Imitate the Action of the Tiger

The Wikipedia entry for ‘Vanguard’ states that it has a number of functions, including “… seeking out the enemy and securing ground in advance of the main force.”

I’m not entirely sure this is what Simon Stevens and NHS England had in mind, but when you consider the current challenges faced by the NHS, military analogies are probably not that wide of the mark. What the ‘main force’ think about it is difficult to discern. One can only hope that they have the guts for a fight, because there is likely to be one. Continuing the military theme, it was Helmuth von Moltke the Elder who famously intoned, “No battle plan ever survives contact with the enemy.”

The success or failure of the 29 Vanguard sites that are currently battle ready will surely depend on their ability to react quickly and imaginatively to events on the ground. The more I think about these Vanguards the more I see parallels with the Accountable Care Organisation (ACO) experience in the United States.

Perhaps unsurprisingly the language used to describe the two is often different and of course the 29 Vanguards here take a variety of forms. However, some common themes present themselves.

Let’s consider for a moment the role of the ACOs in the United States:

  • They are responsible for implementing new models of care delivery aimed at creating a patient centric, value based health system.
  • They are about improving quality and containing costs.
  • They incentivise collaboration among providers across the continuum of care.
  • They are broadly defined as a group of providers that are integrated across disparate settings into a unified network.
  • They are in the business of population health and therefore they endeavour to improve the health of entire populations.

Now go to the NHS England web site and take a look at the Vanguard presentation videos.

Two nations… a common language.

On close inspection differences emerge, but the overriding message is the same. In healthcare business as usual is over. The system is broken and we need to fix it.

If we accept that there are least similarities between The Vanguards here and the ACOs over there then looking at the ACO experience it is worth noting the following:

  • Huge amounts of data are required in order to manage a patient population and to effectively coordinate care across the continuum.
  • Multiple types and sources of data are needed.
  • There is a need to monitor clinical performance and patient outcomes at both the individual and patient level.
  • Population health management depends upon the ability to leverage data for patient identification and risk stratification.
  • The ability to use data to identify and stratify high risk patients allows ACOs to proactively manage each patient’s healthcare needs.
  • There is a laser like focus on the use of analytics to stratify data with the aim of prioritising and monitoring intervention activity and results.
  • There is a focus on holistic views of patients.
  • There is an absolute requirement to fully understand financial risk. ACOs are forensic in their use of predictive modelling to forecast those patients who are likely to be the most costly.
  • Analytics help the identification of clusters of high burden patient populations stratified by condition, geographic location and demographic information.
  • There is an understanding that multi-morbidity is the norm.
  • The aggregation of key pieces of information and the analysis of data are key to driving actionable decisions.
  • The identification of at risk patients means that those responsible for their care – provider and payer – can target interventions and, equally importantly, they can educate patients about their conditions.
  • Population health management strategies are driven by the need to ‘anticipate and prevent’.

All these points are of course relevant and important when thinking about what is needed here in the UK, and the last point I think is particularly interesting because in many senses it asks providers to question what kind of business they are in. Historically providers have been in the ‘care delivery’ business or ‘fixing people’ business. In the world of ACOs public health and preventative care is given huge emphasis. If these new care models are to be successful then Vanguards will increasingly need to be thinking of themselves as being in the public health and prevention business.

This is a big change and it will take no little courage on behalf of all concerned.

“Stiffen the sinews, summon up the blood.”