Q&A on PPH business case with Simon Morioka of Private Public

Simon Morioka, co-founder of Private Public Consultancy, has been advising People Powered Health teams on developing a business case.

What would you say are the top 3 reasons why a business case for the People Powered Health sites is important?

Firstly, the business case is a tool for each site to capture their high-level activities, objectives and targeted outcomes in a way which is consistent and comparable. 

It is a reference point for each site in defining what they are trying to achieve and in measuring progress towards those achievements.  As such, it provides a simple way of sharing related ideas, thinking and learning within and across sites.

Secondly, the business case is a key part of making the overall case for investment in co-production, by demonstrating the added value for commissioners, providers and patients alike.  

At a time of significant pressures on resources, this is important for sustaining the work in individual sites and securing buy-in to similar projects elsewhere.

Finally the business case is a way of helping to identify and work through the challenges of co-production. 

A lot of work has been done to define the principles and understand the benefits of improving co-production in public service delivery, but there can be major hurdles to translating theory into practice.  The work around the business case involves understanding how the benefits we expect can be realised in improvements to quality, cost-effectiveness, and the outcomes for people's lives.  It should provide immediate support to each site in their own goals, as well as a template for future projects.

What is the relationship between the business case and the broader case for change?

The business case sits within the overall case for change.

It offers an evaluation of the strength of co-production based on its costs and benefits.  Without it, it would be difficult to make the case for co-production as a cost-effective intervention and a good use of public money.

Around the business case there is the wider case for change, which makes the overall argument for why co-production is a good idea. The overall case for change draws on a wide range of research and evidence, including the thinking behind co-production, and links with the wider reform agenda. 

It is important that the two support and inform each other, if an overall compelling case for scaling co-production is to be made.

Can you give some examples of the kinds of data that PPH sites might collect when building a strong business case?

The data will be unique for each site, as they will be based on the measures a site has identified.  Tom Mason gave a really useful presentation on how Leeds have gathered their data, which is a great example of this, but it is important that sites select the data that is most relevant and practical for them.

Sites may collect data for the whole population, a segment of the population, or a selected cohort of identified individuals.  We would expect that sites will collect a range of measures, some about observed events and some about patients' views of care.  We are not trying to replicate a randomised controlled trial, but are looking for data that helps establish a good correlation between what was done, and what benefits resulted.

The strongest business cases are built on numerical data about observed events - such as changes to the number of admissions, usage of pharmaceuticals, and lengths of stay in hospital, all of which have a direct effect on the cost of providing care, as well as the patient's wellbeing.  Specific conditions will also have specific clinical measures, which can provide compelling evidence for the efficacy and safety of proposed changes to current practice. 

Finally, the development of Patient Reported Outcome Measures and Patient Reported Experience Measures have highlighted the increasing importance of involving patients directly in evaluating the effectiveness of their own care, and this is something we would strongly support sites in doing as part of the business case process.

What are some of the main challenges that are likely to arise when collecting the data necessary for building a business case? What is your advice for how these challenges might be addressed?

We've heard from most of the sites about this, and we think there are a few themes emerging.

First, it can be difficult to decide which data is important.  

The recommendation would be to collect fewer measures and do this well, rather than try to collect too many and compromise either on the quality of the data, or on the delivery of outcomes.  Commissioners are looking for focussed business cases which provide them with the right amount of evidence, in a way which is clearly presented and builds a compelling case.  It is important to be able to show where a particular measure started (the baseline) and what happened over time.

However, it is equally important that sites do not only chose the measures that show their projects in the best light, but consider the broader effects of any change.  The locality leads are there to challenge and support in this regard!

Second, getting the data from the diverse stores that exist across the health economy is a real challenge.

To address this, sites will need to identify and engage with information teams across partner organisations; it may be worth including the main data owners on the steering groups, and / or identifying specific points of contact and co-ordination.  And to make sure data sharing is as simple as possible, sites can check that their sharing protocols are suitable, or may need to take the opportunity to agree new protocols which would be useful more generally.

In the worst case scenarios, if suitable data cannot be shared, they may need to re-consider the indicators they are planning to use and whether there are other ways of sourcing the data, including direct from the cohort in question.  The principle of informed consent is key, and should be considered in relation to any patient-specific data.

Third, and linked to this, it can be difficult to secure the resources needed to collect all the data.

Again, here it is worth keeping your measures down to a manageable number, and working with the information teams to keep your data collection as simple and automated as possible.

Finally, it can be hard to know whether the data you are collecting is any good.

Here, it is really important to know where the data has come from, so speaking with the team responsible for managing it will help. This will ensure that you know what the data does - and does not - tell you.  The data should be providing consistent messages, and any inconsistencies should be explored until they are understood.  It is important to ensure that what the data is telling you accords with what you are seeing on the ground.

How far is it possible to quantify the benefits of coproduction specifically?

Within the programme-wide business case, it may not be possible to split the benefits of co-production from the benefits of work going on in the sites more generally - none of the projects exists in a vacuum.  

However, we should be able to speak of the correlations between the strength of the co-productive relationships established, and the benefits which have or have not resulted to organisations and to patients, their families and communities. 

If successful, all the projects should be able to show that they embraced co-production, should be able to quantify the corresponding investments they made to ensure this happened, and should be able to evidence the overall benefits which were produced.   This would constitute a powerful argument in itself for the benefits of co-production, as well as a guide for future sites in understanding what they would need to do, and what effects they could expect as a result.

You recently conducted interviews with commissioners to understand how the business case might feed into the commissioning landscape. What were the principle messages to come out of this piece of work?

Overall, commissioning is in a state of flux at the moment.  However, and perhaps unsurprisingly, the financial situation came out consistently as a key driver for current and future decision-making.  All proposals are being evaluated from a cost-perspective and commissioners are more concerned than ever with rigour and process in making the difficult decisions which lie ahead.

On the positive side, many individual and organisations are looking to innovate as a way of managing the pressures of the coming years.

Whilst the financial implications are important, commissioners are also looking for ideas which are strategically aligned, and supported by clearly evidenced outcomes.  A robust, financially-sound and evidenced-based business case is vital for any new development, but if the case can be made, there is a receptive audience for different approaches to tackle the ongoing challenges of delivering health and care in the UK.

Do you think that commissioners understand coproduction?

The interviews with commissioners were focussed on exploring their priorities in relation to business cases in general, and included for those commissioners not involved in PPH sites they were given a brief introduction to the programme - so as such possibly not the best guide. 

However, whilst the terminology of "co-production" may be unfamiliar in, the greater involvement of patients in the design, development and delivery of care was something that a number of commissioners mentioned they were aware their organisations should be supporting. 

What was interesting was that few felt they had made much progress with this in their areas, yet.  So there is a gap between understanding the potential value of co-production, and understanding what this might look like in practice.

What are your reflections on the progress that the six PPH sites have made so far in relation to the business case?

It feels like the sites are making good progress, and are broadly in similar places - no-one should feel that they are significantly behind the others.

It was encouraging at the Away Day that everyone was aware of the need for a robust business case and keen to construct one. We were having informed discussions about the right measures to properly reflect interventions and the right data to populate the measures, with teams focussed on the practicalities now of making this happen.

And it feels like the sites are finding the business case process a useful one. Having some discussions about identifying cohorts, it was interesting that this has caused sites to think about questions like 'who are we targeting?' and 'who will this affect?'.

If the business case continues to provoke questions that help sites hone broader thinking, as well as contributing to the overall case to change, then it will be progressing in the right direction.