Contents

Summary

In the section you will be introduced to two different future worlds in the year 2020. In each of these the same four forces drive forward change but in each case the outcome is very different. The drivers are:

• the development of new technologies and ever larger amounts of information;
• new power structures in politics, in business, and in community life;
• the growing importance of our relationship with the living environment;
• social and cultural change.

In the first of these worlds, "Find my way", our major institutions have been unable to cope with the pace and complexity of change. In the second world, "Trust their guidance", the major institutions have survived in a rapidly changing world by radically revamping themselves.

Before examining these two worlds we will briefly introduce scenario planning and write a few words about the issues for the NHS which the scenarios raised for us. On the fourth and final page of this insert we will say a few things about the main drivers of change which shaped the two worlds of "Find my way" and "Trust their guidance".

What are scenarios?

Scenarios are outlines of possible futures. They explore themes outside of our control but that are relevant to our organisations. Although we believe that the scenarios could happen we are not claiming that they will. Nor are they preferences - we are not suggesting that we should be aiming for one or other of our scenarios.

Why use scenarios?

Many successful companies have for years used scenarios to help their strategic thinking. Military strategists have used 'what-if' scenarios for even longer. In general, the more the world changes in unpredictable and complex ways, the more people benefit from scenario thinking.

Recent surprises and failed predictions

Recent failed predictions include:

Recent unpredicted outcomes include:

How did we create the scenarios?

1. building a data base of the most recent trend data.
2. searching for the key issues
3. finding the drivers of change
4. some creativity

These stories are called the Madingley Scenarios after the village in Cambridgeshire where they were first developed.

What can the scenarios be used for?

• Stretching thinking Even change, as Charles Handy has suggested, is not what it used to be. If the unexpected keeps catching us out, we must widen our expectations. By exploring the world through different scenarios we become aware of possibilities and uncertainties.

• Improving current practice The scenarios provide a 'wind tunnel' for testing current practices and plans. If practices and plans only work under a very particular set of future conditions, then perhaps they need to be broadened today.

• A basis for workshops in your own organisations These scenarios have been designed so that they can be used by all NHS organisations as a basis for working together for effective change.

The Challenge for the NHS

Each of these scenarios provoke us to think about different aspects of the current working of the NHS. A few of these are listed here:

"Find my way"

1. In this world the NHS must establish quick but effective partnerships with other statutory bodies, companies, and community groups.
2. NHS partners and patients will be armed with the latest health information but much of this will be unverified and some of it will be questionable.
3. League tables of NHS organisations will be readily available and poor performers will find it difficult to maintain the trust of users.
4. Health policy-making will be linked to an environmentalist agenda of sustainability.
5. New technologies will require a flexible response to long-term capital investment. However, in a rapidly changing world, any decisions which limit future options should be regarded with suspicion.
6. It will not be possible to allocate health resources on the basis only of scientific evidence; other values will also be important.

"Trust their guidance"

1. In this world the NHS must establish itself as the trusted source of health information.
2. In this world the NHS will only succeed if it can make long-term partnerships with other agencies succeed and this will require mutual understanding and trust.
3. The health agenda will be pursued by many agencies apart from the NHS and likewise the NHS will be expected to pursue other objectives such as environmentalism, reducing inequalities and so forth.
4. Professionals will be trusted but only in so far as their organisations have clearly understood and effectively policed protocols.
5. Many of the current institutions of the NHS will survive but only if they are able to develop a culture of change and adaptability.

Fixed points and uncertainties explored in the scenarios

Relatively fixed points

• Emphasis on sustainability

• New technology

• More information

• Chronic disease

• New concern with ethical issues

Key uncertainties

• What will count as knowledge?

• Will new technology strengthen or weaken existing institutions?

• What will the role of national government be?

• What will be the basis of family and community life?

This is a scenario of empowered individuals in a global village

In this scenario individuals have immediate access to ever increasing amounts of globally available information. The problem they have is in knowing which information to trust. Consequently, people feel empowered by their access to information but at the same time anxious about the status of information and the purpose of their lives.

As new technologies (especially in information and communications and in the new genetics) create ever new possibilities, people want to be able to assess the practical and ethical consequences of using them. However, they no longer have long-term and trusted relationships with the sorts of organisations which would once have led such debates (professionals, churches, national governments). Therefore people have had to debate amongst themselves in changing networks and groups the ethical and practical issues. Typically, groups emphasise the ethics of individual choice and arrive at conclusions which privilege choice and diversity over uniform regulations. Science is treated as just one view of the world among many.

Both organisations and individuals enter into many (often short-lived) partnerships and networks. Institutions in the public private and voluntary sectors frequently change and they are not widely trusted. Action (such as political protest) takes place largely outside stable institutions. It is often sporadic and locally-based even if influenced by a global agenda of political, economic and environmental concerns. Partnership means that the success of each organisation depends upon the success of all others in the partnership but there is no single way in which partnerships are held together and there is a relentless search for effective, fair and accountable ways of organising.

Although the decline of the traditional family prompts concerns about supporting children to be responsible adults, there is a variety of family forms and public policy is focused on supporting children irrespective of the choices of the parents. The most common experience for poorer children is to grow up in a family comprised of their mother and a peripheral, shifting group of childcare workers, friends and serial quasi-fathers. For wealthier people, the family is a more stable unit involving both partners working with additional childcare support bought in (usually provided by poorer women but sometimes by retired people).

The growing number of older people reinforced some of these fears about social breakdown. However, older people themselves took the lead in redefining old age from being 'a problem' to being 'a resource'. Flexible retirement ages after sixty and opportunities for part-time working for older people combine with the virtual disappearance of early retirement to redress the imbalance of workers and non-workers in the population. The generation which had imposed its needs on each successive decade from the mud of Woodstock to Mick Jagger's 'Rock of Ages' concert at Hyde Park in the summer of 2020, was not about to be socially marginalised without a fight.

One of the major institutions to be weakened by this Europe-wide experience is national government. In each country, some power is pulled 'upwards' into global networks and federations. Institutions such as the UN and the EU struggle hard to control this agenda but the quickest groups to react and mobilise support are single issue groups and fleet-of-foot transnational corporations. At the same time, because networks and partnerships are more important, regional and local government has a greater role to play and this pulls power 'downwards'.

Economically, in this world, Britain experienced growth rates above the European average in the period 2000-20 but well below the fastest growing economies. Its emphasis upon flexibility and the importance of symbolic values provided it with an advantage over other European economies. It achieves growth rates of 2.7%.

All in all, this is a world in which we no longer have professionals, experts and institutions telling us what to do. For those with the personal and economic resources to exploit the opportunities available it is exciting and rewarding. The opportunity to explore new relationships and new ways of working is exhilarating. The fresh air of personal choice seems to blow through the stale corridors of power. But for others it is a world which provides few supports in times of need. For these people, the purpose of life is unclear, they struggle hard to sustain meaningful relationships with those they love, the world of work offers very little security, and they are increasingly cut off from the rest of society by a lack of knowledge and money as the gaps between the rich and poor grow ever wider.

How the Scenarios Contrast

This is a scenario of national citizens in secure institutions

In this scenario, the huge supply of information available to individuals and groups has led to a demand for intermediaries who are trusted to sift information and establish its reliability. Some of these are professionals and experts offering guidance on particular categories of information (such as healthcare) meanwhile others provide information about market opportunities which is customised to the particular preferences (and bank balance) of individuals. Similarly, people no longer search the media endlessly but go to one of a small number of multi-media conglomerates which they trust to reflect their preferred values and style.

Professionals are respected as a source of expertise in this world but only where the organisations in which they work have clear protocols and effective ways of guaranteeing quality. Related to this is the growing popular trust in science which, following a series of dazzling scientific breakthroughs, established itself as the dominant view of the world. Major research laboratories have not only developed both the computer and the biomolecular revolutions further but they were also able to cross-pollinate research across these fields.

Another institutions to emerge strengthened (although radically revamped) is the national government. National government was strengthened by regional and devolved government - by doing less Westminster was able to do it better. At almost the same time, the economic crisis of 2002 ended moves towards a federal Europe. However, this was associated with the revival of nationalism which occasionally gave voice to the underlying racism which was still present. Not all ethnic minorities were excluded from the institutions of power, however, and in 2015 both the heads of the British Medical Association and of the Royal College of Surgeons were Muslims. Indeed, those in power increasingly suggested there was much in the community structures of Sikhs and Muslims which should be copied - especially by the poor.

The debate around sustainability was led largely by national government, although care was taken to involve other key institutions (the Churches, long-standing environmentalist groups and so on). The practical and ethical questions surrounding the new genetics provided an important focus. The state was also particularly involved in responding to the panic over 'eco-terrorism' as organised crime secured access to weapons grade plutonium and then to the means of genetic weaponry.

National government also accepted that it was inevitably going to have a role in under-pinning child-care. Inevitably, many saw this as the state sponsorship of irresponsibility (although others were more concerned that it involved a new authoritarianism). At the other end of the age-range, the government was also involved in ensuring minimum standards for older people. However, frail older people who were frail were generally concealed within institutions and fitter people took a more active role in child-care and in part-time work. The institutions available for the poor elderly were oppressive and paternalistic.

Economically, it is a world in which Europe is relatively well-placed with its strong institutions. The EU remains an institution of nation states rather than a federal government but the economy of Europe does especially well in long-term, laboratory-based industries such as bio-technology and in developing long-term relationships of trust with its customers. In Britain there is a growth rate of 2.3% - slightly below the European average.

In conclusion, this is a world in which the major institutions of society were able to manage a process of change and by radically re-vamping their own organisations. In consequence, those not represented within the major institutions feel alienated, despite the efforts of focus groups and citizens juries. The power of institutions to provide support is also the power to patronise. Inequalities do not generally increase significantly, but the poor find that their lives are more thoroughly policed than previously and that institutional support is conditional upon behaving in an approved way. It is not only the poor who are constrained, however. It is a world in which the new establishment, starved of vibrant debate and argument, is in danger of stagnating in its own smugness.

Which signposts might indicate the direction we are going in?

Our scenarios identify four main drivers of change shaping the wider environment of the NHS.

DRIVER 1

The development of new technologies and ever larger amounts of information

In the health field, the coming together of miniaturisation, automation, robotics, minimally-invasive surgery, imaging, and telecommunications will all contribute to changes in the setting and experience of healthcare. Most probably the human genome project will have completed the sequencing of the 100,000 human genes soon after the beginning of the new millennium. This will lead to a new taxonomy of disease based on molecular mechanisms. What we once thought of as a single disease, such as diabetes, will in time be regarded as separate diseases. The segmentation of disease by genotype will require new technologies for the rapid detection of genetic variations among individuals. Alongside this, biotechnology will lead to new diagnostic tests and many genetically engineered therapeutic agents.

All of these new technologies have significant implications for:

• the funding of research, development and new practices;

• the public debate about the ethics of using new technologies;

• the balance in public health policy between the "holy grail" of the hi-tech fix and the more mundane focus on social conditions, inequalities, life-style and so on.

The wider impact of new technologies will come from developments in information and communication technologies. Some go so far as to see the change towards an 'information society' as changing the whole way in which healthcare is delivered:

DRIVER 2

New power structures in politics, in business and in community life

The way in which we get things done - in the economy, society or politics - are all changing. Looking to the recent past we see:

• mass production of goods and services for relatively undifferentiated mass markets;

• producer-led output in public, voluntary and private sectors;

• large scale, hierarchical work-places with large numbers of employees doing identical tasks which change only slowly;

• inequalities organised around relatively fixed structures of class, race and gender;

• most organisations operate in an environment which changes only slowly.

By the 1990s all of this is changing and we can look towards a future in which we see:

• batch production of goods and services for differentiated, niche markets;

• customer-led output in public, voluntary and private sectors;

• small scale work units with multi-skilled workers doing a variety of tasks which change significantly in relatively quick succession;

• class, race and gender still provide some structure to inequalities but they are obscured by new factors (for example the information poor) and reshaped by others (for example, the relative academic success of middle class females) to produce a more textured and complex pattern to inequalities;

• most organisations need to constantly re-equip themselves to cope with a rapidly changing environment.

These changes are being driven by at least three trends:

1. Going global.
2. Return of the local
3. The erosion of tradition

In combination, these will push society towards more partnerships and networks amongst organisations, less formal layering and hierarchy within organisations, and increasingly assertive and promiscuous consumers outside organisations.

DRIVER 3

The growing importance of our relationship to the living environment

In 2020 we will be delivering healthcare in a context where we are all ever more aware of the need for environmental sustainability and of the many connections which link our health to the health of the planet. Some of the trends which have led to this concern with sustainability are outlined in Box 2. During the next twenty years there will be a dense cluster of problems concerning the relationships between technological break-throughs and environmental sustainability. Most observers are anxious but some, at least, find grounds for optimism:

The impact of this on organisations such as the NHS is that not only will they have to apply new budgeting and auditing systems to assess the environmental impact of their activities but also they will be expected to take steps to come into line with wider policies aimed at achieving sustainability.

DRIVER 4

Social/cultural change

The ties which bind us are replaced with new, possibly more fragile, relationships

The main institutions shaping our transition from childhood to adulthood are the family, the school, and the workplace. Together, these provide the back-bone of community life. As we come to terms with the changes in these institutions we will need to find new ways of relating to each other.

Additionally, the next generation will support a growing number of older people. They may even look to establish a different contract between the generations. Women and ethnic minorities who may have felt especially constrained by traditional institutions can be expected to play an active part in re-shaping existing ties where these are experienced as oppressive.

Changes in knowledge will lead to new debates about ethics and values. As knowledge increases we will be required to take decisions about biological and social life which were previously the outcome of chance. This is what Giddens means by 'manufactured uncertainty'. It is not clear that the resulting debates can be contained within the present Party system and organisation of representative government.

But although science will make remarkable discoveries, many will look elsewhere for their values. For example, Buddhism is the fastest growing religion in Britain, complementary medicine enjoys a small but growing portion of healthcare, and New Age religions are gaining ground. Equally , the most rapidly growing parts of more traditional religions are often associated with either fundamentalist or charismatic challenges to the old order.

Join the debate

For further information on scenario planning and how you could use scenarios in your organisation write to: Tom Ling c/o The NHS Confederation.

To purchase copies of full scenarios contact the NHS Confederation 0171 233 7388

Download a longer version of this document. (Word & Powerpoint documents)

A full version is available to purchase from the NHS Confederation on 0171 233 7388.