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How can these challenges be seen as an opportunity to achieve fundamental change to the system? The Routes project, a simulation exercise created by Loop2, allowed senior managers and thought leaders from across the NHS, local government and the third sector to test out a remodelling of the health and social care system in a safe learning environment. Routes for social and health care: A simulation exercise focuses on Crafton – a hypothetical metropolitan borough in central England – and sets up a number of routes to managing change. During the simulation two contrasting viewpoints emerged. One group took a strongly managerial perspective that recognised the need for immediate decisions to reduce expenditure, while putting in place the conditions for a radical transformation in the way that people receive care and support in the longer term. The other group took a more ‘devolutionist’ approach, arguing that the financial challenges across health, social care and housing could not be managed through a top-down approach; they proposed a radical acceleration of personalisation and community engagement. 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In the context of the intense financial and demographic challenges facing both health and social care, this paper offers a fresh assessment of the prospects for integrating health and social care and the opportunities and challenges arising from the government’s proposals.  In the autumn of 2010, The King’s Fund held two seminars, bringing together senior policy experts and NHS and social care leaders to discuss the barriers and aids to integration at national and local levels and the financial challenges facing all services.  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