Tuesday’s news that the NHS in Wales will need to cut more than £380m by April will have come as no real surprise to anyone. Commentators are beginning to run out of clichés and euphemisms for the process of making cutbacks, and the announcement of the findings of Comprehensive Spending Review on October 20th is focusing. The Spending Review is clearly the major political show in town, and has provided more column inches than any other single issue since the coalition came to power. Indeed it has provided the first significant dividing line in the Labour leadership contest – with different views on the speed of deficit reduction and the role of the state providing some clear water between the candidates.

Inevitably attention within the debate on cuts in health is drawn to hospitals and keeping people out of them – but this is just as much about community services in both health and social care. Whatever the focus, in order to achieve the level of cutbacks that are being proposed, politicians and other decision makers are going to impact heavily on local people who will be feeling the pinch most acutely – either because their service has been cut and/or because they have been directly affected as their job is threatened. With such high levels of public sector employment in Wales this double hit is clearly something those charged with implementing the cuts are trying to avoid.

A few brave souls are still talking about these deficit reduction measures in terms of an opportunity to re-shape and re-design for the better, but these voices are being drowned out by the deep and legitimate concerns of communities that their services are under threat and may be lost.

All of this is very familiar, so why post a blog on what we already know? Well, for me, what has been surprisingly missing from debates so far have been questions about how major changes would be made if the threat of financial meltdown was not hanging over our heads. In an ideal world, any such major reconfiguration of services would be justified by providing clear evidence that doing things differently will improve outcomes for service users and patients. Full stop. If that could save money, then great, but that would not be the primary driver. Achieving such change would require fundamental questions to be asked about what, when, how and even why services are provided. But equally fundamentally are a series of questions about the nature of the relationship between us and those that provide services which would need to be considered. This would lead to a different type of partnership – one based on mutual respect and a re-balancing of power – between patients, service users, their families and the professionals that care for them. This partnership is essential to developing new relationships connecting citizens with their health and social care organisations so that they use them differently in the future.

Now, that’s a rather naïve position to take, you might think, given the financial realpolitik of our current situation. But let’s just for a moment move away from all of the clamouring voices and consider how services might look five years from now.

Services will still be severely financially constrained and providing on a more limited basis than now. In all likelihood fewer people will be working in the health and social care sector. The nature of the patients and service users they see may be different given that higher thresholds for receiving treatment or care may well be operating. There may well be fewer buildings from which services are provided and more delivered in community settings. But people will still need treatment and will still need caring for. And if we do not seize the opportunity to re-design the nature of the relationship at the individual level then, to use a well-worn and hackneyed phrase, the crisis will have been well and truly wasted.

Written by Dr Mark Llewellyn, Senior Fellow