Rubber Windmill for health service changes in Wales

Tony Beddow and Mike Hedges MS


In the 1990s East Anglian Regional Health Authority commissioned the Office for Public Management to design and run a simulation event over three days in a Norfolk hotel. The results have passed into the folklore of the NHS, as has the name the initiative was given: the Rubber Windmill. It provides an opportunity to trial and test health changes prior to implementing them.

The stresses placed upon the care system is Wales as a result of both Covid and the shortage of human and financial resources are immense. Both elective and emergency hospital care is facing heavy demands. Social care provision is at breaking point. The demands placed upon the Welsh Ambulance service far exceed those it can meet if the present arrangements continue and ambulances continue to be unable to discharge patients in a timely manner.

In some parts of Wales thought is being given to making significant changes to the care system as a whole, by re-balancing it. To prepare for this it is suggested that potential changes to the care system be agreed and then be modelled within one, or two local health and care systems to see how they might work out in practice. The outcomes from such modelling will inform more detailed plans for change. Modelling should be based on the “Rubber Windmill” exercise that preceded the introduction of the internal market to the NHS in 1990. (A further but different exercise was carried out in 2007).

The 2021 Rubber Windmill in Wales

It is proposed that Welsh Government commit to at least one Rubber Windmill exercise in Wales that aims to expose two current challenges and predict what should happen within the care system as a whole if both challenges are to be met.

Challenge 1 would be to ensure that the maximum waiting time from GP referral to treatment for all routine elective surgery should be six months and just one month for all life-threatening conditions where time is of the essence. The working assumption would be that some increase in theatre and elective bed capacity might be needed AND that both would be protected against by being taken for emergency loads.

Challenge 2 would be to ensure that all patients conveyed to Accident & Emergency (A & E) Departments and Medical Admission Units (MAU) by ambulance are accepted by those units immediately so that ambulances return to base ready for the next call. An ambulance waiting outside A & E is one less on the road and thus not available for the next call. Here it is assumed that in order to create space for the newly arriving patients, those already in A & E or MAU would (in the model) be moved either into in patient acute hospital beds OR into other care settings able to manage the conditions now diagnosed. These settings might include sending patients home with community services being involved immediately or transfer to suitable non-acute settings.

Thus the model would cause those involved in running the exercise to create new services or alter old practices in order to meet both challenges. In modelling the new services, the extent of any additional funding and other changes needed to create the new services should be revealed but so too might be internal transfers of funding between the public bodies involved.


b) A Welsh University should be sought to devise the model and source the data to drive it;

c) One, or at the most two, care economies in Wales (i.e. a health board and the local government partner(s) should be chosen to run the exercise. It is recommended that the localities chosen should have some experience of, and track record for, collaborative working across the main elements of care provision.

d) Once chosen, the Boards, the Welsh Government, and the University partner should agree their approach to managing and predicting the changes in the care system needed in order to meet challenges 1 and 2.

e) This then needs continual evaluation and a final evaluation prior to rolling out to other areas

Tony Beddow is a former Health Service Manager

Mike Hedges is the Senedd member for Swansea East

The Fabian Society in Wales