How to write and appraise a business case

A business case tells a story. It sets out how proposed service developments will be funded and implemented. In its final form, it is a public document signed off by the primary care organisation (primary care trust (PCT) in England) or NHS Trust Board.

How do you go about writing a business case?

Before embarking on writing your business case, it is well worthwhile discussing the proposal with those who will be commissioning the service development. This will give you an understanding of the local and national drivers and barriers—all of which will be buttons you have to push in your business case. It will also give you an idea of how much detail will be required.

Often it will be best to provide an outline business case in the first instance. This will be two to three sides of paper and will summarise the development, provide options for implementation, and provide the costs and benefits of the various options. Where relevant, cost savings over the current model should be provided. A 'do nothing' option should also be included indicating what the consequences would be if no development is approved.

With all business cases, the language used should be clear and jargon free. Avoid acronyms and explain any medical terms. Although you may feel passionate about your service, try to write objectively or it may come across as empire building. Emphasise the benefit to patients and service users. Get a colleague to read through your business case to ensure it makes sense.

How do I structure my business case?

There are different ways of structuring a full business case. One possible structure, outlined below, is taken from an excellent guide from the Care Services Improvement Partnership. ¹

Executive summary

An executive summary contains all the key points of the full business case and is usually not more than a couple of pages long. The purpose is to provide an overall framework of the proposed service development.

Background to the business case

The background to a business case puts the changes into the context of the need for local provision, modernisation of health services, and local and national policy. It also describes the proposed development and what it aims to provide. Emphasise how it will improve quality, safety, and efficiency.

The proposed development

This section describes the proposed development, with an explanation of how the new service will impact on other health and social care services in the area. A description of how services will be resourced in terms of infrastructure (site, facilities, management, etc) and staff (redeployment, recruitment, etc) could also be given here.

Planning structure

The business case should describe how the development fits with wider strategic planning within your locality. It should also make clear how the governance arrangements will work—i.e., who is accountable for this development. This section might also include information about how the service will be managed operationally once the planning phase has been completed.

Making the case for development

This section looks in greater detail at how the proposal for development has been reached. It should include details of any consultation that has taken place. Providing the views of service users can be very powerful.

The health needs of the population

A health needs assessment is the health service equivalent of the business process of defining a market and projecting this into the future. Advice on this should be obtained from the public health directorate. This section could also include current workload compared with projected assessments of demand for services. For example, current workload in diabetes may represent only 50% of potential workload because of undiagnosed cases. It is important that the business case demonstrates that health equity and equity of access have been considered. It needs to make it clear whether proposed services are targeted at particular populations whose health is relatively poor or at groups that tend not to access health services.

Option appraisal

This section explains how the chosen option has been identified as best suited to meet local health needs. Other options should also be described, including ‘do nothing’ and the costs and benefits of each option examined.

Finance

This section looks in more detail at how the chosen option for development has been costed.

Implementation timetable

The introduction of a change in service delivery or a new service requires a strategy for managing that change, including:

• Temporary relocation of accommodation during rebuild or refurbishment
• Continued delivery of existing services during the transition period
• Continued patient safety and maintenance of quality.

Some stages in the process can go ahead only after other stages have been completed, while others can run concurrently. For example, planning permission can be applied for while patients and relatives are being consulted about moving. Setting out a critical path will illustrate the connectivity between the stages of the plan.

The timetable can also outline the set-up of operational issues, such as when staff, including the lead clinician and manager, will be recruited, and timescales for development of policies and protocols.

Evaluating the new service

The business case also explains how the service development will be monitored and evaluated.

Publicising the new service

It goes without saying that if no one knows about your new service it won’t get used. This section of the business case will look at how the service will be launched and promoted throughout the wider system of health and social care.

How do I appraise a business case?

If you are asked by commissioners to give an opinion on a business case, or you are in a commissioning role, it is worth having a checklist against which you appraise business cases objectively. The Care Services Improvement Partnership checklist can be used for this purpose. ² Alternatively, the following checklist, adapted from guidance from both the public and private sectors, provides a framework for appraisal. ^{3 4}

1. Justifying action: has the plan demonstrated need and justified costs?
2. Clarify objectives: are the objectives clear and appropriate?
3. Option appraisal: have other ways of achieving the objectives been considered?
4. Product or service to be delivered: is there clarity about the quantity and quality of key deliverables?
5. Target population and user involvement: who will be the recipients, and have they been involved?
6. Project targets: are these targets SMART (specific, measurable, achievable, relevant, time-bound)?
7. Project outcomes: how can processes (eg, patients treated) be related to public health outcomes (eg, health gain)?
8. Risks and rewards: what are the strengths, weaknesses, opportunities, and threats inherent in the project?
9. Risk mitigation: has action been taken to minimise risks?
10. Assumptions: what important assumptions is this project dependant upon?
11. Implementation: what arrangements have been proposed for personnel, project management, and performance management?
12. Timescales/benchmarks: how long will the project take, and how will you know if it is on track?
13. Finance: are the financial aspects of the proposal appropriate?

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