If public services are going to meet the volatile, uncertain, complex and ambiguous demands of the 21^st Century they need to be redefined and redesigned with resilience at their heart. 

Seeking change by only invoking the big levers of institutions – policy, economic, legal, and so forth – will only get us so far, opening up just as many challenges as they might address. Indeed, the raft of commissions and reviews over the last thirty years have collectively only shifted the pieces of the jigsaw around; they haven’t fundamentally changed the game. Equally, relying on communities to pick up the slack of a retreating state, or placing too much responsibility on individuals already burdened by day to day life are not viable solutions either. 

Instead, trust needs to be built through an understanding of who is best placed to work with opportunities posed by these trends and to mitigate their risks. As institutions, communities and individuals respond to these trends it is essential that a balance is struck both in terms of how narrow attention is (for example, are we ignoring staffing issues to concentrate on embedding new technology, or vice versa) and how collaborative the approach to change is. 

A compelling case for change that shifts the paradigm and harnesses opportunity from disruption requires five things. 

First, we need to collectively address the fatalism caused by a frozen system and political inertia. This will require coordination and motivation from national government and support to local actors. A new culture of effectiveness and innovation will help to build the right conditions for this. 

Second, we need to identify innovations, harness opportunities and align actions for change across the domains of the individual, the community and our institutions with a focus on place-based action. It has to be locally-focused. 

Third, we should scale questions and spread learning. Traditional approaches to scaling begin with ready-made or demonstrable solutions and focus on supporting the implementaion of those with the greatest market or impact potential. In an environment of limited resources and political decision-making, what works in one setting is unlikely to be successfully transposed into a new one. Seeking replication at scale is unlikely to succeed; identifying the values and principles and equipping and encouraging people to go on their own learning journey in their own locality is more likely to be successful. 

Fourthly, we need new ways of conceptualising and prioritising what is important for people. Health and social care settings are characterised by complexity, where people often display very individual needs, and where we still don’t know how different elements interact to impact our health. This context will vary from place to place, requiring locally-prioritised services and activities within a national framework.

Finally, we must address the specific and unique challenges of a system at capacity and existing in a climate of austerity. There is a large body of evidence exploring the negative outcomes that result from a health and social care system with diminishing funding and increasing demand, compounded by the wider system conditions – such as housing and unemployment – on population heath. Whilst efficiency might be an imperative of some innovations, resource available will be a key criteria for the success of innovations.

In summary, seeking efficiency gains within a failing system is to try and do the wrong things better. We need new systems.