001

This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent 1141211_Allocation Decision Han ...LONThis information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent
Decision Handbook
A reference guide for making effective transformation programme
decisions

This information is confidential and was prepared by Bain & Company solely for the use of our client; it is not to be relied on by any 3rd party without Bain's prior written consent 2141211_Allocation Decision Han ...LON
Why focus on decisions?
• Devolved authority, matrixed accountability and divergent incentives in
the NHS produce impasses, inefficient process and sub-optimal results
Situation
Complication
A focus on decisions
can cut through this complexity
Resolution
• A new approach that moves beyond org structure is needed to deliver the
best possible value for patient and public
• Demand for health services is growing faster than funding
• There is consensus that the health service must deliver better value

The purpose of the handbook is to…
Help the health service deliver
better value for patients and public
Guide effective decision making
across all organisations
Support Finance as leaders in driving
robust value-based decision making

What the handbook is and is not
Framework and approach for managing
and making value-based decisions
Guide on what to consider, who to
involve and the process to follow
Single source for tools, templates and
data helpful for each step
Tool to structure analysis or
build a business case
Guide to negotiating
with stakeholders
Methodology to evaluate results
after a decision has been made
WHAT IT IS WHAT IT IS NOT

Who the handbook is for
It is useful for everyone involved in the process of making decisions that
impact value:
• For those who make and coordinate decisions it provides a rigorous
and structured end-to-end process to drive value-based decision making
• For those who have a key input role and make recommendations it
provides clarity on the big picture and helps guide the evaluation process
• For those who provide input and analysis it provides context on the
overall process and links to tools, templates and data to help them input
HELPFUL HINT
Click on the symbols
throughout the handbook to
jump to resources and tools
related to the topic

How to use this handbook
CFO / Finance
Director
Deputy Finance
Director
Finance
Manager
Chief Executive
Commissioning /
Transformation
Director
Commissioning/
Transformation
Head
Before your decision process starts
• Review and understand the NHS approach , “What is value” and big picture
• Scan the appendix for helpful tools, data sources and resources
As you move through the decision process
• Focus on the role of finance to understand where you should be inputting
• Reference the “how” when starting each step for awareness of all moving parts
Before your decision process starts
• Study the NHS approach section closely
• Adapt the example decision set-up, roles and timeline to your situation
• Review and sense-check the high-level role of finance, use it as your guiding star
As you move through the decision process
• Reference the “how” as you start each step (x4) to ensure critical pieces aren’t missed
• Refer your direct reports and colleagues to relevant tools in the appendix
Most people won’t find reading the guide beginning-to-end an efficient use of
time. Depending on your role, we recommend focusing on different sections.
If you are a…
• Review and discuss the “What is value” with colleagues to see how you can
integrate non-finance elements of value into your analysis
• Scan the appendix for helpful tools, data sources and resources
Then you should…..

• “What, who, how and when” - setting the decision up for success
• “How” - deeper look at critical elements for each step in the process
• Role of finance - key actions, analysis, data and tools for finance
Contents
APPROACH
DECISION HANDBOOK
APPENDIX
• NHS approach to effective decision making
• An holistic definition of value
• Data sources and links
• Data tools and links
• Star modelling tool for value-for-money analysis
• AID model for QIPP prioritisation
• Stakeholder map and public engagement tool
• Programme budgeting marginal analysis
• Integrated Risk and Impact Assessment Tool
• Decision Trees
• Full Business Case template
APPROACH DECISION HANDBOOK APPENDIX
TIP: Click on any of the text
below to skip to that section

Setting up decisions for success requires focus on the “what-
who-how-when”
• Define the decision we are
actually trying to make
• Frame the decision in an
appropriate way
• Split into sub-decisions if
necessary
What
• Clarify upfront who will play what
role in each decision (e.g.
decision-maker, recommender)
Who
• Install structured decision
approach
• Design and specify:
- Interactions
- Critical meetings/committees
- Closure and commitment
- Feedback loops
HowWhen
• Clarify timeline for decision and
execution, and key milestones
• Consider creating a decision
calendar for on-going,
interconnected decisions
1 2
4 3

What Who
HowWhen
What Who
HowWhen
• Clarify exactly what decision is
under consideration:
-Make sure everyone is on the
same page regarding how to
define the decision being made
-Frame the decision correctly so
participants can make appropriate
tradeoffs
-Unbundle the decision into its
sub-decisions before working
through next steps
Defining the decision
The “What”: Clear and correct definition of the decision and
its sub-decisions

What Who
HowWhen
The “Who”: The RAPID® framework provides a simple
tool for allocating decision roles
Perform a decision once
made
Recommend a decision or action
Formally agree a recommendation
• Must be consulted
• Must work with R to resolve issues
Provide input to a recommendation
• Must be consulted, may or may
not be reflected in final view
Input Input Input
Recommend
Decide
Perform
Agree
RAPID should reflect what
will work in 90% of
situations
WHAT THE ROLES ARE HOW THE ROLES INTERACT
Make a final decision and commit
the organisation to action
Recommend
Agree
Perform
Input
Decide
® RAPID is a registered trademark of Bain & Company, Inc.

The “Who”: RAPID® roles imply a set of responsibilities
Recommend
Agree
Perform
Input
Decide
• Only one R – person who does 80% of the work to develop recommendation
• R has broad visibility and access to information for relevant inputs
• R has credibility with both Is and D
• Like an Input “with teeth” – must be factored into the recommendation
• Must work with R to resolve any issues
• A is on the R – D breaks a deadlock
• May be multiple Ps
• May involve P as an I to help upfront planning
• Can be multiple Is, but must be consulted, may or may not be reflected in final view
• Assigned only to those with valuable information which could change the decision
• Only one D for each decision
• Locate the D at the right level in the organisation (access to information, reaction times, ability to
make tradeoffs
• If D belongs to a group, clarify how it gets exercised
TIPS & TRICKS
What Who
HowWhen
® RAPID is a registered trademark of Bain & Company, Inc.

The “How”: Combination of the right people and information
in the right sequence to make decisions
• We are clear which facts and evidence need to underpin decisions; working
from one version of the truth for decision inputs
• Necessary pre-decision steps
Critical steps
• Once a decision is made, we move swiftly to launch execution
- Resources allocated (people and money)
- Execution plan in place (actions, accountabilities and milestones)
- Feedback loops in place to drive fast corrective action or replicate successes
Closure
• We ensure we consider the full range of alternatives
• We evaluate alternatives vs. agreed criteria using rigorous data and analysis
Choices
• We establish clear criteria for how we will evaluate options / make decisionCriteria
DECISION
• We clearly communicate decisions once made to all relevant stakeholdersCommunication
• We make effective use of committees and meetings throughout the
decision processCommittees
Pre-decisionPost-decision
What Who
HowWhen

The “When”: Clarification of the timing for the programme
and each sub-decision before the process starts
What Who
HowWhen
For
illustration

Contents
APPROACH
DECISION HANDBOOK
APPENDIX
• Decision Trees

Making a value-based decision requires a definition of value and
its components
Value
Clinical
outcome
e.g. population health,
survival rate, extent of
functional recovery
Patient
experience
e.g. comfort, treatment
by staff, waiting time,
ease of access
Safety
e.g. diagnostic error,
post-op complications,
infections
Revenue costs
e.g. income, time,
salaries, system
maintenance, facilities
Capital costs
e.g. Investment in
infrastructure /
equipment
Outcomes
Resources
1 2 3
4 5
Source: based on Michael Porter (HBR, NEJM), HFMA “Value in Health Care”, Delivery Group interviews
Value can be increased by improving outcomes for a given resource level
or by reducing the resource required to deliver a given outcome

Criteria and metrics within each component of value must be
defined depending on the specific decision
Outcomes
Clinical
outcome
• Population health
• Outcome of interventions relative to patient
expectations
• Degree and speed of recovery
• Sustainability of health
• …
• Prevalence of conditions within population
• Hospital / emergency admission rate
• Quality of recovery (e.g. visual ability post-Cataract op)
• Mortality rate
• Re-admittance rate
• …
Patient
experience
• Ability to access care
• Care environment (e.g. facilities, comfort)
• Personal interactions (e.g. care and respect)
• Timeliness of interactions
• Availability of information
• Involvement in decision-making
• …
• Distance to care facility
• Waiting time for first appointment
• Specialists per population
• Time between referrals and number of referrals
• Patient feedback on experience with interactions
• Patient Net Promoter Score
• …
Safety
• Diagnostic errors
• Post-operative complications
• Medication errors
• …
• Diagnostic error rate
• Complication rate
• Medication error rate
• …
Resources
Revenue
costs
• People
• Facilities
• Equipment
• ..
• Income
• Salaries
• Time
• System running costs
Capital
costs
• Investment in facilities / equipment
• …
• Capital requirement and rate of return
• …
COMPONENTS OF VALUE CRITERIA (EXAMPLES) METRICS (EXAMPLES)
1
2
3
4
5
Source: based on Michael Porter (HBR, NEJM); HFMA “Value in Health Care”; Delivery Group interviews

An holistic value definition must be embedded in the “what-who-
how-when” to achieve best possible value in decision making
Framing your decision context,
objectives and constraints
using a value perspective
What
Getting the right people
engaged to ensure focus on
system-wide value
Who
Taking the right steps,
through the right process
with the right analysis
for an integrated value approach
HowWhen
Starting at the right time,
with the right timetable and
milestones to make considering and
delivering better value possible
1 2
4 3

Contents
APPROACH
DECISION HANDBOOK
APPENDIX
• Decision Trees

How to read the pages in this section
Decision roles
(R-A-P-I-D) of all
key players for
each sub-decision
“WHAT” - DECISION CHARTER “WHO” - DECISION ROLES
“WHEN” – TIMELINE “HOW” – DECISION COMPONENTS
What Who
HowWhen
What Who
HowWhen
What Who
HowWhen
What Who
HowWhen
A reasonable
timeline for the
decision process
with key
milestones
A high-level
summary of
critical steps
through the
decision process
Context, objectives
and constraints set
up the decision for
success

Decision roadmap: “what-who-how-when”
appropriate way
necessary
What
Who
approach
- Interactions
- Critical meetings/ committees
- Feedback loops
HowWhen
1 2
4 3

The decision charter should be framed to emphasise
system-wide value, including objectives and constraints
Constraints
Objectives
Context
• Improve value (cost, outcomes, safety and experience) delivered by the health system
• Deliver services more efficiently to meet population’s health needs
• Changes are sustainable within the broader health economy
• Providers support and implement the changes
• Must reduce projected outlays by £4M
• Manage resources within the financial framework set by NHS England
• Must align with CCG strategic plan and adhere to CCG governance rules
• Must be acceptable to public/political officials and regulators
• Should be acceptable to clinical staff, financial staff and patients
NHS data indicate that a CCG responsible for a small northern industrial town of
~200,000 people is underperforming relative to its demographic peer group in several
service areas. Their budget allocation will increase 5% next year to £210M, while
projected outlays with no commissioning changes are expected to increase 7% to
£214M. The CCG must decide how to improve value and bridge the £4M resource
gap in the health economy, and ensure providers implement the necessary changes.
Decide how to improve value and bridge a £4M resource gap in the health economyDecision
What Who
HowWhen

Example value criteria and metrics for this decision
should be adapted to match your decision context
Outcomes
Clinical
outcome
• Population health
• Prevention
• Outcome of intervention relative to patient
expectations
• Patient recovery
• Sustainability of health
• Prevalence (e.g. hypertension prevalence relative to peer group)
• Prevention (e.g. ratio of hypertension v. heart failure prevalence, % of CHD
patients on aspirin)
• Diagnosis (e.g. % of cancers detected at an early stage)
• % patients treated to a pre-defined care standard (e.g. 8 Key Care Processes for
Diabetics)
• Recovery (e.g. % of patients discharged home)
• Survival rate (e.g. 1 year net cancer survival rate)
• Re-admittance rate (e.g. emergency re-admission to hospital within 28 days (%):
stroke)
Patient
experience
• Access to care
• Experience in care
• Distance to care (e.g. average distance for emergency admission)
• Waiting times (e.g. TIA cases treated within 24 hrs)
• Specialists per population (e.g. proportion of non-STEMI patients seen by member
of cardiology team)
• Time between referrals (e.g. % of cancers receiving treatment within 2 months of
GP referral)
Safety
• NRLS safety incidents by type (e.g. “clinical
assessment” incidents compared to peer
group)
• Clinical assessment incidents
• Treatment/procedure incidents
• Medication incidents
Resources
Revenue
costs
• Delivery model / cost structure
• Activity rates (e.g. imaging frequency)
• Clinician salary
• Admin staff salary
• System running costs
• Activity (total)
• Total programme spend relative to peer group (e.g. spend on primary care
prescribing for CHD)
• Elective/Non-elective programme spend (e.g. spend on non-elective admissions for
GI cancer)
Capital
costs
• Investment in facilities / equipment
• …
• Capital requirement and rate of return
• …
COMPONENTS OF VALUE CRITERIA METRICS (EXAMPLES)
1
2
3
4
5
What Who
HowWhen

This CCG transformation programme decision has four
key sub-decisions
Decide whether to
proceed with preferred
option(s) and
implementation plan
Determine
deliverability of
preferred option(s)
Determine how to improve each
opportunity area and the preferred
option(s) for improvement
Determine areas with greatest
opportunity for improved
outcomes/cost reduction
Closure
How
ToChange
What
ToChange
Where
ToLook
Establish
Charter
1
Set Up Execution
NHS
Right Care
Approach
Communicate
To
Stakeholders
4
2
3
Decision: Decide how to improve value and bridge a £4M resource gap in the health economy
Define
Key
Criteria
Define
Roles
Frame
Decision
Key sub-decision
What Who
HowWhen

appropriate way
necessary
What
Who
approach
- Interactions
- Feedback loops
HowWhen
1 2
4 3

RAPID® roles for this decision are designed to maximise
decision effectiveness and can be adapted to your context
Local
Authority
CCG
Board
CCG
chief
exec.
officer
CCG
finance
director or
equivalent
CCG
commiss-
oning
director or
equivalent
Clinical
Senate
Council
Health &
Well-being
Board
Trust
Board
Trust
finance
director or
equivalent
Trust
clinical
directors
or
equivalent
Consult-
ants
Clinical
Experts
Wider GP
Comm-
unity
Regulat-
ors
Determine areas with greatest opportunity for improved outcomes/cost reduction
D A R A I I
Determine how to improve each opportunity area and the preferred option(s) for improvement
D I R I I I A I
Determine deliverability of preferred option(s)
I D A R I A I
Decide whether to proceed with preferred option(s) and implementation plan
D R A I
A
P
2
3
4
R Recommend A Agree P Perform I Input D Decide
What Who
HowWhen
1
P
Ensuring stakeholders understand their RAPID® role up-front will improve
efficiency, reduce impasses and improve decision quality
Key sub-decision

Sub-decision
Role of
Finance
RAPID
Intensity of
Involvement
Actions
Determine areas with
greatest opportunity for
improved outcomes/cost
reduction
Drive integration
of finance and
outcome/quality
analyses
A
• Generate a broad range of options for consideration
• Translate activity and non-financial data into financial
terms; share insights with CCG commissioning director
Determine how to improve
each opportunity area and
the preferred option(s) for
improvement
Own rigorous
analysis and
insight
generation
I
• Push for rigorous evidence and assumptions on financial
and non-financial benefits
• Assist integration of financial/non-financial analyses into
cohesive value assessment
Determine deliverability of
preferred option(s) A
• Identify, quantify and assign probabilities to resource
based limiting factors, barriers and risks
• Offer finance view on non-financial limiting factors,
barriers and risks
Decide whether to
proceed with preferred
option(s) and
implementation plan
Lead on
delivering value
R
• Responsible for compiling full business case and
presenting recommendation to the board
• As board member, push to integrate financial/non-
financial analyses into a unified assessment of value
2
3
4
1
What Who
HowWhen
The role of finance in this process changes across sub-
decisions
Key
= High intensity
= Medium intensity
= Low intensity
Key sub-decision

appropriate way
necessary
What
Who
approach
- Interactions
- Critical meetings/committees
- Feedback loops
HowWhen
1 2
4 3

Mapping the decision process supports proper
sequencing and execution of all critical steps
Agree terms
with providers /
market
Seek agreement from
Trust board and CCG
finance on
recommendation
Input and
agreement
from
Health &
Wellbeing
Board
Closure
How
ToChange
What
ToChange
Where
ToLook
Establish
Charter
Set Up Execution
NHS
Right Care
Approach
Assess
wider
system
impact
Appraise
relative
options
Develop full
business case
including impact
assessments
Communicate
To
Stakeholders
Define
Key
Criteria
Define
Roles
Frame
Decision
Determine areas with greatest
opportunity for improved
Determine how to improve
each opportunity area and
the preferred option(s) for
improvement
Determine
deliverability
of preferred
option(s)
4
Decide whether to
proceed with
preferred option(s)
and implementation
plan
Define
optimal
service
based on
proven
models
Conduct
Service
Reviews
2
3
Align
stake-
holders
on key
criteria
1
What Who
HowWhen
Key sub-decision
Review
JSNA
Analyse
benchmark
data (e.g.
Commiss-
ioning for
Value pack,
SPOT, etc.)
Assess
baseline
costs
Review
Risk
Stratifi-
cation
Gather
clinical
and
provider
input
Map
resource
use by
population
group
Compile risk
appraisal
and
mitigants
Input from
stakeholders
(e.g. Health &
Wellbeing
Board)

appropriate way
necessary
What
Who
approach
- Interactions
- Feedback loops
HowWhen
1 2
4 3

What Who
HowWhen
Decision timeline of a ‘good case’ scenario
Decision Calendar
Mo1
Mo2
Mo3
Mo4
Mo5
Mo6
Mo7
Mo8
Mo9
Mo10
Determine areas with greatest opportunity for improved
Announce commissioning Intentions / notice of
desired changes
Determine how to improve each opportunity area and the
preferred option(s) for improvement
Identify smaller quick-wins within the overall plan
Identify larger scale transformative changes
Determine deliverability of preferred option(s)
Decide whether to proceed with preferred option(s) and
implementation plan
Announce implementation plan
Sign new or amend existing contracts
1
2
3
4
Iterative process,
misaligned incentives
and behaviours can
extend this process
Closure
HowTo
Change
What
ToChange
Where
ToLook
Key sub-decision

Contents
APPROACH
DECISION HANDBOOK
APPENDIX
• Decision Trees

Criteria Critical Steps Choices Considered Committees
• Focus on areas where
underperforming relative to
demographic peer group clinically
or financially
• Focus on populations that consume
the most resources
• Seek to incorporate cost, quality,
safety and experience
considerations to deliver best
possible value
• Alignment with CCG long-term
strategic priorities, JSNA and other
key stakeholder priorities
• Asset / facility utilisation
• Map resource use by population
group
• Refresh/review risk stratification
• Assess baseline costs
• Analyse peer group, patient and
provider benchmark data
• Review Joint Strategic Needs
Assessment, and long-term
strategic priorities of CCG,
stakeholders and Health &
Wellbeing Board
• Gather patient input
• Programme/pathway budget
allocations
• Provider/care setting allocations
• Contracting frameworks (e.g.
payments linked to outcomes, lead
provider arrangements, capitation)
• Investment in self-managed care
(e.g. web-accessible integrated
digital care records)
• Decommissioning services
• Clinical Reference Group or
equivalent: commissioning board
sub-committee of clinicians
- commissioning head gathers Input as
needed
• Transformation Stakeholder
Working Group or equiv.: Joint
provider / commissioner group
- Input mechanism for Trust finance
and Trust clinical heads
• Health & Wellbeing Board:
includes local authority, public
health, Healthwatch, head of adult
and children's social services reps
- Commissioning head seeks
Agreement. Recommendation must
reflect views, even if dissenting
CCG board
CCG
commissioning
head
CCG finance head
Health & Wellbeing
Board
Trust finance head
Trust clinical
directors or
equivalent
Communication Closure
• Send “influencing paper” with high-level case for change opportunities and
forward view to commissioning, provider, patient and public stakeholders
• Commissioning director or equivalent initiates programme/pathway
review and stakeholder engagement through the Clinical Reference
Group
• CSU or internal business intelligence staff allocated for further analysis
2 3 41
What Who
HowWhen
Sub-Decision: Determine areas with greatest opportunity for improved outcomes/cost reduction
Decision component snapshot for sub-decision one
Click these icons throughout the
Handbook for additional resources
RD A A I I
DECISION
RAPID Roles

• Commissioner submits clinical communication with rationale/preliminary
case for change, including population health, to all clinical stakeholders
• Commissioner submits a Letter of Commissioning Intention to:
- Trust / Provider senior management
- Other commissioners if joint commissioning
• Commissioning and finance directors accelerate the viability assessment,
reengaging provider finance and clinicians, regulators and patient groups
• Clear competitive issues with regulators, and clinical issues with CQC
• Finance / business intelligence staff are allocated for support
• Changes evaluated on their
projected effect on cost,
quality, safety and patient
experience
• Must be feasible to deliver
within the required time horizon
• Must not render other parts of
the health and social care
economy unsustainable (e.g.
impact on specialist/NHS
services, provider-level
economics, etc.)
• Best practice models preferred
to those which are untested
• Align stakeholders on criteria for
evaluation
• Conduct service reviews
• Appraise relative options (expected
outcome and benefit)
• Assess wider system impact
• Determine if public consultation is
required
• Contract Management (e.g.
reducing outpatient follow up ratios
to peer averages)
• Policy Change: policies covering
admissions, prescribing, etc.
• Service or Pathway Redesign
• Allocative (e.g. reallocate from
child to elderly care, invest in
prevention)
• Provider/partner arrangements
(e.g. retender)
• Clinical Reference Group or
equivalent: commissioning board
sub-committee of clinicians
- Commissioning head seeks
Agreement from clinical experts
- Recommendation to the CEO must
convey views of expert clinicians,
even if dissenting
provider / commissioner reference
group
- Commissioning head seeks Input
from consultants, GP, trust finance
and trust clinical directors
2 3 41
What Who
HowWhen
Sub-Decision: Determine how to improve each opportunity area and the preferred option(s) for improvement
Decision component snapshot for sub-decision two
DECISION
CCG chief
executive
CCG
commissioning
head
Clinical
experts
CCG
finance
head
Trust
finance
head
Trust
clinical
directors
Consultants
Wider GP
community
RD A I I I I I
RAPID Roles

RAPID Roles
• Submit/present deliverability assessment to:
- CCG senior management
- CCG Board
- Co-commissioners (e.g. NHS if potential impact on specialist services)
- Health & Wellbeing Board
- Provider Boards
• Commissioning finance director and non-finance staff begin assembling
final recommendation including impact assessments
• Finance staff are allocated to support the director in preparing final
documents for submission to the board
• Simplicity is preferable to
complexity
• Level of provider support
• Level of political / public
support
• Availability of resources to
implement
• Ability to sustain the change
over multiple years
• Funding should follow
outcomes
• Identify limiting factors (e.g. people,
equipment, shortage of GP’s,
insufficient number of trainers, etc.)
• Identify potential barriers including:
- Concerns of Local Authority
- Financial impact on providers
- Concerns of clinicians and expert
patient groups
• Compile risk appraisal
including clinical,
commercial, operational,
implementation and timescale
risks, scores and mitigants
• Determine if programme will
need regulatory approval
• Proposal is deliverable / not
deliverable
• Parts of the proposal are
deliverable
• Parts are deliverable now, parts are
deliverable later
• Recommend modifications to
proposal that make it more
deliverable
- Commissioning head seeks Input
from Health & Wellbeing Board and
Local Authority on her
Recommendation to the CCG Board
• CCG Board Decides based on
commissioning head’s
Recommendation
2 3 41
What Who
HowWhen
Sub-Decision: Determine deliverability of preferred option(s)
Decision component snapshot for sub-decision three
DECISION
CCG Board
CCG
commissioning
head
CCG
finance
head
Trust Board Local Authority
Health &
Wellbeing
Board
RegulatorsRD A I I IA

RAPID Roles
• Communicate full business case / case for change to:
- CCG senior management
- All market, regulatory and clinical stakeholders, especially trust senior management
• Launch public/patient education programme
• Memorandum of Understanding or equivalent is signed by providers and
commissioner articulating the agreed changes
• Changes to contracts made / process initiated
• Commissioner and providers make joint public announcement
• Develop plan to review and evaluate implementation
• Balance implementation risk and
gain we expect to achieve
• Seek to incorporate cost, quality,
safety and experience to deliver
best possible value
• Alignment with CCG long-term
strategic priorities, population
needs defined by JSNA and other
key stakeholder priorities
• Focus on largest opportunities
• Deliverability on a XX timescale
• Develop full business case
including:
- Review impact assessments
(equality & system)
- Complete risk appraisal and
mitigation steps
- Stress test benefits realisation
and cost assumptions
- Compile implementation timescales,
resources, milestones and measures
of benefit
- Develop potential exit strategy if the
benefits don’t materialise
- Determine board reporting
requirements on implementation
• Do nothing
• Incremental change
• Radical change
• Do something
- Commissioning finance head seeks
Input for his/her Recommendation
provider / commissioner group
- Commissioning finance head seeks
Agreement from Trust Board(s) on
his/her Recommendation
• Commissioning Board (e.g. CCG
Board) Decides based on CCG
finance head’s Recommendation
2 3 41
What Who
HowWhen
Sub-Decision: Decide whether to proceed with preferred option(s) and implementation plan
Decision component snapshot for sub-decision four
DECISION
CCG Board
CCG
finance
head
CCG
commiss.
head
Trust Board
Local
Authority
Health &
Wellbeing
Board
Regulators
Wider GP
Community
RD A I I IA PP

Contents
APPROACH
DECISION HANDBOOK
APPENDIX
• Decision Trees

Role of finance snapshot for sub-decision one
Critical Step Actions for Finance Pieces of Analysis Data Data Source
Tools /
Resources
Map resource use by
population group
CCG Finance: Submit
request for analysis to CSU or
informatics department. If only
able to produce activity levels
by patient population, add in
cost estimates
• Activity and statistical
analysis conducted by
CSU or informatics team
• Costing of activities
conducted by finance
• Programme activity by
population sub-group
• Tariff rates by activity
• Community, block and
other contract information
• Secondary Uses Service
• Contract data from providers
(e.g. SLAM)
Refresh / review risk
stratification
CCG Finance: May overlay
cost data on models from
informatics specialists / CSU
N/A
• Outpatient, inpatient, A&E,
and GP data
• Public Health Data
• Hospital Episode Stats
• Secondary Uses Service
Combined
Predictive Risk
Model (Kings Fund)
Assess baseline costs
CCG Finance: Compile
current spend data and direct
CSU/informatics to model
future spend
Provider Finance: Identify
mismatches between tariff
rates and actual cost base
• Assess current and
projected spend by
provider
• Review past programme
category spend
• Assess service line cost
• Spend by provider
• Spend by programme
category
• Service line costing info
• Existing contracts
• SLAM
• Dr. Foster
• SUS
• Internal tracking
• Reference costs
N/A
Compile comparative
benchmarking data
CCG Finance: Work with
commissioning lead to identify
opportunities based on
relative performance against
benchmarks
• Identify outliers of
(under)performance
• Identify explanations
and consequences of
variation
• Programme budgeting
• Primary and secondary care
• Utilisation data
• Evidence from trials in other
regions
• Dr. Foster PPM Module
• QOF
• NHS Comparators, Atlas of
Variation, Commiss. for Value
• SLAM Data
N/A
Review JSNA and long
term priorities of CCG,
stakeholders and Health &
Wellbeing Board
CCG Finance: Assist the
commissioning lead in
presenting the ideas to check
if compatible with long term
strategic priorities
N/A N/A N/A N/A
Role of Finance
• Drive integration of financial analysis and outcome analyses (clinical, safety and experience)
• Generate a broad range of options for consideration
• Translate activity and non-financial data into financial terms; share insights with CCG commissioning director
What Who
HowWhen • Finance’s responsibility
• Non-finance’s responsibility
Sub-Decision: Determine areas with greatest opportunity for improved outcomes/cost reduction
2 3 41

• Finance’s responsibility
Role of finance snapshot for sub-decision two
Critical Step Actions for Finance Pieces of Analysis Data Data Source Tools / Resources
Align stakeholders on
criteria for evaluation
CCG Finance: Lead process with
provider counterparts to formally
agree on metrics (incl. activity data)
underlying case for change
N/A N/A N/A
• STAR tool
• Looking for Value in
Hard Times
Conduct service reviews
CCG Finance: Establish financial
baseline of maintaining current model
Provider Finance: Model cost and
outcome implications and share with
CCG finance
• Cost benefit analysis of
keeping existing model
• Vet cost modelling of
alternative models
assembled by providers
• Medical Appropriateness
• Provider level spend
• Clinical / trial evidence
• QOF data
• SLAM data
• CSU or provider
• Clinical Ref. Group
• Diagnostic Steps of a
Service Review
• Adopt, Improve, Defend
tool
Appraise relative options
CCG Finance: Lead analysis for
economic appraisal. Act as a sense
check, flag interdependencies and
barriers. Review quality impact
analysis produced by head of quality
Provider Finance: Model cost and
outcome implications and
communicate internally
• Economic appraisal
(e.g. financial costs and
benefits, ROI, etc.)
• Programme budgeting
marginal analysis
• Quality / Non-financial
benefits appraisal (e.g.
improved outcomes)
• Cost of current service,
future baseline cost,
procurement and
mobilisation costs
• Programme category and
provider level spend
• Patient experience data
• Safety data
• Evidence from trials
• Audit of spend
• Reference costs
• CSU/ BI activity
projections
• QOF & SLAM data
• HealthWatch
• Dr. Foster
• Orgs running trials
• STAR tool
• Looking for Value in
Hard Times, The Health
Foundation
• Program Budgeting
Marginal Analysis
Toolkit, Right Care
Assess wider system
impact
CCG Finance: Gather and vet the
impact on provider resilience
Provider Finance: Work with clinical
and operations to assess impact and
share concerns with commissioner
• Provider financial and
operational impact
• Equity impact assessment
• Provider Impact
assessment (from
providers)
• Prevalence and activity data
• Provider finance
staff
• CSU reports
• Unify2 database
• Integrated Impact
Assessment Guide,
Milton Keynes CCG
Determine if public
consultation is required
No Finance Role
Role of Finance
• Own activity and financial data, holding stakeholders accountable for their models and due diligence
• Push for rigorous evidence and explicit assumptions on both financial and non-financial benefits
• Integrate financial/non-financial analyses into a unified assessment of value
What Who
HowWhen
Sub-Decision: Determine how to improve each opportunity area and the preferred option(s) for improvement
2 3 41

Role of finance snapshot for sub-decision three
Identify limiting factors
(e.g. equipment, GP
shortage, shortage of
trainers, etc.)
CCG Finance: Lead effort to
articulate resources needed to make
proposed changes
• Forecast of resource
requirements and
availability under
different scenarios
Identify potential barriers
CCG Finance: CFO drives process
as part of senior management team–
linking to provider counterparts.
Provides financial analysis to those
engaging clinicians
Provider Finance: Express finance
concerns to internal leadership and
CCG counterpart
• Assess / validate
financial risk for
providers
• Financial impact on
providers
• Views of Local Authority
• Views of clinicians
• Views of expert patient
groups
• Conversations w/
trust counterpart
• Conversations w/
local authority
counterpart
Compile risk appraisal
CCG Finance: Develop financial risk
appraisal, and gather risk
assessments from trusts and inputs
from CCG departments (quality,
procurement, etc.)
• Risk appraisal including
clinical, commercial,
operational,
implementation and
timescale risks, scores
and mitigants
• Likelihood of occurring
• Potential Impact
• Context
• Inputs from chief
commissioning
officer, head of
quality and
provider
counterparts
• Integrated Impact
Assessment Guide,
Milton Keynes CCG
Determine if regulatory
approval will be necessary
No Role N/A N/A N/A N/A
Role of Finance
• Own rigorous analysis and insight generation
• Identify, quantify and assign probabilities to resource-based limiting factors, barriers and risks
• Offer finance view on non-financial limiting factors, barriers and risks
What Who
HowWhen
Sub-Decision: Determine deliverability of preferred option(s)
2 3 41

Role of finance snapshot for sub-decision four
Develop full business
case
CCG Finance: Finalise
model and estimates for
benefits realisation and
impact assessments.
Support commissioning
director in finalising risk
appraisal/ mitigation, and
rationalising implementation
timescale, milestones and
measures
• Stress test benefits
realisation and cost
assumptions
• Detailed Impact
assessments (equality &
system)
• Complete risk appraisal
and mitigation steps
• Implementation
timescales, resources,
milestones and measures
of benefit
• A stakeholder map
• Communication
engagement plan
• Outline business case
(OBC)
• Service Specification and
data requirements
• Board reporting
requirements on
implementation
• All inputs from
previous
analyses
• Analyses from
previous steps
• Full Business Case
Template, NHS
National Innovation
Centre
• Stakeholder Map &
Engagement Tool
• Risk Appraisal &
Mitigation Tool
Role of Finance
• Responsible for compiling full business case and presenting recommendation to the board
• As board member, push to integrate financial/non-financial analyses into a unified assessment of value
What Who
HowWhen
Sub-Decision: Decide whether to proceed with preferred option(s) and implementation plan
2 3 41

Contents
APPROACH
DECISION HANDBOOK
APPENDIX
• Decision Trees

Data sources for Best Possible Value decisions
Data source Value categories Description Useful for
Quality and Outcomes
Framework (QOF)
Safety / Experience /
Outcomes
GP surgeries metrics on Clinical, Public Health, Public Health,
Patient Experience, Quality and Productivity.
Benchmarking against peer groups and
service reviews.
CCG Outcomes Indicator
Set (CCG OIS)
Safety / Experience/
Outcomes
Outcomes at CCG level to help inform priority setting and drive
local improvement.
NHS Comparators Cost / Outcomes Benchmarking and comparing activity and costs on a local,
regional and national level for commissioners and providers
Indicative sense of where to look deeper.
Data can be old and is not in raw format.
NRLS Organisation Patient
Safety Incident Reports
Safety Data shows patient safety incident statistics for trusts in England
and Wales
Benchmarking against peer groups for
indication of where to look deeper.
Commissioning for Value
Packs
Cost / Experience /
Outcomes
In-depth comparative data for 13 patient conditions, within the
programmes that are most commonly identified as offering the
greatest potential improvements.
indication of where to look deeper.
QualityWatch Indicators Safety / Experience /
Outcomes
Independent scrutiny and data on access, experience, safety,
equity and effectiveness of services across mental, social,
primary and secondary care
Benchmarking, modelling impact on
experience, safety or clinical outcomes for
proposed changes.
Secondary Uses Service
(SUS)
Cost / Outcomes Data can be patient identifiable or anonymised or as required for
the user's needs.
Benchmarking, consumption mapping, and
assessing cost base.
Doctor Foster Practice
Provider Module (PPM)
Cost / Outcomes / Safety Analyse and benchmark hospital admissions data across a wide
range of outcomes, utilisation, trends and patient records across
a region.
Benchmarking, consumption mapping,
assessing cost base, and forecasting
impacts from proposed changes.
Health and Social Care
Information Centre
Population Health Comparative benchmark data, population health, trends over
time, health risk factors, and health inequality.
Useful for benchmarking, developing a fact
base, risk stratification and service planning.
Hospital Episode Statistics Provider Cost / Activity HES is a data warehouse containing details of all admissions,
outpatient appointments and A&E attendances at NHS hospitals
Risk stratification
Patient Reported Outcome
Measures Tool (PROMT)
Cost / Outcomes /
Population Health
Data collected for 4 procedures: hip and knee replacements,
groin hernia and varicose veins. The tool enables commissioners
to examine the relationship between a range of local factors
Risk stratification. Benchmarking against
peer groups for indicative sense of where
you could look deeper.
Service Level Agreement
Monitoring (SLAM)
Cost Monthly dataset provided by CSUs to CCGs including detailed
breakdown of services performed by providers.
Useful for contract management, and
assessing current cost base.

Data tools for Best Possible Value decisions
Tool Description Useful for
Full Business Case Template Detailed outline and suggested analysis for a Full Business Case from the NHS
National Innovation Centre.
Public Sector Business Cases Using
the 5 Case Model Toolkit
Template and guidance, including content outlines, for developing outline and full
business cases for specific decisions.
Outline Business Case / Full Business Case
Health Investment Network programme
Budgeting Benchmark Tool
Enables NHS organisations to identify: how they spend their allocation over the 23
diseases and their respective subcategories; how, and by how much, their
expenditure distribution pattern compares with other commissioners nationally,
locally or with similar characteristics; and how their expenditure distribution has
changed over time.
programme budgeting marginal analysis
Combined Predictive Risk Model A model that used inpatient, outpatient, A&E and GP data to stratify populations
according to their risk of admission. In order to run this model, a software front-end
needed to be built locally. Intellectual property is owned by the Department of
Health.
Risk Stratification
Adopt Improve Defend (AID) A Right Care process that supports both the need to generate good ideas for reform
in the priority areas needing focus and the need to engage the wider health
community in these reforms.
Evaluating and prioritising service model
options.
Socio-Technical Allocation of
Resources (STAR)
London School of Economics (LSE), the Health Foundation has developed the Star
approach that combines value for money analysis with stakeholder engagement,
where an Excel-based tool is used alongside a facilitated stakeholder workshop.
Spend and Outcomes Tool (SPOT) Graphically illustrates where you stand, compared to similar CCG populations, on
the health outcomes you are achieving for your health spend.
Indicative sense of where you could look
deeper. Sense check on proposals under
consideration.
Inpatient Variation Expenditure Tool
(IVET)
Benchmark and compare their inpatient spending (adjusted for age, sex and needs)
on diseases and interventions with other PCTs to improve future investment
decisions.
Calculate potential savings by reducing
admissions across major disease groups and
for interventions with the highest spend.
Public Engagement Toolkit A guide for anyone who needs to engage with the public about health care
commissioning. Designed for commissioners.
Practical advice on how to go about public
engagement
Programme Budgeting Benchmarking
Tool
Framework for estimating / benchmarking expenditure across healthcare conditions,
also known as ‘programmes categories’, across the whole care pathway.
indication of where to look deeper. Data can
be slightly outdated and is not in raw format.

STAR - a modelling tool and approach for value-for-money
analysis and stakeholder engagement
MODEL OVERVIEW DOWNLOADABLE RESOURCES
Source: The Health Foundation, Star Online Demonstration.
Star (Socio-Technical Allocation of Resources) is
an innovative approach that supports
commissioners’ budget prioritisation processes.
By combining a technical value-for-money
analysis with extensive stakeholder engagement
and discussion, Star enables commissioners to
involve the wider community in the evaluation of
a range of current or potential interventions.
• Star comprises a technical tool and a
workshop-led process
• Online video training, demonstrations and
downloadable resources are available
Case Study
Excel modelling
tool
Learning report
and examples
User guide

Adopt, Improve, Defend - an AID for QIPP by Right Care
MODEL OVERVIEW DOWNLOADABLE TOOLKIT
Source: Right Care, ‘Adopt, Improve or Defend’ – An AID for QIPP. September, 2013
A systematic approach to achieve challenging
QIPP targets by identifying and addressing
variations in local healthcare.
The AID methodology provides commissioners
with a structured process to assess, challenge
and improve promising QIPP ideas:
- Adopt – implement the idea as presented
- Improve – adapt the idea
- Defend – reject the idea and retain the current
position
The intention is that the process is intended to
support high-value commissioning on an on-
going basis.

Satisfy
• CQC
• MPs
• Health and wellbeing
board
• Overview and scrutiny
• Local Authority
• NHS England
• Competition and Markets
Authority
Manage
• Provider boards and
governors
• Commissioning boards
and governance
• Partners
• Monitor
Monitor
• Media
Inform
• Patients and public
• Provider workforce
Power
Influence
Low High
High
Low
Note: More detailed guidance and recommendations on stakeholder engagement, tracking, and management can be found here at NHS Networks
Source: NHS Central Lancashire, Public Engagement A toolkit for health commissioners and partner organisations
Institute for Innovation and Improvement, Stakeholder Analysis
STAKEHOLDER MAP DOWNLOADABLE TOOLKIT
Stakeholder map and engagement toolkit

• Compile programme budget spend by category across age groups in
so far as local data and estimates permit.
• Identify the top 10 health programmes in each of the major providers
and look at the differences.
• Discuss the differences and identify the networks and pathways these
patterns reveal.
• Compile programme budget category spend by provider across all
providers
• Compiling this table will help identify relative size of each provider’s
contribution and how programme expenditure relates to provider
expenditure
• Compile the follow data across programme budget category for the
most recent year:
- Spend per 100,000 weighted population
- Average spend per 100,000 population among peer group
- Average spend per 100,000 population in England
Programme Budgeting Marginal Analysis
Source: Right Care, The Third Annual Population Review: Commissioning for Health Improvement
INPUT PROCESS OVERVIEW DOWNLOADABLE TOOLKIT
Step 2
Step 3
Step 4
Step 1

Integrated Risk and Impact Assessment
Source: Milton Keynes CCG, Quality and Equality Integrated Impact Assessment Policy
Identify Identify risks associated with safety, patient
experience, clinical, operations, financial,
reputation, etc.
Score An overall risk score for each element based on
the level of impact and likelihood of occurrence
Investigate Scores above a certain threshold (e.g. above 8)
should be investigated further
Mitigate Mitigation plans should be developed for high
risk/impact items and integrated into the Full
Business Case
RISK APPRAISAL PROCESS DOWNLOADABLE TOOLKIT
Likelihood Description Risk
Score
Very High Will undoubtedly occur, possibly frequently 5
High Will probably occur but not a persistent issue 4
Medium May occur occasionally 3
Low Do not expect it to happen but it is possible 2
Very Low This is unlikely to ever happen 1
Impact
Probability
Very
Low (1)
Low
(2)
Medium
(3)
High
(4)
Very
High (5)
Very Low (1) 1 2 3 4 5
Low (2) 2 4 6 8 10
Medium (3) 3 6 9 12 15
High (4) 4 8 12 16 20
Very High (5) 5 10 15 20 25
Key
Low Risk (1-3)
Moderate Risk (4-9)
Significant Risk (10-14)
High Risk (15-25)
SAMPLE SCORING TEMPLATE

1. Implementation cost is less than £x
2. Changes demonstrate value for
money
3. Contributes to CCG priority areas
4. Has no adverse impact on health
inequalities
5. Meets at least one of the triple aim
components (better health, best
care (clinical & patient), value for
money)
6. Net savings in the system
7. Timeline to payoff/desired benefits
Source: Matthew Cripps. Right Care, Healthcare Reform Business Process Guide. 2013.
KEY CRITERIA
Example QIPP prioritisation decision tree (1/2)

Example QIPP viability decision tree (2/2)
Proposal
Is there evidence
that proposal could
improve health
outcomes for the
population of
Doncaster?
Is there evidence
that this proposal
may deliver better
value for money
(i.e. achieving the
same health
outcomes for less
money)
Do not
proceed
Is this proposal achievable
within realistic timescales; i.e.
are there constraints for
example contractual delays,
financial constraints, HR
issues, training issues that
make progress inappropriate
Can constraints be managed
within resources?
Proceed to
prioritisation
no
no
yes
yes
Step 1: Initial viability assessment v 1.2
noDo not
proceed
no
Source: Matthew Cripps. Right Care Briefing for HFMA on Option Prioritisation and Impact Assessment. May, 2013.

Full Business Case template
Source: NHS National Innovation Centre, Full Business Case Template. 2012.
BUSINESS CASE TEMPLATE DOWNLOADABLE TOOLKIT
This Business Case template provides an
outline structure and notes to describe the
content required for each section in a Business
Case document.
There are many formats for a business case,
but the information you include should be the
background of the project, the expected
business benefits, the options considered (with
reasons for rejecting or carrying forward each
option), the expected costs of the project, a gap
analysis and the expected risks.
You should also consider the other options,
including the option of doing nothing, with the
costs and risks of inactivity. This information will
help you to identify a clear justification for the
project.

Example deliverability dashboard for communicating to
stakeholders
Rating Comments / Context / MitigantsGood/great So-so Poor
• xxxxx
• xxxxx
• xxxxx
• xxxxx
• xxxxx
• xxxxx
• xxxxx
• Xxxxx
• xxxxx
Source: Bain interviews with NHS officials, November 2014
Time to Implement
Availability of
Resources Required
Provider Support
Clinician Support
Public/Political Support
Other…

Key diagnostic steps in conducting a Service Review
Source: NHS Right Care Case Book. Identifying “Value Opportunities” in West Cheshire: Service Reviews and Business Process Engineering. November 2013
Current
Service
Future
Service
Fit for purpose
Efficiency and
market options
Supply and
capacity options
No/low
benefit
Maintain
Redesign,
contract,
procure
Contract,
procure, divest
Divest
Step 1: Define Step 2: Define
Step 3:
Categorise
Step 4:
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