Transforming Urgent and Emergency Care and the Vanguard Initiative

Background

Vanguards are local health partnerships across England specially selected to take the lead in the development of new care models. There are 50 vanguards in total, eight of which are urgent and emergency care (UEC) vanguards. The overall aims of the UEC vanguards are to improve the coordination of UEC services, direct urgent cases to the most appropriate provider and reduce pressures on A&E departments. They are intended to act as ‘blueprints’ for the NHS moving forward.

Vanguards, as new models of care, are central to implementing the NHS Five Year Forward View, which includes setting out a vision to simplify and improve the healthcare landscape, including UEC. Therefore, ensuring that these vanguards are improving the health and wellbeing of patients, the quality and equality of care that patients receive and the efficiency of the overall system is vital.

Goals

RAND Europe was commissioned to evaluate the Southern Cluster UEC vanguards, namely: Cambridgeshire and Peterborough (C&P); South Devon and Torbay (SDT); and Barking and Dagenham, Havering and Redbridge (BDHR). Overall, the evaluation aimed to:

• Evaluate the impacts of the three Southern Cluster UEC vanguards
• Examine the processes underpinning delivery and impact
• Examine implications for future practice and policy (including any insights pertaining to scalability and sustainability of the models).

Methodology

The evaluation used a multi-method approach, including theories of change, document review, workshops, interviews, surveys and data dashboards.

Findings

Progress and impact

Despite having less funding than originally hoped for delivering vanguard activity, progress has been made across core activities.

• Integrated Urgent Care (IUC) clinical hubs supporting NHS 111 service
  IUC clinical hubs are operational and some benefits have been observed across the three vanguards. However, there is still a need for further efforts to strengthen capacity in terms of number of staff and diversity of professions, and for improved activity and outcome metrics (e.g. emergency department attendances).
• Direct booking capacity from clinical hubs
  Direct booking is intended to support efficient patient management and improve patient experience. Progress is being made in terms of booking appointments into out-of-hours services, but less so into in-hours primary care.
• Data sharing and IT infrastructure
  Gradual signs of potential for change in this area are emerging, for example by enabling providers to share summary care records with each other. However, the efforts to ensure an interoperable IT infrastructure and seamless data sharing between UEC providers are progressing slower than originally hoped for due to social and technological challenges which need to be addressed (and are not unique to UEC vanguards).
• Site-specific developments
  There has also been additional progress in site-specific developments. These include the front door triage at BDHR, service options for patients presenting with mental health conditions at C&P and operational polices and service specification for minor injuries units at SDT.

Enablers and challengers to delivery

• Funding had a catalytic role in facilitating the pace of transformation efforts and pump-priming activities, despite being significantly reduced. However, in order to help sustain engagement, there is a need for greater upfront dialogue between national and local stakeholders and further clarity on budgets available.
• Committed leadership and practical mechanisms supporting joint working helped to establish shared understanding and nurture enabling relationships across local actors.
• Patient and public engagement could be further enhanced with more attention on soliciting, consolidating and analysing feedback, and communicating these resulting actions back to the patients and the public.
• Data infrastructure and interoperability challenges need to be addressed for long-term impact at a larger scale – a challenge facing the wider health system and not exclusive to the vanguards. Currently, the IT infrastructure is still fragmented but given this vanguard learning phase, UEC units may now be better placed to pursue data and IT infrastructure-related goals.

Recommendations

• Establish new incentives, skills and accountabilities in the health and care workforce.
• Coordinate more closely between local and national efforts.
• Nurture and further strengthen collaboration between stakeholders and across professional groups, including with the public.
• Consider how vanguard activities can support an end-to-end UEC pathway, securing a whole that is more than the sum of its parts.
• Improve availability of cost and outcome data to facilitate a robust business case for future scalability and sustainability.
• Reinvigorate efforts to secure physical and relational resources for an interoperable data infrastructure.
• Strengthen evaluation and learning capacity.