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!