Cuts without conflict: The use of political strategy in local health system retrenchment in Sweden

Putting a decommissioning programme into action: an interview study with politicians and public servants in a local healthcare organisation

PURPOSE

A local healthcare organisation providing healthcare to 288,000 residents in Sweden struggled with a longstanding budget deficit. Several attempts to overcome the demanding financial situation have failed. A decommissioning programme was launched, and two years later, an evaluation indicated positive outcomes. The aim of this study was to explore factors politicians and public servants perceived as enablers to the successful implementation of the programme.

DESIGN/METHODOLOGY/APPROACH

A deductive content analysis approach using a framework of factors facilitating successful implementation of decommissioning decisions was applied to analyse interviews with 18 informants.

FINDINGS

Important factors were: (1) a review report contributing to the clarity of evidence, which (2) made the clarity of the rationale for change undeniable and (3) strengthened the political support for change. Additional factors were: (4) the strength of executive leadership, (5) the strength of clinical leadership supported by (6) the quality of project management and (7) a cultural and behavioural change seen as an important outcome for the path forward. A way to maximise the potential for a successful implementation of a large-scale decommissioning programme is to build a shared vision and a collaboration grounded in convincing evidence. Include public servants with a clinical background in the executive leadership team to contribute with legitimacy, competence, and trust in the decommissioning programme's intention.

ORIGINALITY/VALUE

The paper addresses the limited knowledge of best practices in decommissioning processes and contributes empirical knowledge from a successful case.

For better or worse: Governing healthcare organisations in times of financial distress

Due to processes of financialisation, financial parties increasingly penetrate the healthcare domain and determine under which conditions care is delivered. Their influence becomes especially visible when healthcare organisations face financial distress. By zooming-in on two of such cases, we come to know more about the considerations, motives and actions of financial parties in healthcare. In this research, we were able to examine the social dynamics between healthcare executives, banks and health insurers involved in a Dutch hospital and mental healthcare organisation on the verge of bankruptcy. Informed by interviews, document analysis and translation theory, we reconstructed the motives and strategies of executives, banks and health insurers and show how they play a crucial role in decision-making processes surrounding the survival or downfall of healthcare organisations. While parties are bound by legislation and company procedures, the outcome of financial distress can still be influenced. Much depends on how executives are perceived by financial stakeholders and how they deal with threats of destabilisation of the network. We further draw attention to the consequences of financialisation processes on the practices of healthcare organisations in financial distress.

A New Way of Thinking and Talking About Economy: Clinic Managers' Perspectives on the Sustainable Implementation of a Decommissioning Programme in Sweden

Healthcare systems may run into economic problems that may require 'active' decommissioning by policy-makers and managers. The aim of this study was to investigate, from a sustainability perspective, the implementation of an extensive decommissioning programme in one of the Swedish regions. Interviews were performed with 26 clinic managers 3 years after initial implementation. Those were analysed inductively, and then discussed based on a model of potential influences on sustainability. Although the programme was only 'partly sustained', the result point to a sustained attention to the health system's poor economy, visible in a great effort by the clinics to maintain their budgets. The most important influences were intervention fit and modifications made at the clinic level (i. innovation characteristics), clinic and health system leadership (ii. context), champions (iii. capacity) and shared decision-making and relationship building (iv. processes and interactions). When implementing decommissioning, it is particularly important to engage managers responsible for the care of patients and clinic budgets from an early stage and to allow them to design approaches based on the staff's and managers' detailed knowledge of the situation at their clinics and of the disease area, that is, to achieve fit at the clinics. In this way, the decommissioning approaches can more likely get the character of quality improvement efforts, which increases sustainability and may lead to positive quality outcomes. Despite being unpopular, the study suggests that decommissioning can have positive effects as well, such as creating opportunities to make difficult but necessary changes and fostering increased collegial support during the centralisation of services.

Factors that shape the successful implementation of decommissioning programmes: an interview study with clinic managers

BACKGROUND

As a response to many years of repetitive budget deficits, Region Dalarna in Sweden started a restructuring process in 2015, and implemented a decommissioning programme to achieve a balanced budget until 2019. Leading politicians and public servants took the overall decisions about the decommissioning programme, but the clinical decision-making and implementation was largely run by the clinic managers and their staff. As the decommissioning programme improved the finances, met relatively little resistance from the clinical departments, and neither patient safety nor quality of care were perceived to be negatively affected, the initial implementation could be considered successful. The aim of this study was to investigate clinic managers' experience of important factors enabling the successful implementation of a decommissioning programme in a local healthcare organization.

METHODS

Drawing on a framework of factors and processes that shape successful implementation of decommissioning decisions, this study highlights the most important factors that enabled the clinic managers to successfully implement the decommissioning programme. During 2018, an interview study was conducted with 26 clinic managers, strategically selected to represent psychiatry, primary care, surgery and medicine. A deductive content analysis was used to analyze the interviews. By applying a framework to the data, the most important factors were illuminated.

RESULTS

The findings highlighted factors and processes crucial to implementing the decommissioning programme: 1) create a story to get a shared image of the rationale for change, 2) secure an executive leadership team represented by clinical champions, 3) involve clinic managers at an early stage to ensure a fair decision-making process, 4) base the decommissioning decisions on evidence, without compromising quality and patient safety, 5) prepare the organisation to handle a process characterised by tensions and strong emotions, 6) communicate demonstrable benefits, 7) pay attention to the need of cultural and behavioral change and 8) transparently evaluate the outcome of the process.

CONCLUSIONS

From these findings, we conclude that in order to successfully implement a decommissioning programme, clinic managers and healthcare professions must be given and take responsibility, for both the process and outcome.

Is the end in sight? A study of how and why services are decommissioned in the English National Health Service

The decommissioning of a health-care service is invariably a highly complex and contentious process which faces many implementation challenges. There has been little specific theorisation of this phenomena, although insights can be transferred from wider literatures on policy implementation and change processes. In this paper, we present findings from empirical case studies of three decommissioning processes initiated in the English National Health Service. We apply Levine's (1979, Public Administration Review, 39(2), 179-183) typology of decommissioning drivers and insights from the empirical literature on pluralistic health-care contexts, complex change processes and institutional constraints. Data include interviews, non-participant observation and documents analysis. Alongside familiar patterns of pluralism and political partisanship, our results suggest the important role played by institutional factors in determining the outcome of decommissioning processes and in particular the prior requirement of political vulnerability for services to be successfully closed. Factors linked to the extent of such vulnerability include the scale of the proposed changes and extent to which they are supported at the macrolevel.

Awareness and opinions on healthcare decommissioning in a Swedish region

Decision-makers may have to decommission services as a response to budget deficits. The aim of this study was to investigate a case of decommissioning with regard to the public's awareness and opinions. The analysis of a survey in a Swedish region that begun the implementation of an extensive decommissioning programme in 2015 shows that the majority of respondents were well or very well informed about the programme (68 %). A large proportion of the respondents thought the decision-makers to a low or very low degree had adopted appropriate measures to solve the economic problems (43 %), but together more respondents were either indifferent (39.5 %) or positive (17.5 %). Regarding the level of satisfaction with the region's healthcare system, compared to prior to the decommissioning period, 30 % were less satisfied while together more were either indifferent (48 %) or had become more satisfied (22 %). The large share of indifferent responses opens up for various interpretations or framings of the programme outcomes. Trust in the regions' healthcare system nevertheless increased during the same period. Furthermore, self-assessed health as well as age and utilization seem to be associated with healthcare system satisfaction during decommissioning. This illustrates heterogeneity in the public's responses to decommissioning, which calls for further investigation.

Decommissioning in a local healthcare system in Sweden: responses to fiscal stress

BACKGROUND

Drawing on the literature on cutback management, this article deals with healthcare decommissioning in times of austerity. Politicians and decision-makers are typically reluctant to decommission healthcare, and if they do, the public generally reacts strongly towards reductions in service supply. Despite this, comprehensive decommissioning does take place, though empirical knowledge about its effects and economic sustainability is limited. To further the understanding of healthcare decommissioning, this paper aims to introduce the concepts of cutback management into the research on healthcare decommissioning, and apply its components to an empirical case of comprehensive decommissioning. In doing so, the study analyses whether decommissioning measures can be expected to generate long- or short-term economic payoff, and considers what other effects they might have on the healthcare system.

METHOD

We developed a theoretical framework that enabled us to investigate the measures through which a local healthcare system in Sweden, region Dalarna, responded to an acute fiscal crisis in 2014, and what effects these measures are likely to generate. The method used was a deductive content analysis of Dalarna's decommissioning program, containing 122 austerity measures for saving 700 million Swedish Krona (SEK).

RESULTS

Dalarna's local decision-makers responded to the fiscal crisis through a combination of operational cuts (20% of undertaken measures), programme cuts (42% of undertaken measures), and structural reforms (38% of undertaken measures). The instruments most commonly used were increased patient fees and the merger of service facilities. By relying foremost on programme cuts and structural reforms, Dalarna adopted the measures most plausible to have moderate or long-term economic payoffs. Successful implementation, however, may be challenging and difficult to evaluate.

CONCLUSIONS

Healthcare politicians and decision makers have better potential to stabilize their long-term economic situation if they rely on responses such as operational cuts, programme cuts and structural reforms, as opposed to across-the-board cuts and cuts in investment and capital expenditures. However, with economics being only one important factor for sustainable healthcare systems, further studies should investigate how these measures affect important principles, such as equal healthcare distribution and access.

TRIAL REGISTRATION

Not applicable.