The vanguard programme, one of NHS England’s attempts to better meet patients’ needs and deliver savings by developing new care models to integrate health and social care services, has not delivered the depth and scale of transformed services it aimed for at the beginning of the programme, says today’s report by the National Audit Office (NAO).
Money originally intended to enable the initiative to transform services was instead spent on helping to relieve short-term financial pressures in the NHS by reducing trusts’ financial deficits, weakening its chances of success.
A key objective of the programme was to design new care models that could be quickly replicated across England. NHS England selected 50 sites to act as ‘vanguards’ which might entail, for example, joining up GP, hospital and community and mental health services in an integrated network or single organisation in one area to improve healthcare for patients.
NHS England’s early planning assumption was £2.2 billion of funding for new care models between 2016-17 and 2020-21, but it used much of the funding to reduce deficits faced by hospitals. Actual direct funding of vanguards was £329 million over three years from 2015-16, with another £60 million spent by NHS England on central support for vanguards. Consequently, with less funding for transformation, the original intention to expand the programme was not realised.
However, while NHS England coordinated the development of local vanguards it did not set clear national objectives or state how new care models would be spread. While this approach provided local, individual vanguards with more freedom to design system change, it makes it harder to assess the performance of the programme overall.
There are early signs of a positive impact on emergency admissions. NHS England’s analysis indicates that in vanguard areas the number of emergency admissions to hospitals has grown significantly more slowly than non-vanguard areas, on average, compared with 2014-15. However, it is still too soon to be conclusive on the impact of vanguards on the demand for hospital services and patient outcomes overall.
Despite not meeting its original intention to expand the models across the country, vanguards have made progress in developing new care models. NHS England forecasts that vanguards will make net savings. As at April 2018, it estimated that vanguards would secure £324 million net savings annually by 2020-21, which is 90% of the £360 million that had been expected. However, it remains too early to confirm these expected longer-term savings and NHS England does not intend to continue measuring savings.
The Department expects NHS England to spread new care models, including those developed by vanguards, to 50% of the population by 2020-21. So far, NHS England estimates that the vanguards provide healthcare to 9% of the population, while 15% is covered by a care model developed outside the vanguard programme.
Almost all vanguards plan to continue with their new care models, but there are some risks to continued progress, including difficulties in recruiting and retaining the right staff, pressures on funding, and poorly-aligned financial incentives across different stakeholders – which are systemic issues and similar to those experienced in other integration initiatives in the NHS.
Before the vanguard programme, the NHS had introduced several other short-lived initiatives to build integrated health and social care services. The timeframe for the vanguard programme funding was three years, although many stakeholders consider that such a transformation often takes 10 years or longer to be delivered successfully. The NAO has seen a pattern of initiatives being continually folded into a successor initiative, sometimes before their objectives are fully achieved.
The NAO recommends that NHS England should strengthen its approach to transformation, by setting out what it has learned from the vanguard programme. The Department and NHS England should also consider setting out clear plans for transforming NHS services over the long term.