How to spread the vanguard

30 March 2015

More than a decade has passed since the last significant change of the NHS provider landscape. In 2002 the then Secretary of State, Rt Hon Alan Milburn MP, announced the establishment of foundation trusts to reward successful NHS hospitals with more autonomy. It was a decisively national policy, addressing a relatively limited set of challenges.

While successful in parts, the concept of foundation trusts was not sufficiently transformative to address the complexity of challenges the health economy was, and still is, facing.

Vanguards are decisively local and intended to provide answers to a range of complex and diverse questions. If successful, they will change the NHS at its core. Ignore them at your peril.

Unlike simple structural changes such as foundation trusts, diffusing the outcomes of vanguards will require a more sophisticated strategy.

Firstly, success needs failure. We should expect a large proportion of vanguards to fail, at least in parts. Failure is desirable as long as we manage to capture the reasons. The opposite has happened in many parts of the NHS in the past, where pilots were not allowed to fail. The culture of “success at any cost” has wasted vital opportunities to learn and stopped the NHS taking sufficient risks. If every vanguard succeeds, the programme has also been insufficiently ambitious.

Second, learning requires evaluation. The UK has a very strong tradition in robust academic evaluation. However, much of this evidence turns out to be of less value when it comes to the diffusion of innovation. There are two particular issues. Firstly, the evidence generated is often what the evidence funders want to see rather than the end user. Funders are often academic bodies themselves; for example, the National Institute for Health Research and their interests do not always align with those of end users, such as NHS managers, procurement departments or those needing to implement change.  Secondly, much focus is given to outcomes, which is fair and proper. But little attention is paid to process evaluation and, even where it is, it is rarely written up in such a way that service providers can easily adopt it in their organisations.

Thirdly, we need to reward the “stealing” of ideas. Too much emphasis has gone towards the new and too little towards the adoption of the existing. Maybe it is time for an HSJ award for the most ideas copied by a provider?

Fourthly, and related to that previous point, we need to build an innovation fertile eco-system within provider and commissioning organisations. Today, in most organisations it is no one’s day job to scout systematically for innovation, and many staff feel disempowered to do so. Imperial College Health Partners is actively developing such an eco-system with its members, where we can learn from successful private sector organisations. If we want to spread the lessons from vanguards, we will need to create able and informed customers.

Finally, local innovation is laudable and will generate interesting ideas. At the end of the day, a national policy framework setting out expectations and enablers will be required to support the diffusion of innovation, and here the US Accountable Care experience may be of relevance.

Dr Axel Heitmueller, Director of Strategy and Commerce, Imperial College Health Partners



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