Windmill 2009: NHS response to the financial storm (The King's Fund, 3 December 2009)

Summary

From this Windmill 2009 simulation event, and discussions with policy-makers, regulators, commissioners and providers, managers and clinicians, an analysis was developed of what will be required if health and social care systems are to respond effectively to the major challenges that lie ahead. It identifies key themes and recommendations for action in each of these.

Content

The simulation questions

In the design stage of Windmill 2009, a wide range of individuals were consulted, from frontline managers and clinicians to policy-makers and economists, to establish the focus for the simulation. A number of questions emerged.

• Will the years of plenty be a sufficient cushion to enable the NHS to make the necessary adjustments without a detrimental effect on patients?
• How will the various groups and organisations involved in the planning and delivery of health care react to the financial challenge? Will they make decisions that help their own organisations or act in a way that promotes the sustainability of the whole health and social care system?
• What will happen at the interface between health care and social care? Will the resource pressures on both sides hamper integrated care?
• Can the system deliver both better quality and improved productivity? What new incentives are needed to support productivity improvements? Will patient care – in particular, access and waiting times – suffer?
• What do the changes mean for public and patient engagement?
• How will the system respond to increasing incidence of mental and physical ill health associated with the effects of unemployment and financial uncertainty?

These questions informed the design of the simulation

The Windmill 2009 process comprised three main stages

• a design workshop in July 2009, which brought together a number of leading thinkers and commentators from across the system, to help identify the main drivers and refine the issues to be explored in the simulation event
• the storm scenario simulation event, held over two days in late July 2009. This brought together around 60 people – policy-makers, regulators, commissioners, and providers (NHS and independent sector) as well as managers, clinicians and representatives of patients and the public. In addition to their contributions during the event, we also received helpful comments and reflections from participants, giving their interpretation of what happened during the simulation
• a moderating workshop held in September 2009 to review, test and refine the emerging findings and messages.

Key themes and lessons for policy-makers, commissioners and providers

The moderating workshop held after the simulation event augmented what happened in the simulation itself. It also made it possible to develop a more pragmatic analysis of what will be required if health and social care systems are to respond effectively to the major challenges that lie ahead. Eleven key themes emerged, summarised in the box below. For each theme, we describe the issues involved, and set out what needs to be done. The main recommendations from the Windmill process are presented in the final section.

• National leaders need to be honest about the scale of the financial challenges ahead.
• The Department of Health and strategic health authorities (SHAs) must resist reverting to ‘command and control’.
• Primary care trusts (PCTs) need to take a leadership role for the whole of their local health care system in developing a response to the financial challenges ahead.
• Commissioners need to improve their understanding of the costs and benefits of local services if they are to reduce spending and drive improvements in productivity.
• Commissioners and providers need to recognise that reducing variations in cost and quality will be necessary but not sufficient to deliver the level of savings required.
• Commissioners and providers need to grasp opportunities to work with the independent sector and third sector where these can make a contribution to innovation and improvement.
• Commissioning at every level needs to be clarified and strengthened.
• Commissioners should look for opportunities to work more closely with local authorities and ensure that the interface between health care and social care does not become a battleground.
• Commissioners should realise the productivity and quality gains in care outside hospital by reviewing and rationalising the estate and harnessing technology.
• Commissioners and providers must actively engage the public and patients in the process of change.
• Providers need to find better ways to engage staff, and to consider all options to improve workforce productivity.