News and Comment

Making the business case for care in times of austerity

Wednesday 27 November 2013


The National Quality Board, sponsored by the Chief Nursing Officer in England, recently published new guidance to support commissioners and providers to make the right decisions in terms of staffing capacity and capability. This builds on compelling evidence showing that lower nurse staffing levels in hospitals are associated with worse patient outcomes. With the NHS facing significant financial pressures and challenged to find cash-releasing savings, it can be easy to treat cuts (e.g. in nursing numbers) as savings; without being clear about the short, medium and longer term impact on such decisions. After all, the Mid Staffordshire NHS Foundation Trust Public Inquiry has shown how the Trust Board’s focus on short term cost control contributed to a range of adverse impact on the quality and safety of care, that have longer term financial (and other) implications. While it may seem like a truism to state that everyone agrees that high quality and safe care is essential, resourcing this is easier said than done, particularly in the face of public spending cuts. Making a strong business case for high quality care requires careful thinking and marshalling of different types of evidence. Directors of Nursing are feeling this weight of expectation like never before.

A business case

Anyone who is accustomed to putting forward business cases in the public sector would be familiar with the need to cover the following 5 components:

  • Strategic case – i.e. having a robust case for change that is aligned with strategic direction of travel
  • Economic case – i.e. evidence that proposal optimises value for money
  • Commercial case – i.e. clear thinking that the proposal approach is commercially viable
  • Financial case – i.e. evidence that the proposal is financially affordable
  • Management case – i.e. plans to demonstrate that the proposal is achievable

While most, if not all, Directors of Nursing would be confident about putting forward clear strategic, commercial, financial and management cases; it is probably fair to say many are less confident in putting forward a compelling economic case. While economic benefits may often been elided with clinical benefits, this assumption that positive clinical outcomes must mean positive economic benefits is no longer sufficient. The NHS is not in the position to resource everything that generates positive clinical outcomes. While efficiency without quality is unthinkable, quality without efficiency is unsustainable. Economic benefits should be demonstrated and considered separately from clinical outcomes, thereby making a clear case that a proposed approach is more cost-effective or represents better value for money.

Nurses making business cases

While the nursing workforce and leadership can often find the task of making the economic case daunting, they should be aware that the key requirements and procedures are highly systematic and that there are tools and guidance that have been developed to help make these accessible to the nursing and wider public services workforce. While these requirements and procedures may be unfamiliar, they are not impenetrable.

Together with Janet Davies (Executive Director of Nursing and Service Delivery) and Dr Ann McMahon (Research and Innovation Manager) from the Royal College of Nursing, I will speaking at the Chief Nursing Officer’s Summit in Birmingham today about a programme designed to build the capability of the nursing workforce and leadership to be able to make compelling economic cases. Given the current and foreseeable demands on Directors of Nursing, it may be a crucial competency that they should be supported in developing. In addition, Directors of Nursing need to understand how they can facilitate and support other nursing staff to help generate the evidence that feeds into compelling business cases.