Vanguards space and time to work and not knock them down when some things don’t come off as planned. That’s the only way we’ll get really different care provision.
HPI: Vanguards are about doing things better and not just saving money ... but money must be saved (and not just redistributed). How can Vanguards help?
SJ: Vanguards have to deliver against the Five Year Forward View triple aim, of prevention, quality and efficiency. Efficiency is fundamental. We have to show that value is at the heart of our changes, and how we can deliver additional efficiencies by the end of 2017-18.
As I’ve said, real change takes time, and involves looking at the service for the whole population and identifying not just your top 1% of users but maybe the top 10%, and redesigning the care system around meeting that population’s need early, preventatively and cost-effectively.
And if we can deliver some efficiencies earlier than the end of 2016-17, that’ll be lovely.
HPI: Have you been engaging with the Carter Review work on new model hospitals?
SJ: The acute care collaboration Vanguards have been doing different things around groups and chains, and includes challenged DGHs like Dartford and Gravesham. And clearly we need to make sure our work and the Carter Review work complement each other and don’t duplicate.
Talking to a number of CEs recently, the myth is that it’s just smaller acute providers in trouble: the sector all face similar challenges. We are linked in with work across the seven arms’ length bodies, which requires a new type of working involved in conversations about how to support care models and success regimes. We know that in challenged places, more of the same won’t deliver what’s needed: local CEs clinicians and other staff tell us this.
HPI: How are you being seen to have the right relationship with other system leaders/ALBs and not as an adjunct to Simon Stevens?
SJ: Our programme works across the remit of all seven ALBs: my team is blended, with people from Monitor TDA, HEE, NHS England all being part of the New Care Models team. So we have people who deeply understand the remit and culture of the other ALBs, and who consistently try to live the values in practice as we are asking Vanguards to do.
The New Care Models board has all 7 ALBs represented, and it reports to the Five Year Forward View board. From governance and reporting perspectives, the Vanguards need us to work across all 7 ALBs, and to work as a team. It’d be naive to suggest there’s not any risk of dis-co-ordination between the ALBs, but it’s one we are mitigating.
HPI: How much concrete evidence of real transformation have you seen? Some people suggest that Vanguards feel somewhat caught between CCGs blocking and acutes letting go? What’s effective in moving obstructions?
SJ: We recognise that it takes time for relationships to translate into action. What’s effective at unblocking problems is the power of having a common purpose, vision and focus. Vanguards were chosen on their ability to put themselves in other system partners’ shoes: the leadership-partnership perspective.
One of our best recent presentations was from Dorset, by hospital CE Debbie Fleming, who said of their partners, "honestly, sometimes we don't get on with each other", and we recognise that is a reality elsewhere.
Again, our job is to support and enable difficult conversations and do all we can for Vanguards. It’s not yet as we want it to be – we have to ensure that all parts of the national bodies are supporting and enabling system-wide planning to enable all system leaders to speak with one voice. The planning guidance will help, but difficult conversations about mid-Winter pressures need support.
In terms of the Vanguards, Don Berwick told our national conference that the national teams and bodies should be there to deliver valentines. Where we hear about specific examples of things getting in the way, we’ll look at what we can do, but it never supersedes local responsibility to try unblocking things. Difficult issues can only be addressed locally.
HPI: What is the process for reviewing Vanguard funding requests to ensure people are genuinely working together?
SJ: This has been an area of educational development for all involved. We asked the Vanguards for value propositions (bids). Any time you seek to make change, you get two broad camps, or schools of thought. In one corner is a group who seem to want the centre to let go, get the money and show nothing for it. In the other corner, the approach is more ‘this is public money and we are taxpayers, and we must show the innovation business case’.
I’m very pleased that the Vanguards have been able to show, as far as possible, how they hope and plan that their systems will deliver against the triple aim: that has been the focus. And it's incredibly difficult for local systems and national bodies reviewing this: where we talk about delivering innovation, it involves a different kind of proof from financial efficiencies and gains.
Supporting this is one of the most difficult to do, but I have to say that the investment committee supported our development of principles for investment, they found it helpful and wanted it to be shared up front. No-one would say this area is easy.
HPI: What is your plan for spreading Vanguards’ learning, which could be seen to have had a relatively slow start?
SJ: In the New Care Models team, we talk about spread, and all agree it’s vitally important so this is not just another pilot. Asked to say how we’ll do this, we say ‘yes, it’s very difficult to spread learning effectively and we have to focus on it’.
I take a pragmatic approach to this, with some science behind. The emerging networks of support need to get more robust. Myriad organisations have members who work delivering care day in day out. We’re working through how we support them to support us to deliver better care more widely.
As I’ve said, there is nothing more powerful than clinicians talking to fellow clinicians. I’m working on behalf of the NCM board to get those membership organisations to understand their role to support spreading what Vanguards are learning: ADASS, LGA, etc.
If we find a common purpose and vision and yet operate in status quo mode, it’ll be no good. We will have an agreed framework building on what’s been happening in the programme. And we can’t plan for learning to spread in two years’ time: it’s got to happen now, and it’s already built in to the support we offer. The approach is based on learning from international examples of sustainable change: build on pioneers who are part of the NCM programme.
Vanguards have been making significant change if not yet at the scale we want and need. There’s nothing more powerful than local front-line colleagues getting on with change, and not waiting.
Having been in the NHS for 24 years, I realise now that (mystical as it may intentionally sound!) the answer lies within ourselves; not with others. We shouldn’t wait for system leaders – ‘them‘ - to tell us what to change and how, as they may not know. We have the Five Year Forward View framework, but any number of policies won’t change the fact that it’s down to us as local leaders.
The urgency is there at Barking, Dagenham, Havering and Redbridge, or Calderdale: people know what’s needed locally and need to find answers at speed. Getting the leadership capacity and capability to the middle managers in organisations, who will drive these changes, is incredibly difficult: we’re asking them to innovate, and support innovation but also to keep things in control.
We have to support both control and innovation at all levels of the system: we need them both.
HPI: The new NAO report says that new models of care will require “significant upfront investment”, but goes on to warn that the “money available for this is reducing as the number of trusts in deficit increases … NHS England has used the assumptions from the business cases for the vanguard programme as the basis for these estimates. NHS England’s guidance says that unless the vanguards demonstrate ‘quantified changes’ in 2016-17, it will be hard to justify national investment.
“It may, however, take time for trusts to deliver any savings, for example, if they are unable to reduce their spending in the short term due to fixed costs. Most costs are for staff and facilities, which do not rise or fall steadily in response to changes in activities. For example, falling numbers of inpatients will only significantly reduce costs for an acute trust when the fall is large enough to allow the trust to reduce staff numbers and close beds and wards”.
Have Vanguards got a handle on the money situation?
SJ: The efficiency conversation and the quality conversation are one and the same. I’ve spent some time in the independent sector, and I learned that it’s OK to talk about the money. If you come and work in NHS care delivery, you’ll find that none of the professionals hesitate to talk about finances. The job is to be accountable for the service we provide including the finances. We must enable this to happen in different ways than it has in the past.
Saving money will be the outcome of successful changes in care delivery. The NCM and Vanguards are part of NHS England’s whole contribution to deliver the Five Year Forward View. Money is a critical third of delivering against the triple aim of quality, prevention and efficiency.
HPI: In Simon Stevens’ recent HSJ interview, he says planning guidance will take significant money from the ‘transition and transformation fund’ to fund provider deficits. Is this robbing Samantha to pay Jim (Mackey)?
SJ: There is a transformation fund for next year: 2016-17. Simon also said that the planning guidance system needs to show how we will deliver system-based place-based leadership. If you look at the Kings Fund document on Vanguards, that’s what we are being asked to demonstrate.
HPI: How big is this transformation fund going to be? Big enough?
SJ: There is money available, that Vanguards will be able to access in 2016-17.
Samantha Jones is director of the New Care Models programme, which is part of the NHS Five-Year Forward View. Interview by HPI editor Andy Cowper.