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Did you read Windmill 2009?

 it makes really fascinating reading.  The Windmill series of Exercises gets experts from a whole variety of backgrounds: different parts of NHS, local authorities, independent providers, patients, users and Trust governors, Department of Health, all to play themselves in a scenario looking at "what could happen if"

This year they started with where we are now (growth money about to run out, election coming up, damning reports of failure to increase productivity, to stimulate the market, retain existing NHS providers where possible) and ran two phases - the first to go from Oct 09 to Apr 10, and the second from Jan 2011 to Dec 11

The key message is that the system is a function of the people in it - wonderful computer simulations are all very well in theory, but in practice what will happen is about how people negotiate with other people, about past alliances and history, about trust (or lack of it) and preconceived ideas.  This is exactly what I found in my study on Payment By Results in 2006 - PBR wouldn't succeed or fail because it was brilliantly designed (or not) but on the integrity of the leadership in each area.  It comes up again and again - leadership makes or breaks services for the public good

So lets see what happened in Windmill

Many promises were made at the start.  DH said "you can do anything you like - except not that . . . nor that . . . nor that (election year you see)"

SHAs said to PCTs "we want to empower you and not performance manage", followed quickly by "you're not reforming fast enough or in the right way, so we need to performance manage you closely"

PCTs said to their providers "you can't merge - election year you know.  You can't make efficiencies or appear to privatise.  You can't you can't"

Providers felt frustrated and users felt sidelined.

By the second year of the simulation the PCT and Local Authority had decided that they could save commissioning costs by merging their commissioning team, but the team had to report to both boards - everyone else said "it's slower and more cumbersome - and anyway the strategy still isn't clear for providers"

Providers were looking for ways to dispose of excess estate (buildings) and wanted DH to buy out the - now overpriced - PFI (public finance initiative) agreements so they could do so - by working together in spite of the commissioners they'd delivered significant savings for a slight improvement in quality.

The independent sector felt they hadn't been given a fair crack of the whip.  Practice-Based Commissioning was working, but only in one area.  The local PBC group had formed a provider arm (PCO) and it was working well, but they refused to invite the other GPs in on the grounds that it only worked because of the partnerships in place - people and relationships again.  Some of the providers had even asked the heretical question "what value does the PCT add?"

Meanwhile patients and users continued to feel left out and staff were aghast that they hadn't been told the scale of the problem

So where do we go from here?

Well it seems to me that this illustrated a serious lack of strategy.  Bear in mind that people were playing themselves - SHA chief execs played the SHA chief exec, Foundation Trust finance officers played the FT finance officers. 

The providers were alright because they reacted tactically and formed loose and expedient arrangements to  make the service cheaper.

But the whole commissioning hierarchy was blindsided, arguing what their roles should be, offering to cut staff to save money (as long as it isn't me), offering freedoms then withdrawing them.

This scenario gave a taster, and there's still time to put it right.

You will need to engage with your GPs, your patients and public, your staff side, and explain just how bad it is.  If the funding is going down in real terms, say so.  If it's just a matter of doing 30% more with the same money, then say that.

Then you need to work out what real freedoms you can offer.

Can you let the providers work out solutions between themselves and tell you the answers?  Can you accept that one size doesn't fit all, that one group of referrers may be capable of forming an integrated care organisation with both primary and community care under the same roof almost independent of the PCT, whereas another may need to carry on as they do today.

there's going to be blood on the carpet.  There'll be more if we try to design the system from the centre outwards, but if we go for local solutions then care won't be uniform.