On the rhetoric side we hear messages that improving quality of care is key to reducing costs and that this will be enough. We hear that commissioners will lead their health systems through the difficulties. We hear that patient choice is still a central theme in current policy and that staff are the most important asset. And we hear that collaborative ‘whole system’ working is the way forward.

Our hypothetical health system however, stuggled to deliver these points in practice. At times the need to reduce expenditure and cope with rising costs and expectations deflected attention from the focus on quality. Commissioners lacked information about the links between the money they spent and the benefits that it delivered for public health and patient experience - presenting real challenges to decisions about how best to target expenditure reductions. Providers, however, having a better grasp on their income and costs and the relationships between the two, moved to collaborate with other partners where there was potential for cost reductions. Convinced that these moves could also enhance and protect services for patients they faced real barriers to ‘whole system’ working from the Foundation Trust regulator and the way it measures organisational performance and sustainability.

Patient choice, which requires an element of spare capacity if it is to work, was seen as a luxury that the Windmill system could ill afford. Private sector providers offering innovate solutions that could save the health system money were swiftly rebuffed as system protectionism and stability became the order of the day.

Staff fared little better as managers felt that engaging staff in discussions about cost reductions was tantamount to turkeys voting for Christmas, particularly where this would involve salary freezes or redunancies. A return to the bad old days of industrial relations challenges looked inevitable.

Windmill 2009 provided a warning of what not to do so what are the positive lessons for health and social care commissioners and providers? You can download the full report from www.kingsfund.org
but here are some of our reflections from the simulation and from working with numerous health systems across the country.

In the post election world the public understand that public expenditure needs to be reduced but Ministerial commitment to real term increases for the NHS may have led many to beleive that the health service is immune from the cuts that will be levied on other sectors. It makes it all the more important that the public as well as GPs and other clinicians are actively engaged in mature and open debates about how resources can best be used. This will need different, deliberative approaches to the typical processes used for public engagement and consultation.

A further difficulty is the preoccupation in many health systems with large scale service reconfiguration where the financial and quality benefits will not be realised for several years. Big changes are important and necessary but they are high risk. Multiple modest developments that will deliver in the short term, the consistent application of tried and tested methods of improving productivity and quality and alternative ways of profiling the workforce are more reliable ways of securing cost reductions.

Capital will be in short supply but there is huge scope to use current building stock across all public services more imaginatively, more productively and more sustainably. The Government may look gleefully at using capital receipts to pay off its high levels of borrowing but must recognise that investment may be needed to support the readjustments that will deliver some of those savings.

The sustainability agenda for most of the health and social care system is a sideshow, despite some impressive strategy documents from the centre. Sustainability is seen as a ‘nice to have’ yet too difficult to contemplate while decisions about reducing costs and protecting services need to be made. Looking at other sectors such as retail and transport however, we see that cost reductions and sustainability, far from being parallel tracks can be mutually reinforcing.

Finally, it is important that the efficiency and productivity spotlight is not solely directed at hospitals. While there has been some national commentary on the scope for more productive community services it is rare to hear commissioners talk about taking 15% out of the costs of delivering primary care. With GP commisisoning collaboratives and the National Commissoning Board set to replace SHAs and PCTs it remains to be seen whether this will be a ‘no go’ area. While GP commissioners will not be commissioning primary care the smart ones will need to look at the way they organise services and practices

The idea behind this exploratory event was to allow a small group of key players from the world of AHPs to step back from their day to day concerns and spend some focussed time and energy on the future. We drew on the wide range of experience and judgement in the room to map out the environment in which AHPs will be operating in the future, to consider what direction the professions should be taking and to think about how we get the right leadership for the journey. The programme was highly participative, was certainly good fun and hopefully will be influential in the way we both find and develop AHP leaders in the future.

You can download the report here.

• Start early – formal consultation shouldn’t be the start of a dialogue with local people. Engagement is for life not just a magical three months. Lincolnshire PCT’s deliberative events with local people were a great example of ways of bringing people with you through discussion and education about the changing context in which health services are provided. Ongoing communication with ;
• Provide examples –many people form their views of health service changes on historical experiences either their own or those of their relatives. Real life pictures and descriptions showing new models of service working in practice provide confidence that some of the more modern proposals that are being put forward are workable
• Get the facts right - people vary in the amount of detail they want to see but some will want to scrutinize the background information. Surprisingly we still see consultations with no ‘numbers’ and no supporting papers. Working papers or web downloads are a good way of providing that supplementary detail.
• Ditch the jargon – an obvious plea for plain English – all industries have their jargon and public services are no exception - often don’t know we are using it – so test out the consultation drafts on some ‘real people’ that don’t live and breathe in your world of work.
• Show the impact – we often see public consultation documents with mini vignettes describing before and after scenarios of health service changes. These can help but what many people want to know is how many people are affected by the proposed changes, what tangible benefits are they likely to see and how will any downsides be managed?
• Imaginative design – the standard public meetings still have a place but typically attract very few people – a consultation that relies solely on this method is unlikely to be effective. Different processes and communication methods –for example, focus groups, text messages, blogs, email groups and tapping into existing networks and meetings - can all help in reaching beyond the usual suspects and engaging specific groups whose views are important.
• Get to the opinion leaders – crucially this includes staff affected by changes as well as community leaders and politicians. This needs detailed work – ideally on a one to one basis - to hear and answer concerns and ensure these significant people are fully informed about the case for change, what the proposals mean for them and ideas they may have for improving them. This isn’t likely to be just a handful of people – we are talking a lot of effort invested in the people that matter.
• Find the good news – we see many consultations which are presented as an inevitable response to pressure and which will reduce patient access. Why would the public or politicians support such proposals? If you are expecting people to back what essentially ‘bad news’ what ‘good news’ can you offer in return?
• Be realistic about support - There are some groups who you may never win round irrespective of how much evidence or opportunities for discussion you provide. Develop a profile of your stakeholder views, be realistic about how far you can expect them to shift and tailor communications accordingly. You may not be able to get local politicians for example to support your cause publicly but getting them to a position where they don’t oppose them may well be a positive result.

The Windmill simulation, sponsored by the Kings Fund. Nuffield Hospitals and Monitor explored how the healthcare system is likely to evolve– will it adapt quickly to market forces and exploit the benefits that a wider range of commercial providers of healthcare can bring – or will the powerful effects of public service culture result in homeostasis? The combination of Loop2’s design and the participation of over 70 leading managers and clinicians produced some intriguing insights into how the NHS as an institution will fare under the new arrangements. For policy makers and organizations alike there are some clear messages about how to handle the next few years and allow the health care reforms to deliver their intended benefits. You can download a copy of the report at: http://www.kingsfund.org.uk/publications/kings_fund_publications/windmill_2007.html

An upgraded mirror could go even further. It could show different actors how they relate to each other - their best sides and their worst – and even the thinking that lies behind the facial expressions and actions.

Simulations are like these hypothetical mirrors. They have the power to transform organizations, the way they see themselves and how other see them and of course change the way they determine their future. They allow organizations to alternate between their present image and possible strategic futures, to explore questions or proposals that clients or staff might put forward or even to understand how best to respond to competitors.

Imagine you had this hypothetical mirror for your organization – what questions would you ask? And which would you take care to avoid. Some organizations would want to alternate between their present image and possible strategic futures – others might ask clients or staff to suggest modifications to look at what might happen.