North Valley Pathology: A Solution in Search of a Case
The North Valley pathology service runs seven laboratories on a 14-year-old laboratory information system (LIS). Last quarter the system was unavailable for 19 hours across three incidents; two laboratories reverted to paper request forms, and 340 samples were recollected. The trust board has asked for a business case to replace the LIS, citing 'modernisation' and 'clinical safety'. A vendor demonstration has already been arranged for next month, and the chief information officer has told the team to 'write up the preferred option'. The regional commissioners have said any solution must support a shared pathology network by 2027 and reduce the cost per test by 12%. Capital available is £6.2m; no revenue growth is funded.
1. Assess whether the trust has a defensible strategic case for change. What evidence is missing, and what should the team do before committing to a preferred option?
Read the worked answer
The trust has a genuine operational problem but not yet a strategic case. A strategic case must establish the case for change from evidence of need, not from a vendor demonstration or an instruction to 'write up the preferred option'.
The symptoms are documented (19 hours' downtime, 340 recollections), but three things are missing: a baseline of cost per test and incident rates, so that the 12% reduction is measurable; a quantified statement of the do-nothing consequence in clinical and financial terms; and explicit mapping to the commissioners' shared-network requirement, which changes the scope from a trust LIS to a network solution and may change the whole option set.
The vendor demonstration should be deferred or reframed as market sounding only. Running it before options are defined anchors the team on one solution and pre-empts the appraisal.
Action: produce a needs statement, a benefits map and SMART objectives, and confirm strategic fit and spending objectives with the board and commissioners before shortlisting any option.
2. The draft objective reads: 'Deliver a modern, clinically safe LIS that improves efficiency.' Rewrite it as two SMART objectives consistent with the commissioners' requirements, and note any dependency.
Read the worked answer
The draft fails SMART on almost every count: 'modern' and 'efficient' are unmeasurable, and there is no baseline, target, date or owner.
Two rewrites:
- 'By 31 March 2027, reduce the fully absorbed cost per test across the seven laboratories by 12% against the 2025-26 baseline, evidenced by the finance ledger and reported quarterly to the board.'
- 'By 31 March 2027, achieve 99.9% measured monthly LIS availability and reduce LIS-attributable sample recollections from 340 per quarter to fewer than 25, reported by the quality lead.'
Dependency: the current cost per test is not stated anywhere in the brief, so the first objective cannot be finalised until that baseline exists. Setting a target before the measurement method is agreed is a common failure, and it usually surfaces late as an argument about whether the benefit was delivered.
The objectives should also name the shared-network scope, because a trust-only solution cannot satisfy the commissioners' 2027 requirement however well it performs locally.
3. The programme director argues that a 'do nothing' option is unnecessary because the system is clearly failing. Do you agree?
Read the worked answer
Disagree, although the underlying point is sound. The Five Case Model requires a do-nothing or do-minimum option as the counterfactual against which every other option is compared. Without it there is no test of value for money, only a comparison of competing solutions.
'Do nothing' here is not passive. The realistic reference case is continued operation plus emergency patching, and possibly outsourced hosting, with a quantified risk of catastrophic failure (probability x impact) and the cost of that mitigation. If clinical risk makes do-nothing genuinely undeliverable, that is itself a finding to record in the strategic case, not a reason to drop the comparator.
Including it also protects the board: commissioners and regulators will ask what happens if the scheme is not funded, and the team needs a costed answer.
Recommendation: define and cost a credible do-minimum, including its failure risk, before the shortlist is fixed.