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Social care funding has increased in real terms for the past decade, but there has been considerable variation in how that funding has been spent – in part because spending on social care is handled by local councils, whose circumstances vary. The wide geographical variations in cost and performance across a number of measures – for example, emergency hospital admissions, delayed transfers – reflect different relationships between health and social care. The government has pledged to facilitate closer integration so that people can receive a more joined-up service. Social care funding and the NHS: an impending crisis? examines trends in spending on social care, looking at three scenarios arising from the 27 per cent real reduction in the central government grant to local authorities that between 2011/12 and 2014/15, social care spending will be fully cut, will receive some protection, or receive no protection. 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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. 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The transfer of commissioning from primary care trusts and strategic health authorities to GP consortia increases the risks of deterioration in quality of care for some patients and a widening of the quality gap between best and worst performers. Reconfiguration that improves quality of care and reduces costs may require consolidation of services across hospital sites. Decisions about reconfiguration will need to weigh the resulting improvements in health care outcomes against the potential costs of reduced competition and choice. 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