Redesigning the health service in real time

A major project to find new models of care for the NHS to cope with increasing demands and financial constraints has been under way now for a year. NHS England’s project to find innovative ways to deliver services began last March with the launch of 29 vanguard sites

A major project to find new models of care for the NHS to cope with increasing demands and financial constraints has been under way now for a year. NHS England’s project to find innovative ways to deliver services began last March with the launch of 29 vanguard sites

These initial vanguard sites are intended to integrate primary and acute care, improve health in care homes, and move specialist care into the community. Later in 2015, they were joined by eight emergency and urgent care sites, while 13 further schemes for hospitals to work more closely together were under development. The total of 50 sites, which have received extra funding, were chosen from more than 380 applications.

The sites are intended to be blueprints for the rest of the health and care system. They are an essential part of the NHS Five Year Forward View, which calls for new ways to deliver care, in part by breaking down traditional boundaries between roles and organisations.

Changing needs

The NHS Five Year Forward View report points out that patients’ needs are changing and new treatment options are emerging, but that professionals who care for people with mental health problems or cancer, or frail, older people, face new challenges. Moreover, in five years’ time, the NHS in England faces a £30 billion a year shortfall between funding and patient need.

Timeline of development of vanguards

  • October 2014: NHS Five Year Forward View calls for new models of care
  • January 2015: organisations are encouraged to apply to NHS England to become vanguard sites
  • March 2015: the first 29 vanguard sites for integrating primary and acute care, improving health in care homes and moving specialist care into the community are announced
  • July 2015: eight urgent and emergency care vanguard sites are announced
  • September 2015: Thirteen acute care collaboration vanguard sites are unveiled to encourage greater links between hospitals
  • December 2015: NHS England publishes a support package for all vanguard sites

Types, aims and locations of vanguards in England

Integrated primary and acute care systems

Joining GP, hospital, community and mental health services

1. Wirral Partners

2. Mid Nottinghamshire Better Together

3. South Somerset Symphony Programme

4. Northumberland Accountable Care Organisation

5. Salford Together

6. Better Care Together (Morecambe Bay Health Community)

7. North East Hampshire and Farnham

8. Harrogate and Rural District Clinical Commissioning Group

9. My Life a Full Life (Isle of Wight)

Multispecialty community providers

Moving specialist care out of hospitals into the community

10. Calderdale Health and Social Care Economy

11. Wellbeing Erewash

12. Fylde Coast Local Health Economy

13. Modality Birmingham and Sandwell

14. West Wakefield Health and Wellbeing Ltd

15. All together better Sunderland

16. Dudley Multispecialty Community Provider

17. Enompass (Whitstable)

18. Stockport Together

19. Tower Hamlets Integrated Provider Partnership

20. Better Local Care (Southern Hampshire)

21. West Cheshire Way

22. Lakeside Healthcare (Northamptonshire)

23. Principia Partners in Health (Southern Nottinghamshire)

 Enhanced health in care homes

Offering older people better health, care and rehabilitation services

24. Connecting Care: Wakefield District

25. Gateshead Care Home Project

26. East and North Hertfordshire Clinical Commissioning Group

27. Nottingham City Clinical Commissioning Group

28. Sutton Homes of Care

29. Airedale & Partners

Urgent and emergency care sites

Improving co-ordination of services and reducing pressure on emergency departments

30. Greater Nottingham System Resilience Group

31. Cambridgeshire and Peterborough Clinical Commissioning Group

32. North East Urgent Care Network

33. Barking and Dagenham, Havering and Redbridge System Resilience Group

34. West Yorkshire Urgent Emergency Care Network

35. Leicester, Leicestershire and Rutland System Resilience Group

36. Solihull Together for Better Lives

37. South Devon and Torbay System Resilience Group

Acute care collaboration vanguard sites

38. Salford and Wigan Foundation Chain

39. Northumbria Foundation Group

40. Royal Free London

41. Foundation Healthcare Group (Dartford and Gravesham)

42. Moorfields

43. National Orthopaedic Alliance

44. The Neuro Network (The Walton Centre, Liverpool)

45. Mental Health Alliance for Excellence, Resilience, Innovation and Training (West Midlands)

46. Cheshire and Merseyside Women’s and Children Services

47. Accountable Clinical Network for Cancer

48. East Midlands Radiology Consortium (Radiology)

49. Developing One NHS in Dorset

50. Working Together Partnership (South Yorkshire, Mid Yorkshire, North Derbyshire)


Huge range of activities

The vanguard sites cover a huge range of areas and activities, from developing new ways to train nurses, to reorganising urgent care and sharing specialist services among hospitals. They are also concerned with the integration of acute and primary services so that GPs, nurses, community healthcare professionals, hospital consultants and social care providers can offer comprehensive out-of-hospital services.

In Northumbria, for example, a shortened undergraduate nurse training programme is being developed, while work is under way to combine health and care services for the entire adult population in Salford.

Director of NHS England’s new models of care programme Samantha Jones says that the scale of the work being undertaken must be understood. The pilots cover about 1,000 GP practices, 36 clinical commissioning groups (CCGs) and 9% of the population.

New care models

‘The vanguard sites are about how health and social care services and institutions can work together to deliver new care models,’ says Ms Jones, who has a nursing background. ‘In effect, they are redesigning the NHS in real time. It is important to ensure that the population we serve receives the most up-to-date care that is fit for the future.’

NHS England, and the regulators Monitor and the Care Quality Commission, are trying to change regulations that prevent services from working together, Ms Jones adds.

NHS England published advice on workforce planning in vanguard sites in December. It states that the staff involved want practical support to develop new and extended roles. Some local healthcare systems have already piloted new roles, including those of physician assistants, care navigators, pharmacists in GP practices and mental health leads in CCGs.

Share expertise

The advice also highlights the need for front line clinical and professional leaders to work and share their expertise across different care settings.

The vanguard sites are making progress in these areas, even though some have been up and running for only a few months. Ms Jones says: ‘It is early days. We need to address some of the regulatory barriers and some of the workforce challenges to develop a multiskilled workforce.’

According to King’s Fund project director Ben Collins, vanguard sites spent much of the past year drawing up business plans, securing funds from NHS England and creating teams to lead their projects.

Integration services

The projects that are most advanced, such as in Somerset and Northumbria, usually involve the integration services, which was often under way before the sites became vanguards.

Mr Collins says the vanguards must ensure that they have transparent objectives that can be measured quickly to see if changes are working.


‘It takes time to get major projects up and running in a meaningful way,’ he says. ‘The challenge is not the model, but how local organisations come together to work in a different way. The transformation is made more challenging because of the fragmentation of the system.’

The RCN says that the vanguards are carrying out important work. But a briefing from the college in September 2015 also warned that many of them are undertaking different integrated-care pilots simultaneously, which can confuse patients and duplicate work.

Many areas are piloting pioneer projects, which are similar to vanguards. Seven pilot projects for NHS Innovation Test Beds, which involves using IT to deliver care, were started in January, and some of these are taking place on vanguard sites.

Mixed picture

A small, unpublished RCN survey into nurses working in vanguard sites late last year found that the picture is mixed, with a significant number of respondents unaware they were involved in a project.

‘What came out strongly was the importance of multidisciplinary, wider team working,’ RCN head of policy Howard Catton says. ‘The people speaking most positively about their vanguard experience were also positive about the strength and maturity of their relationships with other healthcare professionals.

‘It is important that we have leaders who allow new things to be tried, and that we learn together what is good for patients. There is a question about whether there is enough clinical leadership at senior levels in some vanguards,’ Mr Catton says.

Unnecessary visits

Meanwhile, Cambridgeshire and Peterborough vanguard is undertaking a project to reduce unnecessary visits to emergency departments and admissions to hospital.

The trust has set up joint emergency teams (JETs) of two people – a nurse or paramedic and a support worker – to visit people aged 65 or over in their own homes within two hours of a call.

The staff involved in the seven-day-a-week service have advanced assessment skills and decide whether patients need hospital care, or can be referred to a district nursing team or other service to support the patient at home.


Paramedic and operation lead of Peterborough and Ely JET Paul Davies says that referrals, which have so far been made mainly by GPs, are starting to increase as more people find out about the service. In January, the Peterborough and Ely team had 260 referrals.

‘A good 60% of our patients do not go to emergency departments,’ he says. ‘The majority of patients over 65 want to stay at home and, if they have complicated medical histories and have recently been discharged, they are even more keen to do so.’

Case study: South Somerset Symphony Programme

Plans to enhance services for people with complex health needs began in Somerset when staff discovered that 50% of health and social care funding was for services used by 4% of the local population.

The South Somerset Symphony Programme has set up the first of three planned complex care hubs.

The hubs will be staffed by nurses, GPs and hospital consultants, who will co-ordinate care services for about 500 patients with the most complex needs, and thereby help them to stay out of hospital. About 100 patients are seen at the first hub, which is based at Yeovil District Hospital.

Patients with long-term conditions that are less complex will be cared for more proactively through enhanced primary care.

Yeovil District Hospital NHS Foundation Trust, Somerset Clinical Commissioning Group, South Somerset Healthcare GP Federation and Somerset County Council worked in partnership before the vanguard scheme began, and so succeeded in their bid to become an integrated primary and acute care system in the first wave of vanguard sites announced last March.

Support for the vanguard has been crucial to the progress it has made, according to Symphony project senior nurse for strategic development Wendy Grey.

‘Being a vanguard site has helped us enormously,’ she says. ‘We had done a lot of this work beforehand and we knew where we wanted to go, but the vanguard scheme has given us the impetus and finances to help us deliver the model of care.

‘There are lots of barriers to doing things differently and lots of regulations, but working with other vanguard leads and NHS England helps us overcome them. NHS England can take problems up at a higher level.

‘Symphony would have been much harder without vanguard.’


Erin Dean is a freelance journalist

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