Imagine a magic mirror that could show you what the future would look like – how you and the people around you would behave and what would happen as a result of their interactions.
Few if any computer-based forecasting models allow this degree of insight, but behavioural simulations offer unique glimpses of what the future might hold.
Given the current raft of health reforms, this would be a huge advantage. A common complaint we hear is that there is no 'big picture' of how the numerous strands of reform come together. This makes clinicians and managers less certain how best to make decisions in the long-term interests of organisations, services and patients.
It was this challenge that led to Windmill 2007. This initiative, commissioned by The King's Fund in partnership with Monitor and Nuffield Hospitals, was based on a behavioural simulation designed by analysis specialists Loop2 and subsequent discussions with over 100 of the best thinkers and practitioners in the health system.
The simulation focused on 2008-09 and more radical changes that might be introduced in 2011-12, taking place in a hypothetical but realistic health system in England.
Over two days Windmill participants provided valuable insights into how this system would react to some of the major challenges of healthcare reform – including competition and contestability, localising of services, commissioning, reductions in funding, changes to the tariff system, patient choice and voice and the regulatory regime.
Seventy people from all walks of health care gathered in a huge room in a conference centre north of London. Each person was assigned a role closely related to their job, staffing up the various organisations in the 'Glicestershire' health economy: two primary care trusts; three acute trusts; a GP co-operative; an independent sector treatment centre; a private hospital operator; a commissioning services provider; a national chain of chemists; a patients’ panel; a local authority; an overview and scrutiny committee; a strategic health authority; the Healthcare Commission; Monitor and the Department of Health.
The data pack described the organisations' starting positions at the beginning of 2008-09. Each team was invited to work out their objectives for the year – and then set out to achieve them by negotiation with others in the room.
In the simulation, two years lasted two hours – a month every five minutes – so everyone immediately got drawn in to the intensity of the play. There were no rules other than those governing the system, participants brought their understanding of the current policy framework and their own instincts and experience to inform their decisions and actions.
It was fascinating, but what did it tell us about how health reforms need to change to deliver real benefits for patients? Here are some of the conclusions.
No going back
Do not stamp on the brakes. NHS reforms have introduced market principles and processes into what has essentially been a 50-year state-run monopoly. Arguably it’s the biggest change investment in the history of the NHS. We are approaching the 'tipping point' where a regulated market could deliver real improvements for patients. Faltering now, so that two philosophies – a regulated market and a centrally managed system – are allowed to run in parallel could prove disastrous.
If the changes are to stand a chance of working, an unambiguous commitment to a healthcare market managed in the best interests of patients needs to come from the top; from the health secretary and the NHS chief executive.
Moment of clarity
Clarify regulation and market management. The respective roles of Monitor, the Healthcare Commission, strategic health authorities and PCTs need to be focused and clarified, to ensure competition works in the interests of patients and the public
There need to be clearer rules about how the market system should work to explain what constitutes fair competition and how people should behave to discourage anti-competitive behaviour.
Make commissioning work. PCTs are analytically underpowered and nervous about being held responsible for destabilising local providers. It will take time for commissioning to deliver on current expectations. Improved confidence and competence are needed if PCTs are to become impartial commissioners for their populations.
But the health system cannot afford slow evolution. Support from independent sector advisers could help accelerate this development, providing they help develop PCTs and do not attempt to colonise commissioning.
Practice-based commissioning co-locates responsibility for resources and decision making about care. But if it focuses on areas of healthcare that can be shifted from a hospital to primary care setting, it will miss the opportunity to influence significant areas of healthcare spend.
PCTs need to have performance-management processes that are sufficiently robust to ensure practice-based commissioning focuses on the whole commissioning task, and the inherent risks of conflicts of interest of commissioning and providing practices are addressed.
Use, do not abuse the independent sector. It was encouraged into the NHS because it would help introduce contestability and could bring innovation, expertise and responsiveness to patient care.
But procurement processes are often extended and costly, and sometimes indecisive. Private providers and NHS commissioners need a more mutual understanding of each other's perspectives and constraints – without this there is a risk private providers will stop working with the NHS and make true contestability difficult to achieve.
Improve the quality of primary care. Recent GP contractual changes may improve the quality of primary care. But they are unlikely to be effective at tackling poor performance and, on their own, developing services. Greater use could be made of competition in primary care to deliver improved access and a wider range of locally based services.
This should go hand in hand with scaling up primary care. The current model of small independent practices operating on their own or in a jointly owned company or co-operative does not offer a sustainable basis for significant shifts in the way healthcare is delivered.
Significant scaling up and strengthening of primary care organisations is needed for both commissioning and service delivery. The key question is whether practices can achieve this on their own or whether other partners or alternative sources of investment are needed.
Social enterprise – proceed with caution. Despite the hype, within the NHS the social enterprise model is poorly understood by commissioners and providers – and is not yet operating on a scale that allows it to become a model for mainstream service providers.
Get serious about health improvement. The different facets of health improvement may need separation. Commissioners need more powerful incentives to encourage healthcare provision that focuses on keeping the population healthy as well as treating people when they are ill. The leadership of interventions that address the wider determinants of health could be assigned to local authorities.
Engage patients properly. The current formal arrangements for reconfiguring services are clumsy and slow. The government could consider removing the requirement on commissioners or providers to consult formally on service changes.
The various arenas for patient representation are also unsatisfactory – commissioners and providers would be better informed by robust market research methods that allow the opinions of all sections of the community to be taken into account.
The Windmill mirror showed that while there is a good deal to do to make NHS reform a success, there is the potential for real innovation and improvement to patient care.
© 2007 Emap PLC