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Time for a new conversation if the Vanguards are to deliver...

"All growth depends upon activity. There is no development physically or intellectually without effort, and effort means work." Calvin Coolidge, 30th U.S. president

Over Christmas and New Year, I suspect like many of you, I found myself looking ahead and wondering what 2017 will bring the NHS.

The indications are that there will be no new money from the Government, and so with the economy stalled the NHS will remain with a flat-line budget in terms of growth, meaning Sustainability and Transformation Plans (STPs) must deliver.

This places a huge responsibility on the Vanguards to lead the way and demonstrate the art of the possible. While I continue to struggle to see hard, measured outcomes from the Vanguards, I sense 2017 is the year when we will see the first fully integrated Primary and Acute Care System (PACS) appear. For me Salford Royal FT or Frimley Park FT are the most likely candidates for that award, possibly even both.

The key to this, of course, is having CCGs willing to commission in this way. It will mean working with a new payment, contracting and organisational model all in one step, which involves a degree of risk-taking from CCGs.  Consequently it may need intervention from NHS England to make it happen. 

Both Salford Royal and Frimley Park already work within the new PACS model.  If Primary Care joins the party and brings about a fully integrated model of care, this will see providers commissioned, paid and held to account based on shared outcomes for population health. This, of course, is exactly why it requires a new, vertically integrated organisational model and contract for it to work, which is a huge step for general practice to take, particularly with the BMA cautioning against relinquishing the GMS/PMS contract to become part of the fully integrated new models of care. At this stage it appears they would prefer to retain the GMS/PMS and work within the virtual or partial integration models.

However, my view remains that 2017 is the most likely year to see this step be taken – indeed it must surely happen if the level of change required within the current NHS provider models is to happen, coupled with the shift of work from in to, to out of hospital. We need a number of Vanguards to step up to the plate and deliver tangible outcomes, leading the way for others then to follow.

This then begs the question over genuine engagement of General Practice, at scale, in this process. Given that most, if not all, STPs contain a reference to developing a form of accountable care, normally a PACS or MCP, General Practice now needs to get organised into a form of “at scale” representation, where it can speak with one voice. Both PACS and MCP models require a resilient model of general practice at their core, and this cannot happen if every practice needs to be engaged individually.

This is a real problem for most of general practice, where while many have formed federations, networks and super practices, they continue to work as they always have. We also have the problem in a number of areas of federations and networks being dissolved as there has been no engagement of the new entity in changing anything. Starting again in those areas is going to be problematical to say the least.

The answer: a new way to engage, to have conversation, to empower and to take risk to get the outcomes required.

The current top down model of reorganisation used in the NHS, which is based on a once successful management approach, where a parallel organisation exists – the steering group or subcommittee approach - with the chosen few making decisions for the many, and then only engaging with stakeholders once the direction or initial plans have been created. While this process once worked, in today’s environment it is no longer fit for purpose.
What is now well recognised is that if people aren’t involved from the beginning, they are more likely to resist and obstruct change, even when the ideas are good. People recognise that they are being sold something rather than being asked for their input from the start. The time has come for the engagement and inclusivity of all stakeholders involved in the process right at the start.
Whilst challenging, this ensures that the vision created is one that has been developed by all those who have a role to play, whatever that role, leading to buy-in and ownership of what you create as a community for care and bringing about a critical mass for change. 
This need not be a long drawn out process. It can be achieved from an initial exploratory workshop followed by three one-day workshops, to be held ideally 4 to 6 weeks apart.  The workshops involve as many of the stakeholders as possible (e.g. patients, general practices, the CCG, community services, hospital trust, etc). With strong facilitation, you ensure that all members have an input. Between the main workshops there should be mini-workshops, to ensure those not able to attend the main workshops have the opportunity for input and ownership.

The process is best defined as:
1. Initial Meeting - defines the outcomes you want to see
2. Workshop 1 – Winning Hearts and Minds
3. Workshop 2 – Developing the Vision
4. Workshop 3 – Implementation
This is where learning becomes reality and success in your last two workshops will mean success in whatever you are changing or developing.
You can now move to the practical implementation of the vision, the key steps that need to be taken to do this as well as timescales and responsibilities for action.  The time, commitment, input and integrity of the approach from the first two workshops will ensure that you have the ownership, engagement and enthusiasm to deliver the shared vision for your organisation(s), as well as resilience and sustainability.
Whether you are a practice, a super practice, a GP federation, a CCG, a hospital, a local authority, a community provider, a third sector organisation, or any other entity involved in health and social care, this process can work for you. Whether you have 9, 90, 900 or 9,000 conversations to have, this process can work for you and you can achieve the outcomes you desire.
This process ensures you have a sustainable and resilient organisation or pathway going forward, and a team skilled and able to meet not just current challenges, but future challenges as well. 
If you are thinking of developing an at scale provider organisation, or about delivering any form of change, and are looking for a model to engage every stakeholder in that change, and would like more information on how BW Medical Accountants can support you, 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.

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