Decommissioning lessons: accept the anger – and the impact

If you are sitting comfortably, then we’ll begin with the lesson on “decommissioning for GPs”.  When resources are finite –shrinking in real terms given NHS inflation – commissioning to achieve quality, innovation, productivity and prevention (QIPP) can only happen in parallel with decommissioning services which don’t deliver the outcomes you require.  GPs in Clinical Commissioning Groups are hearing that lesson, indeed Pulse published a CPD module on it recently.

More than talking to patients

Decommissioning is about a lot more than just understanding the needs of patients – and that’s a lot harder than it sounds anyway. GPs pride themselves on talking to patients, and so they should.  But having an intelligent commissioning approach to meeting a community’s health needs is much more than this.  Conversely, the reality of stopping an existing service and restructuring things is about a lot more than telling the existing provider their contract won’t be renewed.  It is likely to mean facing the anger of those with a stake in the status quo – which can be almost everyone.

Accept the anger

Mo Girach of the Kings Fund, author of the Pulse decommissioning module, pulls no punches about this: “Accept the anger of users, providers and the wider community and indeed some individual GPs…. listen and accept, don’t be defensive.” 

True, but very hard to do  even with the best seasoned management skills and certainly not what most commissioning GPs grouped in emerging CCGs think they have signed up to. The potential for conflict when trying to make local changes – much less national ones – may prove to be one of the biggest stumbling blocks to CCGs being effective.  It parallels the rising chorus of GP concerns about “conflict of interest” in making decisions about priorities for communities and groups of patients as well as individuals.  But isn’t that what intelligent commissioning is all about,  with the emphasis on the “intelligent” bit?  Things are going to be different in different places.  The tensions are becoming palpable, in the GP tabloid press at any rate.

Change, yes; confusion and conflict, no

It doesn’t  have to be like this.  As the HSJ’s leader says this week: “change is inevitable, but more confusion and conflict is not”.  Think “bottom up” and “evolutionary” changes.   Is this just wishful thinking?  We hope for the best, of course, but fear something worse if recent experiences in reconfigurations around the country and in specialist services are any guide.

To their credit, GP leaders say they understand the need for evidence-led, consensus changes and stress the need for real engagement and strong relationships.  At the recent annual conference of the National Association of General Practice (now a love-in coalition with the NHS Alliance)  Dr Johnny Marshall, the NAPC Chairman’s opening address stressed:

 “It will be the quality of partnership working between practices that will create the most successful CCGs as they seek to better align fiscal and clinical responsibility at practice level and lead a fundamental shift to greater clinical and public engagement in the planning, building and delivery of new and innovative local services.” 

We concur entirely with his sentiments, but wonder how things will play out in the very imperfect world of health service politics and the fight for scarce(r) resources.

Perils of decommissioning

It could be an ominous sign of things to come that powerful providers  are successfully resisting commissioning changes and reconfigurations based on consultation outcomes. A national paediatric cardiac service is the most recent example.

Reconfiguration – which usually can’t be done without decommissioning and reinvestment –  certainly is not going to get any easier.  Or any cheaper.  In the case of the Royal Brompton and Harefield NHS Foundation Trust versus the Joint Committee of Primary Care Trusts, one part of the NHS (a high profile provider under threat of decommissioning) took another part of the NHS (specialised commissioners) to the lawcourts.

That’s something that doesn’t happen.  But it did and they won.  Anger there was too, aplenty.  As Roy Lilley so colourfully expressed it

“You mess with a service like that at your peril.  When the middle classes unleash their wrath may your god help you!  They wage war with word-processors, do battle with spread sheets and call in alumni reinforcements you wouldn’t dream of.”

We are likely to see more of this. Will GP commissioners be up to it or will the Big Beast and the NCB have to step up to the plate for them?   We look forward to seeing the modules on decommissioning a national specialist paediatric service that includes the following essential content:

  • What to do when another part of the NHS takes you to court
  • Dealing robustly with people whose baby’s life has been saved by said service and will protect it til their dying day
  • What hair style to select for that all-important appearance on Newsnight

Evidence of impact

The Pulse decommissioning module offers 1 CPD credit for reading and answering questions and doubles that reward to 2 CPD credits for offering “evidence of  impact”.  Given the contentiousness of decommissioning, one cannot help but wryly wonder if “impact” includes getting pelted with rotten tomatoes – metaphorical or otherwise – by those on the receiving end of the decommissioning decision?  A direct hit on the lead decommissioner should surely count for more CPD points?

Only time will tell if the new commissioners are up to the job, but time is decidedly not on their side. They may face opponents less high profile that the friends of the Royal Brompton and Harefield, but what this experience shows is that even NHS family members can turn decidedly unfriendly when threatened with reconfiguration.  So lesson two for decommissioning by GPs should be: make sure you have your flak jacket and tin hats on when you go into the trenches.

The Moore Adamson Craig Partnership supports user and public participation,  trains lay representatives and develops responsive  health, care and education organisations.


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