Lessons from a Vanguard: one year in

Bridget Fletcher, Chief Executive of Airedale NHS Foundation Trust, reflects on lessons learned from her organisation's first year as an NHS England Enhanced Care Homes Vanguard.

Blog post

Published: 26/05/2016

This blog continues our series of comment pieces from our New Cavendish Group members. In this piece, Bridget Fletcher, Chief Executive of Airedale NHS Foundation Trust, reflects on lessons learned from her organisation's first year as an NHS England Enhanced Care Homes Vanguard.

People are the NHS's greatest asset. And, as you would expect, ensuring they remain so is key to the future success of our Vanguard. Indeed, the often-overlooked challenge of future staffing in the care home sector has been a dominant theme throughout our rewarding year as the Airedale and Partners Enhanced Health in Care Homes Vanguard.

While ours is a new Vanguard, it has a long history. The platform for it is the telemedicine service that we have been running successfully from Airedale General Hospital for a number of years. This is a 24/7, 365 days a year digital hub that provides care homes with immediate video access to a clinical advice service, provided by senior nursing staff and supported by clinicians from a range of specialties.

Against a backdrop of unprecedented challenges – some foreseen, others not – we have extended this approach to improving the care, and end of life care, of almost 8,000 people living in no fewer than 248 nursing and residential care homes. In these first 12 months, we know that our Vanguard is already reducing emergency activity and keeping people safe and well in their normal place of residence for longer.

At the Nuffield Trust’s New Cavendish Group (a network bringing together the chief executives, including myself, of dozens of smaller hospitals), we often trade wisdom about what we’ve learnt and how we can overcome the challenges we’re all facing. Here are some of the lessons we’ve taken away from our experience of developing new models so far.

Tackling looming pressures on the care home workforce

Mirroring the problems we face across the NHS, the workforce is a massive challenge for care homes – one so pressing that it simply cannot simply be left to the sector alone to overcome.

The combination of the introduction of the living wage; the reputation of the sector; its composition being mostly small independent providers; the increasing demands of the inspection regime; revalidation for nurses – the list goes on – is stretching the sector like never before.

And if the care home sector should “collapse”, as predicted in the report by ResPublica last year, it will be the NHS that will have to meet the needs of the care home population. We recognised very early in the life of our Vanguard that it provided us with an ideal opportunity to work with partners to consider the future workforce requirements for the sector in the face of these challenges.

Balance this with the way telemedicine can support care homes to deliver safe proactive care, and we are at a starting point for considering a completely different staffing model for care homes. We are working hard to instil a sense of belonging and ownership of this workforce strategy among the care homes themselves, wedded to a reassurance that we will be there to support them.

The strategy focuses on a new vision for care homes in light of the telemedicine hub and what this means for the workforce of the future in terms of immediate training needs, recruitment and selection, longer-term training and development requirements, culture and leadership, and new roles and skill mix.

Getting this right is essential if we are to deploy the right resources at the right time for the people we care for.

The power of telehealth

One of the greatest surprises has been how well the vast majority of elderly care home residents has adapted to talking with a nurse through a video link. Most have not batted an eyelid at the prospect of sharing their stories over the video link – perhaps showing up some of us in the next generation for our slow adaptation to technology and digital applications.

Telemedicine has a proven track record of success. Take, for example, one of our care home residents who recently reported having severe chest pain, was short of breath and looked grey.

After a full assessment carried out by clinicians over the video link, his condition was diagnosed as nothing more serious than trapped wind. What initially was feared to be a suspected heart attack, requiring blue-light transfer to A&E, was resolved with some warm peppermint tea and paracetamol.

Overcoming challenges

Our Vanguard relies on the support of a wide range of partners – three acute trusts, three local authorities, two community and mental health providers, more than 130 GP practices, a number of third-sector organisations, universities and colleges and more.

It is perhaps the sheer scale of our Vanguard and the diversity of our partners that handed us an early challenge – bringing all of these stakeholders together and arriving at a consensus.

Differences in knowledge, understanding, priorities, ways of working and even language added to the sheer complexity of what was in front of us.

Not everyone has been on the same page at the same time, but through a shared view that we need to be radical in the way we reconsider and redesign how we work together to provide care for the most elderly and frail in our society, we are making significant progress.

Another great challenge of our Vanguard is to demonstrate that telemedicine really can work at scale, and can fit with and support local primary and community services as they undergo significant transformation.

This isn’t about taking over from GPs, district nurses and specialist teams. It is about how we work together as a health and social care system and use different approaches to meet the ever-growing demands of our population.

Telemedicine is knowledge-based and transferable; it is not bound by the limitations of buildings and can be used to support different patient cohorts, different age groups and disease cohorts. It can link with other digital and technical applications to keep people safe and well, and in control of their own health. Working as part of the family of Vanguards over the past year has been inspiring – there are 50 work programmes – and we are learning and sharing with others and keeping each other motivated and enthused when the challenges seem insurmountable.

This shared approach feels like new ground for the NHS, but it is imperative if we are going to be able to continue to drive and innovate in the face of the current financial challenges.

The views presented in this blog are those of the author and do not necessarily represent the views of the Nuffield Trust.

Suggested citation

Fletcher B (2016) ‘What does the future hold for clinical directors in the NHS’. Nuffield Trust comment, 26 May 2016. https://www.nuffieldtrust.org.uk/news-item/lessons-from-a-vanguard-one-year-in


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