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.

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