Windmill 2007 – Simulating health futures for the NHS

Introduction

Windmill 2007 was a major initiative to model the impact of the current health service reforms. It was undertaken in partnership with Laurie McMahon and Sarah Harvey of Loop2, and with Monitor and Nuffield Hospitals.

The initiative was named after the 'Rubber Windmill', a simulation process developed in 1990 by Laurie McMahon and the Office for Public Management for East Anglian Regional Health Authority to explore how the health service was responding to the internal market being developed at the time.

The Windmill approach has huge potential to provide insight into how the current raft of reforms – with many different, and sometimes seemingly contradictory, policy drivers in play – will impact on the system as a whole. This is important, as the current lack of shared understanding about where the system is heading compromises the ability of providers, commissioners and policy-makers to plan investments for the medium to longer term and to avoid unintended consequences.

Background

The Windmill approach is a way of looking at the future that is ‘soft’ rather than 'hard' because it relies on using the combined experience and judgement of real players in the system rather than by extrapolating quantitative data. It is particularly useful with complex social systems where there are a large number of contradictory forces at work.

The original Rubber Windmill produced some key findings that influenced the development of the 1990 reforms – especially around the development of the 'purchasing' role, the need for a clear corporate sense of direction, the importance of financial stability and the critical role that GPs would need to play. The event and its outcomes have, in effect, passed into the folklore of the NHS, and smaller versions of the simulation event have been used over the years to model the impact of new policies or initiatives. But, until Windmill 2007, a large-scale, whole-system simulation had not been undertaken since 1990.

Windmill 2007

Windmill 2007 began in December 2006 with a 'system rules' event, which brought together a number of commentators from across the health system to think about how roles and relationships between the key components of the system might evolve – and to identify the kind of high-level tensions that might emerge. The results helped to establish the framework for the behavioural simulation event, which was run in early 2007.

The Windmill 2007 simulation involved up to 100 'experts' – people actually involved in commissioning, providing and consuming health care – coming together to run a highly realistic, but imaginary, health economy that had been moved forward in time. There was no role play – people used their real interests, understandings and preferences to respond to the issues and challenges of the future. The simulation event took place over a day and a half and was divided into four main elements.

The first was for players to familiarise themselves with the Windmill 2007 health economy (a data pack was distributed the week before the event) and to establish their aims and objectives. Two 'negotiation' rounds were then run – the first for the year 2007/8 and the second jumping further out to 2009/10. The final phase was for everyone to step out of the simulation and draw on their combined experience of the 'game' in order to develop some practical learning about the dynamics of the health system and who might need to do what to ensure that the interests of public, patients and providers are best met.

The analysis of all the learning generated was then brought back for moderation to the members of the original 'system rules' event and to further workshops with key stakeholders. A final report, Windmill 2007: The future of health care reforms in England, was published in June 2007.

Listen to the debate

A breakfast discussion event focusing on the issues raised by the Windmill report, attended by health leaders and opinion formers, took place on 16 July 2007.

Listen to an overview by report co-author Laurie McMahon and hear the views of some senior figures at the event.

For further information please contact John Appleby or Alasdair Liddell.

Further reading