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David Woodhead and Valerie James on tackling decommissioning

Government is stepping away from setting central targets and relinquishing direct control over delivery. Locally identified needs and priorities will take their place. Directors of public health and commissioning will be at the vanguard of service reform in the health service and local councils.

They will craft the vision to improve health, advocate on behalf of the communities carrying the burden of disease, and establish what needs to happen in local services. There will be challenges.

One of those challenges will not be commissioning per se. Most people - staff, patients, community activists and politicians alike - welcome new services. The real challenges will come in decommissioning services. Directors of public health and commissioning will be able to challenge the false perceptions that they are the benign keepers of technical wisdom. They will use their skills to make hard decisions about delivery, as advocates of health, fairness and equity.

Resistance to change

Taking something away, no matter how well crafted the rationale is for doing so, brings about opposition. On occasion, NHS managers make poor decisions and patients are right to protest. Sometimes they cling to services for personal and perhaps sentimental reasons, regardless of whether it is rational to do so. They want the best for their families and might believe that the proposals constitute a threat to their safety and well-being. There is a strong impulse to protect things we care about, even if there is scant logic in so doing.

A colleague recently explained how she found it relatively easy to convince clinicians and managers that prevention activity - at a fraction of the cost of hospital care - needed to be strengthened to reduce demand and ensure the longevity of the NHS. In the moment, she felt as though the public health argument had been won. However, once the reality dawned that hospitals would close and services change, resistance occurred.

Nerves of steel

In a climate where debate about competencies for commissioners focuses on technical and transactional skills, little discussion is evident about the interpersonal qualities needed to drive change. These include the ability to listen carefully to what is being said and not override the concerns of others. Directors of public health and commissioning must seek to understand the source of people's resistance and uncover their motivations and values.

They must realise that despite rational argument, sound statistics and citations from the evidence base, success in trying to change the world will come from their understanding of the systems in which they work and the people their decisions affect. They need to earn the trust and respect of colleagues, patients and the public, even if their intentions are not wholly endorsed. They also need nerves of steel.

Even great leaders are not born with nerves of steel; they have to be grown rather like new neural pathways. Understanding what drives us and embodying those values in the ways we work is crucial. "Walking the talk and enacting the thought" is the challenge leaders face. These skills are far from technical; they are wholly subjective and arise from periods of intensive self-appraisal and critique.

Directors of public health and commissioning will have to operate differently to effect real change. Being on the margins is frustrating, but being in the mainstream brings challenges. As the cliche reminds us: there is little point in having power without responsibility and similarly there is no purpose in having responsibility without power. In years to come we may look back on this time and thank public health and commissioning leaders for pioneering change and securing the health of the population.

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