The NHS Vanguards – quite a critical analysis

There are two vanguards at large in health and care:

  1. The new NHS England vanguard sites
  2. The Vanguard Method for Locality Working

But which of the two vanguards lives up to its name? Which one leads the way in health and care?

Let’s look at the NHS vanguard sites first. They are described as leading the transformation of care for patients in towns, cities and counties across England.

They certainly have all the moves. According to NHS big wigs, they have:


“… to create prototypes for other parts of the country”. “They could experiment, see things which didn’t work as well…”


“I think they’re described as the battering ram of change.”


“the existing vanguards would say we’re trying to go as fast as the fastest pace required… ”


“at scale to fundamentally change the way we deliver urgent and emergency care.”


“£200 million transformation fund and tailored national support.”


“backed by just about everybody”

Patients at the centre

“Services need to be integrated around the patient.”

Science, force, speed, ambition, money – all on behalf of the patient and backed by just about everybody! It’s a shoe-in. What could possibly go wrong?

Let’s take a look at look at the method.

The NHS England Method

The clue to the method is in the title of Chapter three of the NHS 5-year Forward View.

The first part of the chapter title is a question; ‘What will the future look like?’ In the second part of the title comes the answer, ‘New models of care’.

NHS England plans to:

” and stimulate the creation of a number of major new care models that can be deployed in different combinations locally across England.”

This is the method. Support, stimulate and deploy.

NHS England make it clear that this isn’t a time to be silly. There are not to be:

“an infinite number of new care models”

Instead, they have helpfully narrowed it down to a small number of models:

“Different local health communities will instead be supported by the NHS’ national leadership to choose from amongst a small number of radical new care delivery options.”

NHS England goes on to answer the question ‘what will the future look like?’ in some detail. Indeed, they have gone as far as to:

“set out the detail of the principal additional care models over and above the status quo which we will be promoting in England over the next five years.”

You can read in detail about the future here.

NHS England chiefs believe the new models will be forward thinking, distinctive, radical and game changing.

But when you read about the new models in detail, what is striking is where this radical, patient-centred change will take place.

We can look forward to a future of:

Radically different buildings

There will be changes to:

  • Which building staff work in
  • Which building patients are seen and treated in
  • Where buildings are geographically located
  • How long the buildings stay open for and on which days

For example, patients may be treated closer to home, or further away, and have access to services in the evenings and at the weekend.

Radically different acronyms

There will be changes to:

  • The name of working arrangements
  • The name of the buildings
  • The name of services

For example, we will see names like Multispeciality Community Providers (MCPs), Primary and Acute Care Systems (PACS), The Better Together Programme, Better Care Together and The Symphony Programme.

Radically different organisational structures

There will be changes to:

  • The legal status of an organisation
  • Who runs which service
  • Who employs particular staff
  • Lines of accountability

For example, organisations may become or join federations, networks, joint ventures, or vertically integrated teams. Services may be renamed as hubs or community services.

Radically different ways to move money around

There will be changes to:

  • Payment regimes
  • Who pays staff salaries
  • How money is pooled
  • How the money moves around the system

For example, bigger GP surgeries could take on new budgets and employ consultants, the payment regime to hospitals could change and prime contracting and/or delegated capitated budgets could be introduced for specialist providers.

Radically different ways to move patients around the system

There will be changes to:

  • Who you refer your patients to
  • Who refers your patients to you
  • How long referrals take
  • How you help your patients navigate the system

For example, there may be extra staff resources to coordinate care for people with mental health conditions, new waiting time standards and a reduction in the length of stay in hospital.

What could possibly go wrong?

The NHS England method starts with the answer.

The right answer, according to NHS England, is set out in detail in the 5 year Forward View. The job of the vanguard sites is to deploy the right answer. They are incentivised to deploy the answer with money and ‘support’. Other health communities will then be ‘supported’ to copy the right answer from the vanguard sites.

Believing you have the right answer and setting it out in some detail before you start is not scientific. It is based on belief.

It’s a belief that flies in the face of what we already know – that making changes to buildings, structures and referral pathways tends to be slow, bureaucratic and expensive.

The Vanguard Method for Locality Working

Imagine this.

Forget the model you first thought of. Forget federations, Multispeciality Community Providers, mergers, co-location, networks of care and vertically integrated teams. Yes, even vertically integrated teams. Put them out of your mind entirely.

Forget the £200m and your share of it.

Instead of starting with an answer, imagine starting with a question – “What’s needed and why?” Imagine not knowing the answer to this question.

Imagine NHS England having a completely different role. Instead of incentivising sites to implement the right answer, imagine if they supported every geography in England to use a rigorous method to get knowledge.

Imagine if getting knowledge meant listening to patients in their homes and in hospital with one purpose and one purpose only; to understand what each patient needs to live a good life in their individual context. Imagine studying hundreds of case notes, files and computer records to find out if the system is giving patients what they needed. And if the system isn’t giving people what they need, imagine being brave enough to find out why not?

Imagine studying this data across all organisations involved in someone’s care – the GP surgery, hospital, social services, DWP and charities. Imagine believing nothing except what the data and citizens are telling you.

Imagine doing this with an inquiring mind. Imagine being armed with knowledge instead of belief. Imagine being backed by data instead of being backed by ‘ just about everybody’.

Imagine starting with a question instead of an answer.

Imagine what you might learn.

Anyone can learn how to get knowledge on the Vanguard Method in Locality Working university programme now available through the University of Buckingham Business School.


‘The Whitehall Effect, How Whitehall Became The Enemy Of Great Public Services and What We Can Do About it’, by John Seddon

‘Diseconomies of Scale: Saving Money By Doing The Right Thing’, a joint report by Vanguard Consulting and Locality.

Vanguard in Health Integration White Paper

The NHS 5 Year Forward View

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A masterclass in government innovation

Step 1 – A politician speaks

A politician declares the beginning of a successful pilot initiative.

Step 2 – Civil servants type

Civil servants start typing.

They type guidance, supplementary guidance, an expression of interest form, an outcomes framework, a contract, a toolkit and other supporting documents.

These documents tell public sector managers what to type in order to become a successful and innovative pilot.

Step 3 – Public sector managers type

Public sector managers begin typing.

They type what will they do to become a successful and innovative pilot project.

Step 4 – Civil servants pick the winning typists

Civil servants read their own words back to themselves in the expression of interest forms and pick the winning typists.

The winning typists are awarded pilot status and a big pot of money.

Step 5 – Public sector managers type

The winning typists are paid to type up their innovative pilot project as they go along. They type agendas, minutes, reports, strategies, diagrams, monitoring documents and frameworks.

They send a selection of their best typing to the civil servants in London.

Step 6 – Civil servants check typing

Civil servants check the typing and return it to the public servants if any errors are identified.

Step 7 – Public sector managers retype

Public servants make the necessary corrections and resubmit the typing to civil servants until it is sufficiently innovative.

Step 8 – A politician speaks

The politician reads a typed statement out loud for the media to hear.

It reads: “According to evidence, the pilot initiative has been an outstanding success”.

Step 9 – Civil servants type

Civil servants type up the successful pilot, label it ‘Best Practice’ and upload it onto the innovation area of their website.

And so it continues.

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How to be the perfect benefit claimant

Thinking of getting an illness, growing old or losing your job? Wondering if you can claim benefits?

Please read this unofficial government guide to being a benefit claimant first.

There is a right way and a wrong way to be a benefit claimant.


You should have one named illness at a time. We like to see a visible component to every illness. Try to choose an illness everyone has heard of.

Please wrap up one illness before starting another.

Unplanned illness, multiple illnesses or a condition where you have good days and bad days will not be tolerated.

If you have a mental health problem, we prefer this to be serious and consistent.

Under no circumstances combine an illness with losing your job or home.

Your physical and mental health should enable you to travel to appointments at the doctors, hospital and job centre, reliably and on time.

Please do not mix up physical and mental health. You can have EITHER a named mental health problem OR a named physical health problem, not both.

Your hearing and vision should be excellent, especially if you are applying for health or age related benefits.


Your memory should be near perfect. For example, you should know your doctor’s postcode and the year your partner was born. You need to be able to recall these facts quickly and consistently.

You should have a particular gift for filling in forms. Your handwriting should be neat and legible and your typing skills should be excellent.

If you are unable to memorize user IDs and passwords, store them carefully.

Gathering together documents is a crucial skill. It helps to set one room aside in your house to act as an admin hub for your claim.

Please keep your first name, surname and address short and pronounceable.

You must be online, especially if you are on a low-income.

Free time

You should be available between 7am and 9pm for appointments, visits and phone calls every day.

If you are unemployed or have a serious illness, do not go on holiday or celebrate life events. You can’t have it both ways.

Communication skills

You should be able to present your situation in perfect chronological order the first time around.  Please don’t mumble, stutter or be nervous. Your voice on the phone should be clear, loud and confident. If you find yourself mumbling, open your mouth wider and speak more slowly.

Vulnerable people should be particularly clear and consistent in their communication.

You should have an email address, a landline phone and a mobile phone number. Make sure your mobile phone is charged and topped up with credit at all times.


You should be upbeat, confident and polite at all times. Building rapport with job centre staff is an advantage. Genuine emotions are not recognised.

The ability to concentrate for long periods, patience and resilience are important skills when navigating government websites, trying to get through on the phone and filling in forms.

A sense of humour is required when your session expires and you are logged out.

Religious faith can be helpful when you are cut off after waiting 45 minutes to get through on the phone.

Keep it Simple

If you insist on having more than one issue, split your issues into neat and discrete categories. This is particularly important if your life is in a complete mess.

Consistency is crucial. Keep changes in health, personal relationships, home address, telephone number, job or family to an absolute minimum.

Never try to help anyone else with a claim, a friend or family member for example. This is cheating.

A plea

If we could all try a bit harder please to be like this, everything would run a lot more smoothly.

If in doubt, ask yourself this question, “Am I easy to process?”. If the answer is “yes”, you are ready to be helped.

If the answer is “No”, take a long hard look at yourself.

The government is only able to deal with standard, processable and consistent humans.  We train our staff to ignore, lose or punish everyone else.

Humanity has been cut.

So if you are non-standard and inconsistent, it’s tough. Shape up, or you’re on your own.

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Don’t be scared of shorts

Don’t be scared of shorts

Don't be!

Hold me david, I'm scared

Shorts don’t have to be scary

don't have to be scary

Hold me david, I'm scaredBut everyone is scared of shorts


Hold me david, I'm scared

Even the word shorts is enough to instil fear

fear in anyone

Hold me david, I'm scared
Shorts are one of the most dreaded items

shorts worry

Hold me david, I'm scaredThe most intimidating piece of clothing out there

the most intimidating

Shorts terrorise women

 wearing shorts

Hold me david, I'm scaredBut don’t fret


Hold me david, I'm scared

Don’t be scared

 scared to wear shorts

Hold me david, I'm scared

Let go of your fears

let go

Hold me david, I'm scared

Brave this often-feared basic

feared shorts

Hold me david, I'm scaredDon’t be scared of shorts

Don't be!

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Dear Boots Health & Beauty Magazine, May/June, thanks for the love!!

Dear Boots Health & Beauty Magazine May/June

Thanks for asking

Has my first BBQ got me fretting about putting on THOSE summer shorts?

It’s kind of you to ask, but I’m not sure which summer shorts you are referring to. Is it the denim pair?

If yes, I might be wrong but I’m not sure a BBQ would render me constantly and visibly anxious about putting them on. I hope you don’t think me arrogant.

Thanks for understanding

You ask if I am worried about my tummy looking bloated in a bikini and then you address a part of my body directly we’re looking at you, pot belly!.

Are you trying to tell me something, Boots?

Thanks for the permission

You declare enough of beating yourself up. I was just about to stop, I really was but then you suggested that I dig out a photo of myself that was taken when I was happy with my body. It’s confusing, Boots, to know what to think.

You suggest I lavish time on an area I love and then I’ll worry less about the bits I don’t. Before I had chance to worry less, I got sidetracked by the following statement in a feature about weight loss and temptation when THAT brie starts whispering, ‘eat me’.

THAT Brie? Which Brie? If I showed you the two I have in the fridge, could you point it out?

Perhaps you should address the whispering cheese, now that we know it communicates, instead of my suspected pot belly?

Thanks for calming me down

You tell me to keep calm and love my hair. After finding out about my pot belly and the whispering cheese, I do need to calm down. So thanks for the reminder and for the additional point about loving my hair. Once I’ve got over the cheese, I’ll make a start.

Thanks for the compliments

You ask me if I am scared to take THAT strappy top out of the drawer because I’m conscious of my bingo wings. You ask if I won’t even try on shorts because I think I’ve got sumo wrestler legs. We’ve covered THOSE summer shorts already so let’s focus on THAT strappy top. I’m going to have to ask for clarification again. Do you mean the black vest I bought from Topshop in 2009? Or the Zara top I got from a charity shop?

Either way, thanks for asking but taking I think I’ll be okay. Cancer frightens me. Traffic frightens me. Getting a top out of a drawer does not frighten me.

Thanks for the timetable

You tell me how I can have a better bottom in seven days and you offer me a smooth arm action plan. How much better will my bottom be, Boots? Perhaps you could explain what is wrong with my current bottom in your June/July edition? And are you sure I need an action plan to get smooth arms? That sounds like quite a lot of work. If it’s alright with you, I think I’ll stick to an overall vision.

Thanks for the fun!!

You say, now that the sun has put his hat on (we hope!). Ooh, Yes Boots, don’t we all?!!! Thanks for the exclamation marks. The sun has put a smile on my face and I’ve almost forgotten about my fear of putting on THOSE shorts.

You suggest I swap scales for string and you invite me to meet the super suncreams. Thanks for the alliteration Boots and the offer of a meeting. Some might say the alliteration is patronising but I like it. After all, it’s just a bit of fun, isn’t it? You make it all fun – my pot belly, my rough arms and my bloated tummy fun, fun, fun!

Thanks for preparing me

Thanks for helping me to get ready for the social-butterfly season, for helping me to prepare to bare my feet and get sandal ready in no time. Without you to keep me right, where would I be?

I’ll tell you where. I’d be fretting about fitting a pair of summer shorts over that bloated tummy and bottom with an improvement plan hanging over it. I’d be struggling with my rough arms, unable even to get a strappy top out of a drawer. And all the time looking at a photo of myself when I was happy with my body. But I wouldn’t be alone, would I Boots? Because you would still be there, talking to my pot belly.

Thanks for the confidence boost

Thanks for telling me to feel confident and ready to enjoy the sunshine with a little help from these skin perfectors. Because, Boots, as you know, I am not confident and never ready to enjoy anything. No woman is. We must all search for that INNER confidence and even then, there’s no guarantee it’s there. After all, it’s a journey to body confidence isn’t it? A journey back to the photo when we were happy with our body.

But most of all, Boots, thanks for the love

How did you know, Boots, that my feet are feeling a little unloved?

All they have for company is sumo wrestlers legs, bingo wings, a pot belly, a bloated tummy, a pair of summer shorts, a strappy top, a whispering cheese and rough arms.

But don’t worry about my unloved feet Boots, I’m still on a journey with them and I have a new love now.

Yes, thanks to your advice, I have fallen in love with the feel of my skin. So although I may not be perfect, as you have kindly reminded me, at least I can touch my own skin for comfort.

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How to roll out a new computer system in 9 easy steps

1. Have an off day
Most big computer systems start with an off day. A senior person in an organisation has a difficult morning and by the afternoon, they have unwittingly committed their organisation to a multi million pound computer system.  It is the job of the IT salesperson to hunt down anxious individuals and catch them when they’re down. Both parties win – the salesperson gets the sale and the senior officer gets relief.  All workplace ‘what ifs’ and ‘might bes’ can be taken care of by the combined technologies of an integrated system. The new software will make everything that hurts, better.

2. Put together a cost benefit analysis
It is normal practice to write a cost benefit analysis before buying a new computer system. When I say write, I mean engage a consultant to write it.  When I say engage, I mean pay a consultant money to write a cost benefit analysis for a new computer system. Before paying a consultant to write a cost benefit analysis for a new computer system, you need to write a cost benefit analysis for engaging a consultant to write a cost benefit analysis for a new computer system. To write this cost benefit analysis, make sure you are familiar with the correct template for a cost benefit analysis. You can find this document quickly and easily on your existing documents management system.

3. Take it to management team
After 28 drafts, 2 site visits, 14 workshops and a consultation period, you can now take your business case through the approvals process. Anyone who finds fault in your document is a Luddite and should be humiliated on the spot. If you think someone has a reasonable point, attack them with an Einstein quote. Try “”If you always do what you always did, you will always get what you always got” and finish them off with “insanity doing the same thing over and over and expecting different results”. Every big computer system is approved because technology is the future. Evidence of repeated big IT failures cannot help the future because learning from the past isn’t in the future. Technology is the future and the future is technology.

4.Set up a project team
Now your project documents have been approved you can set up a project team to police the roll out. Select people who you can imagine in uniform holding a clipboard and shouting at people in a queue. Call them champions but don’t treat them like champions because they are not. It is the champion’s job to spread fear about the new system. Tell them that all personal documents will be either shared with the rest of the class or destroyed. Everyone must adhere to a new filing system or will be locked out of their own homes. Deny these rumours if challenged and insist that the purpose of the new system is to improve services for the most vulnerable people in our society.

5. Test it out
You now need a large team of Super Users. These people are not super. But it is your job to use them. Think of them as Super Losers. Use your Super Losers to spy on their colleagues and report anyone who doesn’t save new documents in the correct format. The new system has to be run on fear or it won’t work. Users will struggle to find anywhere to save new documents because the new system is impossible to get into, nevermind use. Regardless, the council has spent a lot of money on the new technology enabled future and you must not allow staff to spoil it. If your spies catch anyone using the old shared drive, send them on a training course. Any questions or comments on the new system are ‘user errors’.

6. Talk about teething troubles
Once the local newspaper gets wind of just how terrible the new computer system is and how much is cost, minimise the disruption by talking about teething troubles. Staff may well have hot cheeks and hurting mouths, but this will pass as soon as the new system beds in. Restate that technology is the future and that the organisation is proud to be part of that.

8. Declare a culture change
Once the press has moved onto something else, you can declare that a culture change has taken place thanks to the new culture change. By this time, enough staff will believe the new system is an improvement even if it isn’t. If there are any residual complaints, these can be written off as one-off incidents or ‘not how it is supposed to work’. It will never work as it is supposed to work because how it is supposed to work is a fantasy. Remember, this is the original fantasy you bought when you had that bad morning 16 months ago.

9. Blame someone else
When the whole organisation finally grinds to a password lockdown, you can blame user error, loser error or a breakdown in communication between your champions and the project management team. No one will ever find out who did it. The cost benefits analysis and associated documents will be lost forever in the new system, destroyed by the now out- of -control record destruction policy; the policy originally designed to keep the organisation safe that is now attacking itself. So you don’t need to worry about being blamed. After all, as project manager, it’s your not fault you had an off day. We all have them.

Please not that this is an accurate description of how big IT projects are rolled out in public sector organisations and it is not supposed to be funny.

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The Top 10 tactics politicians use to avoid answering the question

1. I’m very clear

Instead of answering a question, politicians boast about how clear they are. Being clear is the opposite of being vague. Being vague and evasive is bad. Being clear and direct is good. But if you listen to what politicians actually say, they couldn’t be less clear. In stressing how clear they are, politicians suggest the interviewer is muddled. If they would only listen harder and understand better, they too would be clear. Being clear is the gold standard of human thinking, regardless of what you are being clear about. For example, “Look, I am very clear about this. Kittens are evil and should be destroyed. I couldn’t be any clearer”. Indeed. Thanks for that.

2. I’m very relaxed about…

Being relaxed is the opposite of being uptight. Being uptight is bad. Being relaxed is good. Being relaxed displays confidence and certainty. As long as the politician is relaxed, we too can relax and forget a question was ever asked. This is my least favourite of the political tics because it betrays arrogance. It suggests anyone who isn’t relaxed about the opinion of the politician is unnecessarily uptight.  For example, “Some people think some kittens are good. I have a different view. I think all kittens are evil and should be destroyed. And I am very relaxed about that”. Good for you!

3. I’m serious about…

Politicians like to stress just how serious they are about issues. They say out loud “I’m serious about” a serious issue in case we think they are flippant or cavalier. It is as if someone is accusing them of not being serious. Being serious about something is an excellent substitute for answering a question. It is also a subtle way of suggesting other people, the interviewer or other politicians, are being very silly indeed.  The politician can say to an interviewer, “Look, I’m very serious about this. Your bedtime is 7pm and I’m very clear about that”.

4. Let me explain

This one works because it implies that others simply do not understand. It suggests that once explained, everyone will say “Ah right, now you have explained, I agree with you!”. This phrase is often followed by a non- explanation but it can trick the listener into thinking they have had an explanation. For example, “Let me explain. Some kittens have been found to be evil. Therefore we must not assume all kittens are not evil. And I am very clear about that”. Thanks for taking the time to educate me! I understand now.

5. It’s simple

Saying an issue is simple is to suggest the other party is making it complicated or doesn’t understand it. Simple is good. Complicated is bad. It suggests that the answer is so simple, it almost doesn’t need saying. It doesn’t matter if the issue has many different moral, ethical or practical considerations because the politician has apparently cut through all that and has found it to be simple. Saying something is simple is a clever way to disguise your own opinion under the banner of simplicity. For example, “Look, it’s quite simple, kittens are evil”.

6. Look

This is an aggressive opener to any statement. It’s often used by politicians to display faux exasperation with whoever is listening. If only the audience would listen more carefully, after all, the politician is doing their best to answer the question clearly.  I remember my dad using this tactic when he was cross for example, “Look, I’ve told you before, don’t throw spoons at your mother”. “Look” can also be said in a casual matey fashion as if the politician is finally being frank with you.

7. I say to you

This is used by politicians to add emphasis to whatever it is they are about to say and stop the other person from talking, even for a moment. Then the politician can take back control of the conversation and say whatever it is they were planning to say anyway.  After all, you can’t interrupt someone who is about to say something to you. It is also used to give politicians thinking time. For example, “I say to you this. I say to you that kittens are evil”. A similar phrase is “what we are saying is this”. This tactic is used very successfully to change the direction of the conversation well away from the question being asked.

8. I make no apologies for this

This suggests that the politician has cut through any weak, apologetic thoughts and is prepared to be bold and clear. Being apologetic is bad. Being bold and confident is good. By saying you make no apologies for something suggests that there are other people out there who would apologise for it, even if there are no such people. For example, “I gave my son a present on his birthday and I make no apology for that”. As if anyone would apologise for giving their son a present on his birthday.

9. It’s what the British public want

This is an obvious tactic to disguise a party political policy as something that everyone wants. For example, “It’s actually very simple. The British public want to see all kittens destroyed and I am not going to argue against that”. Answering a question by drawing on what the public apparently wants trumps everything. After all, if you know what the British public want, why bother talking about anything else?

10.It’s pretty obvious

This is another Trojan horse for your own opinion. Politicians use it to disguise a heavily value laden position. Saying something is pretty obvious suggests that you have direct access to the objective truth. And if you have direct access to the truth, there’s no need to answer a question properly is there? For example, “Look, it’s pretty obvious and I think it’s pretty obvious to most people. Kittens are evil and I’m very relaxed about that”. Of course!

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