In a report commissioned by NHS England, the King's Fund has reviewed the learning from the PACS vanguards (Primary and Acute Care System) with input from individuals from Programme Leads, Primary Care, Acute Trusts, Mental Health, Local Authority, CCG and Patient Representative.
The goals of the PACS model are to improve the co-ordination of services, provide more proactive support for the health needs of populations and individuals and move care out of hospital where appropriate. A core part of this process has been developing multi-disciplinary teams of health and social care professionals working with clusters of GP practices. The aim of the teams is to provide more integrated care for people with the most complex care needs and to incorporate a diverse range of approaches and interventions.
The King's Fund report, ‘Developing new models of care in the PACS vanguards’, reflects on a new approach to large-scale change, which does not rely on targets, regulation and control but on releasing energy, ideas and innovation from within the workforce. It concludes that among the most important factors to emerge from the new care models programme are valuing the relationships and recognising that bringing about change does require strong relationships, how to spread and scale-up innovations and change, and identifying barriers to change within the system that need to be removed.
Commenting in the report, Chris Ham, Chief Executive of The King's Fund describes two versions of the NHS he has witnessed in his work over the past two years:
"Version one is an NHS under severe pressure from growing demand for care at a time of constrained resources."
"Version two is an NHS finding ways to innovate despite the pressure it faces."
It is, he says, Version Two that he has seen during the work The King's Fund has done with the new care models programme.
Ham adds: "Three years into the new care programme, there is sufficient evidence to suggest that Version Two of the NHS holds part of the solution to Version One. Of course, there is a compelling case for the NHS to be allocated extra funding and to address growing staff shortages, but on their own more funding and additional staff will not provide a sustainable solution. Doing things differently by putting in place new care models is also essential, and the examples I've seen in the PACS and other new care models show that this is now happening."
He adds that progress made by the best of the PACS offers hope for a better future which is already proving a reality in some areas: "Let's call it Version Three."
First hand experiences
In this report, The King's Fund invites those who have led the development of the PACS model to reflect on being part of the programme. Consequently, it offers a "unique set of first-hand perspectives," which share insight and lessons learned that will be useful and relevant to anyone leading future transformation programmes or involved with the ongoing implementation of PACS or similar models.
Included within this report are the following essays:
A National Policy Lead Perspective
Jacob West, Executive Director of Healthcare Innovation at the British Heart Foundation and formerly National Lead for the NHS New Care Models Programme
“The vanguards have been doing something different to traditional service redesign. It’s been about whole system redesign – both of the care model (all the things that affect patients) and of the business model (the IT, funding, decision-making and so on). We have helped codify the specific interventions the vanguards have been implementing – from health coaching and extensivist services to multi-disciplinary teams and predictive analytical tools. But none of these features of the new care models are themselves revolutionary. The innovation is in implementing them in a co-ordinated way, at scale and for the long term.”
A Local Vanguard Lead Perspective
Nicola Longson, Programme Director for 'My Life a Full Life' the Isle of Wight PACS Vanguard and formerly Assistant Chief Transformation Officer for North Derbyshire Clinical Commissioning Group
“There has been, and continues to be, frustration in relation to the legal and technical barriers to introducing new care models – for example, around VAT, pensions, contractual terms and conditions, information governance and procurement laws. More consideration and support need to be given to these issues, so that they are tackled once at a national level rather than each area having to work things through independently and finding local fixes or workaround, which are often less than ideal.”
A CCG Perspective
Andrew Bennett, Chief Officer of Morecambe Bay Clinical Commissioning Group and Sophy Stewart, Head of Engagement and Communications for Better Care Together
“A key learning point from our vanguard experience is about the time and persistence that is required to change operating cultures across a large system. After five years of effort in Morecambe Bay, perhaps we are about halfway there! Though we can demonstrate a wide range of strong and developing relationships between health and care professionals from all sectors, we recognise that it takes time for people to know they have the freedom and permission to work as a team, to co-design for the whole health system and population, rather than simply focusing on what works for their own organisation.”
A GP Commissioner Perspective
Dr Andy Whitfield, Chair and Clinical Lead of North East Hampshire and Farnham CCG
“Everything revolves around good relationships first and foremost. This enables a shared purpose of system success with better care for local people being more important than individual organisational performance. Someone recently asked me which formal contract we had used to commission our new care model. There has been no overarching written agreement, just strong relationships and a belief in collaboration.”
A Local Authority Perspective
Daljit Lally, Chief Executive of Northumberland County Council and employed in a formal joint role between the County Council and Northumbria NHS Foundation Trust where he is the Executive Director of Delivery
"The direct objective was to move away from a funding model that, in Northumberland as elsewhere, was increasingly in tension with our wider aims. The Payment by Results system for acute health care makes episodic crisis treatment the first call on NHS funding. In Northumberland the effect of this has been to lock the local system into a pattern where the CCG is in financial deficit and struggles to invest in community services, wile the acute Trust has to maintain hospital activity to achieve its control total.”
An Acute Trust Perspective
Sir Andrew Morris, Chief Executive of Frimley Park Hospital
"The initiatives introduced as part of the vanguard programme have taken a while to establish and bed in, but for 2017/18 there has been no growth in emergency attendances and the number of emergency admissions has flat-lined, which is a first in 29 years at Frimley. Based on previous experience, we would have expected emergency admissions to grow by 3,000 in 2017/18, but thankfully the various initiatives introduced are having a really positive impact."
A Mental Health Trust Perspective
Sarah Gill, Locality Manager for Older People's Mental Health Services with Tees Esk and Wear Valleys NHS Foundation Trust
"Working alongside the GP and our physical health and social care colleagues offers a more timely and integrated approach to managing the wellbeing of our local population. It has demonstrated the potential to pre-empt and intervene early for people with low-level mental health needs, and to work collaboratively to prevent people reaching crisis point and becoming part of the secondary care mental health system."
A GP Perspective
Dr Robin Hudson, a GP in Northumberland
"More than 80% of the population now have practices on the same IT system which is already integrated with community nursing, diabetes and palliative care teams. Huge payoffs are anticipated if the same IT system is adopted by more providers across the health and social care sector as an integrated IT system will hold the patient's story in one place, ensure safety and promoting communication at a population-wide level."
A Patient Representative Perspective
Steve How, a Governor of Nottinghamshire Healthcare NHS Foundation Trust and the Trust's representative on the Better Together Mid-Nottinghamshire Alliance Citizens Advisory Board
"As with many functions of an alliance organisation, the key is integration, with public engagement and experience as a core transformation activity running through all services and assured by (and by default) a part-time group of local citizens."
An International Perspective
Don Berwick, a leading authority on health care quality and improvement and Founding Chief Executive of the Institute for Healthcare Improvement (for 19 years)
"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 it, 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."
"At the heart of the new care models programme is a good news story - that despite the pressures the health and care system is under, innovation is still possible when the enthusiasm of local leaders is fully harnessed," is among the report’s conclusions.
To read the report and the individual essays in full, download it here.
