Stating the risk of not investing

Within the costing reports and the public health need and practice section of the guidance we outline the preventable burden of disease (of the ’condition’) and the associated costs to the NHS and/or wider public sector. We also state in business cases, such as smoking cessation in the workplace and long-term sickness what these issues are likely to be costing an employer. This works well when making the case to a decision-maker who works within the sectors highlighted. However, what we need ensure is that we align the risk of not investing so that it chimes with the decision-makers we are trying to influence who do not have any obvious risk.

144 5.3.1.5 Aligning the proposal with the organisations strategic goals

One of the key elements is the alignment of any proposal with the decision maker’s /organisational strategic goal. Failure to do this, especially in time of limited

resources, may result in a decision-maker choosing not to invest. When developing the recommendations within CPHE we come from the point of view of who is best placed to intervene and do not often consider why that person would be motivated to intervene.

The recent alcohol guidance recommended that in addition to the health service, professionals within the criminal justice system, social services and other public services should screen and deliver brief interventions. However, the costing report focussed on the introduction of screening and brief interventions within primary care.

In addition, the public health need and practice and consideration sections (which are not in the QRG) do not themselves provide a solid rationale as to why sectors outside of health should invest. It is almost assumed that they will commission these interventions because it is the ‘right thing to do’.

Precise rationales have been provided for certain pieces of public health guidance.

The implementation of the smoking in the workplace guidance and long-term sickness guidance would all have saved the health service money. However, the case put to the funder (the employer) was that by implementing these interventions they could reduce absenteeism and therefore improve their bottom line. The

business case was targeted and spoke to the decision-maker we wished to engage with. They were excellent examples of tailoring the proposal to realise the outcome desired.

Although we do not know how the guidance was received in these other sectors, it seems reasonable to assume that in times of restricted resources, interventions that were not deemed to be core business were not invested in. There may be cases where savings across the public sector formed part of an organisation’s strategic goal. However, when faced with tight budgets, decision makers may first look at their own costs and discount those outside of their sector (Trueman 2001; Byford and Raftery 1998).

145

5.3.2 Considerations

In order to determine what changes are needed to develop a business case we need to know the take up rates of our recommendations. Despite the absence of this knowledge it is clear that a business case provides a rationale for investment that would only strengthen the case for the implementation of our recommendations.

To date the business cases that have been produced have been targeted at employers and the financial savings that they can realise. However, it may be appropriate to develop several different business cases for single pieces of guidance. To give an example, the potential for this was highlighted at the IDeA workshop. A situation was described where a private sector representative went away following a council meeting on domestic violence and convinced his company to invest in this area. His motivation was not to reduce health and social service costs, but to reduce absenteeism in his female employees.

In this situation NICE could develop several business cases. For employers of women, particularly those at risk of domestic violence, the business case is reduced absenteeism and thus reduced operating costs. For those working in social care, the case could be built around ultimately reducing their workload by taking these cases out of the system. In the health sector it could be built around reduced mental health care costs in the future.

All of the scenarios outlined above have an ultimate goal of reducing costs.

However, the development of a business case need not be restricted to realising cost savings. For example, the recently published NHS White Paper proposes an allocation formula for the ring fenced public health funds which will include a new

‘health premium’ designed to promote action to improve population-wide health and reduce health inequalities. Thus, a business case could be built around the strategic aim of reducing health inequalities.

For example, an organisation working in the social housing sector, which is linked to the local authority, may be reluctant to implement smoking cessation guidance as the financial savings will accrue primarily within the health sector. However, it is well known that smoking rates are a major contributor to health inequalities. Smoking is also a significant cause of house fires. Therefore if the business case for

146 implementing the guidance was presented to the housing association as a means of contributing towards the local authority’s goal of reducing health inequalities and reducing the costs of dealing with house fires, it may result in a different response and an investment in smoking cessation services.

Much of the information that is needed to produce a business case exists amongst the different documents produced by NICE. It is possible therefore to bring these elements together in order to produce a business case. There are of course

instances where the data is sparse and as a result it may not be possible to provide a detailed proposal. Key to providing a solid proposal is the justification of why an organisation should invest in an area. It should not be assumed that because it costs society money and people suffer ill health that sectors will invest in order to ‘help out’.

In an environment of tightening budgets we need to justify in all instances, including the health sector, how intervening in an area is in line with the strategic goals of the organisation. As highlighted above it may not be necessary to show a financial return. However, it is necessary to show a clear link between implementing the recommendations and the realisation of the organisation’s strategic goals.

It should be noted that in those situations where people are already implementing interventions to achieve the outcome of interest, it is only necessary to convince them that what is recommended is more efficient (Trueman 2001). However, they may routinely need to justify ongoing investment in an area. In these situations it would be prudent for a supporting business case to be provided.

5.3.3 Conclusions

The development of a business case(s) has so far been undertaken on an ad hoc basis and usually when the main audience for the guidance is an employer. The development of a business case for every piece of pubic heath guidance is likely to have significant process and resource implications for both CPHE and the costing team. For example, it will require the identification and collation of additional information as well as the development of new documents which would ideally be developed in consultation with the end users. Therefore it is necessary to assess whether it is feasible prior to implementing any of the changes highlighted below

147 (see section 6). However, the development of a business case should be an integral part of CPHE’s work, particularly in an environment of decreasing budgets.