So what is decommissioning in healthcare? Basically we use the term ‘decommissioning’
to refer to any planned processes of replacement or removal or reduction in healthcare services.
First of all, it’s important to look at decommissioning just because it’s happening
currently on a scale that we perhaps haven't seen before in the NHS and in systems around
the world. And there are a number of drivers for this. Firstly, arguably, it’s in the
interests of patients for services that are perhaps outdated or not effective to be replaced,
to be reduced and for investment to be put elsewhere in line with changing needs of patient
populations and so on. That’s the kind of positive case, if you like, of why it’s
important.
But the other side of it is that in reality lots of decommissioning is actually driven
by the huge financial pressure that healthcare budgets are under. And this is perhaps the
negative side of decommissioning and drivers of decommissioning. And in reality, often
those two agendas - the quality and the affordability - are not particularly well aligned. So I
think there’s a need to explore in practice what drives decommissioning, the experience
that people have and the outcomes and the equitable outcomes for patients and patient
populations.
We've just finished a four year project funded by the National Institute for Health Research
into decommissioning in the NHS. And the idea was really just to try and explore the experiences
of NHS service planners and decision makers trying to undertake and to implement decommissioning
plans. So really we’re just interested in their experiences, seeing what happens, what
influenced whether plans were implemented as intended or perhaps unsuccessful.
And we also had a stream of work which was looking at the experiences and the perceptions
of those affected by decommissioning proposals and plans, so that included service users
and patients, their carers, other stakeholders such as perhaps independent service providers
and also just members of the public. So we really wanted to get that rounded perspective
on the topic of decommissioning from a research perspective but we also wanted, in line with
the funder’s requirements, to come up with something useful for those intending or planning
to lead these contentious processes of healthcare change in the future. So we tried to generate
some kind of good practice insights and principles for them as well.
In terms of good practice in decommissioning, we basically concluded that there’s no blueprint
that can be applied in all settings and also that perhaps when trying to do decommissioning,
it doesn’t make sense to think about it almost as a kind of extension of ‘business
as usual’, if you like. So it’s something of a special case in terms of the nature of
the change process and the reactions and the politics that surround it. So your usual approaches
to let’s say evidence gathering, consultation and even workforce planning are different
I think when it comes to decommissioning and some of the reactions that it generates.
I think there needs to be more of an emphasis on the relational aspects, the need for trust,
the need for sharing your plans, gaining as wide a support as you possibly can with stakeholders
and local communities really kind of having that discussion in open and honest fashion.
And I think also planning more for the long term, so I think it helps to think of decommissioning
as the end point in quite a complicated and difficult process of exploring options, building
relationships and agreeing a case for change, rather than seeing decommissioning as the
beginning of a process.
So the research that we carried out through lots of interesting perhaps further questions
or other areas that need to be explored. Key amongst those I think is how we measure the
outcomes of decommissioning processes, so often we consider a change process when it’s
implemented for that almost to be a success, but really the measure of success is the impact
on patient populations, impact on health, impact on equity. So I think those are really
important future areas for researchers and the system to explore.
Also I think more needs to be done to understand how we should go about those difficult conversations
between actors in the system who are acutely aware of the limits to what can be provided
and the need to make these tough choices and perhaps external parties, such as local communities,
such as service users affected by some of these difficult decisions; how can we conduct
those conversations in a way which isn't tokenistic but which reflects the realities that this
system faces financially.
So it’s really, really tough conversations. There’s some room to explore how we do that
much more effectively than we currently do.