CLAIRE MORRIS used to work as an ambulance paramedic in Lancaster, in north-west England. But as part of recent changes in the National Health Service, last year she moved 50 miles away to Millom, a town of 8,500 people that has struggled since the closure of its ironworks half a century ago. There she became part of a new system that continues to handle 999 calls, but now also liaises with other health workers to ensure vulnerable residents receive good enough care that they do not have to call the emergency services in the first place.

Such an approach may seem like common sense, but it is far from the norm. Despite its name, the NHS it not a single service. It is a mish-mash that involves nearly 7,500 general practices (clinics of GPs, or family doctors, which are independent contractors); 233 “trusts”, as hospitals and other direct providers of care are known; and some 850 companies and charities that provide care on behalf of the NHS. All of these entities have their own contracts, budgets, employees and incentives. None is responsible for social care, the residential support for elderly or disabled folk that is mostly left to local authorities.

The project in Millom and its surrounding area of Morecambe Bay is one of 50 experimental “vanguard” sites set up by the NHS in England to piece together this fragmented system, which is increasingly struggling to cope with growing numbers of elderly people with multiple chronic conditions. Although the scope of each vanguard varies, all aim to break down silos by combining budgets and having staff from different parts of the health service work more closely together. Simon Stevens, head of NHS England, wants these sites to be models for the rest of the service.

At last, almost unnoticed, the NHS is starting to change at its core. It is a shift that indicates the end of an era of thinking about health care. In 1990 Ken Clarke, then Conservative health secretary, created an “internal market” by separating the parts of the NHS that pay for services from those that provide them. From 1997 Labour added a vast set of targets and a tariff for each procedure, to reward the most active hospitals. The Tory-led coalition of 2010-15 devolved more of the NHS budget to local groups of clinicians; today two-thirds of its spending is done via 207 “clinical commissioning groups”, which buy services from trusts and other providers.

Vanguards deliberately undermine this history. In February Mr Stevens told MPs that the reforms would “effectively end the purchaser-provider split,” adding for those parliamentarians unfamiliar with NHS-speak: “This is pretty big stuff.”

In Millom the stuff seems to be working. Between 2014 and 2016 the town reduced emergency admissions to hospital by 23% and elective admissions by 16%. Emergency admissions from care homes were cut by 10%. Between April 2015 and December 2016, the whole Morecambe Bay region saw small drops in emergency hospital admissions and occupancy rates, even as most of the country saw increases.

Those running the vanguard ascribe the results to co-operation. The NHS is “a bit like ‘Game of Thrones’,” says John Howarth, one of the vanguard’s clinical leaders. “We’re a set of tribes who are often at war…We need to rejoin the tribes into one NHS tribe.” Millom’s one GP practice is in the same building as the community hospital and the ambulance service but, until Ms Morris started there, they barely spoke and never shared data. Now they are in constant touch, with workers going through phone logs to identify pensioners who call 999 because they do not know what else to do, then liaising across the services to work out how best to care for them at home.

Morecambe and wise

GPs in Millom can now phone or videolink with specialists at regional hospitals. Though this takes a specialist’s time (which under the usual NHS model means the hospital billing for a consultation fee under the NHS tariff), it can save more time and money later. In Morecambe Bay, this change avoided 1,400 unnecessary outpatient referrals in the 11 months to February 2017—no small achievement, since a bus journey from Millom to Lancaster can take more than two hours.

A scheme allowing people with minor eye conditions to see a local optometrist avoided 1,600 unnecessary referrals in its first 18 weeks. Some GP practices are hiring nurses and paramedics to screen patients who need not see a doctor. Other vanguards have GPs in their emergency departments to filter those who do not need urgent treatment. Morecambe runs weekly drop-in “café” clinics: the Airways Café for respiratory diseases; the Serenity Café for mental-health problems; and the self-explanatory Leg Ulcer Café (Professor Howarth concedes it may need a new name).

Before the general election in June was announced, Mr Stevens updated his five-year blueprint for the NHS. He announced that the models of care in the vanguard areas would be imitated throughout the system, via 44 similar local agreements known as Sustainability and Transformation Plans (STPs). A pioneering eight areas will go further still, becoming what he termed Accountable Care Systems (ACSs). These bodies are based on Accountable Care Organisations, an increasingly common way of organising care in America, where most involve one or more health-care providers signing a contract with a health-care payer (such as Medicare, the public scheme for retirees) to deliver specific health outcomes for a defined population over a number of years. ACSs are ersatz versions of this model. They largely formalise what the vanguards are already doing: joining providers in one area together, with the aim of coming under one integrated budget which pays hospitals and clinics for how healthy they keep people, not how many procedures they carry out.

“This is a complete reversal of the Health and Social Care Act of 2012 and the reforms under Andrew Lansley [the health secretary in 2010-12],” says Ben Collins of the King’s Fund, a think-tank. If the experiment were expanded, he says, it could in effect lead to the end of the internal market, since it blurs the line between provider and buyer. “We are finally building a model of care based on the actual needs of the population,” says Ranjit Gill, clinical leader of a vanguard in Stockport.

Vanguards and STPs are “workarounds”, in the words of one doctor. Though he supports them, Andrew Haldenby of Reform, another think-tank, says that STPs have “mad geography, no executive authority and inconsistent vision”. To change this would require new legislation, which is beyond the paralysed government. So the NHS is pushing on, trying to prove the plans’ worth before any legal changes are required. It is betting that the benefits of integration will exceed the costs of eroding the internal market.

Will they? True, the current system wastes millions of pounds on an unwieldy commissioning process. And fragmentation is an incentive for employees to optimise their own performance with little thought for the rest of the system. Nevertheless, the imperfect market-based reforms of the past 30 years have helped to cut waiting times, give patients more choice and instil financial discipline.

Three challenges face the NHS as it makes the case for change. The first is that although integration may help patients, it does not always mean savings for the system, since the overall budget is predetermined. Reducing hospital occupancy rates from 95% to 93% is great, says Professor Howarth, but it does not save money. The second, articulated by many doctors, is that the reforms will not be given time to work. The Labour Party is sceptical of STPs, which it sees as vehicles for cutting spending. It wants to halt the plans and give local areas more money before asking them to figure out how to proceed.

The final issue, says Mr Collins of the King’s Fund, is accountability. “The whole reason the purchaser-provider split was introduced was because of unaccountable local monopolies,” he notes. Although the internal market brought only imperfect accountability, what if the new models fail to deliver improvement? “We could find ourselves back in the 1970s,” he warns.