006

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
Decision Handbook
A reference guide for commissioners and providers facing an
investment/disinvestment decision

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 2Decision Hanbook - Investment_ ...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
and provider
programme leads
Commissioning
and provider
programme leads
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 (x7) 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
• Stakeholder map and public engagement tool
• Programme budgeting marginal analysis
• Integrated Risk and Impact Assessment Tool
• Full Business Case template
• Service review
• Required trust business case documentation by investment amount
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, 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
• Service review

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
• Information available
• 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
• Service review

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
- 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
• Value must be considered in terms of outcomes, patient experience, safety and cost and should
strive to reach “best in class”
• Offer services in good standard facilities
• Avoid critical shortage of patients and staff
• Must be acceptable to all key stakeholders including patients/public, clinical staff, financial staff
• Public input must be taken into option appraisal and choice of preferred option
• Must align with commissioning strategy and allocation decisions
• Must consider all viable options and must not destabilise providers beyond their ability to cope
• Two trusts in a rural area serve an increasingly aging population, such that demand for maternity
services has dropped considerably. Currently these services are offered in 5 different locations
across the area, but 3 of these would be sufficient to meet demand. The two service commissioning
CCGs have decided that investment/disinvestment in infrastructure needs to be made to provide
safe and sustainable maternity care.
• The two CGGs now need to decide how to invest/disinvest to maximise value and the two trusts
need to decide how to respond to and implement the commissioning changes.
Decide how to invest/disinvest in infrastructure to provide safe and sustainable maternity
care
Decision
What Who
HowWhen

Example value criteria and metrics for this decision
should be adapted to match your decision context
Outcomes
Clinical
outcome
• Quality of pre, during and post child delivery
care
• Outcome of interventions
• Recovery
• Volume of at risk births (e.g. premature, low weight, medical condition)
• Perinatal mortality and still birth rate
• Volume of births by birth type (e.g. natural, c-section, episiotomy, induced)
• Medical complication rate (e.g. postpartum haemorrhage)
• % of complications successfully treated
• Days to discharge post-c-section / premature birth
Patient
experience
• Accessibility to care facility
• Accessibility to people within care
facility
• Comfort of environment
• Quality of interactions
• Patient choice
• Average and maximum travel time to maternity ward within catchment area
• Ratio of midwives and obstetricians to patients
• Availability of alternative birthing facilities e.g. home birth support
• % of patients able to choose where to have their baby
• % of patients provided with advice on post-birth baby care
Safety
• Avoidance of harm to patient
• Safe environment that supports delivery
of care
• Adequate resourcing
• Rate of avoidable mortality
• Rate of avoidable harm done to patient e.g. infection rate
• % adherence to best practice estate maintenance protocols
• % of time staffed according to best practice minimum staffing levels
• Staff experience (measured as number of patients per staff per year)
Resources
Revenue
costs
• Clinician salary
• Admin staff salary
• System running costs
• “Stranded costs” i.e. costs of unmet overhead as result of disinvestment
• Staff relocation and training costs
• Co-dependency expansion costs (e.g. gynaecology consultant salaries)
• Operating cost per birth
Capital
costs
• Investment in facilities / equipment
• …
• Upfront investment for facility expansion
• Co-dependency expansion costs (e.g. additional facilities)
COMPONENTS OF VALUE CRITERIA METRICS (EXAMPLES)
1
2
3
4
5
What Who
HowWhen

This investment/disinvestment decision has seven
key sub-decisions
Set Up Execution
Decision: Decide how to invest/disinvest in infrastructure to provide safe and sustainable maternity care
Key sub-decision
What Who
HowWhen
Closure
Howto
Change
WhatTo
Change
(trust)
WhatTo
Change
(CCG)
Casefor
change
Establish
Charter
CCGs decide commissioning
configuration (e.g. lead commissioner)
CCGs decide value criteria
CCGs decide service specifications to commission
Trusts decide service
reconfiguration to meet spec
Trusts decide implementation
and mobilisation plan
Decide CCG and
provider contract(s)
1
2
6
4
5
7
CCGs decide case for change3

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

Stakeholders

NHSEngland
Regulators
LocalAuthority
Overviewand
scrutinyboard
CCGboards
Programmeboard
Programmeboard
chair,leadCCG
rep
CCGheadof
finance
Trustchief
executiveor
equivalent
Trustboard
Trustheadof
finance
Trustheadof
medical
Trustheadof
nursing
Trustservicelead
Representativesof
providerinterests
&abilities
GPs
Public
Politicians
CCGs decide commissioning configuration (e.g. lead commissioner)
R
CCGs determine value criteria
D A R I
CCGs decide case for change
I I I A D A R I A I I I I
A D A R I A I I I I I
Trusts decide service reconfiguration to meet spec
A A R D A A A A I I
Trusts decide implementation/mobilisation plan
A A A P D R A A I
Decide CCG and provider contract
D A R A A P P P
RAPID® roles for this decision are designed to maximise
decision effectiveness and can be adapted to your context
R Recommend A Agree P Perform I Input D Decide
What Who
HowWhen
Ensuring stakeholders understand their RAPID® role up-front will improve
efficiency, reduce impasses and improve decision quality
Sub-
decision
1
2
3
4
5
6
7
D
P P
P P

What Who
HowWhen
The role of finance in this process changes across sub-
decisions
Sub-decision Role of Finance RAPID
Intensity of
Involvement
Actions
CCGs decide
commissioning
configuration (e.g.
lead commissioner)
Influence
programme
set-up
On CCG
board only
• Advocate for financial representation on programme board
CCGs determine
value criteria
Advocate for
rigorous
equating of
value
On CGG and
programme
board only
• Push for rigorous evidence and assumptions on financial/non-financial benefits
• Assist integration of financial/non-financial analyses into measure of value
CCGs decide case
for change
Own financial
implications of
change
I
• Partner with clinical and management colleagues to measure and optimise
value
• Assess opportunity cost of ‘do nothing’ and financial implications of change
CCGs decide service
specifications to
commission
Ensure
preferred option
is best value
I
• Partner with clinical colleagues to ensure that options are valued correctly
• Work with clinicians to drive more value from each element of the service
design
Trusts decide service
reconfiguration to
meet spec
Lead on
delivering best
value within
financial
constraints
A
• Ensure that options are valued correctly and best value is prioritised
• Own the costs and risks of achieving commissioning specs
Trusts decide
implementation plan R
• Quantify impact of changes on current situation and long term plans
• Ensure capital and revenue finance teams are communicating and aligned
Decide CCG and
provider contract
Ensure financial
viability A
• Ensure financial impact and deviations from standard tariffs are understood
• Ensure contract does not place financial viability at risk
1
2
3
4
5
6
7
P
P
= High intensity = Medium intensity = Low intensity
Key
Sub-
decision

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

Mapping the decision process supports proper
sequencing and execution of all critical steps
What Who
HowWhen
Key sub-decision
Closure
Howto
Change
WhatTo
Change
(trust)
2
Set Up Execution
Develop
mobilisation plan
incl. partnerships,
procurement, etc.
Negotiate
CCG/provider
contract
Define
roles,
delegate
power
to chair
Frame
decision
charter
Context
objec-
tives,
scope
1
Share
change
rational
with
providers
Draft
Strategic
Outline
Case
Engage
key
stake-
holders
Send
response
to CCGs
letter of
intent
Draft Final Business Case
CCGs decide
value criteria
CCGs decide service
specifications to
commission
WhatTo
Change
(CCG)
Casefor
change
Establish
Charter
Trusts decide
service
reconfiguration to
meet specDraft
FBC
and
send to
CCGs
Trusts decide
implementation
and mobilisation
plan
Decide
CCG and
provider
contract
Set up
comms team,
strategy,
stakeholder
map
CCGs decide lead
commissioning
configuration (e.g.
lead commissioner)
Benefits
realisation plan
Develop
program
me
board
6
CCGs
decide case
for change
3
Send
commis-
sioning
intention
letter
Conduct
public
consult-
ation
Draft
Outline
Business
case and
options
appraisal
Options
nego-
tiation
between
trusts
Draft
Outline
Business
case and
options
appraisal
Draft
Strategic
Outline
Case and
case for
change
Negotiate
CCG/provider
contract
7
Define
key
criteria
Gather
clinical
and
expert
input
5
4

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

What Who
HowWhen
Decision timeline of a ‘good case’ scenario should align
with CCG and trust board and planning calendars
Decision Calendar
Mo
1
Mo
2
Mo
3
Mo
4
Mo
5
Mo
6
Mo
7
Mo
8
Mo
9
Mo
10
Mo
11
Mo
12
CCGs decide commissioning configuration (e.g. lead
commissioner)
- Set up programme board, communications team, and
charter
CCGs determine value criteria
CCGs decide case for change
- Options analysis and identify preferred option (OBC)
- Public consultation (13+ weeks)
- Draft final business case (FBC)
Trusts decide service reconfiguration to meet spec
- Create ‘case for change’ (SOC)
- Options analysis and identify preferred option (OBC)
- Draft final business case (FBC)
Trusts decide implementation and mobilisation plan
Decide CCG and provider contract
1
2
4
5
6
7
3
Clo-
sure
Howto
Change
Whatto
Change
(trust)
Whatto
Change
(CCG)
Casefor
change
Establish
Charter
Iterative process,
misaligned incentives
and behaviours can
extend this process

Contents
APPROACH
DECISION HANDBOOK
APPENDIX
• Service review

Criteria Critical Steps Choices Considered Committees
• Commissioning/geographic dominance
• Commissioning expertise
• Commissioning staff and capacity to
oversee
• Set context, objectives and scope and
align with commissioning strategy
• Assemble a “starter pack” of all
relevant information
• Frame decision charter
• Define CCG roles
• Delegate programme board chair
• Create a programme board
• Create a commissioning committee in
common, designate a lead CCG, or
work as two standalone CCGs
• Borrow staff from another CCG
• Programme Board: Commissioning
led board with representation from
CCG (finance, clinical, management),
all involved trusts (finance, clinical,
management), and representatives
from the health and wellbeing board,
local authority, the public, and service
users, and with support from CSU
- Programme Board Chair is a designated
lead from one of the two involved CCGs,
(preferably the lead CCG in a lead CCG
configuration)
Communication Closure
• Chair to inform CCG boards
• Engage Competition and Markets Authority (CMA), Overview and Scrutiny
Committee, and Health and Wellbeing boards
• Develop stakeholder map for the entire decision process including media,
public, service users, NHS England, local authority, health and wellbeing
board, overview and scrutiny committee, providers, provider workforce
• Set up communication team and strategy plan in place for consultation of
key stakeholders at each key point
What Who
HowWhen
Sub-Decision: CCGs decide commissioning configuration (e.g. lead commissioner)
Decision component snapshot for sub-decision one
DECISION
RAPID Roles
2 3 41 2 3 4
CCG BoardsRD
Click these icons throughout the
Handbook for additional resources

CCG boards
Programme board chair, lead
CCG rep
Programme board
Provider reps (provider
interests and abilities)
• Changes should maximise value
(equals outcomes over costs)
- Clinical outcomes (improved
antenatal/intrapartum/neonatal /postnatal
health, outcome of interventions, recovery
time, etc.)
- Experience (accessibility, info, choice,
comfort, quality interactions, etc.)
- Safety (enough staff/resources, safe
environment, no patient harm, etc.)
- Cost (affordable to reconfigure service &
disinvest in estate, etc.)
• Define criteria • N/A • Programme Board: commissioning
led board made up of cross
stakeholder representatives
- Programme Board Chair will assemble a
Recommendation to take to the boards of
both CCGs who will make the overall
decision on value criteria
- Recommendation must have Agreement
from the programme board and additional
Input from provider representatives as
needed
• Chair to inform CCG boards
• Inform trusts of rational behind intentions to change service
• Engage CMA, Overview and Scrutiny Committee, and Health and Wellbeing board
• Engage key stakeholders per stakeholder map and communication strategy
What Who
HowWhen
Sub-Decision: CCGs determine value criteria
Decision component snapshot for sub-decision two
DECISION
RAPID Roles
2 3 41 2 3 4
AR ID

• Maximise value (outcomes over costs)
• Financing available to providers
• Timing (sequence/pacing) needs to
ensure smooth transition
• Co-dependency impact is acceptable
(e.g. clinical, asset, access)
• Providers loosing maternity services
must be kept sustainable
• Draft Strategic Outline Case
(incl. baseline assessment and
triangulate trust provided data
to commissioning expectations)
• Draft new contract
• Scenarios based on best practice
examples of maternity service models
across the country
• Co-dependency configurations
• Programme Board: commissioning
- Programme Board Chair will assemble
the SOC with emphasis on a case for
change and will take the Recommendation
to the boards of both CCGs who will make
the overall decision to initiate an
investment/disinvestment in maternity care
needed
• Consultation document to stakeholders, specific communications by audience
• Inform trusts of rational behind intentions to change service
• Engage CMA, Overview and Scrutiny Committee, and Health and Wellbeing board
• Send draft of new contract to providers
What Who
HowWhen
Sub-Decision: CCGs decide case for change
Decision component snapshot for sub-decision three
DECISION
RAPID Roles
2 3 41 2 3 4
CCG boards
Programme
chair
Overview
scrutiny
Programme
board
Trust board NHS England Regulators
Local
Authority
CCG head of
finance
Provider reps
that
GPs Public Politicians
R AD A
I
A I I
I II
I I

• Providers loosing maternity services
must be kept sustainable
• Outcome of public consultation must
be acceptable
• Draft Outline Business Case
including options, impact and
risk appraisals
• CCG writes commissioning
intention letter with revised
contract draft to providers to
initiate the service review and
establish an indicative time
scale
• Conduct public consultation
• Meet required procurement
procedures
• Gain regulatory approval if
needed
• Draft Final Business Case
• Number of closures
• Pace and sequence of closures
• Scenarios based on best practice
examples of maternity service models
across the country
• Co-dependency configuration
• Workforce service model
• Pricing and tariff options/implications
- Programme Board Chair will assemble
the FBC from all prior analysis and will
take the Recommendation to the boards of
both CCGs who will make the overall
decision to initiate a service change
needed
• Consultation document to all stakeholders
• Inform providers to requested change in any essential services
• Engage CMA, Overview and Scrutiny Committee, and Health and Wellbeing board,
public and interest groups
What Who
HowWhen
Sub-Decision: CCGs decide service specifications to commission
Decision component snapshot for sub-decision four
DECISION
RAPID Roles
2 3 41 2 3 4
CCG boards
Programme
chair
Programme
board
Overview
scrutiny
Trust board
CCG head of
finance
Trust service
lead
Provider reps
GPs Public Politicians
R A I I
I I I
D A A I

• Financial impact of transition is acceptable
• Timing (sequence/pacing) needs to ensure
smooth transition
• Co-dependency impact is acceptable (e.g.
clinical, asset, access)
• Draft Strategic Outline Case
including case for change
• Draft Outline Business Case
including options appraisal
• Providers/CCGs negotiate
preferred option
• Investigate funding options
• Analyse risk (risk appraisal, co-
dependency evaluation, secondary
impact on other services/health
economy)
• Draft Final Business Case
• Submit business case to TDA if
proposed investment is more than
£10M
• Ensure items from public
consultation are met
• Bring case to trust governors
• Possible service configurations
• Risk share configurations between trusts
• Transitional funding agreements between
trusts and CCGs
• Programme Board: commissioning led
board made up of cross stakeholder
representatives that will expand trust
representation as needed
- Board will act to support and Agree the trust
chief executive’s Recommendation of the trust
level business case process
• Consultation document to all stakeholders
• Engage GPs
• Engage CMA, Overview and Scrutiny Committee, public and interest groups
• Trust responds to commissioners
What Who
HowWhen
Sub-Decision: Trusts decide service reconfiguration to meet specification
Decision component snapshot for sub-decision five
DECISION
RAPID Roles
2 3 41 5 3 4
Trust board
Trust chief
executive
CCG boards
Programme
board
Trust finance
director
Trust medical
director
Trust nursing
director
Trust service lead GPs Public
RD A A A
A I I
A A

• Create benefits realisation plan
to insure improvements are
measured and attained
• Gain approval from regulatory
bodies and legislators (MPs)
• Align with commercial suppliers
(e.g. construction) and
workforce suppliers
• Timescales to maintain stability
including cost vs. speed trade-offs
• Workforce migration
• Risk share of residual/stranded costs,
repurpose of vacated locations
• Integration options
• Delivery line/provider partners (e.g. JV
or contract with GPs)
- Board will act to support and Agree the
trust finance director’s Recommendation
of the implementation plan
• Consultation document to all stakeholders with focus on staff and trade unions • Begin implementation plan aligned with trust planning cycle
What Who
HowWhen
Sub-Decision: Trusts decide implementation/mobilisation plan
Decision component snapshot for sub-decision six
DECISION
RAPID Roles
2 3 41 5 6 4
Trust board
Trust finance
director
Regulators CCG boards
Programme
board
Trust medical
director
Trust nursing
director or
Trust service
lead
Programme
boardD A A AA A PR I PP

• CCGs to formulate terms of contract
and align with CCG financial strategy
- Service specifications
- Outcomes, experience, safety
specifications and KPIs
- Tariffs ( e.g. pay for performance, change
to national tariff standards, exclusions to
tariffs) and local service prices
- Contract amount
- Shared costs to change service and risk
sharing
• Commissioners/providers negotiate
contract(s)
• Sign contract
• Do not sign contract
- Board will act as a facilitator in
negotiations between the CCGs and trusts
and will need to Agree to the final contract
• Trust plan consultation document to all key stakeholders including trade unions • Commissioning and provisioning contract signed
What Who
HowWhen
Sub-Decision: Decide CGG and provider contract
Decision component snapshot for sub-decision seven
DECISION
RAPID Roles
2 3 41 5 6 7
CCG board
Programme
board chair
Programme
board
Trust
board
Trust
finance
dir.
Trust medical
director
Trust nursing
director
Trust service
lead
RD A A P PA P P P

Contents
APPROACH
DECISION HANDBOOK
APPENDIX
• Service review

Role of finance snapshot for sub-decision three
Critical Step Actions for Finance Pieces of Analysis Data Data Source Tools / Resources
Draft SOC incl.
case for change
CCG Finance:
• Gather and triangulate trust provided
activity and financial data to
commissioner assumptions
• Analyse drivers of change (e.g.
declining demand for service)
• Attach comparative values to
outcomes to enable cost vs. outcome
comparison
• Initial assessment of the costs to do
nothing and to change service
• Financial risk assessment
Provider Finance: Work with clinical
and operations to assess impact on
organisation and communicate issues
and concerns to programme board
• Programme budgeting
• Baseline assessment
of outcomes and
spend
• Benchmark outcomes
and spending against
peer group
• Population mapping
• Future activity
projection
• Utilisation data
• Risk assessment
(financial impact,
staffing impact, co-
dependency impact,
secondary impact on
other services/health
economy)
• Monthly Trust
reported activity
and spend
• National outcome
data
• Demographic data
• Available resources
and infrastructure
• Workforce (current
levels and future
need projections)
• Regulatory data sets
(CQC)
• Best practice case
studies (e.g. Royal
College)
• Existing contracts
• SLAM
• Dr. Foster
• SUS
• QOF
• NHS comparators,
Atlas of variation,
Commis. for Value
• Health and social
care indicator
portal
• CQC
• Primary research of
service models
• STAR tool
• Looking for Value in
Hard Times, The Health
Foundation
• The Third Annual
Population Review:
Commissioning for
Health Improvement ,
Right Care
• Impact Assessment
Guide, Milton Keynes
CCG
• 5 Case model guidance
Draft preliminary
new contract
CCG Finance:
• Ensure financials support CCGs’
financial strategy and constraints
• N/A • N/A • N/A • N/A
Role of
Finance
• Partner with clinical and management colleagues to measure value (outcomes/costs)
• Advocate for best possible value within financial constraints as a way forward
• Understand, own, and vocalise the opportunity cost of ‘do nothing’ and the financial implications of ‘do something’
What Who
HowWhen • Finance’s responsibility
• Non-finance’s responsibility
Sub-Decision: CCGs decide case for change
3 4 2 3 4

Role of finance snapshot for sub-decision four
Draft OBC incl.
option appraisal
CCG Finance:
• Attach comparative values to outcomes to
enable cost vs. value comparison
• Input costs into economic appraisal
• Conduct financial model
• Compile option appraisal
• Ensure shortlist options meet financial hurdles
• Risk and impact assessment
• Sign off on financial parts of 5 cases model
Trust finance: Work with clinical and operations to
assess impact on organisation and communicate
issues and concerns to programme board
• SOC analyses
• Option appraisal
• Economic appraisal
• Financial cash flow model of
preferred option
• Risk assessment (financial
impact, staffing impact, co-
dependency impact,
secondary impact on other
services/health economy)
• Competitive assessment
(horizon scanning,
market/system changes)
• Monthly Trust reported
activity and spend
• National outcome data
• Demographics data
• Available resources and
infrastructure
• Workforce (current levels
and future need
projections)
• Regulatory data sets
• Best practice case studies
(e.g. Royal College)
• Existing contracts
• SLAM
• Dr. Foster
• SUS
• QOF
• NHS comparators,
Atlas of variation,
Commis. for Value
• Health and social
care indicator portal
• CQC
• Primary research of
service models
• STAR tool
• Looking for Value in Hard
Times, The Health Foundation
• The Third Annual Population
Review: Commissioning for
Health Improvement , Right
Care
• Impact Assessment Guide,
Milton Keynes CCG
Public
consultation
CCG Finance: Provide briefing resources on
financial content
• N/A • N/A • N/A • Public consultation guidance
Meet procurement
procedures
CCG Finance: Ensure solution provides value for
money, financial standing of shortlisted bidders is
sufficient, and procurement is OJEU and
procurement law compliant
• N/A • N/A • N/A • Value for money resources
• Monitor’s compliance guidance
Gain regulatory
approval if req.
CCG Finance: provide required financial content • N/A • N/A • N/A
Draft FBC
CCG Finance: Validate and incorporate
information from Trust business case process,
conduct final financial analyses, Sign off on
economic /financial parts of 5 cases model
Trust finance: Work with clinical and operations to
report output of OBC/FBC to programme board
• Detailed Impact assessments
• Complete risk appraisal and
mitigation steps
• Implementation timescales,
resources, milestones and
measures of benefit
• All inputs from previous
analyses
• Trust FBC
• Results from public
consultation
• Analyses from
previous steps
• Full Business Case Template,
NHS National Innovation
Centre
Role of
Finance
• Partner with clinical colleagues to compare outcomes to spend, and ensure that options are valued correctly
• Work with clinicians to achieve most value per spend option and drive more value from each element of the service design
• Understand potential financial impact of risks and advocate for investments required to mitigate them
What Who
Sub-Decision: CCGs decide service specifications to commission
3 4 2 3 4

Role of finance snapshot for sub-decision five
Draft SOC incl.
case for change
CCG Finance: Share analysis conducted in
SOC with trust finance team
Trust Finance:
• Review assumptions in LTFM and see if
changes are necessary
• Map activity to tariff and flag any loss
making options with commissioner
• Ensure alignment with integrated business
plan
• Determine indicative financial value of
investment and affordability of options
• Population mapping
• Future activity projection
• Service budget review
• Capacity vs. activity
• Available resources and infrastructure
• Risk assessment (financial impact, staffing impact,
co-dependency impact, secondary impact on other
services/health economy)
• Review case mix over past 3 years and any population
factors that would influence this moving forward
• Service line
reporting data
• PLICs
• Budgeting
• Pop mapping
and future
activity
projections
(from CCG)
• Informatics
(capacity)
• Patient claims,
complaints, and
documented
issues
• Case mix
• CCG SOC output
• Informatics team
• Risk team
• Operations team
• Capital Regime and
Investment Business Case
Approvals Guidance for NHS
Trusts (including business
case checklist)
• Monitor guidance on
transactions for NHS
foundation trusts
Draft OBC incl.
option appraisal
Trust Finance:
• Model service delivery options and financial
scenarios, conduct sensitivity analysis
• Challenge financial implications of options
• Triangulate workforce, financial, activity
plans
• Explore funding sources
• Engage negotiation for pricing and
additional financial support
• Option appraisal ( incl. cost vs. time to transition and
sensitivity analysis)
• Capital vs. revenue analysis
• Stranded costs for unused infrastructure
• Staffing costs to train and relocate
• Risk sharing between trusts/CCGs
• Risk assessment
• Quality Impact Assessment
Draft FBC
Trust Finance: Produce final financial model,
sensitivity analysis, risk assessment, sign off on
economic/financial parts of 5 cases model
• Sensitivity analysis on inputs (population, risk, etc.)
• Risk assessment
• N/A • N/A • N/A
Gain stakeholder
approval
Trust Finance:
• Present financial assurances to governors
• Submit documentation to Monitor if
necessary
• N/A • N/A • N/A • N/A
Negotiate options
CCG and Trust Finance: Work together to
reach a mutually beneficial financial terms
• N/A • N/A • N/A • N/A
Role of
Finance
• Partner with clinical and management colleagues to measure value (outcomes/costs) and ensure that options are valued correctly
• Work with clinicians to achieve most value per spend option and drive more value from each element of the service design
• Own the costs and risks of achieving commissioning specs and ensure achieving spec supports financial health
What Who
Sub-Decision: Trusts decide service reconfiguration to meet specification
3 4 5 3 4

Role of finance snapshot for sub-decision six
Create benefits
realisation plan
Trust Finance
• Ensure the implementation plan aligns
with financial plans of the organisation
• Create financial appraisal documents
• Understand and quantify the benefits
• Create method for monitoring financial
success of project and work with
clinical staff to monitor outcomes
• Monitor cash flow impact incl. cost
overruns/underruns and contingency
plans
• Secure and monitor funding incl. loans
• Analyses from previous sub
decision
• Baseline outcome and cost metrics
• Target outcome and cost metrics
• Data from
previous sub
decision
• Sources from
previous sub
decision
• Benefits realisation
framework
• Prince2 project
management
methodologies
Gain approval from
regulatory bodies
and legislators (if
required)
• Submit documentation to Monitor if
necessary
• Submit documentation to MPs if
necessary
• N/A • N/A • N/A • N/A
Align with
commercial
suppliers (e.g.
construction) and
workforce suppliers
Trust Finance:
• Ensure the project stays within budget
• Asses procurement tenders
• N/A • N/A • N/A • N/A
Role of
Finance
• Quantify impact of changes on current situation and long term plans
• Ensure capital and revenue finance teams are communicating and aligned throughout the implementation of the plan
What Who
Sub-Decision: Trusts decide implementation/mobilisation plan
3 4 5 6 4

Role of finance snapshot for sub-decision seven
CCGs to formulate
terms of contract
and align with CCG
financial strategy
CCG finance: Collaborate with contract
colleagues to create custom contractual
arrangements
Trust finance : Quantify financial impact
of specific terms within the contract (.e.g.
marginal rates, capped values, variation
from standard tariff, shared risk)
• Tariffs ( e.g. pay for performance,
change to national tariff standards,
exclusions to tariffs) and local
service prices
• Contract amount (aspirational cap)
• Shared costs to change service and
risk sharing
• Service specifications
• Outcome KPIs
• Local prices
based on
historical
agreements
• NHS England
national tariffs
• National tariffs and
tariff proposals for next
year
Negotiate contract
between
commissioners and
providers
CCG Finance: Negotiate, agree and
monitor tariffs, contract amount, and risk
sharing
Trust finance : Ensure all commissioning
arrangements add up to the total budget
available
• N/A • N/A • N/A • N/A
Role of
Finance
• Ensure financial impact is understood, especially when contract deviates from standard tariff structure
• Maintain financial viability
What Who
Sub-Decision: Decide CGG and provider contract
3 4 5 6 7

Contents
APPROACH
DECISION HANDBOOK
APPENDIX
• Service review

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.
Benchmarking against peer groups for
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.
National tariffs and tariff
proposals for next year
Hub for tariff information including proposal documents for
upcoming years Planning and tariff management

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.
Full Business Case
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
Capital Regime and Investment
Business Case Approvals Guidance for
NHS Trusts
Detailed outline, suggested analysis and compliance requirements for
capital/investment business cases from the TDA
Capital/investment business case including an
easy to use checklist
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.

Data tools for Best Possible Value decisions
Tool Description Useful for
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
Planning and delivering services
changes for patients guidance
(including Public Consultation)
A framework to help NHS commissioners should work together,
and with communities, providers and local authorities
Guidance for patient and public
engagement including conducting a
public consultation
Monitor transaction guidance for
NHS foundation trusts
A guide to clarify the rules and requirements surrounding
transactions, particularly significant transactions Ensuring regulatory compliance
Benefits realisation framework A guide to help develop a business case, mitigate risks to
realising benefits from case and conduct post implementation
reviews to measure benefits
Business case to implementation
plan
Prince2 project management
methodologies
A project management guide for large projects. Aimed at project
managers.
Understand how an implementation
process should be managed

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

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

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.

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:
Recommend

Source: http://www.ntda.nhs.uk/wp-content/uploads/2013/06/NTDA-Capital-Regime-and-IBC-Approvals-Guidance-for-NHS-Trusts-Final.pdf
Required business case documentation by scale of investment

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