Doing more with less in health care: a multi-method study of decommissioning in the English NHS
Irrespective of moral and political arguments, current fiscal restraints in the English National Health Service (NHS) make decommissioning apparently unavoidable. Decommissioning – that is the removal, relocation or replacement of treatments and services – is being pursued by health care planners in response to the need to balance budgets, but has also been advocated by exponents of evidence based medicine on quality grounds (Hurley, 2014; Malhotra et al, 2015). However decommissioning is viewed by many as incongruous to the principles of a universal health care system free at the point of delivery and has long been avoided by elected decision-makers. As a result, much responsibility for ‘setting limits’ on services and for decommissioning health care is effectively devolved to local budget-holders.
In the restructured NHS, this responsibility lies with Clinical Commissioning Groups (CCGs) (and to a lesser extent its partners in local government). In the first national study of decommissioning in the English NHS we examined the experiences of those that have attempted to lead decommissioning processes via a national survey of CCGs in England, interviews with national bodies and policy makers, and interviews with local implementers of decommissioning programmes.
Our research found high levels of decommissioning activity amongst the CCGs in our sample. 77% of the respondents had decommissioning activities planned, almost two thirds (67%) were in the process of implementing some decommissioning, and over half (55%) had already completed some decommissioning. However our research also revealed that implementation of decommissioning decisions poses considerable challenges for CCGs.
Lack of specific guidance and coordination across national policy, limited capacity (dedicated personnel and staff time) for decommissioning, and organisational ‘memory loss’ as a result of the recent restructure, were cited as factors which hampered CCG progress with decommissioning programmes. Meanwhile pressures for efficiencies appeared – paradoxically – to impede the dedication of financial resources to expensive implementation processes.
The experiences of participants in our study furthermore showed that even well-resourced programmes of change often faltered in the face of resistance from clinical, organisational, community and political interests. Our findings point to the importance of genuine engagement with patient groups and the wider public if ambitious decommissioning plans are to be implemented, alongside a balanced evidence base reflecting patient and system priorities, and backing from clinical leaders.
These issues are of particular concern at the current time as the NHS and its partners prepare to implement regional ‘transformation’ programmes which are likely to involve some degree of decommissioning with unclear processes of public consultation and prohibitive timescales.
Given these challenges, and in the absence of further national precedent, our research suggests that whilst financial austerity may be a clear imperative to decommissioning, much will need to change before decommissioning can be discharged by local, unelected bodies such as CCGs.