This briefing looks at what the vanguards set out to achieve when it comes to supporting people and communities to stay well. It highlights the work some of the vanguards have been doing and shares the lessons that other organisations and partnerships can take from the vanguards’ experiences.
What were the vanguards’ ambitions?
The Five year forward view (the Forward view) set out a vision for a new relationship between the NHS and people and communities. It described the need to harness the ‘renewable energy’ of communities and take action on the broader influencers of health and wellbeing.
The Forward view recognised that empowering people to stay well, with the support of their family, friends and communities, is critical for the long-term sustainability of health and care services and for people’s health and wellbeing. The Care Act 2014 makes clear that having control over their day-to-day life is fundamental to people’s wellbeing. To enable this, we need to consider all the resources that influence wellbeing and identify and mobilise the strengths, skills and capabilities of people, families, communities and local organisations - rather than simply tackle poor health and illness. The Forward view described the need to look beyond traditional health boundaries and work with partners including local government, employers, the housing sector and schools to promote wellbeing.
This new approach recognises that people spend the vast majority of their time caring for themselves, and that services should be designed to support and enable this.
The 'new relationship' also means shifting from the traditional NHS approach of 'doing to' or 'fixing' patients, to supporting people on an ongoing basis to self-care and stay well. This new approach recognises that people spend the vast majority of their time caring for themselves, and that services should be designed to support and enable this. It recognises that people wish to be more informed and involved with their own care, and that this means challenging the traditional divide between patients and professionals, as well as offering opportunities for better health through increased prevention and supported self-care.
There are a range of actions that the vanguards have taken to facilitate this shift, from developing new partnerships with community groups and other public services, to improving people’s access to information, harnessing digital technology, and investing in evidence-based education and self-management approaches for people with long-term conditions.
Underpinning these approaches are fundamental changes to the way that services are organised and funded. The Forward view described that moving to these new models of care would require leaders across the health and care system to change their perspective to look beyond their individual organisations’ interests and towards the future development of whole healthcare economies.
The vanguards have found that having dedicated staff with an in-depth understanding of the local community working on projects adds enormous value.
What can we learn from the vanguards?
Adopting an asset-based perspective
- Health services have historically been designed to 'fix' problems, which has led to focus on deficits (or what people can’t do). In adopting 'asset-based' approaches the vanguards have made bold steps towards achieving the shifts described in the Forward view.
- To change the way people use services, health and social care professionals have to, in turn, examine their own behaviour and attitudes and may need to be supported to do this. Many vanguards have invested in health coaching and communication skills training for clinicians. Effective co-production with people who use services can only be achieved if project leads work in facilitative and enabling ways.
Taking a whole community view
- Before undertaking a new project, it is crucial to understand what resources are already available and where, to prevent any duplication or identify gaps in provision. The Erewash vanguard formed a community development forum, bringing together workers in the community resilience field from both statutory and voluntary sectors to help ensure local services complemented each other and to develop a richer understanding of what was available for local people. A common approach to understanding what already exists and where is ‘asset mapping’ (mapping resources in the community); the vanguard sites have found that the long-term benefits of carrying out asset mapping exercises outweigh the considerable amount of time and resources it takes.
- Organisations involved in the vanguard sites have started to develop partnerships that join up the range of services people in their communities depend on. Building relationships, trust and a new sense of team among staff that have historically worked in separately and often in different ways, takes time. All together better Sunderland vanguard carried out work to develop a local definition of ‘care coordination’ after discovering that the term had different meanings to different organisations and professionals.
- The vanguards have found that having dedicated staff with an in-depth understanding of the local community working on projects adds enormous value. At the Erewash vanguard, a "seemingly endless enthusiasm, in-depth local knowledge and a wholehearted belief in the power of communities to improve wellbeing" have been considered essential characteristics for project leads.
Outcomes that matter to people
- The vanguards have started to introduce payment systems based on the needs of the whole population, focusing on supporting people to stay well, and moving away from payment for disease-specific treatments or activities. Some vanguards, including South Somerset symphony have moved to capitated budgets for whole populations. In developing their outcomes framework, Mid Nottinghamshire Better together vanguard worked to identify outcomes and indicators to incentivise care providers to support service users to achieve their own personal goals and outcomes. At a population level it is not practical or feasible for commissioners to measure the personal outcomes for every patient in the system, so Better together’s framework relies on organisations and individuals to play their role in ensuring that they personalise their outcome measurements. For example, commissioners set broad outcomes and measures that facilitate personalisation, such as ‘people are able to remain independent’ or the percentage of people with a personal budget, while health and care professionals and individuals work together to set personal goals.
- Understanding which people are at greatest risk of ill health has allowed vanguard sites to adopt targeted approaches where they are most needed. Risk stratification tools have been used by enhanced care homes vanguards to identify care homes residents at high risk of unplanned hospital admissions. The use of risk stratification tools by the All together better Sunderland MCP vanguard showed that 3% of the population were driving 50% of health and care costs and enabled the vanguard to design a new care model targeting the most intensive resources at those at greatest risk of ill health.
- At an individual level, tools such as the patient activation measure (PAM) have enabled vanguard sites to understand individuals’ particular needs, deliver more personalised care and target resources towards the people who most need them.
Understanding which people are at greatest risk of ill health has allowed vanguard sites to adopt targeted approaches where they are most needed. Risk stratification tools have been used by enhanced care homes vanguards to identify care homes residents at high risk of unplanned hospital admissions.
Vanguards in action
The aim of asset-based approaches is to promote and strengthen the factors that support good health and wellbeing, protect against poor health and foster communities and networks that sustain health. Asset-based services aim to improve people’s life chances by focusing on what improves their health and wellbeing and reduces preventable health inequities. The focus is on the assets, skills and capacities of citizens and local organisations, rather than their needs and deficits.
South Somerset’s symphony project (a PACS vanguard) is designed to establish greater collaboration between primary, community, mental health, acute and social care, particularly for people with complex conditions. The project is based on the principle of collaborative care, centred around the needs of individual patients.
The vanguard has made use of population health data to facilitate integrated care. On behalf of the vanguard, South, Central and West Commissioning Support Unit collated patient data from all care settings into a single anonymised patient record. They used this record to analyse how patients used care services, for which conditions, and at what cost, over a one-year period.
The analysis showed that hospital costs for patients with asthma and diabetes typically represent the highest proportion of the total cost of care, while costs for dementia patients are typically highest in mental health and community care. The analysis also showed that care costs are driven more by an individual’s morbidity profile than by age, and those with co-morbidities are more likely to require care across different settings with higher costs. This data provided a solid foundation for integrated care.
To change the way people use services, health and social care professionals have to, in turn, examine their own behaviour and attitudes and may need to be supported to do this. Many vanguards have invested in health coaching and communication skills training for clinicians.
The Let’s get moving project aims to improve the health of young people in Morecambe Bay. Working with local primary schools, the PACS vanguard promoted a ‘run a mile’ campaign across the region, including working with schools in some of the most deprived wards. Every day in Morecambe Bay, 2,000 children aged 4-11 now run a mile a day, and the project was recently extended to a further 3,000 children in Lancaster. Even in the initial stages, teachers reported that children’s concentration levels had improved. Early data shows that there has been a dramatic improvement in the children’s physical and mental health, and educational performance.
As part of the Fylde Coast vanguard, Blackpool Teaching Hospitals NHS Foundation Trust is using the patient activation measure (PAM) within its new extensive care services. The service, for people aged over 60 with heart problems, respiratory problems, or dementia, brings together all the health professionals involved in a person’s care under one roof. The PAM, which gives a measure of a person’s level of knowledge, skills and confidence in relation to managing their own health and care, is being used to help the service identify those people who need the most intensive support. The vanguard has also provided training for staff to help them to have coaching conversations with patients and work with them to set goals that the patient wants to work on. At regular intervals, the patient completes a follow-up PAM assessment, allowing the team to continue to adapt their approach.
As part of Erewash MCP vanguard’s community resilience programme, a skills exchange project has been set up which allows residents to trade their time with other individuals and organisations. A time swap coordinator was jointly funded by the NHS and council to coordinate the project. Between November 2016 and July 2017 130 people signed up and 420 hours of swaps took place, far exceeding the target of 180 hours. The vanguard hope that the project will contribute to reduced isolation and increased wellbeing through connectivity among those people involved.