What are the parameters of world class decommissioning?
If world class commissioning consists in part of PCTs commissioning services that provide very good health and health care outcomes and doing it really well, then world class decommissioning involves stopping the provision of services that are less than optimal in health care outcomes or value for money and doing this very well.
So if the commissioning question is how to commission the best very well, the decommissioning question is how to we stop commissioning that which is less than the best. In the recent past the necessity to do this has been hidden by the growth in resources. It has been possible to start doing new things and to continue to do the old things at the same time. This leads to a bit of a mess in provision, but does not lead to any of the really difficult conflicts of stopping doing something.
But now the extra resources are running out it will be essential to start stopping commissioning things.
Why has this always proved so very hard?
It’s important to note that in any service area these sorts of changes are never easy. If you stop commissioning something both the people that provide that service, and the people who receive that service, have to change. So when the retail banks started to develop telephone, and now internet, banking and the hole in the wall replaced waiting in a long queue at lunchtime to cash a cheque, this involved banks in very painful change. They went through some painful conflict with their staff and their customers. Most staff had to change the nature of their job completely, most of them had to work in a different way, in a different place and for some that was just not possible and they left.
Staff and their organisations resist these changes and there is large scale and then small scale conflict. If the change is to go ahead then the conflict needs to be seen as a part of that change and factored into the change management process.
Whilst some customers welcome change, others find it very difficult and, alongside the staff, resist it. But again this has to be seen as a part of the management of change process that the firm or industry are engaged in. For many people the change is experienced as beneficial. Some of us (I always hated going in to banks who made me feel it was their money they were allowing me to take out rather than my own) loved the changes. But you wouldn’t find these people forming a group which demanded change and holding collections to launch a campaign for more change. We (I) felt that this change was going to come and the banks would get on with making it without any help from me.
But the customers, and the staff , that did not like change launched campaigns against the company and this has to be seen as a major part of the whole change process. For the company if you want to change then you have to recognise that this will happen. If you don’t want to face conflict as a part of the process of which you are in charge, then don’t start the change. However for most banks, once the change started to happen in the industry, they had to follow or lose a lot of custom.
And change is a complex thing for banks. Now most of them not only offer hands off banking to all of their customers, but for some they are opening some branches longer than they were before the change. The customer is driving change and improvement all the time.
What does this mean for NHS and world class decommissioning? When a PCT starts the process of decommissioning it needs to recognise that some staff and some patients and the public will be against that change. It needs to factor that disagreement into the way in which it thinks about change and to manage that alongside all other aspects of change.
It is not sufficient to say - We the PCT would like to do this but the
- Doctors won’t let us
- Public won’t let us
- Politicians won’t let us
None of these are external to the work of the PCT. They are not a “them” against the PCT as an “us”, but are internal to your world and the world of change. Since they are internal to your world, then you need tactics and strategy for winning those disagreements.
Its not that they won’t let you but it is that you allow them to stop you.
For as long as PCTs allow parts of their system to stop them from achieving what is necessary for their patients , they will not succeed in world class decommissioning.
I will discuss what this means in the nuts and bolts of change in later posts.