HEALTH SERVICES AND DELIVERY RESEARCH

HEALTH SERVICES AND DELIVERY RESEARCH VOLUME 5 ISSUE 22 JULY 2017 ISSN 2050-4349 Decommissioning heath care: identifying best practice through primary and secondary research a prospective mixed-methods study Iestyn Wiiams, Jenny Harock, Genn Robert, Russe Mannion, Say Brearey and Key Ha DOI 10.3310/hsdr05220

Decommissioning heath care: identifying best practice through primary and secondary research a prospective mixed-methods study Iestyn Wiiams, 1 * Jenny Harock, 1 Genn Robert, 2 Russe Mannion, 1 Say Brearey 2 and Key Ha 3 1 Heath Services Management Centre, University of Birmingham, Birmingham, UK 2 Forence Nightingae Facuty of Nursing & Midwifery, King s Coege London, London, UK 3 Department of Socia Poicy and Socia Work, University of Birmingham, Birmingham, UK *Corresponding author Decared competing interests of authors: Iestyn Wiiams is a member of the Heath Services and Deivery Research (HSDR) Prioritisation Commissioning Pane. Genn Robert is a member of the HSDR Prioritisation Researcher-ed Pane. Discaimer: This report contains transcripts of interviews conducted in the course of the research and contains anguage that may offend some readers. Pubished Juy 2017 DOI: 10.3310/hsdr05220 This report shoud be referenced as foows: Wiiams I, Harock J, Robert G, Mannion R, Brearey S, Ha K. Decommissioning heath care: identifying best practice through primary and secondary research a prospective mixed-methods study. Heath Serv Deiv Res 2017;5(22).

Heath Services and Deivery Research ISSN 2050-4349 (Print) ISSN 2050-4357 (Onine) This journa is a member of and subscribes to the principes of the Committee on Pubication Ethics (COPE) (www.pubicationethics.org/). Editoria contact: journas.ibrary@nihr.ac.uk The fu HS&DR archive is freey avaiabe to view onine at www.journasibrary.nihr.ac.uk/hsdr. Print-on-demand copies can be purchased from the report pages of the NIHR Journas Library website: www.journasibrary.nihr.ac.uk Criteria for incusion in the Heath Services and Deivery Research journa Reports are pubished in Heath Services and Deivery Research (HS&DR) if (1) they have resuted from work for the HS&DR programme or programmes which preceded the HS&DR programme, and (2) they are of a sufficienty high scientific quaity as assessed by the reviewers and editors. HS&DR programme The Heath Services and Deivery Research (HS&DR) programme, part of the Nationa Institute for Heath Research (NIHR), was estabished to fund a broad range of research. It combines the strengths and contributions of two previous NIHR research programmes: the Heath Services Research (HSR) programme and the Service Deivery and Organisation (SDO) programme, which were merged in January 2012. The HS&DR programme aims to produce rigorous and reevant evidence on the quaity, access and organisation of heath services incuding costs and outcomes, as we as research on impementation. The programme wi enhance the strategic focus on research that matters to the NHS and is keen to support ambitious evauative research to improve heath services. For more information about the HS&DR programme pease visit the website: http://www.nets.nihr.ac.uk/programmes/hsdr This report The research reported in this issue of the journa was funded by the HS&DR programme or one of its preceding programmes as project number 12/5001/25. The contractua start date was in May 2013. The fina report began editoria review in September 2016 and was accepted for pubication in March 2017. The authors have been whoy responsibe for a data coection, anaysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors report and woud ike to thank the reviewers for their constructive comments on the fina report document. However, they do not accept iabiity for damages or osses arising from materia pubished in this report. This report presents independent research funded by the Nationa Institute for Heath Research (NIHR). The views and opinions expressed by authors in this pubication are those of the authors and do not necessariy refect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Heath. If there are verbatim quotations incuded in this pubication the views and opinions expressed by the interviewees are those of the interviewees and do not necessariy refect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Heath. Queen s Printer and Controer of HMSO 2017. This work was produced by Wiiams et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. Pubished by the NIHR Journas Library (www.journasibrary.nihr.ac.uk), produced by Prepress Projects Ltd, Perth, Scotand (www.prepress-projects.co.uk).

Heath Services and Deivery Research Editor-in-Chief Professor Jo Rycroft-Maone Professor of Heath Services and Impementation Research, Bangor University, UK NIHR Journas Library Editor-in-Chief Professor Tom Waey Director, NIHR Evauation, Trias and Studies and Director of the EME Programme, UK NIHR Journas Library Editors Professor Ken Stein Chair of HTA and EME Editoria Board and Professor of Pubic Heath, University of Exeter Medica Schoo, UK Professor Andree Le May Chair of NIHR Journas Library Editoria Group (HS&DR, PGfAR, PHR journas) Dr Martin Ashton-Key Consutant in Pubic Heath Medicine/Consutant Advisor, NETSCC, UK Professor Matthias Beck Chair in Pubic Sector Management and Subject Leader (Management Group), Queen s University Management Schoo, Queen s University Befast, UK Dr Tessa Criy Director, Crysta Bue Consuting Ltd, UK Dr Eugenia Cronin Senior Scientific Advisor, Wessex Institute, UK Ms Tara Lamont Scientific Advisor, NETSCC, UK Dr Catriona McDaid Senior Research Feow, York Trias Unit, Department of Heath Sciences, University of York, UK Professor Wiiam McGuire Professor of Chid Heath, Hu York Medica Schoo, University of York, UK Professor Geoffrey Meads Professor of Heath Sciences Research, Heath and Webeing Research Group, University of Winchester, UK Professor John Norrie Chair in Medica Statistics, University of Edinburgh, UK Professor John Powe Consutant Cinica Adviser, Nationa Institute for Heath and Care Exceence (NICE), UK Professor James Raftery Professor of Heath Technoogy Assessment, Wessex Institute, Facuty of Medicine, University of Southampton, UK Dr Rob Riemsma Reviews Manager, Keijnen Systematic Reviews Ltd, UK Professor Heen Roberts Professor of Chid Heath Research, UCL Institute of Chid Heath, UK Professor Jonathan Ross Professor of Sexua Heath and HIV, University Hospita Birmingham, UK Professor Heen Snooks Professor of Heath Services Research, Institute of Life Science, Coege of Medicine, Swansea University, UK Professor Jim Thornton Professor of Obstetrics and Gynaecoogy, Facuty of Medicine and Heath Sciences, University of Nottingham, UK Professor Martin Underwood Director, Warwick Cinica Trias Unit, Warwick Medica Schoo, University of Warwick, UK Pease visit the website for a ist of members of the NIHR Journas Library Board: www.journasibrary.nihr.ac.uk/about/editors Editoria contact: journas.ibrary@nihr.ac.uk NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr05220 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 22 Abstract Decommissioning heath care: identifying best practice through primary and secondary research a prospective mixed-methods study Iestyn Wiiams, 1 * Jenny Harock, 1 Genn Robert, 2 Russe Mannion, 1 Say Brearey 2 and Key Ha 3 1 Heath Services Management Centre, University of Birmingham, Birmingham, UK 2 Forence Nightingae Facuty of Nursing & Midwifery, King s Coege London, London, UK 3 Department of Socia Poicy and Socia Work, University of Birmingham, Birmingham, UK *Corresponding author i.p.wiiams@bham.ac.uk Background: Decommissioning defined as the panned process of removing, reducing or repacing heath-care services is an important component of current reforms in the NHS. However, the evidence base on which to guide poicy and practice in this area is weak. Aim: This study aims to formuate theoreticay grounded, evidence-informed guidance to support best practice in effective decommissioning of NHS services. Design: The overa approach is a sequentia, mutimethod research design. The study invoves (1) a iterature synthesis summarising what is known about decommissioning, an internationa expert Dephi study, 12 interviews with nationa/regiona bodies and seven narrative vignettes from NHS eaders; (2) a survey of Cinica Commissioning Groups (CCGs) in Engand (n = 56/211, 27%); (3) ongitudina, prospective case studies of four purposivey samped decommissioning projects comprising 59 semistructured interviews, 18 non-participant observations and documentary anaysis; and (4) research with citizens, patient/service user representatives, carers, third-sector organisations and oca community groups, incuding three focus groups (30 participants) and a second Dephi study (26 participants). The study took pace over the period 2013 16. Setting: The Engish NHS. Resuts: There is a ack of robust evidence to guide decommissioning, but among experts there is a high eve of consensus for the foowing good-practice principes: estabish a strong eadership team, engage cinica eaders from an eary stage and estabish a cear rationae for change. The most common type of CCG decommissioning activity was reocation or repacement of a service from an acute to a community setting (28% of a activities) and the majority of responding CCGs (77%) were panning to decommission services. Case studies demonstrate the need to (1) draw on evidence, reviews and poicies to frame the probem; (2) buid aiances in order to egitimise decommissioning as a soution; (3) seek wider acceptance, incuding among patients and community groups, of decommissioning; and (4) devise impementation pans that recognise the additiona chaenges of remova and repacement. Citizens, patient/service user representatives, carers, third-sector organisations and oca community groups were more ikey to beieve that decommissioning is driven by financia and poitica concerns than by considerations of service quaity and efficiency, and to distrust and/or resent decision-makers. Overa, the study suggests that faiure rates in decommissioning are ikey to be higher than in other forms of service change, suggesting the need for taiored design and impementation approaches. Queen s Printer and Controer of HMSO 2017. This work was produced by Wiiams et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. v

ABSTRACT Limitations: There were few opportunities for patient and pubic engagement in eary phases of the research; however, this was mitigated by the addition of work package 4. We were unabe to track outcomes of decommissioning activities within the time scaes of the project and the survey response rate was ower than anticipated. Concusions: Decommissioning is shaped by change management and impementation, evidence and information, and reationships and poitics. We propose an expanded understanding, encompassing organisationa and poitica factors, of how avoidance of oss affects the deivery of decommissioning programmes. Future work shoud expore the reationships between contexts, mechanisms and outcomes in decommissioning, deveop the understanding of how oss affects decisions and expore the ong-term impact of decommissioning and its impact on patient care and outcomes. Funding: The Nationa Institute for Heath Research Heath Services and Deivery Research programme. vi NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr05220 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 22 Contents List of tabes List of figures List of boxes Gossary List of abbreviations Pain Engish summary Scientific summary xi xiii xv xvii xix xxi xxiii Chapter 1 Context 1 Chapter 2 Research aims and objectives 5 Chapter 3 Methodoogy 7 Conceptua framework for anaysis 7 Study design 7 Work package 1: synthesis of evidence and expert opinion 7 Summary of the extant iterature 8 Mapping the decommissioning andscape 9 Coecting quaitative decommissioning vignettes 9 Dephi study of research, poicy and practice opinion 10 Work package 2: nationa survey of Cinica Commissioning Groups 13 Work package 3: decommissioning case studies 14 Case seection 14 Data coection 16 Data anaysis 17 Summary of patient and pubic invovement activities in work packages 1 3 18 Work package 4: citizen, patient/service user representative, carer, third-sector organisation and oca community group perspectives 19 Focus group discussions 19 Dephi study of citizen, patient/service user representatives, carer and community groups, and third-sector organisations 20 Integrating across the empirica strands of the study 21 Research ethics approva 22 Chapter 4 Findings from the review of reviews, mapping and narrative vignettes and Dephi study of experts 23 Evidence summary 23 How are terms such as decommissioning and disinvestment empoyed in the iterature? 23 What are the current and previous eves and types of heath-care decommissioning as reported in previous studies? 23 Queen s Printer and Controer of HMSO 2017. This work was produced by Wiiams et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. vii

CONTENTS What are considered to be the main determinants of successfu decommissioning programmes? 25 What modes and frameworks are avaiabe to guide decommissioning and how have these been evauated? 25 What are the remaining knowedge gaps in terms of evidence and practice? 26 Additiona iterature items 27 Summary of additiona iterature 29 Mapping the externa andscape of decommissioning 29 Summary of findings from the mapping interviews 30 Narrative vignettes 32 Dephi study of researchers, poicy-makers and practitioners 34 Round 1 resuts 34 Round 2 resuts 38 Round 3 resuts 38 Changes between rounds 2 and 3 40 Summary of findings across work package 1 41 Chapter 5 Findings from a nationa survey of Cinica Commissioning Groups 43 Extent and nature of decommissioning 43 Aims and intended outcomes of decommissioning 45 Methods and stakehoder invovement 46 Determinants of decommissioning processes 47 Attitudes and competencies 49 Summary of findings from work package 2 50 Chapter 6 Findings from ongitudina case studies of four decommissioning processes 51 Introduction 51 Case study 1: decommissioning as part of the nationa reorganisation of paediatric burn care services in Engand 51 Reorganisation of burn care services in Engand: a brief history 51 Case study activity 53 Defining the probem and mobiisation 53 Buiding aiances and networks 55 Acceptance of the probem and the soution 56 Institutionaisation and impementation 58 Refections 59 Case study 2: oca decommissioning of an end-of-ife home support service 60 Introduction 60 Background: the end-of-ife home support service 61 Case study activity 61 Defining the probem and mobiisation 62 Buiding aiances and networks 65 Acceptance of the probem and soution 66 Institutionaisation and impementation 67 Refections 70 Case study 3: decommissioning in the work of an Area Prescribing Committee 70 The Area Prescribing Committee 70 Case study activity 71 Defining the probem and mobiisation 71 Buiding aiances and networks 74 Gaining acceptance of the probem and the soution 75 Institutionaisation and impementation 77 Refections 78 viii NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr05220 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 22 Case study 4: oca service reorganisation 79 Introduction 79 Background: the proposed reorganisation of oca primary and acute care 79 Case study activity 79 Defining the probem and mobiisation 80 Buiding aiances and networks 82 Gaining acceptance of the probem and the soution 83 Impementation and institutionaisation 86 Refections 87 Summary of findings across the case studies 88 Chapter 7 Findings from the focus groups and Dephi study invoving citizens, patient/service user representatives, carers and representatives from third-sector organisations and community groups 91 Introduction 91 Focus groups 91 Participant views and experiences of decommissioning 91 Designing the Dephi survey 96 Dephi study of patient and service user representatives, carers, the third sector and the pubic 100 Round 1 resuts: the views and experiences of participants in reation to heath and socia care decommissioning 100 Round 2 resuts: deveoping a consensus and comparing with the views of poicy-makers, practitioners, heath-care eaders and researchers 103 Round 3 resuts 106 Comments on statements with a ow eve of or no consensus from round 2 106 Anaysis of overa responses on good and bad reasons for decommissioning and reasons in practice 108 Anaysis of overa responses on approaches to engagement 109 Refections on the methodoogy 110 Summary and refections 110 Chapter 8 Concusions and research impications 113 Introduction 113 Revisiting the research questions 113 What is the internationa evidence and expert opinion regarding best practice in decommissioning heath-care services? 113 How and to what extent are organisations currenty decommissioning services? 115 What factors and processes faciitate the successfu impementation of decisions to decommission services? 115 What are the perspectives and experiences of citizens, patient/service user representatives, carers, third-sector organisations and oca community groups in reation to decommissioning? 117 Bringing together the perspectives of stakehoders in decommissioning 118 Making sense of decommissioning 119 Theoretica refections 120 Impications for heath care 122 Decommissioning is highy context dependent 122 Approaches to decommissioning shoud be modified according to type 122 Terminoogy is important 122 Successfu decommissioning is a ong-term pursuit 122 Deineating decommissioning decision-making 123 Substantive decommissioning requires attention to programme design 123 Queen s Printer and Controer of HMSO 2017. This work was produced by Wiiams et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. ix

CONTENTS Decommissioning programme impementation 123 Management and community engagement in decommissioning 123 Limitations of the study 124 Samping 124 Cinica Commissioning Group survey response rate 124 Pubic and service user invovement 124 Case study progress 124 Case study interviews 125 Recommendations for future research 125 Reaist synthesis of the evidence contexts, mechanisms and outcomes in decommissioning 125 Conceptua and empirica deveopment of oss aversion 125 Exporation of the roe of financia pressures in imit-setting decisions 125 Research into community engagement in decision-making 126 Exporation of decommissioning outcomes 126 Acknowedgements 127 References 129 Appendix 1 Review of reviews data extraction form 137 Appendix 2 Dephi study 1 etter of introduction and round 1 questionnaire 139 Appendix 3 Cinica Commissioning Group survey information sheet and questionnaire 151 Appendix 4 Sampe interview schedues for mapping exercise, narrative vignettes and case studies 167 Appendix 5 Materias used in focus groups 169 Appendix 6 Dephi study 2 etter of introduction and round 1 questionnaire 171 Appendix 7 Detaied findings from Dephi study 1 (rounds 2 and 3) 177 Appendix 8 Detais of case study data coection 183 Appendix 9 Detaied findings from Dephi study 2 (rounds 2 and 3) 189 x NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr05220 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 22 List of tabes TABLE 1 Summary of reviews search strategy 8 TABLE 2 Data coection for the mapping exercise 10 TABLE 3 Detais of narrative vignettes 11 TABLE 4 Participants in Dephi study 1 12 TABLE 5 Case studies and samping criteria 15 TABLE 6 Case study interviews and observations 16 TABLE 7 Participants in Dephi study 2 20 TABLE 8 Incuded reviews 24 TABLE 9 Additiona iterature items reviewed 28 TABLE 10 Findings from the mapping interviews 30 TABLE 11 Current decommissioning activity 43 TABLE 12 Number and type of decommissioning projects 44 TABLE 13 Intended outcomes of decommissioning 45 TABLE 14 Outcomes of decommissioning (%) 46 TABLE 15 Methods empoyed in decommissioning 47 TABLE 16 Stakehoders reported as activey invoved in the decommissioning stages (%) 47 TABLE 17 Factors reported as infuencing the decommissioning impementation process positivey or negativey (%) 48 TABLE 18 Capacity, capabiity and resources (%) 49 TABLE 19 Timeine for case study 2 61 TABLE 20 Timeine and overview of the decommissioning process 80 TABLE 21 Considerations attracting most and east votes across the three questions (number of pacings in top three by respondents) 103 TABLE 22 Statements reated to engagement that attracted most and east votes (number of pacings in top three by respondents) 105 Queen s Printer and Controer of HMSO 2017. This work was produced by Wiiams et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xi

DOI: 10.3310/hsdr05220 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 22 List of figures FIGURE 1 Stages of the decommissioning process 3 FIGURE 2 Fitering fow chart 9 FIGURE 3 Number and types of decommissioning projects 44 Queen s Printer and Controer of HMSO 2017. This work was produced by Wiiams et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xiii

DOI: 10.3310/hsdr05220 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 22 List of boxes BOX 1 Cosure and reocation of oca wak-in centres 32 BOX 2 Attempt to remove and repace a formuary drug 32 BOX 3 Reorganising paediatric hospita services across a region of the UK 33 BOX 4 Decommissioning of aternative therapies 33 BOX 5 Panned care home cosures 33 BOX 6 Reconfiguration of maternity services in an urban area 34 BOX 7 Decommissioning and recommissioning of services for chronic pain 34 BOX 8 Round 1 aggregated responses: considerations that (a) shoud and (b) do in practice inform decommissioning decisions 35 BOX 9 Round 1 aggregated responses: factors that positivey or negativey shape the process or outcomes of decommissioning 36 BOX 10 Round 1 aggregated responses: best-practice recommendations 37 BOX 11 Round 2 responses: statements with a high degree of consensus 39 BOX 12 Additiona statements with a high eve of consensus foowing round 3 41 BOX 13 Key deveopments in reorganisation of paediatric burn care services 52 BOX 14 Exampes of decommissioning cited by respondents 101 BOX 15 Statements based on responses to the question how you woud ike to be invoved in decisions to move or repace services? 101 BOX 16 Round 1 aggregated responses: good and bad reasons for moving or taking away services and reasons for moving or taking away services in practice 102 BOX 17 Methods of engagement proposed in responses to the question how you woud ike to be invoved in decisions to move or repace services? 103 BOX 18 Round 2 responses: statements with a high eve of consensus 104 BOX 19 Additiona statements with a high eve of consensus foowing round 3 106 Queen s Printer and Controer of HMSO 2017. This work was produced by Wiiams et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xv

DOI: 10.3310/hsdr05220 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 22 Gossary Coproduction An equa and reciproca reationship between peope providing and using services. De-adoption The processes of removing a practice or technoogy previousy introduced. Decommissioning The remova, reduction and/or repacement of heath-care services and interventions. Decommitment The process of reducing support for an intervention prior to a decision to decommission. Deimpementation The process of removing a practice or technoogy previousy introduced. Deinsurance Remova of a service/intervention from a heath insurance pan. Deisting Remova of an intervention from a formuary, insurance pan or other (e.g. a register of approved interventions). Derogation Faiure to be in compiance with one or more pre-set standards. Disinvestment Withdrawa of funding from treatments and technoogies that deiver insufficient heath gain for their cost. Divestment Disposa of part of a heath organisation, for exampe through cosure. Downgrading Reduction in the range or eve of speciaism of an organisation s function. Exnovation The process of removing a practice or technoogy previousy introduced. Termination The cosure or discontinuation of initiatives and/or services. Undiffusion The process of removing a practice or technoogy previousy introduced. Queen s Printer and Controer of HMSO 2017. This work was produced by Wiiams et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xvii

DOI: 10.3310/hsdr05220 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 22 List of abbreviations A&E accident and emergency MOC medicines optimisation committee A4R accountabiity for reasonabeness NCAT Nationa Cinica Advisory Team ANT APC BME CCG CER CRG actor network theory Area Prescribing Committee back and minority ethnic Cinica Commissioning Group comparative effectiveness research Cinica Reference Group NICE NIHR ODN OECD Nationa Institute for Heath and Care Exceence Nationa Institute for Heath Research operationa deivery network Organisation for Economic Cooperation and Deveopment CSU Commissioning Support Unit OSC Overview and Scrutiny Committee EOL GP HIV HSDR end of ife genera practitioner human immunodeficiency virus Heath Services and Deivery Research PBMA PCT PFT PIC programme budgeting and margina anaysis primary care trust partnership foundation trust paediatric intensive care HTA heath technoogy assessment PSUP pubic, service user and patient HTR IRP heath technoogy reassessment Independent Reconfiguration Pane STP sustainabiity and transformation pan IT information technoogy Queen s Printer and Controer of HMSO 2017. This work was produced by Wiiams et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xix

DOI: 10.3310/hsdr05220 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 22 Pain Engish summary Background/aim Making the most of NHS resources requires investment in new services as we as stopping services that do not give the best benefits to patients. However, reducing, repacing or removing heath care (referred to here as decommissioning) is difficut to achieve. Our project aimed to provide evidence-based advice on this topic. Methods The study was carried out in stages, with each one buiding on the ast. Stage 1 invoved gathering previous research and the refections of NHS eaders. It aso invoved 30 experts sharing their views on good practice in decommissioning via a questionnaire. Stage 2 invoved a survey of Cinica Commissioning Groups (CCGs) to find out their decommissioning pans and experiences. CCGs hod budgets at oca eves of the NHS. Responses were received from 56 out of 211 CCGs. Stage 3 invoved interviews and observations of four exampes of attempts to decommission services in more depth (incuding 59 interviews). Stage 4 invoved group discussions and another expert survey, this time with 26 citizens, patient/service user representatives, carers, third-sector organisations and oca community groups. Findings/concusions The most common type of decommissioning reported by CCGs was trying to move services. Some of our case studies made progress with their pans, whereas others did not and found this frustrating. There was fet to be a ack of guidance from nationa bodies, and aso a ack of the staff skis necessary for decommissioning. Citizens, patient/service user representatives, carers, third-sector organisations and oca community groups spoke of a strong sense of oss around osing services, and many fet that decommissioning decisions were made mainy for financia or poitica reasons rather than to improve patient experience. Our study identifies important insights for the range of groups affected by decommissioning in heath care. Good-practice principes for eading decommissioning processes and engaging service users and citizens are provided; however, the study suggests that no simpe formua exists for doing decommissioning we. Queen s Printer and Controer of HMSO 2017. This work was produced by Wiiams et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxi

DOI: 10.3310/hsdr05220 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 22 Scientific summary Background Running any heath system efficienty requires the deveopment, adoption and use of new interventions, technoogies and services. Arguaby, in a context of imited resources, it is equay important to repace and remove interventions and services as these become obsoete or superseded (decommissioning). However, theory and evidence in this area suggest that perceived and rea osses associated with decommissioning can make it difficut to impement, adding to financia and administrative pressures on pubicy funded heath systems. Poicy-makers, researchers and oca heath eaders are increasingy turning their attention to how these chaenges can be overcome in ways that maintain and/or improve overa heath outcomes for patient popuations. Research questions The primary aim of this study was to formuate theoreticay grounded, best-practice guidance for heath-care managers by identifying the factors and processes that infuence successfu impementation and outcomes when decommissioning heath services. The study addressed four research questions: 1. What is the internationa evidence and expert opinion regarding best practice for decommissioning in heath care? 2. How and to what extent are NHS organisations currenty impementing decommissioning? 3. What factors and processes faciitate the successfu impementation of decisions to decommission NHS services? 4. What are the perspectives and experiences of citizens, patient/service user representatives, carers, third-sector organisations and oca community groups in reation to decommissioning? Methods The study comprised a mutieve investigation of decommissioning poicies and programmes and was structured into four interconnecting work packages. Work package 1 scoped the project and incuded a summary and synthesis of pubished reviews on decommissioning; a mapping exercise of the nationa andscape of decommissioning; quaitative decommissioning narratives coected via interviews with seven eaders of previous decommissioning programmes within heath and oca government contexts in Engand; and a Dephi study of research, poicy and practice designed to eucidate a consensus on current best practice in reation to the decommissioning of heath-care services (30 participants). Work package 2 invoved a nationa survey of Cinica Commissioning Groups (CCGs) in Engand to assess the extent and nature of current experiences of decommissioning; aims and intended outcomes of panned decommissioning; methods adopted; chaenges and issues experienced in the decommissioning process; and attitudes and competencies in reation to decommissioning. In tota, 56 CCGs responded (27%) and resuts were subjected to descriptive statistica anaysis and content anaysis of free-text responses. Work package 3 invoved four in-depth case studies of decommissioning programmes at varying stages of progression, ranging from initiation and deveopment to fu impementation. These varied according to the stage of decommissioning reached, geography, the scae and compexity of the decommissioning pans, expected eves of opposition and confict, and the tier at which the decommissioning was instigated (i.e. nationa or oca). Data coection incuded documentary anaysis, semistructured interviews and Queen s Printer and Controer of HMSO 2017. This work was produced by Wiiams et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxiii

SCIENTIFIC SUMMARY non-participant observation. In tota, 59 interviews and 18 observations were carried out with interview sampes comprising individuas invoved in the design and impementation of the decommissioning programmes. Work package 4 investigated the perspectives and experiences of citizens, patient/service user representatives, carers, third-sector organisations and oca community groups in reation to decommissioning. This invoved three deiberative focus group discussions with open-ended questions. During the focus groups, we co-designed, with participants, a second Dephi study (26 participants). This was intended to faciitate a consensus on best practice for the engagement of patients and the pubic in decommissioning processes and to enabe comparison with the resuts from the Dephi study in work package 1 with regard to the idea and actua drivers of decommissioning programmes. The overa approach to data coection and anaysis was informed by a conceptua framework drawing on eements of poitica science (interests, institutions and ideas), compex service change, aspects of actor network theory (ANT) and a stages heuristic. We aso drew on the psychoogica concept of oss aversion, which hods that individuas fear oss more than they vaue equivaent gains. In work package 1, narrative review was used to structure the evidence synthesis, and quaitative data were anaysed thematicay. Both Dephi studies empoyed consensus-buiding anaytica methods. Case studies were anaysed individuay and common themes across the case study sites were identified using comparative case study methods and pattern matching. Work package 1 informed the foci of the subsequent nationa survey of CCGs and case studies. Work packages 1 and 2 informed the anaysis of findings from work package 3 and enabed refections on transferabiity of findings. The case studies expored gaps and unanswered questions identified in work packages 1 and 2. Finay, work package 4 enabed us to compare and contrast the perspectives of poicy-makers, researchers and practitioners with those of citizens, patient/service users, carers, third-sector organisations and oca community groups. Externa vaidity and transferabiity were addressed through detaied description and data trianguation between the four work packages. Resuts There is a deveoping evidence base on decommissioning processes in heath care, especiay in reation to the identification of therapeutic interventions for remova or repacement. The evidence is ess deveoped in reation to the decommissioning of services, programmes and organisations and the impementation of such decisions. In these areas, there is itte in the way of guidance to inform poicy and practice. The study of decommissioning therefore does not extend far beyond remova and repacement of cinica interventions from within an evidence-based decision-making paradigm. In our first Dephi survey we empoyed a broad definition of decommissioning that incuded mutipe forms. Participants identified the foowing good-practice principes for decommissioning: identify and estabish a strong eadership team engage and invove cinica eaders from an eary stage estabish a cear rationae and narrative for change ensure cear and thorough project panning and governance secure high-eve poitica support (nationa and oca) at an eary stage base decisions on evidence of what works adopt a whoe-systems perspective from the beginning. Participants beieved there to be a significant gap between the criteria that shoud inform decommissioning (quaity and patient experience) and those that do in practice (cost and poitica considerations). xxiv NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr05220 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 22 Survey resuts indicate that of the 56 responding CCGs, 77% had decommissioning activities panned. The most common intended outcome was improved cost-effectiveness, reported by 38% of CCGs, foowed by patient experience (36%) and improved cinica effectiveness and greater aignment with strategic priorities (both 30%). The most common type of decommissioning activity reported by CCGs was reocation or repacement of a service from an acute to a community setting (28%), foowed by remova or repacement of a service as part of reconfiguration of a service (25%) and cosure of a service (14%). This suggests a mismatch between the predominant focus in the iterature on the remova of individua treatments and the preoccupation in the system with other forms of decommissioning. Respondents identified imitations in the support they received and the resources and capabiities at their disposa to carry out this roe. The experiences of our case studies differed consideraby. Case study 1 invoved a nationa reorganisation of speciaist services for paediatric burn care. This was ed by NHS Engand s Trauma Nationa Programme of Care and the nationa Burn Care Cinica Reference Group (CRG). The review process had been under way since 2013 and incuded proposas for at east one centre to ose intensive care provider status. However, the period of case study fiedwork (September 2014 to May 2016) coincided with an impasse and no significant further progress was made. Those advocating change had formuated reorganisation and decommissioning pans, but appeared to ack access to the range of resources required to impement these. The poitica arena in which the CRG operated was fet to be either disengaged or non-committa in respect of its pans, refecting a perception that the service itsef was somewhat acking in profie and voice. Case study 2 invoved CCG-ed decommissioning of an end-of-ife home support service provided by an independent organisation to approximatey 800 patients over a 4-year period. Decommissioning took pace foowing a review by the CCG (October 2012 to March 2013). Notwithstanding apparenty high patient satisfaction with the service, the review made the case for decommissioning on the grounds of weak cinica effectiveness and potentia cost savings, and the CCG was abe to propose and subsequenty manage the cosing down of the service over the period Apri Juy 2014. Key to the success of impementing the decision to decommission was the management of the reationship with the provider who acquiesced in the proposed changes. Some concerns were nevertheess expressed regarding the avaiabiity of aternative patient pathways during service changes and arrangements for post-discharge patient monitoring. Case study 3 focused on the decommissioning activity of an Area Prescribing Committee (APC) based in a coasta area of the south of Engand. Athough the APC had previousy sought to decommission medicines, no exampes were observed during the data coection phase (November 2014 to May 2016). The shared formuary appeared to be the main mechanism by which to enact repacement or remova and the impementation of such changes was typicay addressed through a gradua process of incrementa patient initiation, with some historica prescribing permitted. Previous experiences of decommissioning that had not been impemented as panned had ed the APC to be cautious over future pans. When decommissioning had been instigated (e.g. the deprescribing of guten-free products), this had achieved mixed resuts in terms of impementation or ese decisions were enacted ony when supported by Nationa Institute for Heath and Care Exceence guidance. Respondents caed for poitica eadership and enhanced evidence support from nationa-eve heath-care bodies. Case study 4 was a CCG-ed review and panned reorganisation of oca primary and acute care services, invoving decommissioning of a oca hospita and centraisation of acute services at aternative sites. Extensive review and strategic panning for the reorganisation took pace over a period of 18 months between 2014 and 2016 and invoved the deveopment of a comprehensive governance structure and engagement strategy with stakehoders, co-ordinated by a designated programme manager. The CCG made progress with panning the reorganisation but impementation subsequenty staed. Points of tension incuded reconciing traveing distances and access to acute services for different communities in the area, non-coterminous provider and CCG boundaries, disruption to cinica systems and pathways for treatment, and resistance by provider organisations. This case study highights the importance of reationships between the providers invoved, the system compexity, and the scae and scope of the proposed reorganisation. Queen s Printer and Controer of HMSO 2017. This work was produced by Wiiams et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxv

SCIENTIFIC SUMMARY Taken together, the case studies highight the need for eaders of decommissioning processes to: draw on evidence, reviews and poicies to frame the probem that decommissioning is required to sove buid actor aiances in order to egitimise decommissioning as a soution to this probem seek wider invovement, incuding of patients and community-based interest groups, in a stages of decommissioning devise impementation pans and time scaes that take account of the structures of authority and mechanisms of enactment that are avaiabe to those eading decommissioning. These concusions are dependent on context. For exampe, the roe of evidence and actors in identifying and framing a need for decommissioning rests on factors such as the scope of the project and the number of actors impicated/affected, as we as the resources that these can mobiise to oppose pans. Simiary, the unusua circumstances in the one successfuy impemented case study process appear to have negated the requirement for securing high-eve poitica support, engaging service users and stakehoders, and adopting a whoe-systems perspective. By contrast, the more eaborate and we-resourced pans of other case studies had not been impemented by the time of competion of data coection. Findings from work package 4 suggest some commonaities between the views of our second Dephi pane (made up of citizens, patient/service user representatives, carers, third-sector organisations and oca community groups) with those expressed by the first Dephi pane. For exampe, support was given to the principe that decommissioning is not inherenty iegitimate and, therefore, that there are circumstances in which repacing or removing services is both necessary and justified (athough the same consensus was not found in reation to moving services). Both Dephi panes aso considered decommissioning, in practice, to be at east party a function of financia pressures and the need to make cost savings. However, the majority of participants in work package 4 fet this to be an unjustified basis upon which to make decisions. Their rejection of cost pressures as a basis for decommissioning was, therefore, emphatic. In this regard, our two Dephi studies indicate something of a fissure between perspectives from research, poicy and practice and those of citizens, patient/service user representatives, carers, third-sector organisations and oca community groups, especiay with regard to the acceptabiity of financia constraint as a factor in decision-making. Resuts from across the work packages suggest that patients and the pubic are unikey to be infuentia in decommissioning decision-making. Opinions diverged, however, on the normative question of engagement: participants in the first Dephi survey did not rank patient and pubic engagement high on the ist of good-practice principes, whereas participants in the second Dephi survey expressed an appetite for substantive engagement and even coproduction of decisions. Overa, the anguage with which participants in work package 4 discussed decommissioning was notaby different from that empoyed by those invoved in work packages 1 3, with more emphasis on the ived effects and consequences of changes to services on users and carers, and on the osses experienced in the process. Concusions This study expands and refines an understanding of the processes reated to decommissioning across a range of heath-care settings and contexts. It is the first internationay to combine ongitudina case studies with a nationa survey and expert Dephi pane, and the first to target such a wide range of respondents. The study found that the broad categories of factors that appear to shape the outcomes of decommissioning incude change management and impementation, evidence and information, and reationships and poitics. The study has far-reaching impications for future practice. Overa, it finds that no decommissioning bueprint exists and that outcomes, especiay of more ambitious programmes, are hard to predict. xxvi NIHR Journas Library www.journasibrary.nihr.ac.uk