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When the Danish philosopher Søren Kierkegaard wrote in the 19th century that life must be lived looking forward but can only be understood by looking back, we can be sure he didn't have health and social care system reform in mind. But can we understand how changes will work in the future when past experience may not reflect new circumstances and challenges?
This was the question that set the agenda earlier this year when more than 50 top leaders, managers and clinicians gathered at The King's Fund to test how the relationship between social care and health would evolve as a result of the triple challenges of NHS reform, the widening gaps between needs and resources, and social care transformation. An illustrious roll-call of partners – the Joseph Rowntree Foundation, the Social Care Institute for Excellence, the Association of Directors of Adult Social Services, the Local Government Association, along with expert co-design and facilitation by Loop2 – reflects the breadth of commitment to exploring how these challenges would play out in practice.
The 'Routes' simulation was set in a mythical but life-like borough of 'Crafton', where most of the reforms envisaged in the Health and Social Care Bill had been enacted. Unlike our previous Windmill exercise in 2009, which focused on how the NHS would face the coming financial storm, Routes looked at the whole system of health, care and support. Participants were drawn from a spectrum of commissioners and providers from the NHS; local government; independent sectors, including housing; and those with a patient or user perspective.
The biggest single challenge was how to move beyond short-term cuts and technical efficiency savings to long-term transformational change that would enable substantial productivity gains and better outcomes for people and communities – a complete rethink of how local health and care systems use their combined resources. There was no shortage of practical ideas about how to do this, ranging from streamlining processes, integrating commissioning, workforce re-profiling and tackling duplication of building assets. The untapped potential of housing-based models of care was also highlighted.
But what also emerged was a distinct tension between a top-down 'managerial' approach to change and a more 'devolved' mind-set that stressed individual choice and control as the drivers of bottom-up change. Health and wellbeing boards were seen as having a crucial role in establishing not only the strategic local framework for health and social care, but also the style and philosophy to underpin the way the system operates. Bringing resources closer together, for example through pooled budgets, would be more difficult where council and commissioning consortia are not coterminous.
You may be surprised to know that the issue of competition and 'any qualified provider' was not a big issue in the simulation. This might be because the majority of adult social care has been commissioned from private and voluntary providers for years – a timely reminder that in the wider world of local government and social care, competition per se is not seen as a block to collaboration and does not have the political toxicity that has coloured its discussion in the NHS.
As the government sets out its thinking about the future of NHS reform – and a big social care White Paper in the offing later this year – the 'Routes' exercise offers some valuable insights for the journey that lies ahead. Hopefully the slower implementation of the NHS reforms announced last week should gives us more time to reflect on how to shape local health and social care systems to benefit local people.