Avoiding the pilot pitfalls: how can the Vanguards help others in the NHS to succeed too?

Let’s follow the logic: to improve quality and efficiency, the NHS needs to change dramatically. Given widespread variation, the parts of the NHS which particularly need to change are those particularly lagging on quality and efficiency. So any programme designed to boost the NHS’s ability to change should surely start by investing support into those areas that are struggling most?

Well, not quite. Pilot (or pioneer, vanguard, forerunner) schemes in the NHS typically select a group which already lead their field, who then continue to lead their field, and the gap between them and other areas is as likely to grow as reduce. Looking at the 29 sites chosen today to be Vanguards – sites aiming to develop and test the new care models set out in the NHS Five Year Forward View and share that learning across the country – this theme can be seen to continue. They include, for example, 13 areas covered by the former Integrated Care Pilots and the current Integrated Care Pioneers.

The question Simon Stevens rightly asks about the Forward View is, how is this time different? How can the Forward View avoid being like similar documents of old which sounded nice but never had the promised NHS-wide impact? The same question applies to the Vanguards. Success will not be so much whether the sites – with the benefit of tailored national support and a share of the £200m transformation fund – improve patient care and create more financially sustainable services in their local health economies. Success will be whether they can truly create a ‘proof of concept’ that other areas can adapt and replicate to accelerate development across the country.

I am optimistic that the Vanguards can succeed in this way. It was heartening to witness the great energy and enthusiasm in the room at last week’s selection workshops (which I was privileged to attend), and to see the quality of local leadership and partners coming together to build consensus for change.

So how do warm feelings get translated into avoiding the pitfalls of pilots past? This is where the real challenge lies – in probably three main areas:

The first trap is that of context. We know that even where interventions or approaches are shown to be successful in one setting, they don’t always successfully spread to a new site, even when well implemented. Why not?

Often it can be attributed to the context or environment in which they were supposed to operate being too hostile to allow any progress. This can apply both locally, by not having the right partnerships in place or lack of local clinical support, or nationally, with central policies or actions that hinder local change.

As Deming, one of the pioneers of quality improvement approaches, observed: ‘intervention + context = outcome’. Having an enabling context which supports and drives change will be essential for all those trying to introduce new models of care and is often the critical ingredient that is overlooked. Not understanding context and taking it into account risks a huge waste of resources, money and effort. So the Vanguards need to think about how they build an enabling context in their areas, and national bodies need to consider how they develop the current blend of policy levers to best support local change.

Next comes the time to think. Even where there is an enabling national and local environment, there are serious challenges in the capacity or ‘headspace’ for people working in local health and care systems to think beyond the pressures of the day-to-day to properly drive change. It’s no secret that central pressure on the delivery of targets means that people working in the NHS often feel that they have to prioritise ‘fire-fighting’ and the provision of central assurance over local ambitions to improve and change services.

In our Constructive Comfort report we put forward the idea of transparent ‘improvement zones’ for those transforming their health economies: where expectations of performance are adapted to allow headroom for the duration of a period of change. This would create the necessary space to allow areas to focus on accelerating change. 

Finally there’s the nuts and bolts of practical help. There will be a real need for resources and support for change for all those looking to introduce new models of care. We know that the majority of organisations or health economies committed to driving change at pace have dedicated teams in place, in addition to explicit frontline time dedicated to it.

We must not underestimate the level of investment in time and resources that will be required to introduce these models in areas that are not currently as well as developed as in the Vanguards. There will be particular need for practical embedded support, as well such as access to a trusted facilitator or ‘honest broker’ to help resolve wicked issues and build consensus to help drive change forward. The Vanguards could be incredibly helpful in being the guinea pigs for a different type of support – being clear as to what’s indispensable and what’s irrelevant.

The Vanguards have immense potential. It would be all too easy to focus their attentions on delivering the best possible care for their area. After all, that is their day job and could well bring catchy results. However, the bigger prize here is how change can be driven in the areas which aren’t in the 29 sites, or even in the 268 applicants – those for whom life is tough and whose problems of today are too consuming to allow much thought for tomorrow. If the Vanguards can help those areas deliver change, then this time really will be different.

Clare is a Senior Policy Adviser at the Health Foundation, www.twitter.com/clareahealth