Launch of a framework to improve how the NHS in England makes large-scale change
About 5 mins
The 10-Year Health Plan signals three big shifts – hospital to community, analogue to digital and sickness to prevention. In many respects these ambitions are not new, but if the NHS is to succeed in fundamentally changing its underlying model of care, then its approach will have to be. The last time the NHS articulated such an ambitious vision for change was in the 2014 Five Year Forward View – when the circumstances around funding, public confidence and workforce morale were more favourable.
Then, as now, the delivery vehicle for this vision included large-scale, national change programmes. These national programmes have always been a key part of policymakers’ toolkits, used to secure large-scale improvement or service change. In a national health system, they are a vital means of achieving consistency of service and spreading good practice. National programmes can involve a mixture of approaches like legislation, guidance, incentives and performance management, as well as softer forms of influence, to achieve system change. They are designed and overseen by a central programme team within the Department of Health and Social Care (DHSC) or NHS England, often with a designated budget.
In the era of New Labour’s reforms in the 2000s, these programmes included the 18 weeks programme and National Cancer Plan. New programmes followed 2014’s Five Year Forward View, including New Care Models and Integrated Care Pioneers, and later, Early Cancer Diagnosis, Community Diagnostic Hubs, Virtual Wards and Elective Surgical Hubs.
Some of these programmes have achieved successes: the 18 weeks programme was instrumental in reducing waiting times and, more recently, elective surgical hubs have increased treatment volumes by around 22%. But other programmes, such as Virtual Wards and New Care Models failed to live up to their ambitions. Indeed, the NHS’s history is littered with national programmes that have had little impact on outcomes.
As DHSC embarks on implementing the 10-year plan, including setting up new national programmes to implement the new Neighbourhood Health Service and other priorities, how do we do better? That’s a question I’ve pondered over the years in my work with national programmes as an evaluator. And now, in collaboration with us, The Healthcare Improvement Studies (THIS) Institute and Ipsos have answered this question, by developing a new framework for national programme planning.
New care models: big programme, limited success
From 2015–19, I led the NHS England team evaluating New Care Models, which were proposed in the 2014 Five Year Forward View. There were five new care models, but the most prominent were Primary and Acute Care Systems (PACS) and Multispecialty Community Providers (MCP). They aimed to bring together primary and community care by creating integrated providers. These two care models were to be developed and tested by 23 ‘vanguards’, supported by a large national programme team in NHS England and over £200m in funding.
What happened?
NHS England stopped funding the vanguards in March 2018 – after just 3 years. None of the PACS or MCP vanguards had put in place the care models envisaged. There was some evidence that emergency admissions had grown less slowly in the vanguards than elsewhere. But integrated care providers didn’t emerge and there was no significant change to the way clinical commissioning groups commissioned services.
The official line was that the models would be spread through the 2019 NHS Long Term Plan. But in reality, the vanguards hadn’t demonstrated a model that anyone else could – or, perhaps, would want to – copy. New funding originally earmarked for spread was eventually reallocated to cover deficits.
What went wrong?
As an evaluator I saw two main problems. The first problem was a lack of clear thinking about objectives, priorities and the theory of change for the programme. Too little emphasis was placed on learning from the existing evidence. Behind the ambitions and projected savings was much wishful, and unchallenged, thinking.
The second problem was unrealistic timescales and expectations. This led to rushed implementation without detailed planning, and hurried attempts to ‘prove’ success. The care models were complex – particularly the contract changes – and they needed time to fully develop.
What went well?
The New Care Models programme was large, ambitious and complex. It created a buzz around integration and the new models of care, winning the hearts and minds of stakeholders. It offered generous support to the vanguards to overcome barriers. And – with more time and planning – it may have paved a way forward for integrated care systems. But it didn’t achieve what it set out to do.
Getting national programmes right from the beginning: the early planning framework
National programmes are an important tool to make improvements across the health system – so boosting the success rate of these programmes is vital. We know that they can work. But what separates success from failure? And how can we help the next generation of national programmes, on which the 10-year plan will ultimately succeed or fail, be more effective?
To answer these questions, we collaborated with THIS Institute and Ipsos to develop a framework for national programmes. This framework draws on the evidence and insights from people who have led, or worked in, some of the highest profile programmes over recent decades. It sets out questions that people designing and implementing programmes should work through, together with a description of what good looks like.
The framework draws on four key insights:
- Health care is highly political, and there’s always pressure for fast results. This means planning can get lost in the drive to start implementing, but that can leave programmes with unachievable ambitions.
- Solutions are often developed before the problem is fully understood – especially where the problems vary by location and population group.
- Political drivers can shift early in the rollout of a programme, often with moving targets and expectations. Leaders must actively manage this across the many players in health: providers, the government and politicians, the public and their own teams.
- As a result, the early planning stage of national programmes is critical for success. Problems which emerge later often start in this period. Programme design decisions currently being made at DHSC will likely reverberate – for better or worse – for years into the future.
THIS Institute has now launched the new planning framework. It doesn’t guarantee success – running a national programme is an art as well as a science. But by focusing on setting up programmes for success from the start, it should help the current generation of policymakers to lead the national changes needed to implement the 10-year plan.
With thanks to Sarah Hardy for her involvement in this project and her valuable contribution to this blog.