Benefits Driven Change

Using some examples from the ISIP Demonstrator Programme, this guide shows how a benefits approach to change can be used to deliver

sustainable service transformation more quickly. It also helps the care community, including external partnerships, to be more flexible in

responding to changing circumstances.

A Practical Guide for the NHS

What is a Benefits Approach?

Programme or Project PlanningAt the planning stage, engage stakeholders in the process of

identifying shared benefits as well as potential individual benefits or

disbenefits.

A Benefits Approach is a cultural thing – it applies to every stage of the project or change programme and should support, not get in the way

ImplementationTo keep stakeholders and staff engaged and focussed, when reporting progress use “this

means” and remind people of the benefits sought.

Use easy-to-understand measures and presentation

e.g. Dashboard.

Delivery and AchievementFocus on the benefits to

patients, to clinical outcomes, to stakeholders, to the whole

community. LOS or admissions avoided are not benefits, though

they can lead to benefits.

Case for further investmentIf the project has been a

success then you may want to expand; alternately another

organisation may want to copy your project. Report in

terms of benefits.

Why does a Benefits Approach matter?

LONG TERM SHORT TERM

PERSONAL Outcome: How would I like to be?

Benefits: What will that give me? These could be in health, time, growth, happiness.

Outcome: What will I achieve this week?Benefits: What value do I get from achieving this? (and does the value I get contribute to my longer-term aim?)

ORGANISATIONAL Outcome: What will we as a community / organisation look like at the end of this transformational programme?

Benefits: What will the value-add be? Organisational or community benefits are more likely to be population health, quality of life / length of active life for a segment of the population, resources freed up and used to deliver additional services, staff career opportunities, etc.

Outcome: For each project: what is the outcome of this project? Projects may have milestones indicating a particular achievement etc.

Benefits: What are the short-term benefits or values of achieving this? (Once again, do the short-term benefits contribute to the longer-term benefits? If not, do they represent ‘quick wins’ which keep people motivated and engaged?)

A benefits approach will help you to engage different stakeholders and organisations, and also enable you to establish baselines and quantify improvements.Whether you are trying to motivate yourself or another (e.g. Cognitive Behavioural Therapy CBT), or changing a community, the principle is the same.

Stakeholder Benefits

Projects, Actions to Change

Outcomes

Benefit

Priority Objective

Stakeholder 1Stakeholder 1

Stakeholder 2Stakeholder 2

Stakeholder 3Stakeholder 3 Stakeholder 4Stakeholder 4

Priority Objectives are national or local targets e.g. “reducing inequalities”

Benefits may be stakeholder-specific or shared, and are the motivating force

Outcomes represent the future state of the service, what it has to be like to deliver the benefits

Projects and Actions to Change are what you do to achieve the outcomes

New Economics Foundation – Measuring real value: A DIY guide to Social Return on Investment

See also NHS ISIP Practical Guide on Stakeholder Engagement

See also NHS ISIP Practical Guide on Stakeholder Engagement

Progress isn’t always direct, but it should always be progress

Asset or Investment exploitation Method• From the Project Plan, work forwards to

determine where the benefits will be

Project-led approach to Benefits

BenefitThe Value-add for

Patients and service

Priority ObjectiveNational or local

target

OutcomeWhat the service

will look like

OutputProject Aims

Project led approach starts here

More community staff to attain more patient contacts

More patient contacts deliver more care at home

More care at home reduces need for hospital attendance and admission

See ISIP Benefits Dependency Mapping Tools

• Decide what you want, and what’s important about that

• Measure what’s important, not just what’s easy

• Make sure each project or output delivers the benefits that you set out to achieve, and contributes to the priority objective

Benefits PlanningAn alternate approach that has been adopted in the LHC

Demonstrators

BenefitE.g. Quality of life

Priority ObjectiveE.g. Reduced

Inequalities

OutcomeCare delivered at

home

OutputCommunity Teams

Quality of Life achieved by Care delivered at home

In order to deliver Care at home, need a project to get the teams in place

Benefits led approach starts here

Reduced inequalities demonstrated by improved quality of life

Demonstrator Experience: Illustrating a Benefits Approach

LHC Demonstrator Case Studies: Benefits Approach in Action

The Tees ENT

Walsall Stroke Project

Clinicians made the decisions on the basis of clear evidence – better care brings financial benefits

Walsall Dashboard Decide a clear mechanism for reporting, which shows how the benefits are being delivered

Liverpool Scheduled Care Ensure everyone agrees the aims and benefits – clarify in writing; simplify many projects into a few programmes with an overall governance structure

West Herts Dermatology Keep it simple – work on one benefit at a time and acknowledge and respond to disbenefits

Demonstrator Experience: The Tees ENTOur situation 74% of patients seen in an

outpatient setting and then discharged – probably suitable for a community setting

National targets to deliver care closer to home

Enthusiasm for changes to service from the Practice-Based Commissioning consortia

Independent Reconfiguration Panel report recommendations, supported by Secretary of State approval, indicate that out of date buildings should be replaced and that new services should be in a well-situated location complemented by well-developed primary care & community services

ENT service currently provided across two hospital sites which has made patient satisfaction difficult to gauge.

What we did Clinicians reviewed the existing

data on waits and cases referred, to examine scope for redesign and anticipated benefits

‘Soft’ market assessment and evaluation of expressions of interest from potential service providers

Worked in partnership with local ENT providers to develop new patient-centred services

Specifications for facilities and equipment requirements were developed by a working team including specialists, GP, audiologists and nursing staff with additional input and guidance from infection control colleagues

Detailed work around patient pathways, service exclusions, diagnostic requirements, administration pathways and reporting commenced after the overall care model was agreed between partners.

What we achieved Referring appropriate cases direct

to the community-based service will reduce waiting times to below 4 weeks and the location and reassurance of an early appointment should be more convenient to patients – evaluation of patient and GP satisfaction will be a priority post go-live (October 2007)

Project contributes to national & local targets including 18 week target, delivery of Care Closer to Home and supporting Practice Based Commissioning

Anticipated financial savings are significant. One of the major benefits of the project is the release of savings to invest in additional care

Development of a skills and knowledge base within the PCT around service redesign.

Demonstrator Experience: Walsall Dashboard

Our situation During 2006, Walsall tPCT

started to use the ISIP process to plan transformational change programmes for Urgent Care, LTC & the 18 Weeks Referral to Treatment initiative

‘Readiness to Change’ had been assessed by a group of Directors from across the LHC showing early development of capability

The aim of the demonstrator project was to develop a whole systems benefits realisation framework & a high level dashboard, to ensure that: programmes of benefits led change were delivered

The PCT improved its capability to deliver change & realise benefits across the programme portfolio

Help from the local change consultant was required to improve capability across the whole process.

What we did Completed a diagnostic process,

which made recommendations to address gaps and areas for improvement

Recruited and trained programme managers and commissioners to expand capability

Reviewed the Benefits Realisation Plans & finalised benefits at programme level (UC, LTC,18 wks & palliative care) with a basket of supporting metrics

Developed a benefits realisation framework covering project, programme and portfolio levels

Portfolio level benefits Improved clinical outcomes Improved business

processes Improved patient

experience Best use of resources

Agreed a process to develop the dashboard

Developed an approach to mainstreaming ISIP.

What we achieved Good governance structure

across LHC to support delivery

Trained programme managers and commissioners in place

A well-developed reporting structure to monitor progress, including dashboards (at-a-glance performance and benefits achievement reports) for the steering panel and protocols for dashboards specific to each organisation

Agreed approach mainstreaming ISIP

Programmes are being delivered to timescale and benefits are being realised.

Demonstrator Experience: Liverpool Scheduled Care

Our situation The stakeholders (PCT and acute

Trust) in Liverpool were clear about the aims of the overall programme

There were a number of existing projects set up to achieve specific parts of this, but they were not coordinated well

Each project had its own project manager and project support office, and in many cases its own steering group.

What we did Using the Benefits Dependency

Network Planning Tool, we were able to identify all of the existing projects and all of their expected outcomes and the benefits that they contributed

Our first attempt was too messy – it was difficult to follow through on an individual project and see where it contributed, and difficult to see which projects contributed to specific priorities and benefits

The Benefits Dependency Network planning tool enabled us to group together similar projects and develop a governance framework and an overarching steering group, with project groups responsible for clusters of projects.

What we achieved A single governance structure

reduced administration, made best use of scarce skills, and delivered more, faster within finite resources

We understood the connections: for example reducing waste (objective) meant resources being applied effectively and freed up resources for new services (benefit), and we could demonstrate this

Working together on projects encouraged us to come up with new services which could benefit the whole community – provider, commissioner, patient and service user, and staff.

“the difference is everybody’s working together, whereas before it was more fragmented”

Programme Manager

“the difference is everybody’s working together, whereas before it was more fragmented”

Programme Manager

Demonstrator Experience: Walsall Stroke Project

Our situation Length of Stay (LOS) for stroke

patients in Walsall was longer than national benchmarks

The hospital needed to reduce beds to support the PFI development

Management of financial risk for the hospital was an important consideration

Commissioners will need to demonstrate maximum efficiency in the longer term.

What we did PCT and hospital jointly

developed a new pathway The pathway involved hospital

AHPs in outreach and early handover to community teams

Community teams are in place to provide rehabilitation in the community, which will integrate people back into their social networks leading to better health outcomes

We reported the current LOS regularly so everyone could see progress.

What we achieved Measures to demonstrate

financial efficiency, clinical outcome, care and efficiency have been agreed and are being reported

LOS has fallen The new pathway has been

implemented Community resources are in

place 18 beds have been removed Transitional financial

arrangements are in place to support risk sharing between hospital and PCT

Planning unbundling of tariff to embed changes.

Objectives Improve patient care by implementing a new care pathway Redesign Stroke Rehabilitation to shift care into a range of community

settings: home or intermediate care settings Thus reduce ALOS (Average Length of Stay) Thus reduce number of stroke beds by 18 to enable PFI.

Demonstrator Experience: West Herts Dermatology

Our situation Some of the ‘benefits’ sought

by the PCT (commissioner) were perceived by the hospital (provider) as a disbenefit, e.g. loss of income

As we mapped the stakeholders (patient, staff, PCT commissioner, provider) and their direct and indirect benefits, we realised that this effect (of conflicting views of benefits) got worse.

What we did We focussed on each benefit in

turn, starting with the most important

This allowed us to examine what contribution each benefit would make, and what needed to be in place to achieve that from each side

A key challenge was to access data which would verify the benefits profile projected.

What we achieved Stakeholders who might have

been rivals now work together to deliver patient-centred services

Where transfer of care outside hospital will release capacity, the hospital trust is planning to reuse this to provide new services (see map below)

A coordinated approach retains the capacity and flexibility.

CATS in place for Dermatology

Reduced Reduced IncomeIncome

Spare Capacity Disposed of

Asset Sales

OROR

Reduced Reduced Capability and Capability and FlexibilityFlexibility

Private Clinics

High Clinical Effect Services

Reduced Costs to Commissioner

Unused Unused Capacity / Capacity / FacilitiesFacilities

Income from “other” Commissioners

Improved Overhead Recovery

Creative use of spare provider capacity

Key Messages

You will always meet opposition to change, and it will always take longer than you thought; focus on the benefits you will achieve, and if you can’t do it all in one go then take smaller steps.

Where is the evidence? Data which shows the current situation (baseline) and monitors progress can be hard to obtain (e.g. IM&T systems don’t align), but is vital when demonstrating that benefits are being delivered.

Be flexible: when priorities or circumstances change, review what actions are needed to ensure the benefits get delivered.

Group existing and new projects into programmes, with a single steering group and governance structure. Understand cause and effect – without causes (action) the effects (delivery) won’t happen.

Keep it simple: dashboard-style reporting, with the benefits relevant to the stakeholder group, will be easier to follow. Different stakeholders may need different dashboards.

Report achievements regularly and widely – keep people motivated and involved.

Where to go for more information

External references:Delivering Quality and Value: ISIP Guide: http://www.isip.nhs.uk/guidance

ISIP Practical Guide: Developing a Shared Vision: http://www.isip.nhs.uk

ISIP Practical Guide: Stakeholder Engagement:: http://www.isip.nhs.uk

RTC Stage I Benefits Planning: http://www.isip.nhs.uk/roadmap

Measuring real value: A DIY guide to Social Return on Investment (New Economics Foundation): http://www.neweconomics.org/gen/z_sys_PublicationDetail.aspx?pid=241

Named contacts:Leonie Beavers, Director of Strategy / SRO, Liverpool PCT, leonie.beavers@liverpoolpct.nhs.uk

Nicola Allen, Head of Planned Care Commissioning / Programme Manager, Liverpool PCT, nicola.allen@liverpoolpct.nhs.uk

Andrea Bigmore, Head of Change Programmes, Walsall tPCT, andrea.bigmore@walsall.nhs.uk

Julia Schofield, Consultant Dermatologist, West Herts Healthcare Trust, julia.schofield@whht.nhs.uk

Amanda Yeates, Project Manager, West Herts Healthcare Trust, amanda.yeates@whht.nhs.uk

Phil Whitfield, Associate Director of Planning and Performance, Hartlepool PCT, philip.whitfield@hartlepoolpct.nhs.uk