We are running our next Neighbourhood Health Academy Live meeting on: How Can Your Business Case Fit the New NHS Landscape of Neighbourhood Health? And here’s why:
Table of Contents
Why NHS Business Cases Assume A Flat World
Most NHS business cases are written as if the world is flat. The same templates. The same logic, the same structure, the same argument, wherever it lands.
That is not the fault of the people writing them. NHS templates were built for a centralised system, one where variation is treated as a defect and best practice is assumed to be the same everywhere. If the model has already been decided nationally, then a business case is a compliance document. You show that you will deliver the agreed thing, affordably, on an established pathway, to a committee that already knows what good looks like.
But the landscape this is built on has changed. Neighbourhood health has changed the ground underneath that process in three ways. Together they mean that the same document now travels uphill in one place and downhill in another, while barely changing a word.
I’m calling these three big earthquakes.
Earthquake One: Strategic Commissioning Has Changed Who Decides, And What They Are Deciding About
The move to strategic commissioning and population health management is not an administrative tidy up. It changes the unit of decision and the focus of decision making.
From “is this service affordable?” to “what does this population need?”
The old question was whether a service was affordable, well run and would fit national standards. The new question is what a population needs and who is best placed to deliver it. ICBs are being redefined (at least in theory) as strategic commissioners, whilst the move to Integrated Health Organisations will shift decision making power from commissioners to providers, with plans for outcome based contracting to become the norm within three years.
(Although what is described as an outcome may well change faster than the outcomes themselves!)
But if activity is detached from outcomes, many different combinations of activities may contribute to an outcome. At the same time the benefits of achieving those outcomes may be shared under the new model. For the chain of contracts and subcontracts to work, from the hospital to the community, everyone in the chain has to be paid for achieving an outcome, even if it was really just a charity that actually did the work.
When you think of it like that, the proposed contractual framework is pretty daft.
You are now competing against every other use of the same money
A case for a population needs to be judged against what happens to that population and what the alternative use of the same money would be. So the comparison is not this will be better, but this will be better than the same money put to X, Y and Z. You are no longer arguing your corner. You are arguing your place in somebody’s allocation of a whole population’s resource. Indeed the recent re-emergence of ‘allocative efficiency’ in commissioning language points to comparative funding models, rather than we have this budget to fix this particular problem.
There is far less to comply with than people assume
The Neighbourhood Health Framework sets targets, not methods. For example: ICBs have been asked to plan for a 10% reduction in non-elective admissions and bed days for frailty and housebound cohorts by March 2029. As well as a 25% diversion of referrals through single points of access for ten specialties by March 2027. Nowhere does it say what an integrated neighbourhood team should actually be, or what good looks like when a VCFSE organisation is part of it, or who is actually responsible for what in achieving those goals.
So the business case is no longer a compliance exercise. It has to argue what should be done, understand the particular needs of the people awarding the funding, and then persuade them that you are offering the best value for achieving an outcome. These all require different skills from simply completing a template with a case.
Earthquake Two: Neighbourhood Health Changes What NHS Organisations Are For
This is the shift people underestimate.
Every organisation in the chain now has a different job
Neighbourhood health does not simply add a new layer of services. It changes the function, role and priorities of organisations that already exist. NHS England’s model has ICBs contracting a single IHO for an area, with that IHO then contracting multi-neighbourhood providers, each working with multiple single neighbourhood providers. The consultation on those contracts openly contemplates organisations holding responsibility for coordinating, commissioning and subcontracting a much wider range of services than is typical today.
A hospital trust that becomes a host, an integrator or an IHO is no longer only a provider. It is now buying things. General practice moving into single neighbourhood provider arrangements is no longer only delivering care to a list of patients waiting. It is now holding population responsibility. An ICB at half its former size, with something in the order of fifty neighbourhoods to think about, is no longer managing services. It is allocating, assuring, assessing and performance managing.
Each of those organisations will have a different job in neighbourhood health. And because the job is different, what they need from your business case is different too.
Why “reducing demand” means opposite things to different people
This is where flat and narrow cases now become inadequate. Everybody in the chain says they want to reduce demand. To a hospital, demand means non-elective admissions and bed days. To a GP, demand means appointments, continuity, and the non-medical need that arrives in a ten minute slot with nowhere to send it. Those are not the same problem. A service that genuinely relieves general practice may push referrals up. A service that keeps people out of A&E may land more work on GPs.
Same words. Opposite meaning. A case written to satisfy both satisfies neither.
Earthquake Three: There Is No Map To This Territory, And Almost Everyone Deciding Is Doing It For The First Time
Until now, the majority of commissioning decisions were made by professional commissioners. What services should be available, what work should be funded, and how we match demand for services with capacity.
Commissioning is a profession, and it is about to be done by people who have never done it
Healthcare commissioning is a profession and an area of expertise. Commissioners spend a huge amount of time understanding the detail of pathways, what is working and what isn’t, what experts, equipment and facilities are required. Setting criteria for referrals, forecasting demand and optimising supply. Whilst gaining consensus amongst stakeholders about any changes to be made, negotiating and agreeing contracts, settling disputes and overseeing the performance of providers.
But with fifty neighbourhoods per ICB, and a significantly shrunk professional workforce, they simply won’t be able to perform that role in neighbourhood health.
Under the proposed hierarchy of contracts, from Integrated Health Organisations through multi-neighbourhood providers and down to individual GP practices and beyond, the vast majority of NHS organisations will become commissioners of local services. Most of them have never done this work before.
Nobody knows what good looks like yet
But more than that. Neighbourhood health is brand new territory. Yes there are pilots, but no one has implemented it at scale before, and frankly no one knows what good looks like. How does a multi-neighbourhood provider commission health work across a town according to the needs of the local population? Few people have done that before.
Our knowledge about how the health system works is useful, but the three big shifts to prevention, digital and community mean that our assumptions and understanding about how contracts and commissioning should work all need to be brought into question.
And that is the opportunity. If nobody yet knows what good looks like, then a well argued business case does not simply compete for money. It helps decide what the answer is going to be. The cases written in the next two years will set the pattern that everything afterwards gets compared against.
Why Is A Business Case Harder In A Community Than In A Hospital?
I have written before about why the business case process itself carries a bias towards hospitals. It is relatively easy to build a case in a hospital, where patients and processes are controlled and costs are known at every stage. It is much harder in a community, where people and relationships are not controlled, where the work changes as you do it, where you are not sure who is going to come through the door and who is going to leave and when, and where outcomes are genuinely less certain and less controllable.
So What Do You Actually Do?
Four practical things follow.
1. Write towards the evidence that exists
Nuffield Trust’s review Shifting the balance of care looked at 27 of the most common initiatives for moving care out of hospital. Seven were proven to save money. Six had a track record of increasing costs. The seven that worked shared a shape: a narrow group of patients, a genuine gap rather than a duplication, patients actively involved in their own care, and staff properly supported.
So if your work sits near care home support, end of life care, or better specialist access for general practice, the literature is genuinely on your side. Say so. If it does not, you need a different argument, not a bolder claim. Don’t get seduced by the grand claims of NHS plans and policies. You have to be rooted in practice and the evidence you actually have.
2. Price in the discovery effect at the start
There is a learning curve to any project or initiative. Don’t forget to factor in that it takes time to get things working. Manage expectations from the start. It is better to start small and grow than to start big and have to shrink.
3. Work out who is actually deciding before you write a word
Which organisation, in which of its new roles, carrying which pressure. The same piece of work can be obviously fundable in one part of this new landscape and invisible a mile away.
4. Build the relationship, not just the document
We build partnerships to make neighbourhood health work, and that means we need to understand each other. We can’t rely purely on the text of a business case to build partnership. We have to nurture and grow it, so that the business case becomes a promise about how we can work together to create a healthier community.
Why your business case is now a strategic asset
Thanks to AI, business cases have become quicker and easier to make, so expect lots of competition. What is scarce is knowing the environment and the people you are writing for, and being willing and able to write differently for different people and places. The quality of a business case, and its tailoring to the people and organisations making the decisions, matters more than ever.
Finally, your business case should not be an afterthought tacked onto your work at the end. In healthcare, developing and building a business case to describe what you do and how you add value needs to be a core strategic asset that you invest in and develop. Fundamentally it is how our healthcare system understands the financial value in what you do. And if you want investment, a business case has to be a core product of your work.
Getting Help With Your Neighbourhood Health Business Case
Come and join us for our next Neighbourhood Health Academy Live meeting: How Can Your Business Case Fit the New NHS Landscape of Neighbourhood Health? Thursday 8th October, 12 to 1pm, free and online.
Further Reading
Fit for the future: towards population health delivery models.” (Read the full article here).
Neighbourhood Health Framework Summary (Read the full article here).
Neighbourhood Health Framework Analysis (Read the analysis here)
Help and Support
I have significant personal experience of creating and deciding business cases in the NHS. If you want to give your work the best chance of getting funded, get in touch and we can talk about one to one support.
