Monday, 29 December 2008

When the tide goes out

Warning - Low Tide
Warren Buffett's classic quote : "It's only when the tide goes out that you learn who's been swimming naked" may have been about the financial markets, but it's just as applicable to evidence-based care.
One of my current projects is researching the assurance processes used within health and care, to recommend a model for assuring clinical content applicable nationally.
It should come as no surprise, but most of the 'evidence based care' pathways we use may be more 'I'm the expert and this is what I think'. Developing pathways in the past has been down to a medical consultant doing it her/his way, then writing it down and publishing.
In Lean service improvement methodology, one of the first steps is to define the pathway, so there's certainly merit in this. But once it's published, who questions it? Who even measures (accurately) whether it's better or worse than any other pathway, and with what scope of measurement (eg cost for this pathway, vs cost for caring for this group of patients)?
Now I'm certainly not suggesting that you question every pathway. I am suggesting you put appropriate measurement regime in place. And I'm certainly suggesting that you question the assurance process which led to the pathways you use, whether it is robust!
For the record, there are some outstanding assurance processes, including NICE (National Institute for Health and Care Excellence) and NHS QIS (National Health Service Quality Improvement Scotland) which have very robust processes for their legally binding guidelines - but most assurance processes consist of a self-selecting panel (and often on the basis of who's prepared to put the effort in) reviewing to a greater or lesser extent and comparing the results with no others or few other pathways.

Tuesday, 16 December 2008

A focus on Delivery

It's very easy to get caught up in a project. Tied up in the minutiae of doing the next task, keeping track of progress, reporting. The HOW.
Add in a day job (what you're paid to do when you aren't doing the new project) and you can see how quickly you lose track of WHY you are doing this.
But just as you become what you think about, so your project will deliver what you focus on. If you focus on activity, then that's all you will achieve.
Focus on the aims, the goals, the outcomes. If the project aims to reduce smoking, then be mindful of achieving an overall reduction in smoking, rather than just the number of people through the door - stop smoking schemes are a perfect example as too often the same people come back year after year (usually the day for New Year Resolutions).
Of course you have to do the activities from day to day such as running stop smoking sessions. But if it isn't working, then change your approach. Where "is it working?" asks whether it is delivering the benefits you seek

Friday, 5 December 2008

the benefits of networking

NHS Yorks and Humber enjoys an opportunity for a group of like-minded people to share stories and learn new skills, through their Benefits Network which this week was hosted in the NHS Information Centre.
People all over the country want to know more, and take part. Inevitably Y&H simply don't have the budget, and can't stand the uncertainty. So why aren't there more Benefits Networks? Is it a Yorkshire thing to want value for money, so to go out looking for it?
Actually everyone has to look for value. Every SHA and PCT in England has had to take notice of Lord Darzi's 'Next Stage Review' and the final publication, 'High Quality Care for All - Measuring for Quality Improvement'. This demands that commissioners seek quality outcomes, and that providers deliver in a meaningful way, not just activity but real quality outcomes - benefits by another name. This will be reinforced by money - HRG4.0 tariffs will include a component for quality of outcome.
One of the discussions was on the small matter of the growth money reducing in 2011. From right now onwards, we need to decide our priorities, in terms of benefits, and focus on delivering them.
This means developing frameworks for understanding benefits, planning for the benefits from individual initiatives, projects and services or better yet, planning the projects, initiatives and work packages to deliver the benefits desired, and then realising the benefits either (in the short term) through proxy measures, or real and tangible benefits.
Acute service providers are being warned to expect reductions in income of up to 25%. Those hundreds of millions of ££ will be available to invest in community services (which could be provided by acute trust staff and teams with appropriate training), but they must be invested wisely!

Sunday, 23 November 2008

5-Case Business Case

I've often advocated the preparation of business cases specific to each of your target audiences.
Certainly you need to understand the financial case and return on investment. Each initiative needs to justify the investment made.
But in public service, the quality outcomes are what justify the investment (when Labour came to power, we as a nation invested approx £42billion in NHS each year. We now invest £100billion - if we wanted to SAVE MONEY we wouldn't go on putting more in).
This means that the business case needs to appeal to each of the major stakeholder groups: those investing the money, the main providers of service (staff, employers), the receivers of service (could be patients and public, though for improvements in process the customer will be other staff), and those who look for quality in public services (politicians, OSC, etc). In my terminology, Quality outcomes, User Experience, Staff Experience and Effectiveness.
I used to write a different business case for each one. Then I found that by combining the business cases, we ended up with a shorter more succinct document that answered every audience, and since everyone used the same document there was no suspicion.
Connecting for Health promotes the 5-Case model, which is broadly along the same lines (a business case for each stakeholder). In their case the 5 Business Cases are:

  • Strategic Case

  • Economic Case

  • Financial Case

  • Commercial Case

  • Management Case

ScorecardIt makes a lot of sense to follow a structured template and you can find out more by examining this example on the Connecting for Health web site.

Monday, 10 November 2008

A new politic

Boris Johnson, Barak Obama, both men without the "old school" political networks.
I hear the Lord Mayor of London is getting rid of some of the prestige projects of his predecessor, on the grounds that they cost too much for the benefits they bring. The President Elect seems to be prepared to turn his back on decades of 'pork barrels'(favours done for each other to win support for the policy they want to get through, famously named after inclusion of the building of a pork barrel factory in one congressman's home state, to support increased budget to the armed forces).
These outsiders may be a good thing. So much of what is eventually agreed by the powers that be (that be what?) are more about ego and prestige than actually doing some good for average Joe s and Jo s.
I will rejoice the day that the most beneficial (especially where this is backed up by evidence) projects go through! I would love to call those to account who cancel or undermine beneficial projects because the presence of a successful solution highlights how little they themselves have achieved.

Thursday, 6 November 2008

Obama's America - is prevention really better than cure?

During campaigning, President-elect Barak Obama hinted at a UK-style health service, with access to healthcare for all.
It does make a lot of sense - healthcare in USA is bringing the economy to its knees, as it simply costs too much for the economy to bear. UK-style healthcare not only costs a great deal less, but provides an excellent standard of care universally from before the cradle (maternity care) to beyond the grave (grief counselling). It's so good that many European countries are emulating it.
But is prevention (the UK model) better than cure?
That depends. Taking age-related conditions such as CVD (cardio-vascular disease), diabetes and cancer; prevention in the form of medication to control the symptoms certainly improves quality of life and probably allows an individual to contribute to society for many years. But it appears to cost much more. An early diagnosis leads to early treatment, which may continue for 40 years. At say $10,000 per year, this is a lot of money. Whereas a late diagnosis may cost $100,000 over a 6 month stay in hospital, after which the patient dies and the costs stop.
In practice, those PCTs (the NHS bodies responsible for purchasing care in each district or county) who have a higher average length of life are in deficit (spend more than they receive) although the average across the country evens out. This reinforces the above assertion - keeping your population alive costs more! As a society, we determinedly add life to years and years to life. For the USA, you need to make a clear decision that you are prepared to foot the bill.

Sunday, 2 November 2008

Successful Benefits Realisation

A bit like golf - keep your sight on the aims, but be aware of the pitfalls along the way.
Do you have compelling benefits that will result if this project is achieved? Does everyone involved agree that they are compelling? If not, does everyone involved have a compelling benefit relevant to themselves, that will be achieved through successful delivery of this project?
What about those who will lose from successful delivery. have you identified them and how they will lose, and have you plans in place to minimise the damage?

This is where a Benefits Framework is applied:

Creating a benefits framework ensures that everybody's benefits - and dis-benefits - are understood
Using a benefits framework tracks the delivery of BENEFITS (as opposed to MILESTONES)and ensures the stakeholder with the most to gain, knows all about the achievement
Effectively, you have PERFORMANCE MANAGEMENT but with the agreement, or even enthusiasm, of staff and stakeholders

Right Skill, Right Place, Right Time

We're all trying to look at workforce across multiple organisations. Emergency Preparedness, Flu Pandemic, Children's Trusts, Health and Social Care workforce groups (regional), and so on.
The key blockage appears to be motivation. Organisations want to know WIIFM (What's in it for me) or they aren't interested. Primary Care Trusts - PCTs (sorry, the local NHS) can give money to independent contractors (GPs, Dentists, Pharmacists - and more) to give up the information, but children's trusts, with the requirement to gather the information across health (multiple parts), social care, education, justice and housing, anyone I've missed? are required to find this information without the cash to offer incentives.
Blockage 2 is comparing like with like. A competence in an aspect of child protection may be called different things by different organisations/ services, and may be a whole course or multiple courses for one service, but a part of a qualification for another. How do you know what you've got?
What about people who aren't using all their skills in their current role (and do we ever?). They are part of the available workforce but they aren't in the current workforce. They need to be factored in when deciding how many more to train.
This is a key interest for me and I'd like to hear from more organisations wishing to understand their children's workforce. Contact me at

Friday, 31 October 2008

Commissioner's responisbility in an age of competition

What prompted this blog?
In common with many others, I don't make enormous profits from management consulting, and rely on a fairly good stream of consulting to pay the costs. Of course once a week has passed without consulting, it can never be recovered.
We've had two interviews for work postponed.
In one case this severely restricts the intense work needed before Christmas from 4 weeks to 2 weeks, which will cause real problems with getting a high quality of work delivered (of course we can do it, but we'll need to put more resource in which compromises people's family time) - reason given: "key people are on holiday" (shouldn't they have checked this before setting the timetable?)
In the other the commissioner changed their mind over a key spreadsheet and we had a frantic few days transferring all of the information from the old submission format to the new and cross-checking for errors.
Sometimes it feels as though the commissioners on a salary (and often on a government-funded salary not tied in any way to outputs) lose touch with reality. All I'm asking is that you act as good stewards of public money, and plan your holidays around your duties not the other way around?

Monday, 27 October 2008

Performance Management after the event

I'm constantly called into situations where a set of projects or initiatives have been started, funded, and after the event the funding body recognises that they need to apply performance management. It's easy to spot - the projects or initiatives have names such as "2.5 Community Matrons", or other indicators that they are based on the resource used rather than the benefits to be delivered.
But for those who've tried, it's very difficult to go back into a project that's already got its funding and say "hold on, we need to performance manage you".
This is the point of the personal motivation approach.
Everything that gets done, gets done by somebody. What it achieves depends on the motivation of the person doing it. So when you go back to a project after it's already started, and want to assign some measures for the delivery of benefits, make sure you include the people who do the work (as well of course as the sponsor, and the people providing the funding).
The key to remember in these situations is that Performance Management is not the same as Benefits realisation. You can Manage Performance in many different ways, but if you want to deliver benefits, you need to steer the performance back to benefits, not just measuring against milestones. I can't emphasise this enough - focus on benefits and that's what you will get. Focus on anything else, and you'll get whatever you ask for - but it may not be what you want!

Sunday, 19 October 2008

Performance Management and Realising Benefits

Party - let's party

Why do you want to performance manage projects, initiatives and existing services?

Presumably to ensure that they deliver the benefits (as defined by the phrase "a benefit is anything that a stakeholder would sees is of value to them"), both those originally promised in the business case which won investment for this project, and those subsequently identified.

Does this mean that I've named the blog wrongly?

Quite possibly. The issue for many, with the term performance management is that it harks back to the days of time and motion, of external consultants telling people they aren't working hard enough, and of the breakdown in communications and trust between workers and between workers and management. So we need a new form of Performance Management, one jointly agreed between customers, workers and the organisations, which measures in a transparent way those outcomes that all can see are benefits (of value to at least one of the stakeholders).

That's where Benefits Realisation comes in.

Benefits are the outcomes of value. A benefit for a customer (or in public good parlance, a service user) may not necessarily be a benefit either for staff or for the organisation, but many organisations have aligned their own direct benefits (financial viability) with indirect benefits which do good in the long term (improved quality of life for users, adherence to public policy, addressing local needs which in turn improves quality of life for a whole group of potential, even if not current, users). Staff clearly benefit from the joy of seeing users receive benefits - it is more motivational to see the results of your work in the faces of the people you help than any amount of pay, for all we need our basic domestic needs (security, food, freedom, growth as reflected in the roof over our heads, basic health and hygiene needs, a car and/or a holiday, and opportunities for personal development) met from the financial reward of the job.

The benefits framework

I'm waxing lyrical about this. I too hadn't fully understood its significance for performance management in combination with all the other factors that contribute to benefits realisation.
Essentially a benefits framework is the agreed delivery of outcomes recognised, agreed and confirmed by all of the stakeholders. A given project, initiative or service may only contribute to one or two of the outcomes for the whole community or organisation, but by using a single framework to cover a wide range of projects, each project can see (and celebrate) its individual contribution at the same time as seeing that contribution within the context of the whole.
Using a framework reduces the effort needed to define, measure and report benefits and their contribution to the whole, as measurement and evaluation methods can be reused in different projects, and measures such as prevalence can be reported by all projects without having to be individually measured.
It's also highly motivating. The individual measures and benefits of a single project may be understood by the staff, users and management of that project, but often aren't understood outside of that project. A framework can take the time to define benefits and outcomes in ways that everyone can understand and accept, so the individual project's contributions can be recognised by all stakeholders and the stakeholders of other projects.

Defining the Benefits Framework

can only be done in conjunction with the stakeholders. There is a format - I've included the overview on and I'm presenting a proposed agenda the workshops as I get around to writing it in web format.

Sunday, 5 October 2008

Life in the Years, and Years in the Life

Famously turned into a catchphrase for World Class Commissioning by Gary Belfield, this quote first came to my attention as the subtitle (on the front cover) of Maxwell Maltz' book "Psycho-Cybernetics".
Maxwell Maltz Psycho Cybernetics
This is one of the founding books of NLP (Neuro-Linguistic Programming), first published in 1960, and holds the premise that you create your future by what you focus your attention on, desired or reviled.
Doesn't this just apply in work!
If you have a concern about something, then that thing turns around and justifies that concern. If you respect people and expect the best from them, you often get the best from them.
The Benefits approaches that I'm outlining here are all about identifying what you want, and so expecting to get it. In traditional project management some of the key focus is on what you don't want, with risk logs, and standards below which you should not fall (tell a child "don't slip" and their mind doesn't hear the "don't"), and so on. Of course traditional project management is vital to delivery of successful programmes, but meeting the numbers, meeting the deadlines isn't quite as inspiring to highly vocational people such as the caring professions as one might like.
But look at benefits. Benefits are those things that one or more stakeholders sees a value in. They are inspirational! It's easy to see when they are being achieved (yes I know I haven't finished publishing the Benefits Frameworks agendas especially the bit about Benefits Register), it's common sense to see why you would want them, and therefore they are going to pack more punch, gain more power in the mind (and according to Maltz, come about because of human's goal-seeking engine).
Use a benefits approach to deliver, and the results may astound you!

Running to reduce poverty, and World Class Commissioning

There's more to life than the benefits realisation, important though that is.

This weekend I ran the Great North Run, self-styled "The world's biggest and most prestigious half-marathon" - I came in 8381st, which doesn't sound too good until you realise that nearly 52,000 people ran the run this year! Actually I think that's too many, as the course never stopped being crowded. For those interested, my race number is 23855 if you want to check my times on the web site. My page on is still open for a month or two if you want to make a late donation!

Anyway, on a long run I find I have a lot of time to think.

In Public Service Magazine this month they report a What Matters survey about what motivates staff:

  • the support needed to do a good job

  • the chance to develop

  • the opportunity to improve the way staff work

  • the resources to deliver quality care for patients

  • I absolutely agree. Nobody comes to work to do a bad job, but without the tools to plan ahead, to understand what will be needed and to plan staffing and workforce education to meet these needs, staff end up working harder and feeling frustrated, as dramatic changes in need catch them unawares.

    That's where the Benefits Realisation work fits in.

    It's a structured approach to planning ahead, very-much outcomes focussed but with the outcomes themselves focussed on what makes a difference.

    WCC Cycle
    World Class Commissioning exhorts us to Understand the Need, Understand Current Service Provision, and Identify Gaps. But quantifying needs in terms of "we have this many of this target group, and only enough provision for half that" only tells you half of the story. What you really need to know is not what you need to expand starting from here, but what would be the very best solution.

    Kate Silvester, the OSPREY champion and leading light on systems change, says that at any time there's around 30% of waste that could be taken out of the system (muda spectacles); I've taken this to mean that the pace of change, of improvements in our understanding, in technology, and in the care possible, moves so fast that a system and care pathway perfectly designed to deliver care three years ago is now out of date to this extent. This means that doing more of what we were doing may not be the most appropriate answer, even though changing the whole system may not be the best answer (because of the disruption, and resources needed during the changeover period) either.

    So what should you do?

    Take a long run, say 1 hour, 53 minutes and 2 seconds, and spend some time thinking about it. No I jest.
    Applying the benefits principles first espoused in ISIP (Integrated Service Improvement Planning), and expanded and matured in this blog and on">my web site will help you. Instead of simple, and somewhat uninspiring, numbers, you'll identify the human story and the benefits to staff (highly rated as a good reason to come to work), patient experience, quality outcomes (also highly rated) and the best investment of finite resources (sadly, what we all seem to think is our sole purpose in NHS).

    Thursday, 2 October 2008

    Benefits Register

    Now to get into some Project Management (PM) stuff.
    Benefits is really about getting from your work what you set out to get.
    How many projects have all of us been involved in where the "benefits" were just some fiction to get granted the money; the moment the money was granted all pretense at measurement, evaluation, reporting or even achieving the benefits flies straight out of the window.
    A project is deemed to be a success if it hits all its milestones - it delivers on time and on budget with few casualties. Rarely is it (in practice) measured against what it sets out to achieve.

    Keeping a Benefits Register across the organisation or across a whole group of projects could put an end to this sloppy thinking.
    In the Benefits Reister we record once and for all the definition of each measure, each benefit, who's interested, who's neck is on the line, how it will be reported, and if a number of projects report on the same benefit, how the total will be aggregated.
    This means that each individual project doesn't have to scrap around for benefits to include in the bid for funding. Each project picks up to 6 Benefits from the Benefits Register that they believe will be the best way to show progress on their project. Then if the benefits they've picked are measured corporately, eg smoking prevalence in the most deprived wards of the city, the individual project doesn't have to go in search of the figtures, they've registered an interest and every time there is an update it goes to all projects which registered an interest.
    I'll go into more detail.

    Suffice to say in this blog that the result will be richer and more meaningful milestone reports coming out from projects, more likely to engage staff and service users, and because of this more likely to inspire stakeholders and sponsors!

    Tuesday, 30 September 2008

    In the Commissioners' shoes

    It isn't easy, commissioning innovative services.

    For one thing, the environment has completely changed. With the sharp separation between commissioner and provider (see "Great Wall of China" - left (whoops someone's turned it into a water park), instead of performance managing a contract, commissioners now have to understand the need, work out the solution, then procure it in a fair and proper manner.
    All this, and typically providers have a monopoly on the data, and whilst commissioners often write reporting into the contract, as long as people get the service they need it's difficult to bring any serious sanction to bear if a provider fails to supply the necessary data.
    Commissioning innovation is more difficult again. I'm not only looking for a new supplier (or at least opening up the market to more and different suppliers), but I'm also looking for a new service and quite frankly I don't know if it will work. Who wants their name to be associated with something that failed?
    As we discovered working with public services and third sector organisations, there's a real issue for innovative service providers to understand what the commissioner needs in order to feel comfortable, and conversely it can be difficult for commissioners to recognise the resource cost of developing new services, presenting their outcomes and occasionally having services which don't work as planned, where people need to be redeployed.
    There's also the personal issue - working with a supplier for years should result in a relationship based on trust. This means that a commissioner recognises, to move a service to another supplier means his/her friends are going to be out of a job. That's why you sometimes see unequal comparisons eg in one local authority they allow 40% overhead on salary costs for internal providers (providers who are part of the local authority) and 20% for third sector organisations - and that's without recognising that many of the overheads in the local authority (buildings, vehicles etc) aren't even declared as they are treated as fixed costs.
    The Innovation Exchange in London is hosting a programme to work with public services commissioners and providers from a variety of backgrounds to explore these issues. This follows Ann James' very successful "Meet the Dragons" event.
    I'm sure there's a lot to be learnt. The event is next week, I'm reporting on it and I'll update this blog.

    Tuesday, 16 September 2008

    Starting at the Top

    How do you usually define your benefits and measures?

    Many people define measures for each project. This means a lot of individual measures, which may only have meaning for the person who defined them. It means that the workstream lead (the senior responsible officer for delivering one of the organisation's overall strategic objectives) gets a pile of project reports and doesn't really have a way to aggregate tehm and report in summary. And it means that front-line staff and volunteers, and service users, often get fed up with "feeding the beast", collecting seemingly meaningless numbers that they never hear of again.

    If alternatively measures are defined at the highest level they can be (typically at workstream or key theme level), then assigned to projects, many of these issues can be overcome.

    1. measures and benefits have to make common sense to people, and it's worth applying a bit of effort when you know the work will be reused

    2. defining the measures (and allowing them to be achieved in more than one way eg for obesity to allow schools to show achievement through numbers in reception year and Year 6, vs obesity programmes showing people losing weight start and end of programme, vs Public Health showing the same thing only measuring obesity in the general population and mortality/ morbidity associated with it) is done once and clearly

    3. projects only measure what is most relevant to their achievement from the existing list of measures

    4. when reporting, the workstream lead can aggregate up the numbers (be sensible, they don't necessarily add together)

    This follows on from the last post but then so it should. Let me know if you find it useful

    Sunday, 7 September 2008

    More uses for Benefits Dependency Networks

    I've just run three more Benefits Dependency Network workshops and attended a workshop event on how to run them.
    It struck me how many different ways this fabulous tool is used:

    For a single project or initiative, it's possible to use a BDN as
    * a surrogate for a SWOT (Strengths, Weaknesses, Opportunities, Threats)
    * a way of anticipating and elucidating all of the benefits (and dis-benefits) that can occur from a particular action
    * listing all of the components or activities of a project and how they link to the final outcomes
    * explicitly and in a group agreeing the drivers or goals of the project, benefits, and measurables

    For a workstream (typically a priority of the organisation or group of projects of a similar nature) the BDN:
    * confirms with the group what the whole workstream is aiming for, and what projects contribute to these aims
    * identifies existing services which no longer contribute to the benefits or outcomes desired
    * where more investment is needed or even whole new initiatives
    * what is dependent on what - the order in time or priority of the projects

    For an organisation
    * highlight and agree the key aims of the organisation
    * see how the strategic aims (typically the commitments made in public) contribute to the key aims, and what other aims or outcomes are needed (eg if the key aim is to reduce inequalities and a strategic aim or publically announced deliverable is to improve access to mental health services, what else do you have to keep doing to reduce inequalities?)
    * identify areas for investment

    Sunday, 31 August 2008

    Rationalising the measurement of benefits

    A bouquet of flowers - the whole is more beautiful than the sum of the parts.  Measures must be in harmony also
    So many innovative teams set out with good intentions (decide the measures and how to report them, baseline, assign tasks and responsibilities) and then find that it simply is too much work to keep measuring and reporting, for too little result.

    The main problems that come up are:

    • too many measures, or too difficult to collect the results

    • difficult to translate into impacts which mean something (financially it's often relatively straightforward, in health in England use the tariff cost; but you don't make a full saving, and what of impacts in other areas such as patient experience?)

    • a specific innovation or new project is often part of a workstream (one of up to 10 key strategic objectives of a health community, for example Public Health, Inclusion). but where measures are chosen for each project it's difficult to aggregate when trying to report the outcomes of a workstream to the Board or Steering Group

    It may be better to work the other way:

    1. Steering Group or workstream stakeholders define: the overall aims of the workstream; the benefits sought, and how these will be measured and translated into impacts

    2. Each project within the workstream picks benefits from the list (aim for up to 6), and have the measurement protocol already defined

    3. additional benefits can be reported or a case made to have these included amongst the overall workstream benefits, but rationalised

    4. projects can show the difference they've made, and workstreams can report on all projects within the workstream

    5. many measures are collected centrally so individual projects can get on with delivering better care for service users

    Questions that typically arise

    • what if a project contribute to multiple workstreams? maintaining the preferred maximum of 6 measures per project, just report the benefits to multiple workstreams. Well-chosen measures will aggregate naturally eg they may not add together they may give an overall result which shows success even if it can't show which project delivered which amount of success

    • what if a benefit is recognised by multiple workstreams? get together and decide on a means of measuring progress towards/ achievement of the benefit which can be applied or used by all the workstreams, so wherever a project selects this measure as the way it will be scored it has a clearly defined way of measuring

    Tuesday, 19 August 2008

    Benefits in context

    I know I've highlighted this before, but it's worth saying again - keep the end in your sights or you will loose sight of it. But with many public sector organisations managing hundreds of individual services, and in many cases over 100 innovations, keeping track of which projects are still delivering/ still relevant to the changing aims gets increasingly difficult.

    There is a way. People rarely need individual services in isolation. Projects shouldn't be seen in isolation and this is the key to managing large numbers of benefits across multiple projects in a changing environment.

    By gathering together the services and innovations that deliver to support a specific client group/ user group, you can identify a small set of standard benefits, create measures that can be aggregated, and use this standardised approach both to measure the delivery of innovation and services, and to report on it at project, workstream and board level. And this applies whether you are the provider of a single service or the commissioner of a whole range of services.

    So: gather the workstream together and create a benefits dependency network and agree on it.
    This defines the key benefits you hope to achieve from all of your projects, how they link with the organisation's objectives and aims, and how each individual project contributes to those key benefits.

    Is this just a paper exercise? No:
    1. fewer sets of measures, clear definitions, and a straightforward way to aggregate
    2. when objectives change, you can see which projects are affected (which projects will deliver the "old" benefit and now need review to ensure they deliver the "new" benefit)
    3. you'll immediately spot which projects are working against each other instead of in concert

    Notes when doing this:

    • you may identify a project (or even an existing service) which doesn't appear to contribute to any of the benefits you identified. Have you missed some benefits that need to be on the chart so they can be measured and reported? If not, could it be that this project or service isn't relevant any more? Hard decision
    • benefits with no projects contributing to them. do you need targetted investment? Does it have to come from you or from another directorate/ organisation?
    • aggregating projects: too many individual projects is confusing - spend at least 30 mins and probably longer working out what goes with what, at least in terms of benefits delivery
    • include projects which contribute but may be funded from/ most connected with different work streams
    • simplify the measures so that individuals working on, benefiting from and sponsoring projects can quickly see what's going on and feel a sense of achievement
    • this leads neatly into Benefits Profiles

    Sunday, 27 July 2008

    Benefits - means to an end, or end in themselves?

    It's tremendously easy for a project to take on a life of its own and for the benefits to follow the project, rather than tying the benefits to the organisation or programme strategic aims and forcing the project to maintain its link with the benefits. Benefits realisation is often facilitated/ managed by someone not directly working with service users. Have a look at an aspirational vision statement - "we will reduce or eliminate inequalities in healthcare by 2012".
    In order to make this achievable, it needs to be broken down into specific milestones and specific steps, though in fairness the vision statement was never meant to go into this level of detail. Vision statements, or even the desired outcomes that make them up, don't mention the enablers. I don't remember a single vision statement for a hospital or primary care trust - the care providers - that talks about IM&T or worksforce, no mention of (for example) the shared electronic patient record, or more advanced practitioners to do the work. This makes it easy for the goals of the projects themselves to become disconnected from the overall aims of the organisation. This means that you need to define or find tangible, measurable, time limited (milestone) sub-goals or sub-outcomes which feed into the main outcomes, with each sub-outcome contributing to one or more outcome but often with a number of sub-outcomes contributing to any particular strategic outcome. Define them in tangible terms (SMART?), and break them down further. The discipline of drawing Benefits Dependency Networks (BDN) is valuable here. The BDN illustrates what benefits you expect to achieve, and what project is dependent on which other. With finite and limited resources, you need to know what to prioritise - very often enabler projects such as IM&T don't deliver end-user facing benefits, so it is easy lower the priority on these. However failure to deliver enablers at the right point in the project timescale mean other projects cannot deliver their benefits. Review your project. Which benefits as defined above does it contribute to (and which was it set up to contribute to)? What else is it delivering besides the sub-goals or outcomes defined above? How much resource is being put in solely to deliver these ancilliary goals? Should you be doing this? When developing new roles in the NHS Modernisation Agency, often the original driver for developing the roles had been "forgotten" in the course of pursuing an exciting project - the new role began answering questions and needs quite different from those originally envisaged. If this is the case you will come a cropper when the day of reconning comes! So focus on the original aims and treat all other successes as secondary - great in addition, but no substitute.

    Sunday, 6 July 2008

    Commissioning for Innovation

    innovate or die posterA number of pieces have come together in the same place which prompted this blog:
    • July 2007 audit on Futurebuilders' funding: don't expect the money back because innovative proposals take years to become accepted
    • CSIP published "Snakes and Ladders; Do's and Don't's for commissioners": lists many barriers to any provider coming forward with innovative solutions
    • this month's Public Sector Magazine supplement, Innovation through People

    Innovation is inherrently risky. Small change carries small risk, but small change usually means incremental change to an existing system, rather than transformation.

    With radical change it's much more difficult to know whether it will work or not. Easington Practice-Based Commissioning cluster (a grouping of GPs offering to identify areas of need and commission new, mostly community-based, patient pathways) which is in the East of County Durham Primary Care Trust prepared a home management plan for people who suffer from COPD (Chronic Obstructive Pulmonary Disorders). Without the plan, the only option someone suffering an exacerbation is to call 999 - when you can't breathe you're in a life-threatening situation. The most usual course of action for the attending ambulance is to take the person to A&E, which in this case is a substantial journey for ambulance, for patient and for friends and relatives.
    With the plan, the patient has an immediate opportunity to self-medicate - up their existing inhaler or nebuliser dosage to a pre-determined level, and only resort to stronger medication if they observe no change. They then call community nursing to review the case - but it's a whole lot less traumatic and a whole lot more cost-effective than the trip to A&E and probably hospital admission.
    But how many patients will actually use the plan? Is it written in a way that someone suffering an exacerbation can follow? Having used the plan, how many actually end up in A&E? Does all of the investment in the new pathway repay in savings? What about staff and patients - do they get any benefits?
    We decided the only way to see what would happen was to try it out - at risk. As it happens, the only cost has been the dedication of people's own time in preparing and launching this scheme, and the results are already showing a very real benefit to patient experience and to use of resources. But what if it hadn't delivered - would the initiators and those involved have a black mark against them for failing?

    New Types of Worker's "Benefits and Case for Investment" programme hit this same problem. Voluntary Sector organisations stepped forwards with their most innovative projects, and asked commissioners from local authority, health and major charities to guide them to make the case for investment.
    Of course there are two sides to every story - the innovation teams assumed a level of knowledge, for example about individual budgets, that could only be gained from attending national conferences and many commissioners are too busy doing the work to keep up with the 'next big thing'. The commissioners asked why the presenting teams didn't use their (the commissioners') language and why they didn't address this year's targets (rather than next year's). However the outcome was disappointing - effectively the commissioners said "the budget is overcommitted and we can't take a risk on something that might not pay off".

    the INNOVATE buttonFor the facilitators (me!) there are a lot of lessons to incorporate about repeating the briefings, keeping the energy high and the atmosphere informal, and stepping in when things get heated. But for most negotiations there is no external facilitator: innovation isn't a push-button affair - there's a real risk that by the time innovation is needed, all of the innovators will have given up and gone elsewhere.
    But it still leaves the question "how much of an already overcommitted budget should you put aside for innovation? How much should you invest in R&D?". 8%? 15%? 8% of £1billion budget is £80million. An enormous risk, and of course it has to come from somewhere else. But public sector can't search out innovative solutions to the developing problems without making this order of commitment!

    Sunday, 29 June 2008

    Asking for the Money – the second workshop

    Four projects made it through the programme. Four months ago, in March, we brought 4 organisations representing 5 innovative projects together to transform their fundraising efforts from cap-in-hand to sustainable funding.
    Since then, one organisation (the one with 2 projects) suffered 6 weeks staff sickness and had to drop out, and another stepped forward. Expert commissioners from six organisations (three local authorities, two well-known charitable funds and a healthcare commissioner) came forward to hear the presentations and offer advice, and I gave one to one coaching each month to each of them.
    I think we all came to the second workshop, the one where innovative projects had to present their cases based on what they’d learnt, and where the expert commissioners were to offer advice, with trepidation. I didn’t sleep the week before.
    The projects spent the morning sharing what they’d learnt and other tips for approaching funders. In the first half of the afternoon the projects presented their cases, and the panel didn’t stint in their criticism and suggestions for improvement. For the second half the projects went to one room to consider the process and what they’d learnt, and the panel went to another to summarise their advice. A very instructive day!

    What would I do better another time?
    • Give the projects time as individual teams to consider what they’d learnt before sharing it (this worked really well in the first workshop in March)
    • Introduce the panel of expert commissioners at lunchtime and before the presentations, which would have made it less formal and more personal.
    • The projects were all selected as “hard to fund” – I think the panel were expecting ‘bread and butter’ proposals presented in a ‘bread and butter’ way, whereas gathering and presenting the evidence is difficult for real innovation. I hadn’t made this clear.
    Going forward
    • Right now we’re preparing a written report to help innovative proposals who weren’t able to attend this programme. I’d like to run more programmes because it delivered so much value to the projects

    Wednesday, 11 June 2008

    Bringing home the money

    Don't be embarassed to ask for money!

    Time and time again I talk to charities and public sector workers who can't ask for the money they need to deliver the service people deserve. Money isn't dirty. Money isn't evil. Even the love of money isn't evil. Money is like energy - you use it for good, or you use it for bad, and the more that passes via you the more you can achieve.

    On Monday I gave a workshop on Evaluating Innovation at the "New Ways of Working in Health and Social Care" conference in Manchester. My theme helped innovation make the leap from prospective funding (looks like a good idea, here's something to get you started) to sustainable long-term funding (fantastic - we get all this and you only need this much per user to run the service). I picked on measurement, because it's often the weakest part of many proposals - how can you show that you are making a difference?

    The points are these:
    • commissioners are people too: they will put money into innovation that looks likely to succeed - and you can show that you have already succeeded by showing the results you achieve (and show you mean business by submitting to evaluation)
    • there is a finite amount of money - but it is enormous (health for example has £100billion to spend). If you can show that your idea will deliver more 'bang per buck' in the things that matter - care, outcomes, patient satisfaction, value for money (and not even all of these: if we wanted to save money on health we'd still be spending £42billion not £100billion), and raise it up the priorities list above competing projects, then you will get funded - provided you can generate enough confidence that you can succeed
    Get a sponsor/ mentor. Do a great thing. Dare to dream. And be quite open and honest about the resources you need!
    strategic process for business case

    Good luck! Hugo

    Monday, 2 June 2008

    A good bottle of wine

    I looked at some typical templates for preparing business cases the other day - filling them in is like riding an intellectual roller coaster:
    1 - your name (easy)
    2 - contact details of the person proposing (yup, can do that)
    3 - write 200 words describing the service (wow, launch straight into it and try to get your brain in gear)
    4 - have you done a risk assessment? (tick yes or no)
    and so on - demanding one moment, the next pedestrian.

    So how to tackle this?
    Identify the demanding bits (why is this service needed, what difference will it make, bottle of fine wine and a glasstimescales, summary) and get yourself into the right frame of mind for completing them - may I suggest an evening in front of a nice coal fire with a good bottle of wine (or a bottle of good wine - wine anyway).
    Identify the easy bits - save these for completing the following morning when you need something straightforward to do
    The same demanding bits turn up time after time:
    What would happen if you didn't make the change (also known as Need, Reason for this project, Background, etc). If the situation will go away by itself then you hardly need to make a case for change, do you?
    What is the change (typically one sentence saying what you are going to do - actually this doesn't come up very often, a lot of business cases consist of 4 pages of how terrible it is now, and 6 pages of how wonderful it will be if the business case is approved, with very little on what you are going to do!)
    What difference will it make (the basis of this whole BLOG - how to evaluate and report the benefits of the change)
    When, how much you need, what cash flow pattern, major milestones (absolutely vital. So many innovative projects are only just starting out when 12 months in someone says "how's it going - can't see much going on" and pulls the money for the next 'good idea'. Most health and care innovation takes 18 months before you can see any benefits, so say so and put in some milestones (such as 8 months = job advert) to show progress.

    Have lots of fun, and keep it down to 1 bottle (and one side of A4)

    Monday, 26 May 2008

    Case Study - Assistant and Advanced Practitioners in Radiology

    As medical care becomes more proactive and subtle, so better and more rapid diagnostics are needed. This typically falls to the imaging disciplines, such as Radiography.
    NHS Modernisation Agency's Changing Workforce Programme (CWP) ran an Accelerated Development Programme to assist the implementation of these roles, and one site was City Hospitals, Sunderland.

    Why this was needed?
    Increased numbers of tests have not been accompanied by increased numbers of radiologists; radiologists take many years to train and the increased volumes of referrals meant that for example in City Hospitals Sunderland the waits for routine barium enemas had increased to 30 weeks.

    What happened?
    Radiologists ran barium enema lists themselves under the supervision of a radiographer, with their reports checked by the supervisor rather than the whole reporting process remaining with the senior radiographer.

    What difference did it make?
    Waits dropped from 30 weeks to 2 weeks over a period of 11 months. Turnover of staff in role dropped by 10%, and agency spend by 47%.

    Lessons learnt
    Staff want to do the best job they can, so giving them more opportunity and the responsibility to know their own limits and ask advice can deliver tremendous wins for all parties.
    The same staff handing more patients means lower cost per patient - this has to be offset against the cost of training to enhanced levels but the results were conclusive that it was cost-effective.
    We also audited the number of changes the radiologists made to radiographer reports and found that the radiographers achieved excellent reporting with only a few changes needed.

    Case Study - enhancing the role of Medical Secretaries

    NHS Modernisation Agency's Changing Workforce Programme (CWP) ran an Accelerated Development Programme (2002-04) to roll out enhanced roles for Medical Secretaries.

    The Need (Why did we do this?)
    European Working Time Directive was beginning to impact on doctors' hours - whereas previously doctors could work any number of hours (helped by the "on call" shift not being particularly busy so the doctor could sleep) a combination of factors (including more call-outs at night) meant this position was no longer teneable. The result - anything that could be done by someone else should be done by someone else, to make the remaining hours as effective with limited resource as possible.

    What did the Medical Secretaries start to do?
    Instead of simply typing up notes and tapes, and taking phone calls often only to ask the doctor to ring the patient or GP back, Medical Secretaries began to join ward rounds with the consultant and doctors taking notes as they went around, and to make appointments/ change lists/ give diagnoses where the diagnosis confirmed what was expected by the patient or GP, and so on.

    What difference did it make?
    On doctors: the range of freed up time was between 0.5 and 15 hours extra time made available per week, showing how much time had been taken up with administration tasks some of which the doctor was ill-equipped to manage. For GPs this enabled between 4 and 27 extra patients to be seen per week. Result: proper rest and recuperation in time off.
    On secretaries: apart from completing administrative duties much more quickly and with greater accuracy (often not having to undo the doctor's attempt at administration before doing it right), the development of the role provided more career opportiunties for this group of staff - applications per vacancy were noted to have increased.
    On patients: although no quantitative studies were done, changes to appointments and adding extra patients could be done much closer to the time of appointment, and discharge letters were sent out to GPs much quicker with no systemic delays.
    On costs: the numbers of administrative staff broadly remained the same, and as administrative staff developed their skills so their pay went up: however services continued to be delivered to the same number of patients at a time when the number of doctor hours were restricted back to 56 hours. The 46 sites that were involved in the ADP thought it very valuable and have continued to spread the enhanced role, though the actual cost per patient appointment for the whole team has not been possible to ascertain.

    Sunday, 18 May 2008

    Case Study - funding for training ECPs

    In olden days, physicians delivered care in hospitals, and primary care was delivered by witches. OK very olden days, but it took a long time before it was acceptable for a doctor to deliver care in the patient home (Edinburgh Medical School 1760s), and certainly the 'scoop and run' ambulance service originally designed to recover the wounded from the field of battle in the Crimea has no intention of delaying a patient reaching the safety of the hospital right up until now.
    But things have changed. Hospital A&E began filling up due to a number of factors, the principle ones being a maximum 4 hour wait (access to care) and less easy access to GPs (new GMS contract). In rural areas where hospitals are often distant from the patient need another factor contributed - ambulances could be tied up taking a patient to hospital which played havoc with response time targets.
    What was needed, so Warwick Univ, East Anglia Ambulance Trust (EAAT), Joint Royal Colleges Ambulance Liaison Committee (JRCALC), and just about everyone else but completely independently, decided, is a practitioner who can
    • respond to a request for unscheduled care at the scene of the accident or need
    • treat minor injury or illness on the spot and discharge the patiet fully treated (or stabilised to see their GP in due course) or refer the patient to a non hospital pathway
    • thus saving both attendance at A&E and possible admission
    EAAT put a community nurse and a paramedic into the same car to see how it would work. Warwick Ambulance Trust designed a training course to teach paramedics the bits of nurse training and nurses the bits of paramedic training - both resulted in an advanced practitioner (single person) with years of experience delivering health care and the minor injuries, minor illness and referral bits of a nurse and trauma and live sustaining bits of a paramedic. A few arguments later and the name Emergency Care Practitioner or ECP was born.

    How much benefit did they bring (and how much did they cost)?
    I embarked on a detailed exercise to find out how many patients the average ECP would divert from A&E by treating at home or referring to another pathway, and how valuable this would be. At the same time both Sheffield Univ (ScHARR) and I researched how much the average ECP cost to train, including equipment, car, backfill, etc.
    The results are published in "The ECP Report: Right Skill, Right Time, Right Place" (Sept 2004). Each Whole Time Equivalent ECP saved around £26,500 overall whilst working on emergency responses, taking into account the number of saved ATTENDANCES at A&E, their higher salary and cost, the times they had to call an ambulance for the patient, etc. We had no idea how many admissions they would save so we didn't include it in the calculations (this came later, ramping the benefits up in "Measuring the benefits of the emergency care practitioner" (July 2007).
    Each ECP cost around £40,000 to train including backfill whilst on training, uniform, equipment, medicines, etc. This means it takes less than 3 years (allowing 1 year whilst they qualify) to get your investment back.

    The explosion in numbers
    With clear numbers, ambulance trusts began training ECPs and there are now (4 years later) nearly 1000, which indicates an investment by tens of NHS Trusts of £40million.

    Difficulties encountered
    It hasn't been plain sailing.
    The benefits (A&E avoidance is given above, but they also worked in Out of Hours and A&E or Walk-in Centre settings) didn't benefit the ambulance trust who paid for the savings, they benefitted the Primary Care Trust. Ambulance Trusts either had to swallow a considerable sum in training, or negotiate for a paymet from the PCT.
    At the same time ambulance trusts were hit with a new response time target and perceived that experienced paramedics spending perhaps 2/3 of their time on non-ambulance duties starved them of staff to meet this target (I modelled London's response times and showed they could do even better by training up a critical mass of ECPs - but see next)
    Politics got in the way. Driven by a few people who hadn't invented the ECP, ambulance trusts began to clamour for an "advanced paramedic" who could avoid A&E admissions but not do any of the other ECP things like Out of Hours or Walk-in Centre. Research showed that it was the rotation (especially time spent in A&E) that really caused the change of behaviour but this was politics, not evidence.

    Where are we now?
    In spite of the above ECPs are providing care in large numbers throughout England, employed by ambulance trusts, primary care trusts, GP surgeries and private companies. The title isn't yet regulated because this is a long and drawn out process, but the evidence is there that this new practitioner, the first successful really new practitioner for decades, really is a cost-effective solution delivering excellent patient care. Of course none of this could have happened if it hadn't been an excellent solution, but without clear numbers it would have been difficult for trusts to justify putting ££millions into training up ECPs to deploy them.

    With massive and heartfelt thanks to my friends on the ECP national team who made the ECP happen in the first place and gave me the support I needed to prepare the benefits case: Chris Wintle, Belle Connell, Mark Bilby, John Gosnold, George Alberti, and so on; and at Changing Workforce Programme and Skills for Health who kept on supporting ECP programme.

    Sunday, 11 May 2008

    Running an Aims and Outcomes workshop for multiple projects

    The New Types of Worker project has commissioned me to run a programme with a number of third sector organisations to help them make the move from development grant to sustainable commissioned services. It is one of the most exhilarating projects I've done, because the projects themselves are so varied and fascinating.

    In essence, the 4 month programme consists of:
    Month 1 - get to know each project and the people, bring them all together to network, confirm the aims for each project and how they will know when they've reached these aims.
    Month 2 - coaching to ensure each project is collecting evidence to show they are progressing
    Month 3 - coaching to report the evidence and demonstrate impact and cost/ benefits
    Month 4 - practice session (as a workshop) with commissioner representatives who can say "when you show that, it makes us feel you're really going to contribute. When you show that, it doesn't add any value"

    For this blog I'm presenting the outline of the Month 1 workshop

    Aims of the workshop
    recognise that development grants are exactly that - development. At the end of a development grant the project should have approached commissioners of services for sustainable funding based on delivery of a specific service
    recognise you are not alone - others are in the same place

    set milestones:
    • agree everyone's understanding of AIMS,
    • what success looks like,
    • how you can measure this,
    • the mechanics of collecting measures
    Invite between 4 and 6 new projects (each probably supported by a development grant or funded internally, each having confirmed that they don't know how to find ongoing funding because if they can get ongoing funding they don't need this programme - this is for the really difficult cases)

    Timing and Agenda
    10:00 meet, refreshments, networking
    allows people to go into the office first if they must, time to catch breath, sit in groups with their project, get things off their chest

    10:30 each project has 5 minutes to introduce themselves and explain what the project does
    everyone finds out what every project is about in a structured manner, with no interruptions as there will be plenty of time for feedback and questions through the day.
    structure of presentation is:
    • name of project
    • people presenting at the workshop
    • objectives
    • successes
    • barriers
    11:30 discussion on the nature of funding, the need for funding in order to provide a service, priorities of commissioners in terms of
    • National Indicators to achieve
    • demonstrating value for money
    • dividing a finite pot of money between competing priorities and competing providers
    • the must-do (delivering core services) vs the nice to (most of the innovation is not core services)
    what makes their offering believable to commissioners will be evidence - how much, how many - so the importance of assembling and reporting this in an easily accessible way
    gets everyone to the same understanding of the issues, gives people a bit of time to digest what they have heard about each project and who they will want to network with afterwards

    12:00 refreshments and networking time
    can ask questions on the last session, but also talk to projects facing the same issues as your own

    13:00 in groups of 2 – 3 projects, each project focus of attention for 30 mins or so, focus on
    • their own achievements
    • outcomes and measures
    • process for gathering measures
    • actions and timetable

    as each project is focus of attention, the other projects in their group help them to understand what they have actually achieved (people often miss the most obvious achievements as we assume they are “normal” or “not important”). Facilitators support the group deciding what are the outcomes they wish to measure and how to measure them; the final outcome of this section should be for each project to have an action plan both for connecting with the most likely sources of funds and talking about what they have achieved, and a plan to assemble the evidence to illustrate these achievements

    Break part-way through to share feedback and "borrow" ideas, drinks/refreshments

    2:30 feedback from tables (what was difficult, how difficulties were overcome, next steps for each project)

    some of the best feedback is from an independent peer. Sometimes you don't present the best things you are doing because they seem "normal" to you; other times the obvious solution may be so big that you can't see it right in front of you. By making each project centre of attention we got really powerful input from credible people (people in the same situation)

    3:00pm what support is now available to selected projects:

    • Follow up action plan after 4 weeks (1-2-1 facilitator plus project) – from deciding measures to collecting measures
    • Next coaching session after another 4 weeks – using the information collected to make a story which illustrates the impacts and benefits both anecdotally (selected case studies) and quantitatively (how many, how much, how effective)
    • Next workshop 3 months after the first – networking and sharing what you learnt; presentation to a panel of experienced advisors who will say what they like, what they want to see more of, what isn’t relevant to funding bodies. All projects will form the audience for these presentations so all can learn from the advice given to each project. Consolidation of the feedback given
    • Note a key component of any business case is the information presented – does it meet the priorities of the potential funding body and does it illustrate that you are competent and likely to deliver on your promises. This applies whether the presentation is in written form, in person, or in any number of other ways

    3:30 workshop closes

    this structure partly works because it allows people to talk to people in the same situation. It isn't a "teacher-pupil" relationship where the presenter "tells" everyone and they either do it or they don't; people have time to get comfortable with their peers before receiving input and we got fantastic results really quite quickly.

    Facilitators are needed to deal with queries and to keep time - moving projects on when their 5 minutes (at the start) or 30 minutes (during discussion) were up, and explaining what was expected at each stage in the form of outputs.

    Clear explanations and guidelines are vital to get people away from what they perceive are their priorities - typically the things that keep them awake at night (and often not the real priorities at all). Provide a clear structure and expectation and people will be really creative and productive

    I hope you find this interesting and fun to do. Third Sector and Public Sector work is brilliant because people aren't really in competition with each other and are so generous with sharing and contributing - Hugo

    Monday, 5 May 2008

    Building an Evidence-Based Business Case - NHS version

    How your aims may intersect with the organisation's aims
    Resources, Money, Staff, Management Buy-In - everybody wants it. To be fair, without it innovation won't happen. But how to get it?

    NHS as an organisation has to deliver services 24 hours a day, 365.25 days per year (don't forget the extra quarter day!). This means the people at the top have to be operational, and innovators have to convince them of the safety, quality and achievability of our solutions.

    But it isn't all about money - if it were we wouldn't have increased spend on NHS from £42billion to £100billion since 1997.

    So how to create a business case to convince these operational people?

    Before you start
    1. To ask myself: What is my proposal? Understand WHY (values, ethics, high level NHS values)? Why should it be supported? What are my chances of success (the hairdryer model)?

    It isn't what you say, it's who you involve
    2. Identify stakeholders and the wider stakeholder group - Who will benefit (not "the patient", which organization has a vested interest in this aspect of improved quality? Eg if it is to do with Public Health then it is the Public Health bit of the PCT, if to do with improving patient flow for elective care then the Hospital will be most interested). From this, who are the best sponsors and who are the gatekeepers? How do I involve patients and front-line clinicians?
    Who you should involve - Public, Clinicians, Management, Data, Father Christmas3. What are their priorities? You should refer to organisations plans - eg LDP, business plan etc to understand priorities. Do the benefits from my proposal support one or more of their priorities/wider NHS priorities e.g. Selbie 6? In what way? If none of my benefits support any of the priorities of the organization then consider going no further (or try harder to find a link). What about non-NHS organisations eg Local Authority, National Government, Charities

    Nobbling the right people

    4. think about the journey my business case will travel, which committees. Who is the best person to help (typically a Director or Senior Manager)? - this is the SPONSOR
    5. Who has evidence, audit or other information that I can use to build my case?
    6. Who would like to support me, or who would be offended if they weren't involved? Keep your friends close and your enemies closer – how do you get your case onto people’s agendas – make the links?
    7. Talk to the people who would like to help and who have the information I can use, and start building the case. Identify the weaknesses and talk about them early. At what point do you need to switch from pull (consensus – lets all join in) to push (this is the way we’re going!)

    Writing the case

    8. Assemble a team – involve patient or patient rep, and cross-check you have the right stakeholders e.g. third sector, independent providers. Agree what the problem is you are trying to solve. If more than one, then identify which is the most important and keep the others in reserve. Agree on what the options are. Do PESTE (political, economic, social, technological and environmental issues) and/or SWOT (Strengths, Weaknesses, Opportunities, Threats) on the options. Pick the best one or two.Strengths/ Weaknesses/ Opportunities/ Threats for a number of options
    9. Work up a more detailed benefits/risks/costs/timescales on the best options. Be clear about scope. Delegate each task to the person best able to do it - play to people's strengths and flatter their skills
    10. Think hard about this one - if you say you are going to make savings, say how you will realize those savings. For example, if you are going to save money, can you actually get that money out of the system? How? If it means fewer working hours, then what are you going to do with the hours saved that the panel will think is worth while (eg ECPs on 999 responses save hospital attendances, but A&E costs the same amount to run. So the savings come initially because you stop the rise in the number of A&E attendances rather than because you reduce the number of attendances, and the rise would cost money. Then the ECPs have impacts on other pathways which might cost money but are cheaper than an alternative, or which might save money but how can you realize those savings?)
    11. Work out a 90 second message that you can all agree, and try it out on each other. You will probably need slightly different messages for different audiences but make sure they are sufficiently similar that anybody hearing any message recognizes that it is for the same proposal. Try out your 90 second messages on a couple of guinea pigs, if necessary referring to notes, so that all of you have practiced at least once and can say it under stress (in a chance encounter with the Chief Exec in a lift, for example). Keep everyone informed, including ‘observers’ (with a passing interest) so they can input as appropriate and get involved if they want
    12. Write a summary of the business case in the format above (Context, Proposal, Benefits, Costs) that you all agree with, that fits onto no more than a side of A4 or a side and a half, and that carries the message. Get someone who isn’t connected, preferably from outside NHS, to read it
    13. Fill in the detail in accompanying appendices (eg Options Appraisal, Workforce Strategy, Finance and Costs, Corporate and Clinical Governance, Affordability & Risk, Glossary of Terms)
    14. Go back to your Sponsor (or get the person you have as an intermediary to go back to them) and try out your proposal. If they don't like it then find out how they think it could be improved.

    Presenting to a Committee
    15. From your sponsor and anyone else, find out which committee is the best one to review your case, and which budget the investment will come from. Who do you know on this committee? Who can you contact? Hopefully your sponsor is on this committee but if not then you need a second sponsor who is on this committee. Don't send proposals to the wrong committee - that just waste's people's time.
    note that you may have to present to more than one committee,
    • because you may have committees which pre-filter proposals, ie deciding which proposals have sufficient merit to go before the board?
    • you need the support and information from a sub-committee reporting to a main committee in order to get the change or investment you seek
    16. When is the best time to put your case before the committee? At the start of the year when they have the new budget? At the end when they have money left over? Immediately after a scandal in the media? This will depend on how much and how long it takes to get benefits amongst other things. Work out a strategy to put your case before the right committee and to contact (the team or through intermediaries) as many members of that committee as possible. Most important question: Are you the right committee? Second most important (you may need to talk about the proposal first) Will they support it? Does it need changing for them to support it? Often a committee wants to see evidence that you have consulted front-line staff and service users, and if you can get these stakeholders involved in presenting the case it will help considerably
    17. Once you've been through this process, if most of the people you've spoken to on that committee support your proposal and you've had no serious objections then you will have no trouble. If you have any serious objections, even one, you need to understand why they object. It could kill the proposal
    18. Note the proposal that goes to the committee, after people have commented and suggested changes, may be a bit different from your original idea. Is this a problem? Have the suggestions made it better?

    I know it is a fairly long process but writing a business case is even longer and there's no point in putting a lot of effort into the business case but not being prepared to put a little bit more into making it robust.

    Monday, 28 April 2008

    Accolades 2008 - nominate by Friday 2 May 2008!

    ACCOLADES 2008

    ...still time to enter!

    Nominations close FRIDAY 2 MAY 2008

    Read on to learn more about the many benefits of winning an Accolade and to get some useful tips for nominating!

    Dear Colleague

    To achieve an Accolade proves an organisation's success in achieving the highest standards of workforce development within social care.

    If you or someone you know has not already done so, then its not too late to get involved in the Accolades 2008. So please feel free to circulate this information to anyone who you think may be interested in participating.

    Now in its sixth year, the Accolades has grown in stature to become one of the most prestigious and enjoyable events of the social care calender.

    There isn't much time though as nominations close on Friday 2 May 2008 and completed nomination forms need to be returned by this time.

    People can get involved by nominating an employer or an organisation for a range of categories. Details of these can be found in the Nomination Booklet, which is attached at the end of this e-mail.

    The benefits of winning an Accolade are many.

    For those people who use the services provided by an Accolade winner:

    * satisfaction that the award is a reflection of the efforts made to improve the life of people who use services, by providing opportunities for workforce development of those supporting them

    For an Accolade winning organisation:

    * pride

    * good for business

    * opportunity to evaluate your own progress and achievements

    * external validation of your work - acknowledgement of what you believe you do well (even the every day things)and is good practice, is confirmed by those at the forefront of the social care sector

    * increased recognistion, credibility and reputation

    * free publicity - national and local press, sector publications and journals, radio and television coverage

    * opportunity to attend a prestigious national event and celebrate what is good in social care workforce development with other leading organisations

    For individuals/teams employed by an Accolade winner:

    * personal jubilation

    * recognition and reward for your efforts

    * opportunity to attend the gala event

    Top tips for completing the nomination form:

    * approach it as a team (where possible) - use the different skills that each of you may have

    * consider what you do well in relation to the different categories

    * consider what are your achievements or practices that you are proud of

    * decide on which category to enter

    * take time to study the criteria

    * make notes of policies, systems, procedures, implementation and outcomes relating to the criteria

    * decide on how you are going to present the information within the nomination e.g. chronological order of how and when systems/policies etc. were implemented in practice

    * always provide evidence in support of the statements you make e.g. give examples of what or how you are doing things - don't just state you are doing them

    * always remember what your work means to people who use your services and what benefits they get from it

    * make the most of the word limit you have available (most Accolade winners would say that the hardest part of completing the nomination form was keeping within the word limit!)

    Many thanks to Joy Johnson, HICA Care Homes & Trevor Hewitt, Barnsley Adult Social Services - Accolade 2006 & 2007 winners, for sharing the benefits that their organisations have enjoyed from winning an Accolade and for passing on their top tips for entering.

    Further information in support of the Accolades are attached below.

    This includes:

    - a Nomination Booklet


    - Category Information Sheets (for all categories) <>

    - Nomination Form A (to be used for nominations for categories 1, 2, 4, 5, 7, 8, 9, 10 & 12) <>

    - Nomination Form B (to be used for nominations for categories 3, 6 & 11 only) <> To request hard copies of the nomination materials please e-mail

    or call 0113 241 1275.

    Thank you.