Writing a Business Case for Equipment or a List

A consultant wants a new arthroscopy stack. The current one is eight years old, the image quality is poor, and there is good literature on the newer system. They write two sides explaining all of that, send it to the clinical director, and hear nothing for four months.

Meanwhile a colleague in another specialty gets their equipment. Not because their evidence was better, but because they wrote a document that answered the questions the people holding the money were actually asking — and the surgeon with the arthroscopy stack answered a question nobody had asked.

This is a learnable skill, and it is the difference between consultants who can change things and consultants who complain that nothing ever changes. It sits within our governance series.

The mistake, stated once

You are making a clinical argument to a financial audience.

"This implant has better ten-year survivorship" is a clinical fact. To a general manager holding a fixed budget and a list of nineteen competing requests, it is not yet an argument. The questions in their head are: what does it cost, what do we get, what happens if we say no, where does the money come from, and what breaks if this goes wrong.

Answer those and you will get a hearing. The clinical evidence then does its work — as the foundation of the case rather than the whole of it.

The structure

Most health systems use some version of the five-case model, and it is worth writing to it even where nobody has asked you to, because it forces you to cover what decision-makers need.

Most surgeon-written cases contain a partial strategic case and nothing else.

Capital and revenue are not the same money

This trips up almost every first-time author and it makes cases unanswerable.

Capital is the one-off purchase — the stack, the robot, the instrument set. It comes from a separate pot with its own approval cycle and its own deadlines.

Revenue is the ongoing cost — consumables, maintenance contracts, servicing, staffing, training, disposables per case.

A case that asks for capital and is silent on revenue will stall, because the first question will be who pays for the consumables, and nobody will approve a machine that cannot be run. Give both, and give revenue as an annual figure and a cost per case.

Options, including doing nothing

An option appraisal with one option is not an appraisal, and its absence is the fastest way to have a case sent back.

You need, at minimum:

1. Do nothing — and, crucially, what that actually costs. This is the option decision-makers must always consider, and it is where a good case is often won: the current stack fails mid-list twice a year, each cancellation wastes a session, and that has a number attached.
2. Do the minimum — repair, refurbish, extend the maintenance contract.
3. The preferred option — what you actually want.
4. A more expensive option — which you reject, with reasons. Including this demonstrates you have considered proportionality rather than simply asked for the best thing available.

Explicitly rejecting a more expensive option is disproportionately persuasive. It signals that you are reasoning about value rather than advocating for a wish.

Quantify the benefit

This is where clinical authors are weakest, and where the work actually pays off. "Better outcomes" is not a benefit an accountant can act on. Convert it.

Two disciplines make these credible:

Use your own data where you can. Your department's actual cancellation rate carries more weight than a figure from a paper about a different health system.

Be conservative and say so. A case built on the most optimistic reading of the literature invites the reader to discount everything. State your assumptions explicitly and use the cautious end — then note that the benefit is likely greater. That reads as competence.

Where you cannot quantify something honestly, say so and describe it qualitatively rather than inventing a number. Fabricated benefit figures are noticed, and they poison your next case as well as this one.

Cash-releasing versus cost-avoiding

A distinction that will be applied to your case whether or not you understand it, so understand it.

Cash-releasing savings free actual money that can be spent elsewhere — a contract not renewed, a post not filled.

Cost-avoiding savings prevent future spending that would otherwise have happened — the revisions you did not have to do.

Most clinical business cases deliver cost avoidance. That is legitimate and worth stating, but do not present it as cash-releasing, because a finance colleague will spot it immediately and it will cost you credibility across the whole document. Label each benefit as one or the other.

Note on jurisdiction: benefit calculations depend heavily on how your service is funded — see How Orthopaedic Care Is Funded. What counts as a saving in a fixed-budget system differs from an activity-funded one. Work out which levers your organisation actually responds to before you build the numbers. Do not include billing or item codes; they are irrelevant to the argument and change constantly.

Risks, honestly

Every case needs a risk section, and a case without one reads as naive rather than confident.

Naming the risk that most worries you — and mitigating it — is more persuasive than omitting it and hoping. The reader will think of it regardless; better that they read your answer than invent their own.

The politics, which are half of it

A business case is not decided solely on the document.

• Find out the approval route and the calendar. Capital cycles have deadlines. A case submitted in the wrong month waits a year.
• Talk to your clinical director first. Never let the first they hear of it be a formal submission.
• Get the finance manager involved early. They will tell you what the case needs to contain, and a case co-produced with finance is far more likely to pass. They are not the obstacle; they are the translator.
• Get procurement in early. They know what is on framework, what can actually be bought, and how long it takes.
• Line up support — theatre lead, other consultants who will use it, nursing lead. A case supported by one enthusiast reads as a personal preference; a case supported by the department reads as a service need.
• Link it to something the organisation already cares about — a waiting list target, a known risk on the register, an incident, a national programme. Cases that attach to an existing priority move faster than freestanding ones.

Say how you will know it worked

Almost nobody includes this and it markedly strengthens a case, because it converts a request into a commitment.

Specify the measures you will report, the baseline, and when you will report them — ideally as a run chart, per Run Charts and SPC for Surgeons. Offer a review at twelve months against the benefits you claimed.

Two reasons this works. It signals you believe your own numbers. And it makes your next case dramatically easier, because you will be the person who delivered what they promised last time — which, in an organisation making these decisions repeatedly, is the most valuable currency you have.

Why cases fail

In rough order:

1. Clinical argument only. No costs, no options, no benefit quantification.
2. No do-nothing option. The reader cannot see the cost of refusing.
3. Revenue costs ignored. Capital requested for something that cannot be run.
4. Unquantified benefits. "Improves patient care" with no number.
5. Optimistic assumptions. Best-case figures that invite total discounting.
6. Wrong timing. Missed the capital cycle.
7. No allies. One consultant, unsupported.
8. Too long. A twenty-page document nobody reads.

On that last point: two to four pages plus appendices. Decision-makers read the summary and the numbers. Put a genuine executive summary at the front containing the ask, the cost, the benefit and the recommendation — assume it is the only part that gets read, because frequently it is.

The summary

Write to the five cases. Give capital and revenue separately. Always include the do-nothing option and cost it. Convert clinical benefit into numbers, conservatively, using your own data where possible, and label each as cost-avoiding or cash-releasing. Name your risks and mitigate them. Get finance and procurement involved before you submit, not after. Commit to measuring whether it worked.

The surgeons who get their equipment are rarely the ones with the strongest clinical evidence. They are the ones who took the trouble to answer the question that was actually being asked.