In order to succeed with complex changes such as decommissioning activities, Robert et al. previously identified a number of factors [4]. The current study highlighted that the clinic managers considered eight of these factors crucial in their efforts to implement a decommissioning programme. Based on these findings, recommendations for successful implementation would suggest, at first, that it is necessary to create a shared image of the rationale for change by using evidence to frame the problem in a credible way. Furthermore, the processes of deciding on decommissioning activities must be based on evidence, with the clear goal of not compromising quality, patient safety and ethical responsibility. Another important factor is to involve clinic managers from an early stage to take responsibility for the process and results in order to legitimise the process. Furthermore, it is crucial to secure an executive leadership team represented by clinical champions to ensure that the organisation’s overall goals and objectives are achieved. In addition, all managers of the organisation have to be prepared to handle a process characterised by tensions, resistance and strong emotions. Along the way, there is a need to communicate demonstrable benefits as well as transparently evaluate the outcome to achieve a fair process.
The executive leadership team managed to communicate the seriousness of the economic situation and the rationale for change became clear to the clinic managers. The review report, with comparisons to other Swedish regions, clarified that many other regions were shown to have more cost-effective organisations. Similar arguments pointed out the importance of presenting and framing the rationale for change in a credible way, has been put forward previously by researchers [8, 26]. The clinic managers in the study felt it had been a fair and inclusive process, with extensive participation, transparent, knowledge-driven and professionally controlled. They expressed, regardless of professional background, that their professional skills, knowledge and commitment had been encouraged by the executive leadership team. These statements are similar to researchers that argue that particularly clinic managers with a physician background prefer that problem identification and decision-making has a scientific approach to facilitate the leadership [27]. However, in previous research, policymakers’ and clinic managers’ ability to include and evaluate the huge amount of evidence on costs and efficiency that needs to be considered in decommissioning processes has been questioned [28]. The strategy in Region Dalarna was to base the problem formulation and decision-making on a scientifically based review, and it seems like this strategy and opportunity appealed to the profession. Researchers emphasise that decommissioning is to be guided by evidence, e.g., obtaining data of existing clinical practice and by using systematic reviews to achieve the best quality of care in the decision-making processes. This requires professionals with competence, engagement, and adequate resources to ensure that evidence drives the process of decommissioning [29].
The clinic managers described the executive leadership team with clinical champions as strong, clear and resolute, and with capability to prioritise the organisation’s overall objectives. The division managers were appreciated for their capacity to lead with integrity and courage, challenge the status quo and having confidence in the professions’ competence to make wise decommissioning decisions. They also had the skills to effectively communicate demonstrable benefits and clarify the relationship between decisions taken and the quality of care. These findings are in line with results in studies that emphasise that the executive leadership team, and in particular the clinical champions, are key influencers during decommissioning processes [12].
Early in the process, the clinic managers and their employees contributed with suggestions on how to decommission services at their clinics. This strategy of early involvement and delegation of large parts of the responsibility for the decommissioning process to the clinic managers and healthcare professions resulted in a feeling of responsibility among the staff.. At the same time, the clinic managers’ and the profession’s formal responsibility forced them to make decisions to minimise risks related to patient safety and quality. This strategy to give the healthcare professions opportunity to be involved and to initiate changes have been reported as successful in previous studies from Sweden [30].
That budgetary pressures are the main driver for decommissioning instead of, e.g., quality and patient safety, have been identified by international experts [4]. However, in our study, the discrepancy between these ideals and budgetary pressures seems to have been adequately balanced by the professions and supported with high-quality data to reduce potential risks to patient safety and quality of care. Researchers also claim that other challenges are associated with decommissioning e.g., that lack of experience on how to carry out decommissioning activities often leads to confusion over roles and responsibilities [2]. According to our results, the executive leadership team, strengthened with legal and analytical expertise, clarified roles and limits of responsibility to facilitate the decision-making processes. This is consistent with results from studies that recommend local healthcare organisations to address the local context, strengthen commitment and clarify expected results and roles in order to succeed with changes as decommissioning activities [6, 13].
Turning to human aspects of change, the clinic managers described the experience of a very demanding, emotionally tiring but personally developing process. The capacity to deal with tensions and very strong emotions during the processes was expressed as an important ability among clinic managers. The clinic manager role as being the one with ability to bridge and soften the negative consequences at staff level during changes have been emphasised in studies [19]. The newly formed divisions created a team feeling that contributed to collegial support among the clinic managers. This collegial support facilitated and to some extent relieved the responsibilities, empowered and strengthened the managers to deal with the outrage that inevitably arose among the staff to some decommissioning decisions. The clinic managers meant that commitment widened, from one’s own, narrow task to include discussions about the entire division’s challenges in the decommissioning process.
In the present study, we identified about three quarters of the 30 subcategories in the decommissioning framework, and we have discussed the most frequently discussed subcategories by the clinic managers. These subcategories were largely the ones that were highly ranked in importance by the international experts in the Delphi study that led to the framework by Robert et al. This indicates that that this framework also has bearing on empirical cases. Although the framework enabled an analysis of important factors based on international experience and can facilitate comparisons of importance in decommissioning processes at different levels in organisations, the categories are to some extent related and difficult to distinguish. A more explanatory description of the categories would have facilitated the analysis to be carried out with greater precision. In future studies, it may be of interest to study if and how the most important factors in implementing decommissioning decisions vary between different levels in healthcare organisations, for example between politicians and clinicians. It may also be of interest to further explore the relationship and interconnections between the three categories and the subcategories. Another good addition would be to investigate the clinic managers’ opinions about all factors through a survey based on the framework by Robert et al.
Furthermore, there are similarities between factors enabling successful decommissioning processes and factors described in frameworks of e.g., de-implementation, implementation and knowledge mobilisation [3, 31, 32]. The latter processes usually starts for the reason that evidence suggests that other interventions could be more beneficial for patients. Although decommissioning may include evidence assessments, it is a broader approach that also addresses resource allocation in the form of re-evaluation and adaption for a multitude of reasons e.g., addressing inequalities, responding to changing demographics, or re-evaluation of resources in order to handle pandemics.
Lastly, this study about decommissioning is timely because healthcare costs are rising in Sweden as well as in other countries, and there is no choice but to address the challenge of how to create more efficient healthcare systems. For example, a mapping of the English NHS showed that as many as 77% of the clinical commissioning groups had decommissioning activities planned [2]. Among the activities reported in the same mapping, the most common type of decommissioning activity was relocation or replacement of a service from an acute to a community setting (28%), removal or replacement of a service as part of reconfiguration of a service (25%) and closure of a service (14%). However, to improve decommissioning policy and practice, it has been identified as crucial to develop a better understanding of how decommissioning programmes unfold in different types of health systems. In this study, the unfolding was studied through the experiences of clinic managers, who are the primary implementers of decommissioning decisions. Our results suggest that when the clinic managers, along with the profession, have the responsibility to identify possible savings and efficiency improvements in the organisation it is likely that quality and patient safety, clinical effectiveness and cost-effectiveness guide the decisions, even if the initial driver was cost/budgetary pressures. Healthcare professionals and in particular, the clinic managers are accountable for patient safety and ethical considerations which becomes inescapable when they have responsibility for both decision and results of the processes. However, to be successful in implementing decommissioning decisions, they need leadership support, convincing evidence and being able to handle strong emotions.
Limitations
Lastly, a number of restrictions in our study should be mentioned. At first, since health systems differ both between and within different countries, some aspects of the framework may be more or less applicable to particular cases. Subcategories such as, e.g., the reputation of existing providers, availability of alternative services and quality of partnership working with relevant agencies were not mentioned at all in the interviews. This can potentially be explained by the way Swedish healthcare is organised in the regions, but may also be a result of the questions asked during the interviews, which were rather broad in character. However, at the end of each interview, we asked the respondents if there was anything we had missed talking about and if there was something they wanted to add. As all respondents considered that the interview covered what they perceived as most important, we did not revise the interview guide which is an option in interview studies.
Another potential limitation is that the interviews were conducted almost 3 years after the start of the decommissioning process in 2015. There is thus a risk of recall bias even if the decommissioning process was still ongoing at the time of the interviews (i.e., in 2018). However, since some time had passed it is also possible that the clinic managers had had time to reflect on the initial phase of the decommissioning programme and thus be clearer about what was success factors. Third, the clinic managers may also have had an interest in portraying themselves in a favorable way, even though there were no examples in the interviews.