Catterick Garrison health and care complex a first

NHS Property Services was a key partner leading on producing the business case for the ICB, and this project was also a first in England in terms of integrated partnership working between the NHS and the MOD. I was tasked with providing strategic advice and programme support, including the business case co-ordination for several years. It was fantastic news to gain final approval in January this year for the NHS element of this project.

We recently surveyed NHS Estate leaders, and asked them whether they felt confident at all, or not that confident, in writing business cases. Nearly 50% said they had been unsuccessful in securing funding of up to £10 m, and a third felt ‘not confident’, or ‘not that confident’, in writing business cases.

Experience developing business cases

This is where our expertise can help and support ICBs. I am one of a team of NHS Property Services colleagues experienced in developing business cases for a range of healthcare estates projects — from refurbishments to new-builds, in areas ranging from primary and community health to acute care. By working very closely with the MOD we delivered a business case that we are proud of — using the specialist skills and experience in healthcare property development and strategic asset management that NHS Property Services colleagues have.

The first and most important point to make is that to be able to construct a successful business case, specialist skills are essential. One of the toughest sections of the business case to deliver is the evidence that the project will deliver improvements in health outcomes.

Identifying and quantifying benefits is a key part of gaining approval for a business case. You need people who can work with the Project team to demonstrate how the project will improve health outcomes — such as longer, healthier lives, or a better cancer detection rate, and then feed these benefits into the economic modelling.

The strategy for delivering the Catterick Garrison business case — as with any other — is to outline what the problem is and how you aim to solve it, and determine your key drivers, service requirements, investment objectives, measurable benefits, critical success factors, and key risks. You also need to identify the key inputs for each of the five cases: Strategic, Economic, Commercial, Financial, and Management, and who will be involved in completing them.

The MOD has different processes and working ways to the NHS, with its integral review process and Subject Matter Expert (SME) sign-offs meaning that its FBC is less than 20 pages. For Catterick, NHS Property Services provided the ICB with a business case containing almost 100 pages, with 51 appendices. Developing a Green Book-compliant business case is a complex, detailed, and resource-intensive process. When you are working with partners this can add to complexity, so you need to set out how you will work, and what you all need to do to achieve success across the key organisations, or you will not be able to deliver a sensible path forward.

A big learning curve

It has been a big learning curve to work with another government department, so my advice to anyone starting a business case is to factor in who you will be working with, and then take time to learn their working style as part of your strategy.

NHS Property Services’ role on the Catterick Garrison project was to deliver an approvable business case which demonstrated the long-term healthcare benefits identified by the ICB. At its heart was an investment in the infrastructure, but true success will be through service integration and enabling the right clinical capacity. The MOD has been a fantastic partner in the process, adapting to the challenges of sharing a building with the NHS, and what that would mean in terms of a long-term partnership between the two.

Both the NHS and the MOD had to ensure they could afford to complete the project, and in such financially challenging times, it was very important for both organisations to work together in a very structured way to ensure that we didn’t go ‘off piste’ and cause unnecessary costs to the project. As this was the first project of its kind, we also had to factor in all the research opportunities and national research bodies that would be involved in helping to prove we would deliver these health outcomes over an extended period of time. This meant the strategy was quite complicated, and had to take account of all the varying needs of each organisation to ensure that health outcomes and economic outcomes were equally met.

Engage leaders and stakeholders

Engaging with leadership and stakeholders, and getting their genuine commitment, is vital to completing any business case and gaining the necessary funding approvals. To try to bring your business case to life, make sure that you use good visuals such as artwork to clearly show to everyone involved what the project will look like, and how it will be constructed. This was used to great effect with the Catterick Garrison project.

Equally, ensure that you get all the stakeholders to visit the site and see the issues and problems you might face to make sure they are fully on board from the very beginning.

Develop a good dialogue with the healthcare workers and community to reap the benefits of the project; hearing from them will create more support around the project, and lead to better outcomes. Essentially, building a project that the public will approve of and find value in is an essential element of public and patient interaction. You also need to evaluate the impact of the proposals on the local community, and the impact of any change through your equality impact assessment.

Your Project director may only oversee a business case like this two or three times in their career. It is a highly specialist area, and it is important that you get the most out of the time you get with them. They may not have the time to consider the minute detail; the Project team developing the business case needs to ensure it gives fair warning of what is going well, and when we need the team’s political support to unlock issues. In this role you need to be flexible, and have a high level of resilience, as you will undoubtedly run up against issues, and it is important that you have the leadership in place to resolve them.

Get to know your Project team

There are a lot of steps to take before you put pen to paper and write your business case. You really need to identify who from the wider project team will be involved in the business case development, and understand their level of knowledge and experience. In the case of Catterick Garrison, it was important that I also got to know and understood the MOD’s different ways of working and how we could best work together.

We had not done anything similar before, or indeed worked together before, so it was even more important for us to get to know each other. It might be that you have lots of experience, but others on the team may need a bit of hand-holding, and it will also take time to decipher the jargon that different organisations use. You need to be able to deliver the project jointly, and work well with your Project team; being flexible, resilient, and open with your ways of working, is more likely to lead to success.

With Catterick Garrison we had to work out from the start: is the project affordable, and how will it be funded? We had to think creatively, and work out how we could deliver cost savings. In this case, we took advantage of the benefits of partnering with the MOD, looked at the space required, and jointly saved 10-15% on space by sharing a significant proportion of the staff and support spaces. Some examples of this are having just one reception for the building, combining waiting areas, and having a single staff room.

In addition, make sure that you double-check that you have covered all potential costs — elements such as where the equipment will come from, and who will maintain it, often get overlooked. You need to be able to properly justify why the investment is worth it and what health benefits it will provide.

Modelling the running costs

It is important to also consider the operating costs for the building. It is well worth modelling running costs, and making sure all of the service-providers can afford them before you set off. Early cost and feasibility appraisals can avoid further costs and professional fees.

Keep a keen eye on your requirements; every room, of course, increases your costs, and you do not want to get to the end of the design process and realise that you cannot afford to deliver what you need.

Make sure that you also complete your site investigations, secure planning consent, and work out how your utilities will be delivered. Consider starting site acquisition, asbestos removal, demolition, and site clearance plus diversion of services — this might need a separate business case, but it means you will be able to start earlier on the site once you have the correct approvals.

Contingencies ‘there for a reason’

Remember that your project or programme will always cost more than you think it should — recommended Optimism Bias and contingencies are there for a reason. It may seem odd to add 30% onto your figures at the beginning, but as you get more certainty these allowances will reduce, and you should be 0% at the time of delivery. We have seen extreme increases in construction costs, well above normal inflation rates, and world events mean that we may continue to see volatile changes. This means that monitoring market conditions is more important than ever, and should remain a top priority.