SWANN SPoR Phase 2: Designing a New Early-Intervention Service Pathway | David Agyei | Submitted 5 June 2026
Submitted document: approx. 4,000 words. All sections below are the full text of the submitted proposal.
This proposal outlines Phase 2 of the SWANN SPoR (Spot, Prevent, Observe, Respond) project at Shropshire Council, a programme designed to establish a new early-intervention service pathway to prevent escalation of need and reduce demand on statutory adult social care.
Phase 1 of the SWANN programme launched in October 2024 with three commissioned providers: ICE Creates / Live Well Shropshire, British Red Cross and Community Resource. However, Phase 1 has not performed as intended. Professional referrer uptake has been near-zero from two of the three providers, a significant backlog of outstanding referrals has accumulated due to a CRM feedback loop failure, and there is no data infrastructure capable of demonstrating demand deflection. These are not delivery failures alone; they are system design failures that Phase 2 must address structurally.
Phase 2 has been initiated to design and implement the digital and data infrastructure required to make the SWANN pathway functional, measurable and scalable. The six Phase 2 development priorities are: (A) electronic referral form on Dynamics 365, (B) provider access to CRM, (C) monitoring dashboard, (D) public self-referral launch, (E) data capture improvements and (F) Liquid Logic assessment note. This project is being delivered in a context of significant financial constraint: Shropshire Council declared a financial emergency in September 2025 and borrowed 121 million pounds in exceptional government support. Every investment must demonstrate its contribution to demand deflection and cost avoidance.
The proposal is structured around the five-case model and covers: strategic case, economic case (including a cost-avoidance analysis), commercial case, financial case and management case. It includes a project plan, risk register, RACI matrix, implementation timeline and appendices covering leadership evidence and an employer statement.
SWANN (Social Wellbeing and Neighbourhood Network) is a commissioned early-intervention programme sitting within Shropshire Council's Adult Social Care directorate. It was established in response to the evidence that timely community-based support reduces escalation to statutory services. The three commissioned providers operate across Shropshire: ICE Creates through its Live Well Shropshire programme, British Red Cross and Community Resource.
Shropshire Council is operating in a position of severe financial distress. The financial emergency declared in September 2025 has resulted in a Major Change Programme, increased MHCLG oversight, an LGA peer review and an improvement board. In this context, the council's commissioning strategy has been explicitly refocused on early intervention and prevention. SWANN is directly aligned to this strategic direction. However, without Phase 2, SWANN cannot demonstrate that alignment with evidence.
| Problem | Root Cause | Phase 2 Response |
|---|---|---|
| Near-zero professional referrer uptake from British Red Cross and Community Resource | Telephone-only referral pathway incompatible with practitioner workflows. Long hold times, no confirmation of receipt, no feedback loop. | Workstream A: electronic referral form with automated routing and receipt confirmation. |
| Referral backlog and delayed client contact | CRM mailbox encryption failure caused 29 ICE Creates referrals to become inaccessible. Clients waiting up to one month. | Immediate fix applied (new SWANN mailbox). Workstream B: CRM provider access to eliminate email dependency permanently. |
| No evidence of demand deflection | No dashboard, no standardised data sharing protocol, no tracking of referral outcomes against care escalation rates. | Workstream C: Power BI monitoring dashboard. Workstream E: improved CRM data capture. Workstream B: provider access enabling structured outcome recording. |
| Priority | Workstream | Lead |
|---|---|---|
| A | Electronic referral form (professional and self-referral) on Dynamics 365 portal | Kate Hobbs / David Agyei |
| B | Provider access to CRM for structured referral updates and outcome recording | Katie Done / Adam Riglar |
| C | Power BI monitoring dashboard for contract and quality management | Lesley Richards (main contact) |
| D | Transition self-referral from soft launch to public access | Lisa Middleton / David Agyei |
| E | Signposting recording in CRM; next of kin field addition | Katie Done |
| F | Liquid Logic assessment note (senior decision required; not in delivery scope) | TBC |
Phase 2 is being delivered using a sprint-based framework, adopted on the advice of Steve Humphrey (PMO Lead) and selected in preference to waterfall delivery for the following reasons: the EPA submission window was five weeks, making a full waterfall plan impossible before the project had produced any outputs; the first governance documents (RAID log, ToR) were needed in week one, not at the end of a planning phase; and the requirements workshop in week three produced immediately actionable outputs that a waterfall approach would have deferred.
The sprint framework does not mean an absence of documentation. The Plan on a Page (POAP) operates as the standing governance record. It has grown from a one-page overview to a five-page document tracking all six workstreams, weekly sprint goals, risks and team responsibilities. It is updated weekly and shared with the full project team via SharePoint.
| Sprint | Period | Key Outputs |
|---|---|---|
| Sprint 1 | w/c 19 May | RAID log built; POAP v0.1 drafted; weekly meeting series established |
| Sprint 2 | w/c 26 May | ToR v1.0, Success Outcome Statement, Cost Avoidance Analysis sent to commissioner. POAP v0.3 endorsed. Four-document governance package sent 28 May. |
| Sprint 3 | w/c 2 June | Requirements workshop 2 June. User stories, field list, acceptance criteria agreed. Referral form build scope confirmed with Kate Hobbs. |
| Sprint 4 | w/c 9 June | Referral form build progressing. Second requirements workshop 10 June. Signposting list categorised; failure demand principle applied. Post-submission additional evidence. |
| Target | By Sept 2026 | Electronic referral form live. Dashboard development commenced. Provider access specification underway. |
| ID | Risk | Owner |
|---|---|---|
| R_001 | Absent financial baseline undermines EPA submission and programme business case | David Agyei |
| R_002 | Portal and referral form build blocked by CRM team absence | David Agyei |
| R_003 | No named strategic owner above commissioning level: governance gap and escalation route undefined | Steve Humphrey |
| R_004 | ICE Creates / Live Well Shropshire under excessive concurrent mobilisation demands | Lisa Middleton |
| R_005 | Post-EPA continuity gap: project management resource unconfirmed beyond 18 June | Steve Humphrey |
| R_006 | Low professional referrer uptake while telephone-only referral pathway remains in place | Lisa Middleton |
| R_007 | Absence of standardised cross-provider data sharing agreement | Adam Riglar |
| R_008 | Phase 1 institutional knowledge inaccessible: Sarah Knight on extended sick leave | Steve Humphrey |
| Activity | Responsible | Accountable | Consulted | Informed |
|---|---|---|---|---|
| Electronic referral form build | Kate Hobbs | Lisa Middleton | David Agyei, Katie Done | Jim Ford, Adam Riglar |
| Requirements specification | David Agyei | Lisa Middleton | Kate Hobbs, providers | Steve Humphrey |
| Dashboard development | ICT team | Lesley Richards | David Agyei, Lisa Middleton | Steve Humphrey |
| Provider access to CRM | Katie Done | Lisa Middleton | Adam Riglar (ICE Creates) | David Agyei |
| Governance documents | David Agyei | Steve Humphrey | Lisa Middleton | All team |
Phase 2 is built on a simple causal logic. The three problems identified in Section 2 each have a direct structural solution. This section sets out how each solution produces the intended outcome.
Professional referrers cannot use the telephone-only pathway. This is not a training issue or a motivation issue. It is a workflow compatibility issue. A health visitor cannot interrupt a home visit to make a phone call to a service that may put them on hold. An electronic referral form, accessible from any device, with automated routing and receipt confirmation, removes this barrier entirely. The outcome is measurable: referral volume from professional sources will rise within 90 days of the form going live.
Providers currently receive referrals via email and respond with three bullet points. This is incompatible with complex referral journeys involving care home residents, individuals with complex mental health presentations and cases requiring follow-up coordination. Provider access to CRM enables structured outcome recording, end-to-end referral tracking, and a real feedback loop between the council and providers. Chelsea Pallen (co-ordinator) has already introduced a quality gate for complex referrals. Provider CRM access embeds this quality function in the system rather than relying on individual gatekeeping.
SWANN cannot be renewed without evidence of demand deflection. Evidence requires data. Data requires infrastructure. The monitoring dashboard, improved data capture fields, and CRM-based referral tracking together create an evidence base that did not exist in Phase 1. This is not a reporting exercise. It is the mechanism by which the council can demonstrate to MHCLG, to its improvement board and to its own elected members that this investment is working.
Phase 2 is successful when: at least one professional referral pathway is fully digital; providers can update referral status directly in CRM; dashboard development is underway, with requirements agreed and build initiated; and the council can produce a monthly summary of demand deflection activity with confidence in the underlying data.
Sprint-based delivery is well-evidenced in contexts where requirements are partly unknown at the start of a project and where early delivery of outputs generates confidence and momentum. This project has both characteristics: the full requirements for the electronic referral form were not known until after the 2 June workshop, and producing the RAID log and POAP in week one created visible governance immediately in a project that had previously had none.
The limitation of sprint delivery without documentation is acknowledged: what gets done but not written down is lost. The POAP mitigates this. Every sprint decision, risk update and team action is recorded in the POAP and the RAID log. These are the project's institutional memory.
The 2 June requirements workshop used structured facilitation to elicit user stories, agree the referral form field list and set acceptance criteria for the electronic form and provider portal. This is a standard business analysis technique (aligned with BABOK v3 requirements elicitation practice). The outputs were immediately actionable: Kate Hobbs used the agreed field list to begin the Dynamics 365 portal build within the same sprint.
The 10 June second workshop extended this by applying Co-pilot assisted thematic analysis to the signposting list, applying the failure demand principle to the mandatory field discussion, and agreeing acceptance criteria for the provider portal. This workshop provides post-submission evidence of ongoing structured requirements leadership.
A power/interest matrix was used to differentiate stakeholder engagement strategies. Lisa Middleton (high power, high interest) was managed closely: the POAP was shared with her before wider circulation, her endorsement was obtained before the governance package was sent, and all major documents were sent to her in advance of any period of unavailability. Jim Ford (medium power, high concern) was converted from a potential blocker to a core team member by treating his Phase 1 concern as legitimate and designing a response to it. Lesley Richards' direct feedback on her role description was acted on immediately, adjusting "dashboard lead" to "main contact person."
The cost-avoidance analysis uses a proxy-and-literature method, drawing on ADASS unit costs (2024/25), PSSRU Unit Costs of Health and Social Care (2023) and NHS England social prescribing evidence reviews. Every figure is explicitly labelled as a proxy or assumption. The purpose of the analysis is not to present verified financial modelling but to demonstrate the methodology for capturing value once Phase 2's infrastructure makes tracking possible. The five outstanding questions for Lisa Middleton (data owner) are documented. A meeting to obtain real figures is scheduled for 23 June.
| Escalation type | Unit cost range | Source |
|---|---|---|
| Formal Care Act assessment | 600 to 900 pounds each | ADASS unit cost data 2024/25 |
| Short-term reablement episode | 1,500 to 3,000 pounds per episode | PSSRU Unit Costs of Health and Social Care 2023 |
| Long-term home care package | 15,000 to 22,000 pounds per year | ADASS 2024/25 |
| Residential care placement | 35,000 to 55,000 pounds per year | ADASS 2024/25 |
| Step | Figure | Assumption source |
|---|---|---|
| Projected annual referrals once form live | 200 | Assumption pending Lisa Middleton data |
| Assumed deflection rate (preventing escalation) | 20% | NHS England social prescribing evidence, lower end of range |
| Escalations avoided | 40 | 200 x 20% |
| Assessment cost avoided | 30,000 pounds/year | 40 escalations x 750 pounds mid-point |
| Of 40 avoiding escalation, proportion entering care packages | 60% | NHS Digital older adults data |
| Care packages avoided | 24 | 40 x 60% |
| Care package cost avoided per year | 360,000 pounds/year | 24 packages x 15,000 pounds/year (ADASS conservative) |
| Total illustrative annual cost avoidance | 390,000 pounds/year | Conservative proxy estimate |
No additional budget is requested. All Phase 2 development activities are being absorbed within existing ICT and commissioning resource. The council's CRM team (Kate Hobbs, Katie Done) are using existing Dynamics 365 licences and development capacity. The Power BI dashboard will be built within existing ICT reporting capacity. This project has a zero additional spend position.
Meeting with Lisa Middleton to address these questions: scheduled 23 June 2026. Answers will allow the proxy assumptions to be replaced with actual Shropshire data.
Phase 2 is governed through a weekly project team meeting (SWANN Phase 2 Wednesday series), the POAP as the standing governance document and the RAID log as the formal risk and decision record. Lisa Middleton chairs the project team meeting and holds effective accountability for commissioning decisions within Phase 2. Steve Humphrey (PMO) is the primary escalation route for resourcing and governance above project level.
The single unresolved governance gap is the absence of a named strategic owner above commissioning level. This is documented as RAID risk R_003, owned by Steve Humphrey. Lisa Middleton holds effective accountability for operational decisions, but there is no confirmed escalation route for decisions above commissioning level. A meeting to resolve this is scheduled for 23 June 2026.
| Resource | Role | Availability |
|---|---|---|
| David Agyei | BA Lead: requirements, governance, project coordination | Full time to 18 June (EPA). Post-EPA: to be confirmed. |
| Kate Hobbs | CRM Developer: referral form build | Part time; annual leave risk documented (R_002) |
| Katie Done | CRM Analyst: provider access, data capture | Part time |
| Lisa Middleton | Commissioning Officer: decisions, commissioner engagement | Part time; primary contact |
| Steve Humphrey | PMO: governance, escalation, quality assurance | Weekly 1:1 oversight |
The most significant implementation risk that cannot be resolved before the EPA is R_005: post-EPA continuity. David Agyei's project management resource is confirmed to 18 June. What happens to Phase 2 governance after that date is not yet confirmed. This is owned by Steve Humphrey. The POAP and RAID log are designed to be transferable: any successor project manager can pick them up without institutional knowledge from David Agyei.
| Option | Description | Assessment | Decision |
|---|---|---|---|
| Option 1: Do Nothing | Continue Phase 1 as currently operating. No Phase 2 development. | Phase 1 failures persist. Referral volume does not grow. No data infrastructure. Contract renewal unjustifiable. MHCLG scrutiny risk increases. | Rejected. The do-nothing option is not neutral; it actively worsens the position. |
| Option 2: Standalone digital form (outside Dynamics 365) | Build a separate online form using Microsoft Forms or equivalent. Lower development complexity. | Faster to build. Removes dependency on CRM team. However: creates a data silo. Referral data does not flow into CRM. Provider updates remain email-based. Dashboard remains impossible. Cost avoidance cannot be evidenced. | Rejected. Solves the referral access problem but leaves the evidence and accountability problems unresolved. |
| Option 3: Dynamics 365 portal (chosen) | Build the referral form within the existing Dynamics 365 CRM. Professional and self-referral versions. Integrated with existing care management system. | More complex to build. Dependent on CRM team capacity (risk R_002). However: enables end-to-end tracking. Provider access possible from same platform. Dashboard can draw directly from CRM data. The financial case becomes evidenceable. | Chosen. The integration is the value. Without CRM integration, Phase 2 cannot solve the evidence problem. |
| Moment | What happened | KSB area |
|---|---|---|
| Jim Ford's Phase 1 concern (20 May) | Jim raised concerns that Phase 1 was incomplete and Phase 2 should wait. Rather than treating this as obstruction, David acknowledged the concern, documented it as I_002 in the Issues Log, and redesigned the Phase 2 scope to incorporate a Phase 1 tidy-up workstream. Jim Ford became a core team member. | Change leadership; stakeholder management; conflict resolution |
| Kate Hobbs questioned a meeting (June) | Kate questioned the purpose of an upcoming SWANN meeting. Rather than defending the diary slot, David produced a structured 30-minute agenda with four named outcomes and sent it in advance. The meeting proceeded. | Communication; stakeholder management; building relationships |
| Governance package timing (28 May) | David was OOO on 29 May. Rather than waiting until his return, he sent the four-document governance package (ToR, POAP, Success Outcome, Cost Avoidance) on the Thursday evening so Lisa had the weekend to review. This decision is documented in D_008 of the decision log. | Self-management; planning; stakeholder communication |
| Lesley Richards' dashboard title (27 May meeting) | Lesley gave direct feedback that "dashboard lead" implied a workload she was not able to commit to. David amended the RACI to "main contact person" before the meeting ended. | Active listening; responsiveness; stakeholder management |
| 2 June requirements workshop facilitation | David facilitated a structured requirements session with the CRM team. Outputs: user story list, agreed field list, acceptance criteria framework, build sequence agreed. The workshop produced immediately actionable specifications that Kate Hobbs used to begin the portal build in the same sprint. | Requirements elicitation; facilitation; project delivery |
| 10 June second workshop (post-submission) | David prepared a structured facilitation guide using Co-pilot analysis. The workshop applied failure demand principles to mandatory field design, categorised the signposting list into themes and agreed acceptance criteria for the provider portal. This is additional post-submission evidence of structured analytical leadership. | Analytical thinking; facilitation; requirements elicitation |
David Agyei is a Senior Business Analyst within the PMO at Shropshire Council. I have been his line manager throughout this apprenticeship programme and have directly overseen his work on the SWANN SPoR Phase 2 project.
I can confirm that the project described in this proposal is real, current and consequential. SWANN is a live commissioned programme within Adult Social Care. Phase 1 has had significant operational challenges, and Phase 2 is a genuine organisational need, not a project constructed for assessment purposes.
David has demonstrated genuine project leadership throughout Phase 2. He established governance arrangements that did not previously exist: the RAID log, Terms of Reference, POAP and success outcome statement were all produced by David within the first two sprints. He has managed a multi-agency stakeholder group with appropriate professional judgment, and he has handled real operational tensions (the Phase 1 backlog issue, the CRM team capacity constraints, the absence of a strategic owner) with maturity and transparency.
His approach to the financial analysis is appropriate. He recognised early that he did not have the data to produce verified financial modelling, sought the data he needed from the commissioner, labelled all proxy assumptions clearly and produced an analysis that demonstrates the methodology while being honest about what is not yet known. This is the right way to handle this situation.
I am satisfied that the evidence presented in this proposal reflects David's genuine work and genuine competence. I commend it to the assessment panel.
Signed: Steve Humphrey, PMO Lead, Shropshire Council | Date: 4 June 2026