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Author: Paul Nordon, independent business consultant; Edwin Chamanga, senior lecturer, Kingston University and St George's University, London

No matter your current position or grade, do you ever have thoughts about how to make quality improvements, engage with service development or service reviews, or wonder about why you don't hold another clinic in the north of your clinical commissioning group to make life easier for patients, or wish that you had an extra pair of hands. If you do think about the way your service is offered and want to share ideas about how to improve it, then you have the 'bones' of a business plan — but every idea has a cost, and that cost has to be carried by someone in a distant department, who does not share your intimate knowledge about the potential impact of the idea, proposal or plan (IPP). For this reason, any IPP should be developed as a business plan.

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Tissue viability nurses or nurses are often faced with clinical challenges which can be resolved by having good business acumen. Traditionally, nursing has never been business-orientated, but rather considered a hands-on profession. However, with changes in service demands, improvements in research and advances in technology, nurses are now faced with the need to seek more funding from their managers, or finance director through capital fund or technology fund, and, in some cases, even approaching commissioners depending on the size of investment, which can be a few thousands of pounds to hundreds of thousands of pounds. A lack of business case writing skills in nursing, does though make it challenging for nurses to present their ideas and pitch for funding.

Across the country, nurses have ideas, such as:

• Purchasing new equipment that can help improve patient and practitioner outcomes.
• Opening new satellite clinics in other localities.
• Designing a whole new service, either as a standalone or an integration to the already existing service.
• Needing an extra band 5, 6 or 7 nurse.

These are just some of the projects you may want to present to your organisation. However, for your project to demonstrate impact, return on investment, and efficiency, you need to present it in the form of a business case. Below is an example case study, which will be used to populate the template questions that follow, to help you get an understanding of business planning.

CASE STUDY

John is a tissue viability nurse who works for a community NHS Trust in the south-west of England. For the past two years, John and his team have realised that their caseload is getting bigger, and it is becoming a challenge to cover their catchment area operating from one central base. Some of their patients are also struggling to get to the specialist clinics — a situation which was even worse last winter following a week of snow. The team realised that their service was becoming less sustainable and difficult to deliver. Therefore, John and his team decided to put together a business plan to set up a satellite clinic in one of the villages, which would offer specialist services three times a week to reduce the amount of pressure to the current clinics. However, for the satellite clinic to be a success they had to scope for space, look at the clinical administration, equipment, IT, access adaptations, recruit a band 6 tissue viability nurse, all of which needed to be costed in their business case.

For their business case to be a success, they addressed the following components in relation to their proposal.

Rationale:

• Why are you doing this?
• What problem does this solve?
• How will things be different?
• Is there any evidence of gaps or needs?

They had to justify the need for the satellite clinic based on the changes in their caseload, the pressure the team was under, and how they struggled to meet the demands of those in their catchment area. Above all, they had to demonstrate how the new clinic would make a difference, not just to the team, but to the patients too.

Local context:

• What is the current situation?
• Provide numerical data — patients, time, expense, outcomes with any comparators
• How many people does this affect?
• What are the key national policies?
• What are the key local priorities?
• How does this fit with local strategies?

In this section, they used audits which demonstrated that their referrals had increased. Their patients were staying on their books for longer than before, and also an area in their catchment which never used to have a high volume of referrals was beginning to have an increase in referrals. They looked at:

• Patient waiting lists to access their service against local pathways and national pathways/guidelines on access times
• Numbers of deteriorating patients requiring hospital admission which could have been avoided if they had been seen earlier
• Patient feedback from the friends and family test
• Contacts against referrals per month, staff morale and sickness rates
• Analysis of avoidable hospital admissions they could have prevented.

Aims and outcomes:

• What do you hope to achieve? Will this offer any savings?
• What are your objectives?
• What does success look like?

Their objectives were to provide a cost-effective, consistent, accessible service across the catchment and prevent patient deterioration. Savings were demonstrated by evidencing that if a patient is seen early, the cost to the provider and commissioner is reduced — be it the number of dressing changes, frequency of visits, or prescribing of antibiotics or advanced therapies in cases of deterioration. Benefits to the patients included improved quality of life and healing rates, or early referrals for complications which may need further investigations.

Implementation:

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• What are you actually going to do?
• Who is actually going to do it?
• How will you work with other colleagues and organisations?
• What will the client/patient experience look like?
• What are your project monthly milestones?

In this section, the team had to detail the different people with varying skillsets who were needed to achieve their idea. These included the estates team (for site and equipment provision), the IT team (for communications), human resources (for job adverts), finance (for costing of resources, e.g. 0.6 band 6 nurse) and the programme/project/portfolio management office (PMO) (who would help with process mapping the project milestones, etc).

If you include a project plan

• List the tasks
• Estimate the time for each task
• Consider overlapping tasks
• Draw Gannt (bar) chart.

Some members of John’s team had skills in project management and they were able to produce a project plan. However, they also had a PMO within their organisation and it is part of their role to support with project planning to both novice and advance business case writers.

Promotion and marketing:

• Who do you need to communicate with?
• How will you communicate with them?
• What are the benefits of your project?

John and his team looked at different marketing strategies, which included a satellite clinic launch where they invited GPs, who were local to the area of the new clinic. They designed posters for GP practices, community halls, invited district nursing teams to the launch, and changed their referral form to accommodate the new clinic as a preferred referral site. Patients who were attending the existing clinical but lived closer to the new clinic were given an option to choose. This gave flexibility to both patients and staff — it was care closer to home for many who had previously had to travel longer distances.

Monitoring:

• How will you measure success?
• What are the health outcomes?
• What is your monitoring strategy?
• How will you collect and analyse the data?
• How will you disseminate this?

John and his team continued with yearly activity audits on the provision of his services, looking at avoidable wound care-related hospital admissions and complications. Performance levels against referrals and contacts were monitored monthly using SystmOne (TPP) data. Friends and family tests were also used to indicate service impact. Condition-specific patient-reported outcome measures (PROMs) were also implemented. All this information was compiled into a report, which was sent to both the local provider board and clinical commissioning group (CCG).

Financial information:

• How much start-up funding will you need? Will this be phased?
• What will you spend it on?
• Include staff, equipment, travel, venues, etc
• What is the financial value of your outcomes?
• What is the value that you will add?

Having consulted with all the people highlighted in the implementation section (above), John and his team were able to advise on how much they needed to support the satellite clinic.

Risk:

• What could go wrong?
• What have you put in place to stop this happening?
• Prioritise the risks
• Include finance, clinical, data, operational.

CASE STUDY CONCLUSION:

John and his team realised that their new clinic had the potential of poor uptake due to patients resisting change, and not wanting to move away from where they had been receiving services before. Ultimately, this could have resulted in poor return on investment. So, they educated the patients that they would still receive the same treatment just in different locations. By promoting the service to the local GPs, all new patients who lived closer to the satellite clinic were offered the closest clinic as a first choice.

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