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My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

Read my statement in full »

World Class Decommissioning

Filed Under (Health Improvement, Primary Care Trusts, Public service reform, World Class Commissioning, World Class Decommissioning) by Paul on 15-10-2009

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All staff in Primary Care Trusts should recognise the structure of this post on my blog.

Between now and December 18th all PCTs are preparing their Commissioning Strategy Plans. In the New Year they will be visited by a Panel chaired by their SHA, and will for a day, be inspected against a set of criteria. This will lead to a judgment about where they are in terms of their competency as world class commissioners. There are 11 competencies that they will be judged against.

On my blog I have been running an argument that over the next few years the most important set of skills and competencies that PCTs will have to develop are those of world class decommissioning and only secondarily its reverse Unless a PCT becomes very very good at stopping doing old things it will not have the resources to start doing new things.

Of course the NHS has always been in the process of stopping doing old things, but it has often not done this very well. In the next few years we will have to get much better at that process. It takes skills in a similar way that commissioning takes skills.  

What this post does is link the skills that it takes to the first four of the world class commissioning competencies. It demonstrates that you can judge your skill against the outcomes of decommissioning in the same way as you can its reverse,

It may well be that, by the time the panel comes to a PCT near you, they will be more interested in decommissioning than its reverse.   


World Class Decommissioning- Skills and activities relating to WCC Competencies

Competency Number 1 Are recognised as the local leader of the NHS

The extent to which the PCT has the capacity to provide leadership to decommission services can be shown by the extent to which they explain the problems of their local health system through other’s power to stop them from successfully decommissioning     

Leadership of the local NHS demand that PCTs have the capacity to develop the very best health care by involving all aspects of the local community in those improvements. This must involve existing and new providers; the medical professions; the local public and local politicians. If any of these groups do not recognise the PCT as the local leader of the NHS then they will resist such improvements and stop the PCT from successfully making them.  

The PCT is constantly searching for better value and better outcomes in improving the health and health care of its population. To achieve this and to ensure that  local people have the benefit of health improvement and health services that keep up to date with the most modern methods and medical technology, the PCT is always driving providers and alternative providers to create new and extra value. This frequently involves a lot of changes in service and occasionally full reconfigurations.


The PCT will have a strong rationale for these changes and improvements which it needs to make clear to the public and local stakeholders. Indeed it will have developed that case for change with those local stakeholders. But the PCTs will know that its case for change will not be uncontested by other stakeholders. Some providers will disagree and there will probably be a public disagreement.

A PCT with the capacity to lead will recognise that this contested explanation is probably going to happen for most major changes in commissioning which involve any decommissioning. It will therefore prepare its case and deploy that case for change with skill and confidence because it will have prepared that case with clinicians and stakeholders. . It will not run away from such an argument because it will recognise that it is carrying out its role of securing improved health and health care for its local population. A good PCT will recognise that leadership has the power and capability to lead such changes.

Leadership of the local health economy is never easy since the case for change and improvement needs to be constantly put against those who want to resist those changes. Proving local leadership of the NHS means the PCT will have to demonstrate the case for change and improvement effectively.

Contrast this with other PCTs who do not have the capacity to lead.

In some parts of the country PCTs fail to develop the very best health and health care that they can because they recognise that such improvements will need existing health care to be decommissioned and they are aware that such decommissioning will cause a public argument with the provider that is being decommissioned. They therefore fail to commission the very best service because they are anxious about that public argument.

Under these circumstances the PCT explains its failure to commission the very best health care by saying  they believe ‘the public will not let them; or the medical profession will not let them or local politicians will not let them. ’

In many parts of England reconfigurations have never been completed because the PCTs have felt that they ‘will not be allowed’ to develop health and health care in the way in which they know is best. They believe they do not have the capacity to provide that leadership

Competency Number 2 Work collaboratively with community partners to commission services that optimise health gains and reduce health inequalities and deliver increased productivity

It is clear that successful PCTs commission improvements in health and health care working closely with local partners. Just as those partnerships are crucial to PCTs to commission health improvement and health care so are they crucial for successful decommissioning.

Aligning the agendas of partner organisations is never a simple task and this difficulty can often be used by PCTs as an excuse for why they fail to optimise health improvement and health care gains. They see other organisations that have either radically or slightly different agendas with different core business.

If these differences are important at times of plenty, they become seminal at times of financial problems and can be used by the PCT to explain a failure to decommission because ‘the local authority that has a different agenda would not let them’. The fear that other organisations will not ‘let them’ make difficult changes can drive the PCT into making them in isolation. Such isolation creates a self fulfilling prophesy, with the local authority feeling excluded because in fact it is being excluded from these difficult decisions.

Local partners will all be looking very closely at their own budgets and developing approaches to value for money which ask hard and searching questions of all the public money they use to commission services. It is entirely possible – and was indeed the normal activity in the past – for each of these partners, including the PCT, to make their own decision without thinking of their partners. When this happens then it is almost inevitable that some of the changes in one organisation cause costs for another. Those financial decisions taken in isolation will impact upon the effectiveness of the commissioning of all the other organisations.

It is therefore vital that difficult decisions taken about decommissioning are taken in partnership with all other partner organisations so that they can understand the way in which each decision that is taken has implications on others. 

World class decommissioning organisations will have a long lead in times to making major decommissioning decisions and will use that lead in time to openly discuss options with partners in their locality. Indeed it is likely that in the next few years major public sector budget setting will take place much more jointly between such partners so that the public service pound is much better invested.

Competency Number 3 Proactively build continuous and meaningful engagement with the public and patients to shape services and improve health 

In the past the only right of engagement that the NHS has provided the public with is the right to say “no” and to stop change. As a consequence this is the main activity, saying no to change, that the public has historically engaged in with the NHS. Such a relationship – where one part of the relationship does something and the others regularly says no to it, is not a happy one.

Consequently this has usually left the NHS frightened of the public, hoping that they really don’t have to involve them at all. Such a fear means that the public are generally involved very late on when the only real action they can take is to say no. In this way the cycle is recreated. Leaving the NHS afraid and ages with the public saying no.

World class decommissioning organisations can only succeed in their task by transforming this relationship. This must start by recognising that the public are not necessarily conservative when it comes to changes in the health service and all the time placing them in that category means that this again is the only place they are allowed to reside.

Your locality will have a range of patient organisations around long term and other conditions which you should seek out and with whom you should discuss changes in commissioning. Such organisations can reflect the very best of advanced practice and are unlikely to simply want to defend the past. Indeed they often have very detailed knowledge about how to commission services which will successfully move people out of hospitals. They may even want to play a role in the provision of newly commissioned services.

Ensure that such organisations are at the core of your public engagement about change and that the medical staff involved in these changes discusses them with those public organisations. As we said in competency 1 it is crucial to possess and deploy an argument for change and to take the public seriously enough to have that argument with them.

The very best world class decommissioning demands that the public become active partners in the creation of new value in the NHS. Unless the public agree with the way in which new forms of value are being created, they will resist these changes and the value will not be created.

Competency 4 lead engagement with all clinicians

Clinicians are at the forefront of scientific change and improvements in medical technology. One of the main initial reasons for change in the services that you are commissioning will have been a set of clinician led improvements. It is very simply within the mechanics of decommissioning to lose what is essentially a set of clinician led reasons for the change, Given that you will have discussed the detail of your decommissioning programme with a range of clinicians before you started to develop it into practice and it is important ensure that they are involved in making and delivering the argument for change. Ensuring that clinicians remain a part of this process throughout is an essential aspect of the change.

It is important to remember that there is a higher number of scientifically trained staff in the NHS than in any other organisation in the UK. Nurses and doctors have training that contains at its base the importance of scientific argument as a precursor to action. A scientific training does not necessarily mean that you will agree with the logic of an argument for change, but it does provide you with a very good basis for marking out such an argument.

Professionals with a scientific training will, as with any other member of staff in an organisation, will also have become used to working in a certain way. The cultural certainty of the argument this is the way we do things in x, works for doctors and nurses in the same way as for other staff. For people who are tied to doing their work the way they always have change is difficult. Therefore doctors and nurses, as with all staff, have an experience of habit which may make them resist change.

However, they also have the experience of science as a part of their world view and those commissioners arguing for change will want to be able to use a scientific argument for change against the conservative argument for habit. Clinicians will be on both sides of this argument for change. But they will be an active part of the argument for decommissioning only if you utilise them in that argument.

It is in this area that clinical engagement becomes a part of world class decommissioning. Whilst the process is different, the experience of the NHS with clinical engagement about change is similar. Often NHS managers are anxious about how clinicians will .take to an argument for change. This means that managers wanting to create a change will be anxious about involving clinicians and will do so a little later than they should. As with the public this is much more likely to lead to opposition.

So it is important to engage clinicians in the arguments about decommissioning from the very beginning of the process. Having clinicians involved at the beginning and ensuring that they play a role in shaping the argument for change will not stop an argument taking place, others will argue in favour of the service that you are decommissioning, but it will ensure that the argument FOR change contains a strong clinical input.     



One Response to “World Class Decommissioning”

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    You could, of course just decommission PCTs. The champagne is on ice for this happy day.

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