‘It ain't what you do it's the way that you do it’: lessons for health care from decommissioning of older people's services

Abstract

Public sector organisations are facing one of the most difficult financial periods in history and local decision-makers are tasked with making tough rationing decisions. Withdrawing or limiting services is an emotive and complex task and something the National Health Service has always found difficult. Over time, local authorities have gained significant experience in the closure of care homes - an equally complex and controversial issue. Drawing on local knowledge and best practice examples, this article highlights lessons and themes identified by those decommissioning care home services. We believe that such lessons are relevant to those making disinvestment decisions across public sector services, including health-care. The study employed semi-structured interviews with 12 Directors of Adult Social Services who had been highlighted nationally as having extensive experience of home closures. Interviews were conducted over a 2-week period in March 2011. Results from the study found that having local policy guidance that is perceived as fair and reasonable was advocated by those involved in home closures. Many local policies had evolved over time and had often been developed following experiences of home closures (both good and bad). Decisions to close care home services require a combination of strong leadership, clear strategic goals, a fair decision-making process, strong evidence of the need for change and good communication, alongside wider stakeholder engagement and support. The current financial challenge means that public sector organisations need to make tough choices on investment and disinvestment decisions. Any such decisions need to be influenced by what we know constitutes best practice. Sharing lessons and experiences within and between sectors could well inform and develop decision-making practices.

Sustainability in Health care by Allocating Resources Effectively (SHARE) 6: investigating methods to identify, prioritise, implement and evaluate disinvestment projects in a local healthcare setting

“…A range of theoretical approaches to facilitate implementation of disinvestment decisions has been proposed but the authors do not report application or evaluation of these strategies in the disinvestment context. These include communication and educational materials [6, 7, 63, 70, 107, 109]; financial incentives and pay-for-performance [46, 70, 109, 126, 127]; reinvestment of resources saved [8, 18, 107, 128]; clinical champions [18, 77]; clinical pharmacists to monitor and advise prescribers [129]; quality standards [70, 127]; professional standards, maintenance-of-certification activities and practice audit [70]; prompts through guidelines, protocols, clinical pathways and decision support systems [6, 7, 24, 48, 109, 126, 127]; requirements to report variations from mandatory guidelines [127]; monitoring and reporting of outcomes [107, 109, 126]; public reporting of provider performance [70, 109, 126, 127]; training and re-organisation of staffing and equipment [107]; and “ picking low hanging fruit ” before tackling more difficult projects [18]. The Schmidt framework for disinvestment notes that both process and outcome evaluations should be undertaken but provides no other details [95].…”

“A game of two halves?” Understanding the process and outcomes of English care home closures: Qualitative and quantitative perspectives

“…Despite the importance of these issues, there is little formal evidence about what happens when care homes close (Le Mesurier & Littlechild, ; Robinson, Glasby, & Allen, ; Scourfield, ). Holder and Jolley's () international review of forced relocation between nursing homes identified a possible 3,500 initial results (2000–12), but no studies about the outcomes of care home closures in the UK, and only one previous UK research team exploring closure process (Williams & Netten, ; Williams, Netten, & Ware, ).…”

Sustainability in Health care by Allocating Resources Effectively (SHARE) 2: identifying opportunities for disinvestment in a local healthcare setting

“…More recently, questions about the concepts, context, settings, systems, processes and principles for disinvestment have been addressed in systematic reviews [7, 9, 13, 20–24] and other studies [8, 10, 11, 25–29] and more examples of individual projects have been published [20]. No papers discussing the concept of an organisation-wide, systematic, integrated approach to disinvestment in a health service organisation have been identified [30].…”