We begin with a description of what the CMs did to implement the programme and then continue with aspects that relate to potential influences on sustainability as well as sustainability outcomes.
Implementation: from closings to updated routines and task shifting
One of the most difficult tasks was to close units, which in most cases resulted in negative staff reactions, including irritation, disappointment and resignations, although there were relatively few layoffs. The lack of guidance when closing units was mentioned by the CMs. A CM said: “I needed to talk to someone who had done it before. How should you go about it?” (#6). The CMs referred to a lack of guidance regarding such diverse things as how to dismiss or replace staff, terminate locality leases, electricity and telephone contracts and empty the facilities of furniture and equipment. However, some CMs also permanently closed clinics that were already temporarily closed due to staff shortages. This action was not perceived as problematic. Some CMs talked about this decision as a relief as they actually had an opportunity to close down units that had constant troubles with staffing, facilities or care quality. A few CMs also merged units, which posed some problems, e.g., the merging of different cultures and ways of working. They handled these issues by introducing repeated meetings and new working groups. Some of the CMs described the merges as a way of increasing quality, for instance, by creating an environment with a higher level of collegial support (not working alone at many geographically scattered units).
Many decommissioning activities were less drastic. Several CMs described how they reduced their spending by scrutinising all regular expenditures, such as lab tests, x-rays, laundry and meals, and many mentioned that they scrutinised their prescriptions and how they handled pharmaceuticals. Other CMs, however, had a hard time finding things to save on. One CM explained that (s)he had no expensive materials to save on, and that the only option was to save on staff. Thus, staff who retired were not replaced and, consequently, a lot of competence disappeared.
Furthermore, a CM conveyed that the clinic tried to adhere even more closely to the indications for surgery, i.e., to operate on the ‘right’ patients. In another area, the admission criteria became more formalised, which meant that they did not admit patients who did not need it, even if they turned up during night hours and had a long way to go home. Some of the CMs also mentioned more permanent changes like new ways of working. A CM mentioned that their clinic now prescribed medications that required less frequent monitoring at a health centre because changes were made to primary care access in their geographical area, as part of the programme. There were also several examples of altered patient pathways, e.g., a new patient flow model for diabetes patients, and giving patients return visits the next day with a junior physician instead of admitting them to hospital or letting them stay an extra day. Models to reduce length of stay and the number of revisits were also mentioned, as well as new ways of scheduling doctors to use their time more efficiently. One CM exemplified how they reduced the number of visits per patient by organising the visits differently. Now they handed out medical devices to children with asthma at the first visit and taught the children and parents how to use it immediately instead of booking a new visit.
Several CMs also spoke about task shifting, which was regarded as a more effective way of using the existing resources and competencies. A quote illustrates this: “If there is something a registered nurse can do instead of a doctor, we do it. If there is something an assistant nurse or secretary can do instead of a registered nurse, we try to do it” (#3). Medical secretaries represented a group that got many new tasks, such as booking and calling patients.
Involving the CMs and communicating the changes
Most of the CMs described that they were highly involved in formulating the decommissioning programme. They were all invited to a formative meeting—where the main actions were determined—and were then prompted to go back to their clinics and work out the details. The CMs saw themselves as the ones who truly understand the services, and what was possible to change or remove, and felt that the responsibility for the implementation was theirs. Most of the CMs put a lot of effort into communicating the decommissioning activities to the staff (sometimes individually even though there could be over 100 staff members), and they generally saw this task as most important in the initial implementation of the changes. One of the CMs said that the most important thing was to convince the staff. “It is the first and last, information to the staff and to get them on board” (#27). Some of the CMs said this task was tough and mentioned that they had to be clear about the necessity of the changes, which sometimes involved “putting the foot down” (#24) and explain that the decommissioning activities were not optional and why they were necessary. Some of the CMs, however, expressed that this action was something of a balancing act. “If you do it too fast and too hard, then the staff says ‘I quit’” (#22). Some CMs also mentioned that it was their task to inspire and enthuse, and they arranged lectures and study visits to give the staff input. One of the CMs said it was important to be the one convincing the staff that the unit could handle the coming changes. They also saw it as their task to harbour the staff’s fear, anger and frustration.
Organisational support: from fragmented and poor to great
While the CMs saw it as their responsibility to implement the decommissioning programme, many of them simultaneously mentioned that their mandate as managers was curtailed when control of spending tightened and the authority to decide over staff numbers and employment was transferred to the central HR function (which was one crucial administrative aspect of the decommissioning programme). They were particularly negative about the lost authority to manage their own staff in terms of deciding how many were needed, to replace those who retired and reward them. However, although some questioned the practice of central HR deciding on all employments, some CMs said this change entailed that they now questioned whether they really needed new staff members or to replace staff that retired. One manager mentioned specifically that (s)he thought they had had some overcapacity earlier and that they were now able to adjust to an appropriate staffing level by not rehiring.
When the decommissioning programme started, the region had just completed a reorganisation of the local health system, namely by dividing all medical areas into four divisions headed by division managers, at the time four experienced physicians. Most of the CMs felt they were supported by their division manager when performing the decommissioning activities. One of the CMs expressed: “It has been an enormous support to be in a division, I have to say. It has not been like this previously, when we have made changes. Then you were very lonely as a CM…” (#21). The CMs mentioned that they tried to support each other in the divisions and that their networks were an opportunity to find out whether someone had previously done something that they themselves planned, and to ask how they approached it. They also discussed such things as salary levels, so people seeking employment could not play clinics against each other. However, several CMs said that while the unity within the divisions increased (“we have become a close group, we can really discuss our questions” [#27]) it became more difficult to communicate among the divisions.
In contrast, they perceived varying degrees of support from the region leadership. Some of the managers said they lacked HR support while others found it adequate (HR was centralised from the clinics to the region during the same period of time as part of the decommissioning programme). See Table 3 for examples of how the CMs perceived the support.
//Table 3//
Intensity: from huge momentum to status quo
Most of the CMs agreed that the decommissioning process was intense at first, but they said that that the intensity faded over time. One of them explained: “I think it is completely different now. Then it was drastic: ‘what will happen, will we end up on an even keel? ´” (#5). Another one said that after a while “It was not as ‘wow’ as it was the first time” (#27). Some of the CMs also mentioned that the discussions became less strategic at division meetings. They also mentioned that they did not perceive the region leadership being as active anymore (they appeared less often at division meetings, et cetera). One of the CMs thought the region leadership had lost speed and was lacking in the strategic planning to reach the goals. Similarly, the clinics returned to having less frequent meetings. At the beginning of the decommissioning programme, many clinics changed the management structure, in particular the frequency of leadership meetings. One CM said that they had frequent meetings with the clinic management team (to test new routines, evaluate, modify and evaluate again), and continued with it until 2017, when they returned to monthly meetings.
Changes in the local environment
Many CMs mentioned that it was rather difficult to separate changes linked to the decommissioning programme from other types of processes that were occurring in the local health system over the years of implementation. One of the CMs explained: “What is difficult is that, the situation back then, the greatest problems in 2015, are not the greatest problems now (#1). One important change on which most of the CMs reflected was the rapidly growing problem with staff shortages, which forced them to reduce bed spaces. They described the difficulty of trying to save money while spending a lot of effort on recruitment. One of the CMs explained how (s)he saw it: “It is a lot of talk about the improved financial situation, but I'll be damned, that’s because we have so many vacant positions!” (#20). Some of the CMs thought that the region leadership had focused too little on the staffing situation, e.g., what was the appropriate level and how the shortage could be solved in relation to the decommissioning programme.
Too little systematic follow-up and feedback
Many CMs described that after approximately 3 years there were still too little systematic discussion about the region’s priorities. Although it was not the opinion of all CMs, many of them thought there had been too little focus on follow-ups and not enough feedback from the region leadership to the clinics during the decommissioning programme, in particular after the first year. Several of them mentioned that these types of activities must be highlighted and evaluated regularly, otherwise the day-to-day activities at the clinics take over. Furthermore, a common opinion was that they had been given information about the financial effects but not about other types of effects, such as clinical outcomes or patient satisfaction. One manager expressed his/her hesitation: “They say that the quality has not deteriorated, but it is hard to say if it has actually” (#23). Another CM meant that it was hard for the CMs to feel satisfied with the work they had done as they wondered how it had affected quality.
An altered way of thinking about economy?
Many of the CMs mentioned that they were still very cautious about purchases. One of the CMs said: “I believe we have the economic thinking with us still. It lingers. /…/ I am always asking if we can afford it. I ask my economist a few times extra, discuss with the clinic management team. Maybe with the division manager” (#25). Several of the CMs mentioned that the decommissioning programme led to a new way of thinking and talking about economy, a higher level of awareness about the economic situation and a sharper pressure to keep the budget. Many of them conveyed that they had started collaborating more closely with their controllers. At the same time, the programme revealed a lack of knowledge of economy and the economic systems among some of the CMs. For example, one of them said: “Economy at this level is complex I think. Still, I do not understand half of it to be honest” (#8).
However, one difficulty the CMs talked about was that they felt some CMs no longer took the task of implementing the decommissioning programme seriously enough, that they seemed to have forgotten about the spending restrictions. Several of the CMs were of the opinion that the leadership should punish the CMs who did not adhere to the decisions or take the savings as seriously.