Don Berwick

As an International Visiting Fellow with The King’s Fund, I spend several weeks a year in the UK. One of my favourite assignments when I’m here is to meet with teams from the vanguards and the leadership team for the new care models programme to talk about how the programme is going and how to make it work even better.

My visits are spaced far enough apart to notice the progress being made in the vanguards; some of them are making extraordinary gains and growth. They are enthusiastic about their role and many are discovering and implementing their new models of care at pace, with green shoots of success sprouting up all over the country. This is hard work for them – especially with financial and performance pressures – but I am very optimistic about the future.

Among the biggest challenges for vanguards now to is maintain the tempo, and to learn how to improve even further. There is no question in my mind that many of the vanguards will succeed; the crucial question now is one of time.

So how are the vanguards working to improve outcomes?

They are investing heavily in team-based care, co-ordinating care, and working to anticipate the needs of patients, carers and communities instead of being reactive. They are empowering clinicians – both generalists and consultants – and they are giving patients more of a voice and more of a role in their own care. Vanguards are learning that when care is co-operative and when they are able to listen much more closely to what patients and their carers want – what matters most to them – then demand for acute services can fall, while patients’ outcomes and wellbeing improve.

The new models of care being piloted by the vanguards are already achieving reductions in A&E use, unscheduled hospital use, and elective consultations, often helping patients avoid interventions they don’t actually need, while simultaneously assuring that their real needs are met.

The care home vanguards have developed an especially powerful and comprehensive model by working together and actively sharing lessons. On my most recent visit, the Gateshead Care Home Project vanguard explained the basic framework for this work – which includes a strong evidence-based assessment process to better understand the needs of residents. There is multidisciplinary teamwork, which expands the array of resources a team can call on and a strong focus on nutrition and physical activity, which are key factors in maintaining the wellbeing of frail older people. These are all scientifically supported, evidence-based interventions, which robust processes are being built to support.

The active learning from one another is what I especially love about the care home vanguards. After all, the new care models are, at their core, a learning system. We have 50 vanguards across England that compose a major, national expedition with a common purpose, and as they progress we can see thematic new designs emerging among them.

Fylde Coast Health Economy vanguard (@YCOPFyldeCoast) looked outside the UK for lessons, benchmarking systems from the US and other nations that are working with very high-risk patients. The Fylde Coast team calls its model ‘extensive care’. The multidisciplinary team involved include a geriatrician extensivist (a GP who has acquired specialised skills), care co-ordinators, and outreach workers. This is a new way to think about helping high-risk patients, which is paying off in more appropriate and effective care and lower cost.

Another design change is anticipation of need; that is, moving from a system that waits for trouble and then tries to deal with it, to a system that is able to predict that a person is heading for trouble and intercept the risk proactively. Care that gets in early can avert pain and suffering and, at the same time, save money.

I’m also impressed by many vanguards that are moving services from hospitals to primary care settings. For example the relocation of specialty dermatology services at Modality Birmingham and Sandwell vanguard (@Modality_MCP) – the results so far have been superb, and even more progress lies ahead.

So how can we work to help spread this best practice across the country?

I spoke with the vanguards about this at length during my visit the other week. I envision three parallel phases: spread within each vanguard; spread among vanguards; and, spread from vanguards to the NHS and care services as a whole.

Spread within vanguards involves generalising innovations that develop first in one location or specialty, but that can be used more broadly. For example, Tower Hamlets Together vanguard (@TH2GETHER) has a novel and exciting approach to moving specialty nephrology care for people with chronic kidney disease from nephrologists to fully supported general practitioners. Tower Hamlets’ advanced clinical information systems and its ‘clinical effectiveness group’ have been big assets in the success of this redesign.

The result has been improved access and outcomes for patients, and much higher job satisfaction and more sensible use of time for both the nephrologist and the GP. My visit with the vanguard included exploration of how many other disciplines and specialties could make use of this redesign. The list rapidly grew to a dozen or more, and the local challenge is to achieve the spread of this great concept within the hospital trust.

A second level of spread is among the organisational members of a learning set of multiple vanguards. Taking the best new models from each can lead to a powerful ‘quilt’ of redesign components. That requires a culture among the vanguards, such as that so ably demonstrated by the care home vanguard learning set, which values and celebrates movement of lessons among the members.

The third level of spread is from vanguard to the NHS and care services as a whole. This is a high-stakes challenge for the new care models programme overall and for NHS England, NHS Improvement and the other NHS five year forward view partners. It will require the continual development and improvement of many channels for shared learning, coaching, peer-to-peer communication, and strategic leadership. The investment in vanguards opens the possibility that every single NHS trust and every single GP group can benefit. Of course, many productive and promising innovations will arise within the NHS in organisations other than vanguards, and these too can be sources of lessons and inspiration for all.

The new care models programme is a big bet that active, positively toned support and some running room for pioneering collaborations can generate new ideas, prove their worth locally, spread effectively among network members, and in a timely way offer pathways to better care, better health, and more sustainable costs through the NHS. Time will tell, but from what I can see, the game has begun well.

• Governance and accountability of new care models: approaches being taken in the vanguards