NIHR DC Discover

NIHR Signal Wider stakeholder involvement could overcome resistance to modernising healthcare services

Published on 17 October 2017

doi: 10.3310/signal-000493

Among principles that can help when decommissioning out-dated, unsafe or poor value services are clear leadership and transparency about the reason for change with patients, clinicians and local communities.

Modernising healthcare often involves reducing, replacing and removing services. This is called decommissioning and the task varies with the local context.

This NIHR-funded study reviewed previous research and conducted interviews and surveys. Case studies showed consistent problems across different decommissioning activities, ranging from a lack of resources to implement the change and a lack of political involvement, to the need for evidence-based support.

Decommissioning is important to ensure that other, better, services can be provided within financial constraints. Both clinical effectiveness and patient experience need to be considered. This study shows that despite the differences and the impossibility of designing one decommissioning format for all activities, good communication and engagement with all stakeholders is crucial.

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Why was this study needed?

With the constant development of new interventions, health systems need to adapt to run efficient healthcare services. This is particularly important when resources, in the form of budget, infrastructure or staff, are limited.

The NHS is under great pressure to improve services and develop a system that is sustainable in the long run. Decommissioning is viewed as innovative and necessary to change services that are out-dated, are not considered clinical priorities, represent poor value for money or may present risks to patient safety.

Several challenges stand in the way of the successful decommissioning of healthcare services, and the best way to implement these changes has not yet been identified.

This study aimed to bring together current evidence, expert opinion and community perspectives when considering barriers and facilitators to decommissioning healthcare services.

What did this study do?

The study took place over 2013-16, was focused on the NHS and was performed in four parts. Part one included a literature review, interviews with seven leaders of previous decommissioning programmes and a survey of 30 health professionals.

Part two was an online survey of clinical commissioning groups (CCGs) in England, with responses from 56 (27% of all CCGs). Part three comprised four case studies of decommissioning projects through document analysis, 59 interviews and staff observations. Finally, the authors conducted focus group discussions with 30 patient, carer and local community group representatives.

Among the limitations of the study are the small number of participant CCGs and a lack of a standard way to track outcomes resulting from decommissioning activities.

What did it find?

The research found that:

  • There is a lack of international evidence on the best process for decommissioning services.
  • Healthcare professionals believe that decommissioning activities need clarity of reasoning for change and executive and clinical leadership.
  • There is a high level of decommissioning activities within the NHS, reported in 77% of the clinical commissioning groups that answered the survey. The most common activity reported was moving of services. The main intended outcome was improved cost-effectiveness, followed by improved patient experience.
  • Citizens, patient representatives, carers and local community groups felt a strong degree of loss when services were decommissioned. They often thought that it was for financial or political reasons rather than to improve patient care. They did agree that, under some circumstances, replacing and removing services is necessary and justified, but no consensus was achieved for moving services. The same survey (part four of the study) showed a general interest from patients and the public to engage decommissioning activities. This was not identified in the initial survey of NHS leaders and experts as part of good-practice principles for decommissioning (part one).
  • The case studies identified multiple barriers to decommissioning, mostly due to resource constraints, system complexity and lack of support for the changes by clinicians, patients and the local community.

What does current guidance say on this issue?

No national guidance is available for decommissioning of healthcare services. CCGs have developed decommissioning standard operating procedures or policies setting principles and procedures of these activities. These documents outline steps involved in the process including setting up a steering group, consultation with stakeholders and providing adequate notice of the proposed changes to all involved.

What are the implications?

This study draws attention to some of the difficulties faced when decommissioning services.

The authors found that when financial pressures were downplayed as the reason for decommissioning, this often led to greater general opposition to the process through increased cynicism. Wider stakeholder involvement, including patients and the local community with more transparent reasons for change, could help to avoid this situation. It might also provide more opportunity to discuss concerns, identify potential gaps in service provision following decommissioning and achieve agreement on alternative solutions.

However, the lack of information on outcomes limits the ability to make firm conclusions.

Citation and Funding

Williams I, Harlock J, Robert G, et al. Decommissioning health care: identifying best practice through primary and secondary research – a prospective mixed-methods study. Health Serv Deliv Res 2017;5(22).

This project was funded by the National Institute for Health Research Health Services and Delivery Research.

Bibliography

Examples of Clinical Commissioning Group policies and procedures for decommissioning:

Callaghan F. Policy for Service Review and De-Commissioning Decisions. Rushcliffe: NHS North and East Clinical Commissioning Group, Nottingham West Clinical Commissioning Group, Rushcliffe Clinical Commissioning Group; 2016.

NHS Northumberland, North Tyneside, Newcastle North and East, Newcastle West, Gateshead, South Tyneside, Sunderland, North Durham, Durham Dales, Easington and Sedgefield, Darlington, Hartlepool and Stockton on Tees and South Tees Clinical Commissioning Groups. Standard Operating Procedure: CCG SOP03 Decommissioning Procedure. Northumberland, North Tyneside, Newcastle North and East, Newcastle West, Gateshead, South Tyneside, Sunderland, North Durham, Durham Dales, Easington and Sedgefield, Darlington, Hartlepool and Stockton on Tees and South Tees Clinical Commissioning Groups; 2013.

NHS Walsall Clinical Commissioning Group. Disinvestment and Decommissioning Policy. Walsall: NHS Walsall Clinical Commissioning Group; 2016.

NHS Wolverhampton Clinical Commissioning Group. Decommissioning and Disinvestment Policy. Wolverhampton: Wolverhampton Clinical Commissioning Group; 2014.

Why was this study needed?

With the constant development of new interventions, health systems need to adapt to run efficient healthcare services. This is particularly important when resources, in the form of budget, infrastructure or staff, are limited.

The NHS is under great pressure to improve services and develop a system that is sustainable in the long run. Decommissioning is viewed as innovative and necessary to change services that are out-dated, are not considered clinical priorities, represent poor value for money or may present risks to patient safety.

Several challenges stand in the way of the successful decommissioning of healthcare services, and the best way to implement these changes has not yet been identified.

This study aimed to bring together current evidence, expert opinion and community perspectives when considering barriers and facilitators to decommissioning healthcare services.

What did this study do?

The study took place over 2013-16, was focused on the NHS and was performed in four parts. Part one included a literature review, interviews with seven leaders of previous decommissioning programmes and a survey of 30 health professionals.

Part two was an online survey of clinical commissioning groups (CCGs) in England, with responses from 56 (27% of all CCGs). Part three comprised four case studies of decommissioning projects through document analysis, 59 interviews and staff observations. Finally, the authors conducted focus group discussions with 30 patient, carer and local community group representatives.

Among the limitations of the study are the small number of participant CCGs and a lack of a standard way to track outcomes resulting from decommissioning activities.

What did it find?

The research found that:

  • There is a lack of international evidence on the best process for decommissioning services.
  • Healthcare professionals believe that decommissioning activities need clarity of reasoning for change and executive and clinical leadership.
  • There is a high level of decommissioning activities within the NHS, reported in 77% of the clinical commissioning groups that answered the survey. The most common activity reported was moving of services. The main intended outcome was improved cost-effectiveness, followed by improved patient experience.
  • Citizens, patient representatives, carers and local community groups felt a strong degree of loss when services were decommissioned. They often thought that it was for financial or political reasons rather than to improve patient care. They did agree that, under some circumstances, replacing and removing services is necessary and justified, but no consensus was achieved for moving services. The same survey (part four of the study) showed a general interest from patients and the public to engage decommissioning activities. This was not identified in the initial survey of NHS leaders and experts as part of good-practice principles for decommissioning (part one).
  • The case studies identified multiple barriers to decommissioning, mostly due to resource constraints, system complexity and lack of support for the changes by clinicians, patients and the local community.

What does current guidance say on this issue?

No national guidance is available for decommissioning of healthcare services. CCGs have developed decommissioning standard operating procedures or policies setting principles and procedures of these activities. These documents outline steps involved in the process including setting up a steering group, consultation with stakeholders and providing adequate notice of the proposed changes to all involved.

What are the implications?

This study draws attention to some of the difficulties faced when decommissioning services.

The authors found that when financial pressures were downplayed as the reason for decommissioning, this often led to greater general opposition to the process through increased cynicism. Wider stakeholder involvement, including patients and the local community with more transparent reasons for change, could help to avoid this situation. It might also provide more opportunity to discuss concerns, identify potential gaps in service provision following decommissioning and achieve agreement on alternative solutions.

However, the lack of information on outcomes limits the ability to make firm conclusions.

Citation and Funding

Williams I, Harlock J, Robert G, et al. Decommissioning health care: identifying best practice through primary and secondary research – a prospective mixed-methods study. Health Serv Deliv Res 2017;5(22).

This project was funded by the National Institute for Health Research Health Services and Delivery Research.

Bibliography

Examples of Clinical Commissioning Group policies and procedures for decommissioning:

Callaghan F. Policy for Service Review and De-Commissioning Decisions. Rushcliffe: NHS North and East Clinical Commissioning Group, Nottingham West Clinical Commissioning Group, Rushcliffe Clinical Commissioning Group; 2016.

NHS Northumberland, North Tyneside, Newcastle North and East, Newcastle West, Gateshead, South Tyneside, Sunderland, North Durham, Durham Dales, Easington and Sedgefield, Darlington, Hartlepool and Stockton on Tees and South Tees Clinical Commissioning Groups. Standard Operating Procedure: CCG SOP03 Decommissioning Procedure. Northumberland, North Tyneside, Newcastle North and East, Newcastle West, Gateshead, South Tyneside, Sunderland, North Durham, Durham Dales, Easington and Sedgefield, Darlington, Hartlepool and Stockton on Tees and South Tees Clinical Commissioning Groups; 2013.

NHS Walsall Clinical Commissioning Group. Disinvestment and Decommissioning Policy. Walsall: NHS Walsall Clinical Commissioning Group; 2016.

NHS Wolverhampton Clinical Commissioning Group. Decommissioning and Disinvestment Policy. Wolverhampton: Wolverhampton Clinical Commissioning Group; 2014.

Decommissioning health care: identifying best practice through primary and secondary research a prospective mixed-methods study

Published on 18 July 2017

Williams I, Harlock J, Robert G, Mannion R, Brearley S & Hall K.

Health Services and Delivery Research Volume 5 Issue 22 , 2017

Background Decommissioning – defined as the planned process of removing, reducing or replacing health-care services – is an important component of current reforms in the NHS. However, the evidence base on which to guide policy and practice in this area is weak. Aim This study aims to formulate theoretically grounded, evidence-informed guidance to support best practice in effective decommissioning of NHS services. Design The overall approach is a sequential, multimethod research design. The study involves (1) a literature synthesis summarising what is known about decommissioning, an international expert Delphi study, 12 interviews with national/regional bodies and seven narrative vignettes from NHS leaders; (2) a survey of Clinical Commissioning Groups (CCGs) in England (n = 56/211, 27%); (3) longitudinal, prospective case studies of four purposively sampled decommissioning projects comprising 59 semistructured interviews, 18 non-participant observations and documentary analysis; and (4) research with citizens, patient/service user representatives, carers, third-sector organisations and local community groups, including three focus groups (30 participants) and a second Delphi study (26 participants). The study took place over the period 2013–16. Setting The English NHS. Results There is a lack of robust evidence to guide decommissioning, but among experts there is a high level of consensus for the following good-practice principles: establish a strong leadership team, engage clinical leaders from an early stage and establish a clear rationale for change. The most common type of CCG decommissioning activity was ‘relocation or replacement of a service from an acute to a community setting’ (28% of all activities) and the majority of responding CCGs (77%) were planning to decommission services. Case studies demonstrate the need to (1) draw on evidence, reviews and policies to frame the problem; (2) build alliances in order to legitimise decommissioning as a solution; (3) seek wider acceptance, including among patients and community groups, of decommissioning; and (4) devise implementation plans that recognise the additional challenges of removal and replacement. Citizens, patient/service user representatives, carers, third-sector organisations and local community groups were more likely to believe that decommissioning is driven by financial and political concerns than by considerations of service quality and efficiency, and to distrust and/or resent decision-makers. Overall, the study suggests that failure rates in decommissioning are likely to be higher than in other forms of service change, suggesting the need for tailored design and implementation approaches. Limitations There were few opportunities for patient and public engagement in early phases of the research; however, this was mitigated by the addition of work package 4. We were unable to track outcomes of decommissioning activities within the time scales of the project and the survey response rate was lower than anticipated. Conclusions Decommissioning is shaped by change management and implementation, evidence and information, and relationships and politics. We propose an expanded understanding, encompassing organisational and political factors, of how avoidance of loss affects the delivery of decommissioning programmes. Future work should explore the relationships between contexts, mechanisms and outcomes in decommissioning, develop the understanding of how loss affects decisions and explore the long-term impact of decommissioning and its impact on patient care and outcomes. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Expert commentary

Managing a change well which involves the perceived loss of a service by the public is hard. Failure rates in attempts to remove, reduce or replace a health service (‘decommissioning’) are high. Healthcare commissioners and leaders of sustainability and transformation partnerships have a tough job on their hands as they are called upon to adapt, improve and change the NHS in their local area. This timely, well-written and engaging study offers evidence-based guidance to overcome the barriers, including building alliances with the public, developing a compelling narrative and ensuring a wider acceptance for change.

Naomi Chambers, Professor of Healthcare Management, University of Manchester