In our last issue Richard Bourne pointed to the weakness of many ‘business cases’ setting out proposed changes in the NHS, and challenged the frequency with which  commissioners and providers resort to spurious claims of “commercial confidentiality” to avoid disclosing the extent of this weakness.

Now a new research paper has for the first time attempted to develop “quality indicators” for healthcare business cases. It has many weaknesses, not least in accepting without question the claims that an undisclosed  number of the business cases they examine were of a “confidential and sensitive nature,” and therefore offering no specific critiques of identifiable business cases.

Nor do their examples include any of the high profile business cases for major hospital reconfiguration. The authors appear unaware of any stakeholders outside of the narrow management bodies who are drawing up and appraising the business case, so any notion of public accountability is entirely lacking.

The authors do not ask whether the business case is drafted by the NHS managers responsible for delivering services, or contracted out to high cost, management consultants.

Moreover, no doubt partly because of the researchers’ limited and rather naïve approach, none of the questions they ask of business cases includes any critical appraisal of the honesty and integrity of the documents, and no check on the assumptions made or the quality of the so-called ‘evidence’ on which the business cases are based. There is no serious discussion of equality issues.

The study limits itself to cases for relatively small scale projects, and appears to ignore any public right to know or be consulted. The authors  seem unaware of the way in which for decades complex, tendentious “business cases” have been used by some NHS management in the way a drunk uses a lamp-post: more for support than illumination.

Indeed many business cases are little more than cynical PR spin to sell a proposed change rather than a serious and critical  exposition of the facts.

The researchers’ lop-sided approach is made worse by the fact that rather than assessing major business cases in the public domain, they chose instead to “maintain ongoing dialogue with identified ‘gatekeepers’ within the CCG to gain access to business cases.”

While the limited critique offered by this paper is definitely better than no critique at all, the authors have bought so heavily into their relationship with the CCG that they fail to see any need to acknowledge or relate to the type of criticisms raised of business cases over the years by critics including local councils, trade unions, health professionals, community campaigners and political parties.

These criticisms tend to focus on the merits of the changes being proposed, the ‘evidence’ produced, the practicality in terms of funding and staffing, the viability of the plans, and the needs and views of the communities affected.

The authors, from Bristol and Birmingham universities, do howeve recognise that: “a ‘poor’ business case may lack persuasion or, in more serious cases, misinform decision-makers about the relative strengths and weaknesses of available options.”

They correctly make the point that bigger does not mean better: “Longer business cases were not necessarily any better at providing full coverage of the quality indicators, indicating that length alone does not necessarily guarantee quality.”

They also note that “only one business case explicitly linked its proposal to a set of local needs.”

However they go on without any sense of irony to discuss the application of the ‘SMART’ approach (specific, measurable, achievable, realistic and timely) despite having found that fewer than half of the NHS business cases analysed (7/15) even included explicitly labelled aims or objectives.

To progress beyond this limited exercise the authors would do well to break away from their debilitating ties to the CCG and begin talking to campaigners who have made detailed and successful challenges to business cases – in Shropshire, Huddersfield, West London, South East London and elsewhere – and to trade unions who even now are challenging business plans that seek to justify hiving off staff into “wholly owned companies”.

There’s a real world out there: it would be good to see academics engaging with it a little more.

John Lister
Author

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