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Vanguards: A blueprint for the future of the NHS

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Last year, individual organisations and partnerships were invited to trial new ways of running primary and secondary care services in their local area by becoming ‘vanguard’ sites for the NHS as part of its Five Year Forward View (FYFV).

The move has significant implications for pharma and other healthcare organisations since NHS England envisages that the new care models developed by vanguards will provide a blueprint for the future of the NHS.

Vanguards have been tasked with making health services more accessible and more effective for patients by dismantling NHS care pathways that are no longer working well and taking a fresh approach to service design.

Better communication and joined up working between different parts of the NHS, including GP and hospital services, emergency services and community-based organisations, are integral to this new approach.

For example, vanguards will join up the often confusing array of A&E, GP out of hours, minor injuries clinics, ambulance services and 111 so that patients know where they can get urgent help easily and effectively, seven days a week.

The new ways of working proposed by vanguards could also result in fewer trips to hospitals as cancer and dementia specialists hold clinics in local surgeries; one point of call for family doctors, community nurses, social and mental health services, or access to blood tests, dialysis or even chemotherapy closer to home.

An overview of vanguards

In March 2015, NHS England and its national partners announced the first of 29 new care model vanguards and since then a total of 50 vanguards have been created across the following five areas:

Integrated primary and acute care systems: These vanguards integrate primary and acute care systems – joining up GP, hospital, community and mental health services.

Enhanced health in care homes: These vanguards offer older people better, joined up health, care and rehabilitation services.

Multispecialty community provider: These vanguards will move specialist care out of hospitals and into the community.

Urgent and emergency vanguards: These initiatives will improve the coordination of urgent and emergency care services and reduce the pressure on A&E departments.

Acute Care Vanguards: These vanguards will link local hospitals to improve their clinical and financial viability.

Vanguards in action

In March 2016, one year after the first vanguards were introduced, NHiS Commissioning Excellence organised an advisory panel discussion, involving eight vanguards, including four multispecialty community providers, a GP super-practice and an acute care collaboration. Representatives shared their experiences and discussed planned initiatives and objectives.

Our subsequent report entitled ‘The Role of Vanguards in the Development of New NHS Commissioning Structures’, provides fascinating evidence of how NHS vanguards are redefining patient pathways and trialling new ways of working.

For example, with many emergency departments overwhelmed by patients (who often use them inappropriately) and struggling to meet waiting time targets, one GP super-practice has placed senior primary care clinicians in its emergency departments. Here they provide a triage system that redirects non-emergency patients to appropriate services – e.g. pharmacies or GPs. This has cut down average waiting times to an hour and is minimising waiting time breaches.

Children and elderly people are the biggest drivers of attendance at emergency departments; however, new pathways have meant they can be offered a community or home-based care package rather than being admitted. In another vanguard organisation, clear structured pathways for stroke patients have led to significant reductions in length of stay.

A target for many vanguards is to bring care closer to the patient hence they are shifting acute care away from hospitals and into the community. To this end, many GP practices and clinical commissioning groups (CCGs) are introducing specialised services facilitated through cooperation between practices within an area. For example, one partnership aims to provide community outpatient and diagnostic services from a single large practice. They will expand a range of local social, mental and hospital services, to provide a single point of access to community care, including nursing, dialysis and chemotherapy in the home.

With so many people affected by preventable conditions, such as diabetes and obesity, the focus of care needs to shift from managing ill health to preventing it developing in the first place, where possible. This will require investment in strategies to identify patients at risk to facilitate earlier diagnosis and intervention, and may involve joint working with employers and the third sector.

Some GP practices are updating their appointment systems, introducing triage approaches involving telephone consultations with the option of a face-to-face consultation based on the initial assessment. GPs are encouraged to use latest technologies for appointments including telephone appointments, Skype and online booking. In one GP super-practice, low-risk patients with simple problems are assigned the usual 5- or 10-minute appointment. Those considered to be at high risk, vulnerable or with complex care needs, are offered hour-long appointments. This has reduced unnecessary follow ups and increased the number of people that can be seen in a risk-targeted manner

How can pharma get involved with vanguards?

Vanguards are designed to replace old models of health and social care that are no longer working. They are also showing the way for service changes within their local Sustainability and Transformation Plans footprints. Getting involved early on could bring huge commercial advantage to pharma companies. However, competition is fierce as vanguards are bombarded with offers of help from the industry.

Rather than asking vanguards how it can help, pharma should offer tailored solutions that fill clearly identified needs. For example, if a vanguard is working in a disease area that is relevant to your company, find out what you can do help. However, try to be generic in your approach, since many vanguards want to tackle wider issues around diseases. For example, pharma could identify how many people with epilepsy use A&E following a seizure, but the wider vanguard perspective could be to risk stratify why any patients, including those with epilepsy, attend A&E.

All vanguards have been running for at least a year, so they are already quite advanced. Also, they are working to a plan which is very tightly monitored by NHS England: consequently, they aren’t interested in proposals that would require them to deviate from it.

What they do want from pharma is something that could help them achieve their goals quicker. Since technology, such as Skype and decision support software are key to transforming the NHS, this could involve the development of digital tools, phone apps and other IT services like remote diagnostic or review tools. It could also involve partnership working on relevant vanguard programmes.

It is vital to keep abreast of what is happening in vanguards and attending key national conferences to listen, rather than to sell, is key. We recommend the Health and Care Innovation Expo 2016; the NHS Confederation Annual Conference and Exhibition; Best Practice Show; Commissioning Live events and the Health and Care Commissioning Show.

Areas of opportunity for pharma

As mental health has moved up the policy agenda across government, improving outcomes for people with mental health problems has become a major commissioning priority. The NHS’s Five Year Forward View for Mental Health is a call to action to accelerate the pace of transformational change in both services and attitude.

NHS Vanguards are rapidly gathering momentum to transform and integrate mental healthcare. To this end, nine integrated primary and acute care system vanguards are working on joining up GP, hospital, community and mental health services so that mental and physical health care will be on an equal footing in these local areas.

This year, Lundbeck Ltd, Shire Ltd and Sunovion have been sponsoring NHiS’s six regional Mental Health Commissioning Network conferences, which are held every six months and enable active discussion and the exchange of ideas to cope with the challenges faced when treating people with mental health problems, in a more integrated way in the new NHS. It also enables vanguards to showcase best practice.

Conclusion

The NHS needs an extra £30bn to deliver the Five Year Forward View: £8bn was promised from the Treasury pre-Brexit – the remainder will come from doing things differently. Vanguards are leading the way in helping to achieve this goal by developing new models of care that will become a blueprint for the NHS. The commercial benefits for pharma companies that get involved with vanguards at this early stage could be immense. But the onus is on pharma to decipher where it can plug gaps and to propose joint working initiatives that will help vanguards to achieve their goals.