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NHS working at scale: Vanguard Sites

"You are the way you are because that's the way you want to be. If you really wanted to be any different, you would be in the process of changing right now."
Fred Smith, The founder of Federal Express.

I first highlighted the engagement issues between Federations and CCGs in June 14; however, much to my dismay for the majority, these remain completely unresolved. 

Why, I hear you ask, am I then revisiting this topic now?

The reason is The Five Year Forward Vision, and the sudden interest from CCGs in becoming “Vanguard sites”, the applications for which have tight timescales and very clear requirements [1], including:

- an ambitious vision of what change they want to achieve to the model of care in order to meet clearly identified needs and preferences of their local population

- a record of already having made tangible progress towards new ways of working in 2014

- a credible plan to make move at serious pace and make rapid change in 2015

- funded local investment in transformation that is already agreed

- effective managerial and clinical leadership, and the capacity and capability to succeed

- strong, diverse and active delivery partners, such as voluntary and community sector organisations

- positive local relationships, for example the support of local commissioners and communities.

- the appetite to engage with other sites across the country, and with national bodies, in a co-designed and structured programme of support aimed at:

a) identifying, prioritising and tackling national barriers experienced locally;

b) developing common rather than unique local solutions that can easily be replicated by subsequent sites; and

c) assessing progress, through a staged development process

- a commitment to richer, standardised data to enable real-time monitoring and evaluation of health and care quality outcomes, the costs of change, and the benefits that accrue.

One further, and vital, point to highlight:

- Working initially with a selected group; ambitious health economies characterised by stable and collaborative leadership, high levels of patient and professional engagement, sound clinical services and finances, and a developed vision for the future.

I am amazed at how many CCGs appear to believe they have all of this in place and are ready to drive forward locally with providers, and take on Vanguard status. My view is we will get close to 150, and possibly more, applications. However, my key concern is the number of applications, albeit in draft form, I have seen this week, where General Practice is identified as only “supporting” the bid, where the bid is being led by a mixture of other organisations and “partners”, all underpinned by CCGs.

How can any bid for Vanguard status, where the requirement is to deliver fully integrated care, hope to succeed if General Practice is only a “supporter” and not a partner, or better still, leading the process?

Approximately 90% of initial patient contacts happen in General Practice and yet this appears to have gone unnoticed in many bids.  In these bids General Practice is marked down as playing a supportive role rather than a leading role.  This is particularly frustrating in areas where the GPs locally have invested and risked their own funds in developing federations to represent General Practice at scale.

My clear hope is that the team appointed to review each of these bids by Simon Stevens will see through this and will dig deeply in to any claims of strong engagement to ensure the words are indeed matched by actions. 

Please keep in mind that engagement is not meetings - you can have as many meetings as you want; engagement is “an arrangement to do something or go somewhere at a fixed time”.  For me the key point is the statement “to do something”; the doing should already be clear before even contemplating making an award against any bid. Any CCG supporting a Vanguard bid should surely be able to demonstrate transformational change since authorisation, through its commissioning of services?

Additionally, the “something” for me should be that any bid can clearly demonstrate collaborative working with outcomes (collaborative meaning “work jointly on an activity or project”). This should include a systematic deconstruction and rebuilding of services, which makes the appropriate shift from in hospital care to out of hospital care. This of course also opens up the opportunity for use of the new contract options; Prime, Principle and Alliance – all still grossly underused by CCGs.

Given the rationale for Vanguard sites, the current financial position within the NHS, and the significant challenges we face in the next 3-5 years, the newly emerging GP federations offer significant opportunity. That opportunity, though, can only be realised where health economies are willing to take a small risk and a leap of faith and understand, and appreciate, that working in collaboration across providers is the right way forward.

One health economy, with one budget, is surely now the way forward, with a focus on placing the patient in the most appropriate setting for the care they require, with the healthcare professional best placed to deliver that care available in that location.

The challenge and opportunity for those genuinely ready for Vanguard status is the deconstruction and complete rebuilding of services, and not tinkering around the edges with a pathway redesign.  Hopefully, with real scrutiny and accountability running through the assessment of any bids, we will see genuine Vanguard sites – “a position at the forefront of new developments or ideas”.

"Far better is it to dare mighty things, to win glorious triumphs, even though checkered by failure than to rank with those poor spirits who neither enjoy much nor suffer much, because they live in a gray twilight that knows not victory nor defeat."
Theodore Roosevelt, 26th U.S. President

Finally, to answer another prominent bloggers question, “what does the NHS need to change into?”

The NHS doesn’t need to change into anything.  What it requires in order to remain the NHS as we know it, free at the point of access, is clinical change, with investment, real investment, in General Practice, via federations, as part of that. 

Federations offer the ability for General Practice to work at scale and with pace, to deliver high quality services; consistently well across all practices. They achieve this by having teams working to agreed thresholds and standards. These thresholds and standards simply require the right balance between standardisation and consistency, while also allowing for local empowerment and flexibility. Above all they require accountability, from federation to practice, for the services and outcomes, something the federations we support are comfortably achieving without the need for threats and/or confrontation.

It’s not rocket science, but I am not sure that CCGs unwilling to engage in “doing” will see it that way.  I still see many instances, daily, of CCGs creating bureaucracy for the sake of it; hiding behind “the system” rather than working to challenge the ways of the past and the system they work within. Time for some foresight and local health economies owning, driving, deconstructing and rebuilding their local system, not having one imposed that they maintain and then blame.

Where we have one CCG, one FT, one Community Service provider, one Mental Health Trust and one GP Federation, the time has come for the Federation to be an equal partner in shaping and then delivering care, not an add on supporting role where others impose a view that General Practice is then supposed to implement.

For more information on how BW Medical Accountants can support you in forming and developing a federation, or to arrange to speak to one of our experts please contact or call 0191 653 1022.

Additionally, if you should have questions for us please email and we will do our best to answer these within the blog.

[1] Co-creating models of care – NHS England Document

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