Anticipating NHS reforms: Back to the Future?

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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.


Sunita Berry

Network Director, AGWS Cardiac & Stroke Network,
Comment date
04 July 2011
Isn't there an elephant in all health and social care rooms? Whisper it loudly, when people say that 70% of hospital beds are occupied by older people - the know that most of the 'healthcare' going on is really social care in all but name. Yes there are bells and whistles diagnostics, all very sexy with bleeping machines - and some may even receive an exciting 'operation'. But mainly there are people - in beds, largely kept in beds and factory farmed 'care'. The challenge for healthcare is to acknowledge that far from cutting edge, most medicine would be only too recognisable by the physicians of 100 years ago. Yes our healthcare budget is nearly £100bn - but the majority of it goes in providing social care. We sent the carers out to work - and sacrificed care at the alter of retail sometime ago.

vinesh kumar

Programme Manager, H&Social Care Integration,
London Borough of Redbridge
Comment date
30 June 2011
The Routes simulation document is very concise and practical.

In Wittgenstein's 'On Certainity', he asks us if when squirrels store nuts for winter it is because they think they have solved Hume's 'problem of induction'? No , they just do it. Why? Because we just act in certain ways....

And I think this 'acting in certain ways' is something that both Health and Social Care has got used to because of the distinct ways they function as separate entities and the 'Rules' over the years that had made them to excel in the 'art of interpretation' and act in certain ways...and in the process not necessarily producing great outcomes.....
The challenge will be to make them understand the 'Zeitgeist' (which social care has realised to an extent, although not fully) that prevails, especially the 'power of citizens (and there are great examples of this power in the online world) and adapt themselves together (rather sooner!) to produce sustainable change.

I also hope the Govt takes your recommendations on Outcomes/Operating framework from the Routes document.

tim gilling

deputy executive director,
centre for public scrutiny
Comment date
24 June 2011
I like the approach taken to health and well-being boards - that the relationships between members should be around shared outcomes rather around accountability. This will create a clearer role for scrutiny - we have just published the results of two years work with councils focusing on tackling health inequalities. This may the kind of approach that scrutiny needs to take in the new era.

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