August 2021: National Evaluation of the Vanguard New Care Models Programme: Report of qualitative case studies
This report forms part of a wider evaluation of the National Vanguard programme, funded by the NIHR Policy Research Programme and taking place between 2017 and 2021. The aim of this national evaluation is to explore the implementation and impact of the Vanguard New Care Models programme. This study forms part of a wide-ranging evaluation for the programme, which incorporated internal evaluation by the NHS England Operational Research and Evaluation team, locally commissioned evaluations of each Vanguard as well as this independent evaluation.
The National GP Worklife Survey was run for the 10th time in 2019, and the results are now available. We found that the mean level of overall satisfaction, measured between 1 (extremely dissatisfied) and 7 (extremely satisfied), increased by 0.24 (95% CI: 0.08, 0.40) points from 4.25 in 2017 to 4.49 in 2019. Mean levels of satisfaction increased between 2017 and 2019 to varying degrees in all nine domains of job satisfaction, although this remains lower than the peak of satisfaction found in 2005. Overall hours of work showed a slight decline, but responses to questions about stressful aspects of the job suggest that GPs feel they need to work increasingly intensively. Intentions to quit practice remain high, with 63% of respondents over the age of 50 reporting a considerable or high likelihood that they will leave patient care roles in the next five years. More worryingly, perhaps, 11% of GPs under 50 suggested they might also leave, although this is a slight decline since 2017.
This report describes and explores the newly publicly available aggregated national Community Services Data Set (CSDS). The data are available monthly from October 2017 aggregated to provider level for public use. A brief review is provided about data held by CSDS: 1) a range of Care Activities provided; 2) Care Contacts stratified by gender, age group, attendance status and medium, through which the care contact was conducted; 3) Patient Care Contacts, i.e. the number of patients who used care contacts, by gender and age group; 4) Immunisations by age group; 5) Patients with Referrals by gender and age group; and 6) Referrals to community services by gender and age group, source, reason and age group. This report includes an assessment of the data quality for researchers’ and policy makers’ information. We used the data between October 2017 and September 2019, with some initial insights made from the dataset between October 2017 and December 2018.
The current NHSE legislative proposals to restructure the NHS, set out in this government white paper in February 2021, represent a profound change to the way that services have previously been overseen and planned. PRUComm colleagues are concerned about the lack of detail and the failure to explain how current functions will be carried out in the new system, as well as the effects on accountability of the proposals. This report summarises the main issues we think the proposals raise.
The objectives of the study are to find out:
- How the local leadership and cooperative arrangements with stakeholders (statutory, independent and community-based, including local authorities) are governed in the light of the ICS governance recommendations in the LTP. How statutory commissioning organisations including local authorities are facilitating local strategic decisions and their implementation; and whether different types of commissioning function are evolving at different system levels.
- Whether ICSs are able to allocate resources more efficiently across sectoral boundaries and bring their local health economies into financial balance.
- How individual organisations are reconciling their role in an ICS with their individual roles, accountabilities and statutory responsibilities.
- How national regulators are responding to the changes in modes of planning and commissioning and actual service configurations, in the light of the changed priorities for these regulators set out in the LTP.
- Which mechanisms are used to commission services in ICSs. In particular, how is competition used to improve quality and/or value for money of services; and are more complex forms of contract (such as alliancing) being used? How are local organisations reconciling new service configurations with current/evolving pricing structures, and thus how are financial incentives being used?
- How locality priorities, including those of local authorities, are reconciled with the wider priorities embodied in STPs and ICSs. In particular, how is co-ordination achieved between STP and ICS plans, local priorities and existing programmes of work such as any local new models of care?
The first phase of our research suggests that systems are still developing relationships and refining the governance arrangements to allow system partners to work effectively together to achieve their aims using the system form. Overall, systems are a challenging environment in which to make binding decisions, particularly those of a contentious nature. System partners are seeking to reconcile potentially competing interests in their governance arrangements: balancing representation, inclusivity and consensus with the need to act; the accommodation of both cross cutting pieces of work and issues specific to certain groups of organisations; and of the principle of subsidiarity and the need for system oversight. Measures being introduced include proposals to streamline membership of governance forums, the incorporation of existing governance architecture into system structures, and the recruitment of system leaders who hold positions of authority in statutory bodies within the system.
The development of system governance which ‘goes with the grain’ of the local context appears an important way of enabling the full engagement of local government in systems and places, and facilitating governance arrangements which are clear and functional. Interviewees acknowledged that it remains challenging to get the division of responsibilities “right” between systems and places. Not all commissioning could be carried out at ICS level, and it was necessary to make commissioning decisions at place level too. It was anticipated the progression towards a single CCG per system would lead to the delegation of some commissioning decisions to place level. At place level, agreements to formalise co-operative working and agreements to share risk, such as Alliance agreements, are under discussion but not yet widely implemented.
We found a broad acceptance among partners of the need to work collaboratively together, and to take decisions in the best interest of the system. However, some interviewees still doubted that, given the current legislative environment, partners would prioritise the interests of the system above individual roles, accountabilities and statutory responsibilities when faced with decisions significantly against organisational interests. It appears that a shift from competition to a collaborative ethos in the NHS is underway, but this is a long-term undertaking. Local government bodies were concerned about their potential exposure to financial risk, and loss of control over limited council resources.
The question of how systems were accountable, to whom and for what was far from settled. The developing landscape has made things unclear on the ground for NHS partners, with the potential for confusion in the way responsibilities flow between the system, the regulator, providers and places.
Systems were starting to make use of opportunities to agree the allocation of central resources between partners, to develop shared resources in ways that had not been possible before, and to explore novel and unique initiatives based on system partnerships, but these types of initiatives were not yet common practice. At the time of the fieldwork, action to achieve long term financial sustainability in the case studies had not been agreed or implemented.
The governance structures of STPs and ICSs are complex and making decisions through these structures can be difficult. System partners are keen to embrace collaboration, and systems are starting to make use of opportunities to agree the allocation of resources and to develop shared resources in ways that had not been possible before. It is not clear how however, ICSs and STPs, in their current form, are addressing contentious issues such as the need to achieve financial sustainability. System working is not aided by accountability relationships that are unclear to some. It is important that system governance structures ‘go with the grain’ of the local context, in order to facilitate meaningful engagement of local government, and to improve the clarity and functionality of decision making processes. The division of functions between systems and places is not straightforward. As CCGs merge to become coterminous with systems, there is a need for clear arrangements for the necessary commissioning functions at both system and place level.
The Expert Panel, chaired by Professor Dame Jane Dacre, will support Parliament in holding the UK Government to account against its pledges on health and social care. Professor Peckham is one of six core members selected by the Committee for their knowledge of the key issues affecting patients.
The Panel is piloting a new evaluation system that will give Care Quality Commission-style ratings on the government’s performance in meeting policy commitments, grading them from “inadequate” to “outstanding”. Its first area of evaluation will be maternity services in England.
Professor Peckham is also a professor of health policy at the London School of Hygiene & Tropical Medicine, and director of the Centre for Health Services Studies at Kent’s School of Social Policy, Sociology and Social Research, and has over 20 years of policy analysis and health services research experience.
Today we can publish the interim report from our Primary Care Networks evaluation. The initial stages of the project included: interviews with policy makers to explore their objectives for PCNs; quantitative analysis of the size and shape of PCNs on the ground, including their make up and disease burden; and telephone interviews with CCG leads responsible for supporting PCNs as they develop. We show that there are multiple policy objectives espoused for PCNs, and that these may not be mutually compatible, at least in the short term. We also show that PCNs are highly variable in their size and constitution, and as such will face differing challenges. Finally we highlight how important CCG support and managerial expertise has been in the early stages of PCN development. We consider the implications of these for ongoing policy development as PCNs respond to current challenges.
Research by PRUComm members Marcello Morciano, Kath Checkland and Matt Sutton has recently been the subject of an NIHR Evidence Alert. The research explored the impact of the Vanguard New Care Models programme, finding a modest and delayed impact of the programme on emergency hospital activity. The research suggests that judging the impact of integrated care programmes requires a longer term perspective.
Professor Kath Checkland and PRUComm colleagues from the University of Manchester recently contributed to the publication of a collection of essays on the current challenges facing primary care in the UK. Bringing together the findings from a wide range of research projects, ‘On Primary Care’ addresses current issues including: the development of primary care networks; ‘place-based’ approaches to service organisation and the potential role of Health and Well-being Boards; integrated care and the experience of Devolution in Greater Manchester; the role of Community Pharmacy in the provision of primary health care; GP recruitment; and the provision of care by multidisciplinary teams. Written before the current pandemic, the publication includes a foreword exploring the impact of covid-19 and the challenges ahead.
The publication has garnered significant interest from local and national policy makers. Kath Checkland said: "Primary care is changing rapidly and it is vital that policy decisions are based upon the best available evidence about what is happening, as well as the impact of previous policy. This publication brings together a range of evidence, including work carried out by PRUComm. We think that it will be a valuable resource for those interested in contemporary developments in primary care."
PRUComm researchers have published a new study in the British Journal of General Practice that found that patients’ abilities to see their preferred GP has fallen greater in English practices that have expanded, compared with those that stayed about the same size.
At the same time, English practices that have expanded have not achieved better access to care or provided better overall experience. Being able to see the same GP is highly valued by many patients and previous studies have suggested that it may lead to fewer hospital admissions and fewer deaths.
Over the last few years, the UK Government has encouraged expansion, mergers and greater collaboration between practices. This was intended to enable them to deliver services in new ways, work more efficiently and lengthen their opening hours. Most recently, in 2019, Primary Care Networks – collaborative groups of practices serving larger populations – have been set up across England.
The study analysed changes in reported ability for patients to see a preferred GP, their access to care and overall patient experience over the last few years based on responses to the UK GP Patient Survey. This survey asks questions of several hundred thousand people each year.
In the 644 practices that had expanded by more than 20% between 2013 to 2018, the proportion of patients saying they were able to see their preferred GP fell by 10% from 59% to 49%, while in the 5,602 practices that had stayed about the same size (i.e. less than 20% change in number of patients), the same proportion fell by 7% from 63% to 56%. The fall remained greater in practices that had expanded even after allowing for other characteristics of the practices, such as age distribution of the registered patients, rurality and level of poverty.
Professor Forbes said: ‘Larger general practice size in England may well be associated with slightly poorer continuity of care and may not improve patient access. This goes to show that bigger may not be better with English primary care. Better health outcomes for individuals and patient experience for those with long-term conditions must be prioritised. Continuity of care is an important feature of good quality primary care and it is vital that we preserve this for the benefit of patients. It is also important that we collect good data about collaborative working and practice growth and monitor the effects on patient experience.’
- August 2021: National Evaluation of the Vanguard New Care Models Programme: Report of qualitative case studies
- June 2021: 10th National GP Worklife Survey
- June 2021: Exploration of the National Health Services Community Services Data Set Report
- March 2021: NHS Reorganisation
- Feb 2021: Integrated Care Systems interim report published
- Jan 2021: Stephen Peckham appointed to government select committee
- Dec 2020: Primary Care Networks: exploring primary care commissioning, contracting, and provision
- Nov 2020: Evidence on the impact of the Vanguard programme
- Nov 2020: Publication of ‘On Primary Care’
- Continuity of English primary care has worsened with GP expansions
- Mar 2018: PRUComm Annual Research Seminar [Event]
- Apr 2016: The future of commissioning [Event]
- Mar 2016: Examining the impact of the Health & Social Care Act: Examining developments in the English health system from 2013-2015 [Event]
- Feb 2013: Healthcare Commissioning Seminar: A summary
- Feb 2013 PRUComm research seminar on healthcare commissioning [Event]
- Jun 2011: How can evaluation contribute to health policy in England? [Event]