Most people see the business case process as a form of medieval torture administered by accountants. They also, with some justification, question the quality and value of the business case once created.
Fragile benefits - an interview with Steve Worrall
Posted by APM on 8th Jul 2011
Continuing the series of interviews with people involved in benefits management, Helen Anthony interviews Steve Worrall from BT Health to gain some insight to the realisation of benefits when IT solutions are being implemented within the health service.
First, can you tell me a bit about yourself and your role in benefits management?
I lead on benefits within BT Health. This practice provides a number of programmes to the NHS. The programme I am currently working on is called "The Local Service Provider" which is delivering health solutions, in particular, electronic patient records, to NHS trusts in London and the south of England. The purpose of the benefits role is to help the NHS trusts get the most from their solution by helping them understand how the solution can affect and help their processes and ways of working to optimise the benefits. As the trusts are semi-independent bodies within the NHS, each has its own history, working practices and ways of doing things, and each has its own directives and drivers. My work takes account of their different starting points and objectives to enable the individual trust to deliver the benefits it wants.
How does your role fit in with others in the team?
I work alongside the transformation specialists as part of the overall deployment team. There is a dedicated transformation consultant who works with the trust and I provide specialist benefits support as required and provide the toolkit, making sure that it is there in a useable form and is effective for them. My work complements the transformation consultant's work. The transformation work is about process mapping, communications and stakeholder management. The benefits work is about making sure that the trust understands what it wants to achieve and can manage the benefits throughout the deployment and track them after completion.
How does that work within the NHS?
Benefits management is still a relatively new idea for the NHS. So we have to look at what is available and appropriate, and then give this the right level of rigour for the work we are doing. So we adapted the mainstream approaches for the NHS. Our approach is based on the Cranfield model.
Where in the project life-cycle or engagement do you get involved?
I provide end-to-end support. So we start with supporting the business case and then there are benefits activities at each stage in the lifecycle. The first step is to identify the initial benefits and the key stakeholder groups and their perspectives. For instance, the CEO will be looking for different benefits from the clinical director, service providers, administrators and patients. This is then followed through with the users during the project delivery and finally with support for reviews after the end of the projects.
Doesn't the trust already know what benefits it is looking for before approaching you?
To a certain extent, yes, but we still need to work with them to put more detail around them and develop the benefits story. Benefits often start off as a set of bullet points and targets in the business case. We carry out benefits mapping to understand the dependencies and develop detailed benefits registers to put flesh on the bones. The benefits are then validated during process mapping workshops; measures are identified and baselined to make sure some real evidence of delivering benefits can be collected.
We then align this with the downstream activities, for instance in process mapping we want to make sure that the future state supports the benefits required. We may find that there are required benefits which are not supported by the proposed changes, because it's easy, in large deployments with large systems and many users, to forget the benefits and make decisions which don't take into account the initial intentions. Sometimes the benefits identified initially can't be realised. When you are developing the business case you don't have all the necessary information and as the project is delivered you learn more about which benefits are viable and which aren't. With a project like electronic patient records you are investing in an infrastructure - like motorways, you know you need to have them in place, but it is sometimes difficult to identify the measureable benefits. You know that they are huge, but finding the measures to quantify them can be quite difficult, particularly within a specific department. We try and work at many levels; we have the conversations at a strategic level but then work with the services on the ground to make sure they are aligned and comfortable with the benefits. This is something that I think all organisations struggle with, not just the NHS. But when it works it can give real benefits.
How does people's understanding of benefits change through the project life-cycle?
Projects like this introduce real changes to the way people use information in the NHS. Historically the focus has been on protecting patient information and the electronic patient record systems are designed to share information appropriately between authorised users, for greater patient benefit. This requires a change in thinking and a real understanding of the overall benefits. This is not unique to the NHS; the same considerations apply in other sectors, for example, when account management systems were introduced into sales organisations, and sales teams were expected to share customer information for the greater benefit of their organisation.
Implementing something like electronic patient records enables diverse benefits in the long term; however there are also benefits to be gained early on. For instance, people start to realise how long paper-based forms take to move from one place to another; it is really interesting when you do the baselining, some of the information is eye-opening. As soon as the system is up and running, patient notes can be viewed almost instantaneously wherever there is access to the system.
How do organisations view benefits management?
Sometimes benefits management is not seen as important, it is viewed as a nice-to-have. Whereas people understand that process mapping, stakeholder management and training, for example, are crucial for the success of the project; there is a sense that ignoring benefits management will not affect the project. We see a real difference when organisations embrace benefits management. People start to use the richer functionality of systems to help them with their jobs rather than sticking to the bare minimum of usage. It is important to understand that it is not the technology, but the way people use it that delivers the benefits and the best use follows from understanding what benefits can be delivered.
How do you persuade organisations that benefits management is worthwhile?
Through conversations with the sponsor group in the first instance, by helping them to understand the connections between what they want to achieve and the changes that need to be made and how benefits management supports these. It is important to ensure that this group sends the right messages to the organisation for benefits management to be recognised as an important part of the project. I think there is a legacy that 'IT' is something that we need to have for performance reporting and entering information is a necessary chore but it isn't really essential to care delivery. That perception is beginning to change as the Facebook and Twitter generation are coming through. This is a cultural shift over the last 10-20 years which we are beginning to see having real effects. Clinicians are beginning to see that information entered into a system and shared can be used to greater benefit, as multi-disciplinary teamwork is adopted and patients move along the care pathway from one service or care setting to another.
Have you seen any changes in benefits management over the last five years and what do you think we might see in the future?
I think people are beginning to understand what it involves and what it can deliver, and the ideas are becoming more part of how projects are delivered. In the past there was a tendency for business cases to be put to one side once the project had been authorised. The focus of benefits management is to get projects to deliver what was promised in the business case. Going forward, portfolio and value management will become important in making intelligent decisions on projects. We are moving from a situation where people get benefits from individual projects to one where benefits can be compared across portfolios of projects so that investments can be prioritised.
What do you think is key to making benefits management work for an organisation?
It is important to recognise that benefits management is not just an exercise with spreadsheets restricted to the finance team. Benefits are much wider than cost savings and return on investment. They should cover the whole balanced scorecard. In the NHS they include quality of care, patient safety, productivity improvements and improving the whole patient experience. It is important to recognise that benefits management is intrinsic to what we do and to integrate it with the transformation and change processes.
Within the NHS there are a lot of non-financial measures and data already collected for national and local quality and performance targets and we try to use these wherever possible. We also make use of surveys, as perceptions are as important as the KPIs.
Are there any particular challenges within the health service?
Healthcare is a complex environment that does not readily lend itself to automation. There are large volumes of people coming and going and the clinicians have to focus on the immediate needs of the individual patient rather than the overall picture of the service. There are challenges in making the technology fit this environment. So there is a barrier to making change because of the physical constraints; however, we are moving into greater integration of systems and better use of IT and making that work where you are dealing with thousands of patients and open access. Benefits management is dependent on having good information for baselining and reporting. We often struggle in getting this information together in this situation; especially when funds are limited and back office services are being cut.
Have you ever gone back to a trust after the completion of a project?
Yes, we go back and help with benefits reviews. Ultimately the benefits are owned by the organisation itself, but we go back and help them where appropriate. The reviews often point to areas where further work, such as using richer functionality, can increase benefits. Sometimes when they haven't achieved a benefit they were expecting we help them understand what has happened. Benefits can be quite fragile and easily lost if people aren't careful about how they use the outputs from the project. When you understand why the benefit has not been achieved you can start to put things right. It is important to realise how the benefits will manifest themselves, for instance financial benefits are not always cash releasing, and to fully realise the benefits sometimes needs decisions and actions outside the project.
What aspirations do you have for benefits management in the future?
I would like to see benefits management become more user-friendly and intuitive and people coming together in their understanding of the need for benefits management. Sometimes people baulk at the "benefits" word and so we talk about how can we get the best out of the project - what we want to achieve and what would be a good result. I had a colleague who used to do "Hopes and Fears" workshops to bring out the benefits and risks. It is about using the kind of language people are comfortable with, seeing the big picture of what we are trying to achieve, and how the particular project can contribute towards this and support us in our everyday work.
Basic benefits management tends to follow the same approach of business case with benefits identification followed by realisation planning and measurement. I think there is room for innovation in this to make the process simpler and more intuitive. Also, I'd like to see development of the tools integrating them with transformation tools to help understand the organisations priorities and the change levers available and associated measures. Whatever we do it has to work with the people involved, so that it is informing everything we do, not just abstract and remote from projects. Good benefits management should be about joining up the organisation.
What tips might you give to someone who wants to introduce benefits management into an organisation?
It needs to be clear that the benefits are wanted from a senior level in the organisation; senior managers and sponsors need to maintain interest throughout the project lifecycle, asking to see the benefits and for their realisation to be reported on a regular basis. For those who are managing the benefits on the ground, they need to realise it is not just about spreadsheets and reporting; you need to go out and talk to people and share the message. Benefits realisation is about communications and alignment. If everything is aligned the benefits will be delivered.
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How to optimise our investment in change initiatives and achieve business benefits - particularly when applied as a complete package.
Joanna and Chris from the National Audit Office (NAO) delivery team gave a convincing presentation on the challenge of demonstrating how major projects had realised forecasted benefits. Her introduction as Leona Lewis by me, Neil White, raised guffaws from the audience and immediately lifted the energy in the room. Joanna generously took this in her stride.