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

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: 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 although this was mitigated by the addition of work-package four. We were unable to track outcomes of decommissioning activities within the timescales 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.