Strategic recommendations and practical tips to help nurses write thorough and convincing business cases. This article is accompanied by a self-assessment questionnaire so you can test your knowledge after reading it
At a time of cuts and savings in the healthcare system, how can nurses convince decision makers to put money into improving or expanding services? A clear, concise and comprehensive business case is a good place to start. This article provides nurses with strategic recommendations and practical tips, stressing that a strong business proposal will need to be linked to local and national priorities, and articulated in the language of financial constraints. Nurses are often reluctant to write business cases but, with the right knowledge and support, they can successfully bring a service improvement idea into the strategic arena.
Citation: Carter H (2017) How to write a robust business case for service development. Nursing Times [online]; 113: 7, 25-28.
Author: Helen Carter is an independent healthcare adviser, Carter Consulting, Oxford.
Writing a business case, while time-consuming, is not complicated – but getting it wrong can be costly and frustrating. At a time when the healthcare system is trying to cut costs, nurses who want to improve or expand services need to able to write business cases that stand out and convince decision makers. This article outlines the national context, provides practical advice for all nurses – and specialist nurses in particular – and gives tips for linking a local service improvement idea to an organisation’s general targets and constraints. The advice given is not a guarantee that nurses will win their case; however, as integrated health and social care moves forward, it will certainly allow them to share their expertise of working with specific patient groups and identify how their roles can add quality to service provision.
What is a business case?
A business case is a formal, structured written document submitted to those responsible for approving and/or funding a service development initiative or project. You will need one if you want to obtain, for example, large or costly pieces of equipment, better information technology systems, additional staff, service changes or new services. A business case is usually made at a local level. By contrast, a business plan is the overarching document describing a major initiative or the strategy of an entire organisation – the two terms are sometimes used interchangeably. To increase the chances of a business case gaining approval, it can help to present it as part of a wider initiative, rather than in isolation.
Writing a business case is a time consuming process that usually follows a period of data collection, audit and analysis. It is not difficult in itself, but getting it right can be tricky, especially if the authors are not aware of the local, regional and national priorities that will influence the decision. A business case should reflect the organisation’s priorities, values and goals, and its author(s) should try to understand the complexity of service development and funding.
Understanding the national context
Year on year, there is a continued focus in the NHS on improving productivity to make savings by 2020/21. Clinical staff are expected to participate in the efforts to improve efficiency and reduce costs while maintaining high-quality services.
For nurses who are keen to be part of the current transformation of health and social care, this is a good time to try to influence the process, but they need to understand the national context and learn to articulate the needs of their services in the language of financial constraint. If they do so, there is a realistic possibility they will secure the resources needed to enhance services. There are a number of national documents, frameworks and priorities of which they need to be aware.
Better Care Fund
The Care Act (2014) provided a legal framework for the allocation of money from the Better Care Fund, which organisations can access to promote the integration of health and social care. The Department of Health and the Department for Communities and Local Government (2016) have identified the national conditions that bodies responsible for Better Care Fund plans are expected to fulfil in 2016/17.
Sustainability and transformation plans
Sustainability and transformation plans (STPs) were announced in NHS planning guidance at the end of 2015. NHS organisations are now required to develop five-year plans to determine the key priorities for their geographical areas and identify how services are going to be delivered in an integrated way across health and social care.
There is a push towards strengthening primary and community services, as well as encouraging individuals to take responsibility for their health. From April 2017, STPs will be the only way to secure additional NHS funding, with the best plans receiving funding quickly.
The King’s Fund has assessed STPs (Ham et al, 2017) and concluded that:
- They offer the best hope for the NHS and its partners to sustain services and transform the delivery of health and social care;
- They are wide-reaching and propose changes in several areas, from prevention to acute and specialised services;
- A high priority for many STPs is to redesign services in the community to reduce demand for in-hospital care;
- Proposals to reconfigure hospitals could improve quality but need to be scrutinised and considered on their own merits;
- Proposals to reduce capacity in hospitals will only be credible if there are robust plans to provide alternatives in the community;
- Cuts in social care and public health, as well as the lack of earmarked funds to support transformation, will affect the ability of NHS organisations and their partners to implement STPs.
In its assessment, The King’s Fund points out that there is widespread criticism, anger and anxiety in the face of these latest proposals, which appear to be reinventing the wheel or overcomplicating a system that is already suffering hardship (Ham et al, 2017).
NHS England mandate
The government published its mandate to NHS England (NHSE) in January 2016 (DH, 2016a). This set out the objectives, budget and how NHSE’s performance would be measured for the current financial year. On 31 March 2016, NHSE published the NHS outcomes framework and indicators for 2016/2017 (DH, 2016b), which set the priorities for the coming year. The key themes were improving health, transforming care, controlling costs and enabling change.
The DH (2016a; 2016b) set out indicators and improvement areas to which NHSE would be held to account, which included:
- Preventing people from dying early;
- Enhancing the quality of life for people with long-term conditions;
- Helping people to recover from episodes of ill health or injury;
- Ensuring people have positive experiences of care;
- Treating and caring for people in a safe environment and protecting them from avoidable harm.
Key components of a business case
The key components of a business case are described in Table 1. It is likely that your organisation already has a business case template; alternatively, examples can be sourced online. Your organisation may also have a template for risk assessment, which will help you identify risks; these may become apparent as you scope the project.
Before you start writing, remember to find out what your local policy is in terms of:
- Processes to follow;
- People to consult;
- Authorisations to be gained.
This will help avoid disappointment if your bid is not well received.
Nurses who want to get involved in writing a business case need an in-depth knowledge of the scope, feasibility and issues of the proposal. This will involve plenty of discussions with stakeholders. It is important to include stakeholders, patients and line managers in any initial discussions and brainstorm exercises. Qualitative and quantitative feedback from patients can give a strong sense of how services work and why gaps in services are a cause of concern.
Many charities aim to support specialist nursing roles and are likely to be able to provide national data, as well as possible funding sources, to support a bid. For example, the British Heart Foundation (2015) has published evidence of the success of the role of cardiac nurse specialists in the community. Nurses considering writing a business case can benefit from seeking advice from charities in their specialist area.
The five-case model
To help public sector organisations bid for funds, HM Treasury has devised the ‘five-case model’ (HM Treasury, 2015). This requires business cases for new initiatives to contain evidence that:
- The intervention is supported by a compelling case for change that fits with other parts of the organisation and the wider public sector – the ‘strategic case’;
- The intervention represents best value for public money – the ‘economic case’;
- The proposed deal is attractive to the marketplace, can be procured and is commercially viable – the ‘commercial case’;
- The proposed spending is affordable – the ‘financial case’;
- What is required from all parties is achievable – ‘the management case’.
In the current economic climate, nurses are expected to streamline their work to make savings. However, they are not traditionally taught how to be financially astute, and often lack confidence in the area of service development. By developing the confidence needed to deal with financial issues, nurses can influence change in practice and make their ideas a reality.
When writing a business case, it is vital to identify the financial impact and implications – how much is the initiative expected to cost? How much is it likely to save? A new service will need funding, so the costs and benefits of developing it should be fully researched. All financial aspects must be considered, and presented in as much detail as possible. Estimates are acceptable as long as they are based on the most up-to-date evidence available; they can be updated as the project moves forward. If an organisation is going to invest money in a project, leaders and commissioners will want to know the return on investment (Box 1).
Box 1. Return on investment
To calculate the return on investment (ROI), the benefit (or return) of an investment is divided by its cost, and the result is expressed as a percentage or a ratio.
ROI = (gain from investment) divided by (cost of investment)
The ROI provides an evaluation of the benefits of an investment over a period to time, so it can be used to predict savings and indicate value for money.
As the BHF (2017) explains: “the financial section of any business case is crucial and will be analysed closely. When putting this section together, it’s important to get help and advice from your organisation’s finance department to make sure that any additional or hidden costs are stated clearly.’
The financial section also needs continual review, so if things go haywire, the project is rethought, refocused – or ended.
Questions to consider are:
- What are the estimated costs?
- How will the project contribute to savings, and over what time period?
- What is the measure of success?
- What predictions are being made and how have they been calculated?
- What are the opportunities to update information throughout the project?
Below are some practical tips on how to write a business case that will be taken seriously and stand out from other proposals in a board meeting. Some may seem trivial, but decision makers are human beings who all have their dislikes – to make sure nothing is going to trigger the ‘reject’ or ‘delete’ button, you need to:
- Be clear who your audience is and write at their level of understanding;
- Know your specialty and how it fits into the wider context;
- Be concise;
- Be specific;
- Be factual;
- Use reliable sources of data. Avoid anecdotes – but do use case studies if they add to the proposal;
- Know your finances;
- Make the document interesting to the reader;
- Avoid abbreviations (or add a glossary at the end);
- Use the format that is standard in your organisation;
- Check grammar and spelling;
- Get someone to proofread your proposal.
The British Association of Dermatologists has a checklist that helps clinicians maximise the chances of decision makers supporting their business case (Box 2).
Box 2. Business case checklist
- Is the need clearly stated?
- Does the proposal contribute to the achievement of NHS policy and priorities, and the trust’s objectives and plans?
- Are the benefits clearly stated?
- Is it clear how the benefits will be realised?
- Are the demand, capacity and income forecasts robust?
- Are the capital and revenue costs robust?
- Is it clear why the preferred option has been selected?
- Is the project affordable?
- Are the risks and plans to mitigate them explicitly stated?
- Do the main stakeholders support the project?
- Does the team have the capacity and capability to deliver it?
Source: Adapted from the British Association of Dermatologists
Another useful checklist is the SMART acronym, according to which your project needs to be:
- S – specific
- M – measurable
- A – achievable
- R – realistic
- T – time-bound
What is the value of specialist nurses?
When writing a business case, you may want to demonstrate the value there is in employing specialist nurses. The Royal College of Nursing (2010) has identified that the role can save money, arguing that it helps to:
- Reduce waiting times;
- Avoid unnecessary hospital admissions or readmissions (through reduced complications post surgery, enhanced symptom control and improved patient self-management);
- Reduce the length of post-operative hospital stays;
- Free up consultant appointments for other patients;
- Deliver services at the point of need or in the community;
- Reduce patient drop-out rates;
- Educate health and social care professionals;
- Introduce innovative service delivery frameworks;
- Give direct specialist advice to patients and families.
The BHF (2015) adds that specialist nurse roles are also important in providing care throughout patients’ disease trajectories, from diagnosis to end of life.
There have been concerns that the role of specialist nurses may become overlooked or misunderstood and, in 2014, the RCN highlighted that funding issues were having a negative impact on the role, stating that we were in a situation: “whereby funds are being transferred from the NHS for integrated health and social care with no guarantee that the money will be spent on care provision” (RCN, 2014).
There are different ways to approach integration across organisations, services or between individuals, and different models have been successfully implemented in the UK and beyond (Goodwin and Smith, 2011). The RCN calls for nurse-led teams in hospitals and the community, and in specialist services to develop working relationships and collaborate across health and social care (RCN, 2014).
As Fletcher (2011) pointed out, specialist nurses are held in high regard by patients, and consistently so, compared with other health professionals. It is crucial to gain feedback from patients. However, as Fletcher explained, this feedback in itself is not sufficient evidence for commissioners, as it can be considered anecdotal, and specialist nurses: “need to ensure they have evidence their services are cost-effective and improve patient safety and outcomes.”
Writing a business case can be frustrating. It is made easier by engaging decision makers from the outset to ensure the proposal is set within the national context and identify how it will help the organisation to reach its targets.
You will need to gain the right strategic support and source as much accurate data and information as possible. Researching ideas, gaining feedback from stakeholders inside your organisation and, where possible, influencing people from partner organisations, will help your project gain momentum. Involving patients and getting qualitative feedback to support the quantitative data will enhance your proposal.
Nurses are often reluctant to write business cases, and it mainly falls to leaders or commissioners. However, with the right support, they can develop the confidence to articulate a service development idea formally and bring it into the strategic arena.
- A business case is a formal document submitted to decision makers for approval and/or funding of a service development initiative
- A convincing business case must link the proposed service improvement to local, regional and national priorities and constraints
- The financial section of a business case will be analysed closely, so costs and benefits need to be made clear
- If nurses learn to articulate the needs of their services in the language of financial constraints, they have a good chance of securing funding
- The current move towards more integrated health and social care means this is a good time for nurses to try to influence decisions
- Test your knowledge with Nursing Times Self-assessment after reading this article. If you score 80% or more, you will receive a personalised certificate that you can download and store in your NT Portfolio as CPD or revalidation evidence.
- Take the Nursing Times Self-assessment for this article
British Heart Foundation (2017) Business Case Toolkit.
British Heart Foundation (2015) An Integrated Approach to Managing Heart Failure in the Community.
Department of Health, Department for Communities and Local Government (2016) 2016/2017 Better Care Fund: Policy Framework.
Department of Health (2016a) The Government’s Mandate to NHS England for 2016-17.
Department of Health (2016b) NHS Outcomes Framework 2016 to 2017.
Fletcher M (2011) Assessing the value of specialist nurses. Nursing Times; 107: 30/31, 12-14.
Goodwin N, Smith J (2011) The Evidence Base for Integrated Care. London: The King’s Fund and the Nuffield Trust.
Ham C et al (2017) Delivering Sustainability and Transformation Plans. London: The King’s Fund.
Royal College of Nursing (2014) Integrated Health and Social Care in England: The Story So Far.
Royal College of Nursing (2010) Specialist Nurses: Changing Lives, Saving Money. London: RCN.