Thursday, June 16, 2016

Social impact bonds in Japan – it’s not always about saving money

In the previous blog in this series, I shared some key messages from a recent speech I delivered at the 2016 Social Investing and Corporate Social Responsibility Forum, held at Meiji University in Tokyo. In this blog, I summarise some of the thinking shared with Japanese colleagues on a second topic they had asked me to touch on:

Can you structure outcome metrics in a way that is not motivated directly by budgetary savings but by social wellbeing?

Level of outcomes

We can look at outcomes at the individual level, the group level and the system level. At the individual level, outcomes are obviously about achieving and improving individual wellbeing. At the group level, we may aim for improving social wellbeing. At the system level, there can be policy or political priorities that focus on social wellbeing. There can also be economic benefits that are being aimed for, and also budgetary ‘cashable’ savings.

Meeting the priorities for outcomes at one level may not always lead to (or support) achievement of priorities at another level. Outcomes for individuals, for instance, may not always lead to savings for the system. An intervention aimed at reducing the social isolation of a socially excluded group may uncover previously unmet needs, resulting in these people being put in touch with other services. While this is a good thing, it does mean there is a direct service use cost, at least in the immediate short term, that was not previously there.

Wellbeing, rather than savings, as a driver

If we are to take an approach that prioritises the achievement of individual/social wellbeing as opposed to the achievement of budgetary savings, there are different ways for structuring outcome metrics in support of this goal.

(a) Taking a wider definition of outcomes and accounting for their value: This recognises that there are different perspectives of the value of the same outcome. For example, when we talk about the ‘cost of crime’, members of the public do not really think of the cost of policing, the cost of incarceration, etc. Instead, they are likely to think about the economic, social and emotional harm inflicted on the victim and communities experiencing crime. A wellbeing perspective will therefore need to take these into account, over and above the system costs.

(b) Acknowledging public ‘willingness to pay’: The public can value things even when the financial implications of those things may not be clear. This ‘willingness to pay’ is underpinned by what we as a society think of as ‘right’ and ‘of value’. It can be influenced by cultural, ethical or moral norms. For example, there can be a strong moral case for supporting war veterans.

Public ‘willingness to pay’ is subjective, contextual, and can change. For example, prior to the UK Government announcing its Comprehensive Spending Review (CSR) at the end of 2015, there was widespread expectation that the government would cut policing budgets significantly. In fact, the government had hinted this will happen. The CSR took everyone by surprise when it was announced that policing budgets would be protected. Why had this happened? In a nutshell, the global terrorism threat had become increasingly significant. Public expectations around policing and security have gone up the political agenda, and it would have been untenable politically to cut policing budgets in such a context.

How may this look like in terms of structuring outcomes

First, there can be situations where the primary outcome metric that triggers payment is savings related, but there are also a range of other wellbeing outcomes being monitored and tracked. For example, in the Essex County Council SIB, the primary outcome metric that triggers payment is ‘care days avoided’. There are a range of secondary outcomes, such as strength of family functioning, emotional wellbeing, educational outcomes, etc. Data on all of these are analysed and discussed by the Programme Board on a regular basis. The seriousness to which the various players consider outcomes holistically is demonstrated by the fact that the social investors have committed to re-contacting the families who have received Multi-Systemic Therapy some time after the intervention has ended to check whether a range of outcomes are sustained over and above the duration for formal outcomes monitoring required by the SIB.

Second, there can be outcome payers who are prepared to pay for outcomes even when they are not linked directly to savings. These outcomes may be paid for as stand-alone outcomes. One of the outcome metrics that triggers payment in the Lisbon Junior Code Academy SIB, for example, is ‘logical thinking’. Logical thinking, obviously, is not something that leads directly to budgetary savings, but is a life skill that will serve an individual well throughout his and her life and can operate in very different situations.

Third, rather than to pay for stand-alone wellbeing outcomes, these may be blended in with other types of outcomes that may be more savings-related. The New South Wales, Australia, Benevolent Society Social Benefit Bond shows how this may be done. Payment is triggered by the Performance Percentage. Performance Percentage is a weighted average of three separate measures. This provides a model for how wellbeing outcomes can be woven in with others to create a composite outcome that triggers payment.

Reflection

As many of the initial SIBs are underpinned by a savings logic, it is easy to think that SIBs can only be structured with this objective in mind. The outcomes focus of SIBs should challenge us to be clear about ‘outcomes for whom?’ Shifting the gaze away from system-level outcomes onto outcomes for others requires us to think of different ways to identify and structure outcome metrics to support the achievement of individual and social wellbeing.

Thursday, June 9, 2016

Japan in Spring: the budding potential for Social Impact Bonds

I was flattered to have been invited back to Japan in April to speak at the 2016 Social Investing and Corporate Social Responsibility Forum, held at Meiji University in Tokyo. Japanese colleagues specifically asked me to touch on the following issues:

  1. How do the various Social Impact Bond (SIB) players identify and structure outcome metrics?
  2. Can you structure outcome metrics in a way that is not motivated directly by budgetary savings but by social wellbeing?
  3. What data do the various SIB players need to collect, and how do they analyse and use the information?
  4. What are some lessons that OPM have learned from evaluating SIBs?

This is the first, in a series of blogs, summarising some of my key messages.

 

How do the various SIB players identify and structure outcome metrics?

There are a number of factors to consider when identifying metrics for SIB-funded programmes. However, this is an art not a science and it should support – not obscure – the achievement of meaningful outcomes.

The ‘3 Ms’

I work to three key principles called the ‘3 Ms’, namely, metrics should be:

Meaningful

a) While SIBs are focused on outcomes, for contracting purposes, the duration of SIBs has to work for the outcomes payers, social investors and service providers. Hence, metrics are usually some form of intermediate or proxy indicators. There should be a compelling rationale to believe that if these intermediate/proxy outcomes are generated, then it is plausible that the longer term desired outcomes are likely to be achieved.

b) Metrics should be easily interpretable. What does it mean if an indicator goes up, stays the same, or comes down? Take ‘reporting of crime’ as an example; if crime reporting goes up, is it because there is more crime (which is bad) or is it because people are getting better at reporting crime (which is good)?

Measurable

a) Can the outcome be measured consistently and robustly? Where it is not already collected routinely, what are the resource implications for collecting the data, and are there tools and processes for collecting the data well.

b) Do we have the systems in place to support good measurement?

Monetisable

As SIBs are based on the ability to pay for stated outcomes, there needs to be some mechanism for pricing those outcomes. It is common to find outcomes being priced based on some projected savings resulting from those outcomes being achieved, but outcome pricing does not always have to stem from budgetary savings.

Roles in identifying and structuring outcome metrics

Social investors, outcome payers, service providers and intermediaries are all very diverse and have different motivations, so it can be hard to generalise. Crudely speaking, their roles and significance of their roles can vary depending on the type of SIB.

Outside of the UK, individually-negotiated SIBs are most common. This type of SIB means that the outcome payers often work very closely with service providers and sometimes with the help of external intermediaries to help them define and structure outcome metrics.

In the UK, we similarly have individually-negotiated SIBs (for example, the Essex SIB that OPM has been evaluating). However, UK is unique because we have many SIBs developed through an Impact Bond Fund model (e.g. the Innovation Fund, Fair Chance Fund, Youth Engagement Fund). Under this model, government departments (as outcomes payers) spent a lot of time analysing data and came up with what is known as a ‘rate card’ that specifies the different outcomes that the government is interested in, how the outcomes should be measured, and the maximum price that the government will pay for each outcome.

There are now SIBs that are developed by service providers and sometimes intermediaries. In these cases, the service provider or intermediary led the development of the outcome metrics. For service providers, it is usually because they have a long history of delivering a specific intervention and have been measuring its effectiveness in a particular way.

Structuring outcome metrics and payment

Crudely speaking, this is done at the individual level or at the group level. At the individual level, outcomes are specified for the individual participant/beneficiary. It may be one outcome per participant, or could be a series of outcomes for that person. This is the approach used in the Impact Bond Fund SIBs. In the first round of the Innovation Fund, the rate card issued by the UK Department for Work and Pensions specified that one of the desired outcomes was ‘improved behaviour at school’. This outcome was to be measured by ‘letter from teacher’. The achievement of this outcome for the pupil triggers a payment of up to £800.

In comparison a group-level approach can be structured in two ways. First, you focus solely at the intervention group and define the number or the percentage within that group that needs to demonstrate the outcome. This is the approach used in Germany’s SIB which specified that at least 20 individuals out of the group of 100+ must experience the outcome for payment to be triggered.

Alternatively, you can compare the intervention group against a control group. In these scenarios, there are often thresholds set for outcome levels. For example, the Peterborough SIB structured its outcome metrics in a way that supported two different payment triggers. The first is when an intervention cohort demonstrates at least 10% reduction in reoffending compared with the control group. If this condition is not met, a second way for triggering payment is if all three intended cohorts have an average reduction in reoffending of at least 7.5%.

Reflection

It strikes me that while the principles underpinning outcome metric selection are clear, the act of identifying and structuring them in support of SIBs is as much an art as it is a science. There is no single approach that works in all cases. I think it is important that we do not get lost in the technicalities and forget about what is really important. Instead, we must always keep a clear eye on outcomes and make sure that we identify and structure metrics in a way that supports meaningful achievement of those outcomes.

 

Thursday, May 26, 2016

Our work with the Royal College of Nursing to showcase the costs and benefits of nurse-led innovation

With funding from the Burdett Trust for Nursing, we have been working in partnership with the Royal College of Nursing (RCN) to build nursing capability in economic assessment and to help nurses demonstrate the value of nurse-led innovation in practice. In April we held a breakfast event jointly with the RCN and Hospice UK, Demonstrating the value of nurse-led innovations in End of Life Care, which shines a light on nurses working in hospice and care home settings. The full video of the event – including presentations from Dr. Chih Hoong Sin (OPM), Dr. Ann McMahon (RCN) and Antonia Bunnin (Hospice UK), not to mention case studies from practitioners themselves – can be accessed via here.

For any questions regarding this partnership or our economic evaluation work, please contact Chih Hoong on csin@opm.co.uk

Tuesday, May 17, 2016

Evaluation of the Reducing Social Isolation and Loneliness Grant Programme

Social isolation and loneliness in older people is a widespread issue that has gained much attention in recent years. We know that being isolated and lonely can impact on a person’s quality of life and lead to more intensive use of health and social care services.  

In Manchester the three Clinical Commissioning Groups provided grant funding targeted to reduce social isolation and loneliness amongst Manchester residents aged 50+. Grants were awarded to voluntary sector organisations to deliver 27 projects across the city. The Programme ran from September 2014 until March 2016 and was managed by Manchester Community Central (Macc).

OPM was commissioned to evaluate the Grant Programme. The evaluation sought to demonstrate outcomes and provide evidence around ‘what works and why’.

This presentation was delivered at the final Programme celebration event attended by representatives from the CCGs, other North West CCGs, Manchester City Council, Macc, local research organisations, plus VCS leads and volunteers from across the city. It presents the headline findings from the evaluation and showcases two projects in depth. Our final evaluation report will be available in the coming months.

Click here to download the presentation slides.

Tuesday, May 17, 2016

Evaluation of the Reducing Social Isolation and Loneliness Grant Programme

Social isolation and loneliness in older people is a widespread issue that has gained much attention in recent years. We know that being isolated and lonely can impact on a person’s quality of life and lead to more intensive use of health and social care services.

In Manchester the three Clinical Commissioning Groups provided grant funding targeted to reduce social isolation and loneliness amongst Manchester residents aged 50+. Grants were awarded to voluntary sector organisations to deliver 27 projects across the city. The Programme ran from September 2014 until March 2016 and was managed by Manchester Community Central (Macc).

OPM was commissioned to evaluated the Grant Programme. The evaluation sought to demonstrate outcomes and provide evidence around ‘what works and why’.

This presentation was delivered at the final Programme celebration event attended by representatives from the CCGs, other North West CCGs, Manchester City Council, Macc, local research organisations, plus VCS leads and volunteers from across the city. It presents the headline findings from the evaluation and showcases two projects in depth. Our final evaluation report will be available in the coming months.

Monday, September 21, 2015

OPM continues social impact bonds knowledge sharing relationship with Japanese universities

Earlier this month we were delighted to welcome an SIB research delegation led by Meiji University back to OPM.

The visit is the latest development in the partnership supporting a 5 year empirical study funded by the Japanese Government into how social impact investments, especially SIBs, affect governments, social service providers, service users, and the standard of social services in the UK – further evidence of the interest internationally in the progression of the UK social impact bonds market since the world’s first was implemented in Peterborough Prison 5 years ago.

The delegation first visited OPM last November to hear about our experiences evaluating the Essex County Council SIB and ‘Peninsula LIST’ project, and continuing the relationship in April OPM’s Director of Business Development Dr Chih Hoong Sin spoke at the 2015 Social Investing and Corporate Social Responsibility (CSR) Forum, held at Meiji University in Tokyo – presenting his observations of the nature of the ‘first wave’ of UK SIBs and the lessons to be learned from the world’s most developed market.

OPM’s expertise, it is hoped, will contribute to the launch of the 1st Japanese social impact bond.

This latest meeting was particularly timely. At the time of writing the UK still accounts for the largest number of SIBs globally (31), having been the first to pioneer the pay-for-performance vehicle that leverages private funding to finance public services five years ago. In addition, Social Finance had recently announced details of the first UK social impact bonds to perform above expectations and deliver outcomes sufficient to return investor capital earlier than expected. 

Yet the international backdrop is more mixed.

The Riker’s Island SIB, which aimed to reduce recidivism among 16 to 18-year-olds who entered New York City’s Rikers prison by at least 10% had been terminated due to failing to achieve the agreed targets, while a new report from the Brookings Institute (Chih Hoong Sin is referenced as a study participant on page 52 and OPM’s evaluation of the Essex Family Therapy SIB features on page 84) this summer called for increased transparency and knowledge sharing on the potential and limitations of impact bonds to move this agenda – how to better ensure the achievement of outcomes for vulnerable populations – forward.

In this context we were in a position to update our Japanese colleagues on the progress of our evaluation of the ‘Essex SIB’ – the first in the world to be commissioned by a local authority – and the ‘Peninsula LIST Project’, that aimed to use an SIB as vehicle to commission public services across 4 local authorities in the South West of England.

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If you would like to find out more about OPM’s evaluations of the ‘Essex SIB’ and ‘Peninsula LIST’ projects, please contact Chih Hoong Sin, Director of Business Development at CSin@opm.co.uk or on 0207 239 7877.

Wednesday, May 27, 2015

Social Impact Bonds: UK and comparative perspectives – Part 2

I was recently invited to Tokyo, Japan, to share learning from the UK experience of designing and implementing Social Impact Bonds (SIBs). The UK was the first country in the world to implement a SIB – the innovative model that levers private capital to fund services aimed at generating measurable social outcomes for defined target groups – and it continues to lead the world in this field. It is unsurprising, therefore, that there is a lot of interest internationally in the UK experience.

Knowledge gap

There has been a noticeable shift in interest. No longer are the questions ‘what is a SIB?’ or ‘why should we use a SIB?’ commonplace – we are now more likely to hear ‘how might we make a SIB work for us?’ Japanese academics, leaders from industry, local government, charitable foundations, and the voluntary and community sector are in the midst of designing the first Japanese SIB and are hungry to learn more from the UK. Enquiries ranged from ‘what are the operational issues we need to plan for and anticipate?’, ‘how might we overcome some of the likely challenges?’ to ‘are current SIB models directly transferable to Japan?’ This final question, according to feedback from Japanese colleagues, is where a real gap in the knowledge base exists. OPM, given its unique position in straddling the commissioner, provider, and evidence worlds; coupled with links with the social investment sector, is seen as well-placed to share learning around these issues.

Some lessons learned and shared

Here are a few of the many issues I discussed with my Japanese counterparts:

  1. Knowledge of SIBs is often partial

SIBs are evolving rapidly. It is notable that much of what I encounter both here in the UK and in Japan reflects an understanding of the ‘first wave’ of UK SIBs. For example, many commissioners tell me they are put off from considering SIBs because of the long lead-in time and high development costs. While the Essex SIB took 23 months to develop and at a cost of around £300,000; there are now SIBs that are much quicker to commission. The Birmingham SIB is a case in point. Similarly Evidence-Based Social Investments (EBSI) developed a ‘spot purchase’ model of SIBs designed to reduce transaction costs for commissioners.

  1. SIBs are not exercises in technical design and financial modelling

Significant amounts of time can be spent on getting the technicalities (such as the outcome data, comparator data, savings and repayment modelling)  ‘right’. However, planning for SIBs should always include sufficient resources for engaging not only the workforce that is likely to be involved in delivering or supporting the intervention, but also for engaging with stakeholders inhabiting the wider ‘ecosystem of services’ that the intervention is to be introduced into. Without this, implementation will almost always come up against barriers caused by inconsistent processes; lack of shared understanding etc.

  1. What do we mean by ‘evidence’?

SIBs and evidence go hand-in-hand. SIBs can favour ‘evidence-based interventions’ due to greater certainty around likely outcomes (and hence repayment). ‘Evidence’ overwhelmingly refers to outcomes and effect sizes. There are two obeservations here: First, could this focus upon ‘evidence-based interventions’ lead us to favour only the types of interventions that are backed by ‘evidence’ and/or those backed by certain types of evidence (e.g. from randomised controlled trials)? If so, can SIBs genuinely support innovation? Second, any intervention, even when proven to be effective, will only work well if implemented effectively in complex local contexts. Do we pay enough attention to what effective implementation looks like in different contexts?

  1. Who defines ‘social impact’?

As the ‘first wave’ of UK SIBs are commissioner-driven, the definition of ‘social impact’ has largely reflected their priorities (e.g. size of potential savings). This doesn’t always have to be so. In fact, such a limited interpretation of SIBs will stunt their development. Indeed, with the newer types of provider-driven SIBs, there are alternative ‘voices’ being heard with their own interpretation of what ‘social impact’ looks like.

Conclusion

SIBs will be not be suitable for all types of interventions and target groups. Through all the twists and turns, it is vital that stakeholders remain focused on the outcomes for people we are trying to support. SIBs are an innovation designed to help address some of society’s most intractable social problems, and should be considered as part of an arsenal of commissioning approaches. Equally within SIBs, we should continue innovating; pushing the idea further to explore the possibilities for achieving meaningful social outcomes for some of the most vulnerable groups in society.

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You can view the slides from Chih Hoong’s presentation in Part 1 of this blog.

If you would like to find out more about OPM’s evaluations of the ‘Essex SIB’ and ‘Peninsula LIST’ projects, please contact Chih Hoong Sin, Director of Evaluation, Research and Engagement at CSin@opm.co.uk or on 0207 239 7877.

 

Tuesday, May 26, 2015

Social Impact Bonds: UK and comparative perspectives – Part 1

OPM’s Director of Evaluation, Research and Engagement, Dr Chih Hoong Sin, spoke at the 2015 Social Investing and Corporate Social Responsibility (CSR) Forum, held at Meiji University in Tokyo.

Chih Hoong was invited by the Department of Public Management and the Institute of Non-profit and Public Management Studies, in partnership with the Japanese Ministry of Education, Culture, Sports, Science and Technology (MEXT). The invitation to speak followed on from a visit to OPM by a delegation of senior academics from Meiji University back in November as part of a research project funded by the Japanese Government to support the launch of the first Japanese social impact bond (SIB).

At the event Chih Hoong spoke alongside colleagues from the UK Cabinet Office, PwC, and St Mungo’s Broadway on the emergence of Social Impact Investment and the Transformation of CSR in the UK and Japan.

Chih Hoong presented his observations of the development of Social Impact Bonds in the UK and on the lessons to be learned for the future. A number of findings he reported related to the ‘first wave’ of UK SIBs, which were of particular relevance to Japanese colleagues in the early stages of SIB planning:

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Chih Hoong reflects on discussions with Japanese colleagues in Social Impact Bonds: UK and comparative perspectives – Part 2 of this blog.

If you would like to find out more about OPM’s evaluations of the ‘Essex SIB’ and ‘Peninsula LIST’ projects, please contact Chih Hoong Sin, Director of Evaluation, Research and Engagement on CSin@opm.co.uk or 020 239 7877.

Tuesday, March 3, 2015

Chih Hoong Sin interviewed for HSJ Workforce Supplement

Chih Hoong Sin, OPM’s Director for Evaluation, Research and Engagement has been interviewed for the latest Health Service Journal (HSJ) Workforce Supplement on the benefits of Specialist Nurses.

Chih Hoong was among a select group of patients, researchers, academics, healthcare managers and those working in charities and patient support groups – as well as nurses themselves – who were asked to share their perspectives on the difference specialist nurses can make.

Some of Chih Hoong’s thoughts are featured in the ‘How specialists can help you’ and ‘Meaningful efficiencies’ sections which are available to view here.

 

Tuesday, February 3, 2015

The NHS financial crisis: E-QIPP-ing the nursing workforce with the skills to drive quality and efficiency improvements

It seems that not a week goes by without some form of media headline trumpeting the scale of the financial crisis confronting the NHS. NHS finances is a major issue requiring urgent and sustainable solutions. In the past few years, the National Audit Office repeatedly questioned the sustainability of savings made to date. The easiest savings have been made – through a pay freeze for public sector staff, reductions in the prices paid for healthcare, and cutting back-office costs. Yet these savings have yet to be driven by fundamental service transformations at scale. The latest report by the Public Accounts Committee underlines the depth of the problem, pointing out that the proportion of NHS trusts and foundation trusts in deficit increased from 10% in 2012-13 to 26% in 2013-14. According to the regulator Monitor, the problems are particularly bad for hospitals, with 80% of acute foundation trusts reporting a deficit half way through the current financial year.

More worryingly, there is evidence that ‘cuts’ may be conflated with ‘savings’. This reflects the lack of a whole system approach in looking at how we make decisions about resource allocation. 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 impacts on the quality and safety of care, that have longer term financial (and other) implications.

In relation to nursing, a study published in the British Medical Journal indicated that reducing cost through shedding or not replacing frontline nursing staff impacts on the quality and safety of care that, in turn, have implications not only on patient outcomes but also on the financial costs to the health and social care system.

Putting NHS finances on a sustainable footing requires not only different ways of doing things, but also new skills. While it has been estimated that innovations designed and implemented by clinicians could have a value of £9 billion per year in the UK, to date little has been done to harness this potential. As the largest professional group within the NHS, nurses play a critical role in delivering services and innovations in a way that achieves clinical outcomes and patient satisfaction, and will be vital in helping the NHS meet its quality and efficiency challenge. However, nurses often lack the skills to formulate and put forward arguments about the economic impact of what they do, over and above the clinical outcomes they contribute toward achieving. Nurses and other healthcare professionals often feel like they are reacting to, rather than driving efficiency initiatives.

OPM developed a programme aimed at building the capability of nurses and other members of the public service workforce to be able to generate evidence of the costs and benefits of various services in order to inform ongoing service improvements. Since 2013, OPM has been delivering this programme to cohorts of nurses in partnership with the Royal College of Nursing (RCN), with generous funding from the Burdett Trust for Nursing. Evidence to date shows how trained nurses contribute proactively to the Quality, Innovation, Productivity and Prevention (QIPP) agenda – in many cases helping to generate ‘cashable’ savings.

For example, a nurse in Scotland produced an economic assessment that showed how her heart failure nurse liaison service helped reduce both hospital admission rates and lengths of stay per admission, while also reducing demands on other professionals’ time. She was able to calculate efficiencies of around £454,928 per year, representing a return on investment of £489 per patient. More importantly, based on the evidence, she was able to make recommendations for where there may be further scope for increasing efficiencies. She identified that by improving part of the patient referral pathway, the service is likely to generate additional efficiencies, the potential return on investment rising to between £671 and £779 per patient per year. Based on this evidence, she was able to mobilise other colleagues and senior management to effect service re-design in a way that secures both quality and efficiency. This is testament to how an empowered workforce, with the right skills, can help the NHS meet its financial challenge while maintaining a clear focus on high quality care.

The Public Accounts Committee noted that radical service reconfigurations require “significant upfront investment”, and that this will become increasingly difficult with less money available for such investment as more NHS organisations move into deficit. Equally, a case may be made that securing a sustainable financial future for the NHS requires not only investment in services and service transformations; but also investments in the workforce to be able to drive meaningful change ‘on the ground’. Valuing public services means valuing our public service workforce, and seeing them as part of the solution.

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Download a copy of ‘A guide to economic assessment in nursing’ by clicking on the icon below:
Front page from Economic-Assessment-2015
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Note: The programme is currently being delivered to cohorts of nurses in England, and there are still a few places available. More information about the programme, and the process for registering an expression of interest to participate, is available from the RCN website. ‘A guide to economic assessment in assessment in nursing’  supports the provision of RCN and OPM training in how to perform economic assessments and use economic evidence to demonstrate the value of nurse-led innovation.