QIPP Right Care NHS West Kent PCT Health investment slide pack July 2010
About this health investment pack • Purpose / Objectives – to highlight the scale of variation in healthcare at PCT and GP Practice level and demonstrate how Programme Budgeting tools can help the search for unwarranted variation and support the health investment process • The analysis presented provides a high level narrative in terms of expenditure, expenditure drivers, and the resulting outcomes for one disease area per PCT • By triangulating data from a variety of sources, the analysis draws on a wide evidence base to provide consistent messages and therefore minimises opportunities to highlight data quality issues • This pack cannot draw comprehensive conclusions but provides a summary of readily available and free to use national level information sets for local organisations to raise questions and investigate further • PCTs who want to explore these variations in more detail should take this forward through their DPH and Public Health Observatories and Quality Observatories • As the NHS moves towards commissioning by GP Consortia it is imperative that PCTs establish a clear framework and evidence base for making and evaluating health investment decisions 2
Overview • These slides use Programme Budgeting tools to show that, compared to similar PCTs, West Kent has; • Average expenditure on Respiratory problems • High rate of mortality from COPD • Below average prescription expenditure on Respiratory problems • High reported prevalence of COPD and a high ratio of reported to expected prevalence of COPD • Below above average flu vaccinations for patients with COPD • Spend of £500,000 more than the national average for inpatient admissions for Respiratory problems adjusting for age, sex and need of population 3
What is Programme Budgeting? Programme Budgeting: • Outlines how PCTs cut their cake in terms of 23 ICD 10 defined programme budgeting categories; hence is a • a retrospective appraisal of resource allocation broken down into ‘programmes’ - with a view to influencing and tracking future expenditure in those same programmes. • Allows for cross sectional and time series comparisons, at England, SHA, PCT and increasingly, practice Level. Marginal Analysis - An appraisal of the added costs and added benefits when the resources in programmes are increased, or deployed in new ways. - Programme Budgeting and Marginal Analysis provides a framework to help commissioners make, track and evaluate health investment decisions.
23 Programme Budgeting Categories What is Programme Budgeting? • 14 Skin Problems • 15 Musculoskeletal System Problems (excludes Trauma) • 16 Trauma & Injuries • 17 Genito Urinary System Disorders (except infertility) • 18 Maternity & Reproductive Health • 19 Neonates • 20 Poisoning • 21 Healthy Individuals • 22 Social Care Needs • 23 Other Conditions 1 Infectious Diseases 2 Cancers & Tumours 3 Blood Disorders 4 Endocrine, Nutritional and Metabolic Problems 5 Mental Health Problems 6 Learning Disability Problems 7 Neurological System Problems 8 Eye/Vision Problems 9 Hearing Problems 10 Circulation Problems (CVD) 11 Respiratory System Problems 12 Dental Problems 13 Gastro Intestinal System Problems
Information Available for PCTs • This pack will provide an update on the products available to commissioners including: • Programme Budgeting Spreadsheet; • SPOT (Spend & Outcome Tool); • Programme Budgeting Atlas; • NHS Comparators. • Inpatient Variation Expenditure Tool (IVET) • These tools allow commissioners to compare expenditure and outcomes at disease level. • To access these tools visit; • www.networks.nhs.uk/nhs-networks/health-investment-network/key-tools • These tools are a starting point for the process of making health investment decisions.
Programme Budgeting Spreadsheet – Expenditure per 100,000 population (weighted by age, sex and need) West Kent PCT has average spend on Respiratory compared to PCTs nationally adjusting for age, sex and need of population
2008/2009 Programme Budgeting Spreadsheet – Respiratory Expenditure per 100,000 population (weighted by age, sex and need) Green circle shows West Kent PCT has average expenditure on Respiratory both nationally (blue diamonds) and when compared to similar PCTs (purple triangles)
APHO Spend and Outcomes tool (SPOT) • The Spend and Outcomes tool has been developed by the Association of Public Health Observatories. • The tool allows PCTs to compare their expenditure and outcome data for each of the 23 Programme Budget disease categories on a single page. • The tool is interactive and allows PCTs to select different outcome measures and different views of the data – including a comparison with any other selected PCT. • A very useful tool that quickly allows PCTs to identify areas of expenditure that warrant further investigation.
2008/2009 APHO Spend and Outcomes Tool – Each diamond represents a disease category and shows spend and outcomes compared to the national average West Kent PCT has average spend and better outcome for Respiratory compared to PCTs nationally Mortality from bronchitis, emphysema, COPD
2008/2009 APHO ONS Cluster Average – Each diamond represents a disease category and shows spend and outcomes compared to the cluster average West Kent PCT has average spend and worse outcome for Respiratory compared to similar PCTs Mortality from bronchitis, emphysema, COPD
Programme Budgeting Atlases • The Programme Budgeting Atlases are provided on our behalf by the National Centre for Health Outcomes Development, under contract to the Information Centre for Health and Social as part of the Compendium of Public Health Indicators. • The Atlas links programme budgeting expenditure data, as presented in the programme budgeting spreadsheet with an array of outcome data. • By using mapping software, bar charts and correlation plots, the Atlases provides an illuminating and user-friendly way of analysing and presenting data. • Atlases available via an NHS Net connection from: nww.nchod.nhs.uk
Mortality from bronchitis, emphysema and other COPD: Directly age-standardised rate per 100,000 population, all ages, all persons 2005-2007 West Kent PCT has the highest mortality rate from bronchitis, emphysema and other COPD when compared to similar PCTs
FHS prescription expenditure: Respiratory system: Thousand pounds per 100,000 unified weighted population, 2007/2008 West Kent PCT has below average FHS prescribing expenditure on Respiratory compared to similar PCTs
Prevalence of COPD (QOF), Percent, all ages, 2007/2008 West Kent PCT has high reported prevalence of COPD compared to similar PCTs
Fev1 checks for patients with COPD (QOF), Percent, all ages, 2007/2008 West Kent PCT has a high rate of Fev1 checks for patients with COPD compared to similar PCTs
Vaccinations against influenza for patients with COPD (QOF); Percent, all ages, 2007/2008 West Kent PCT has below above average flu vaccinations for patients with COPD compared to similar PCTs
Emergency readmission to hospital within 28 days of discharge: Respiratory system. Admissions excluding day cases, indirectly age-standardised percent, all ages. 2007/2008 West Kent PCT has a high rate of emergency readmissions for Respiratory problems when compared to similar PCTs
NHS Comparators NHS Comparators provided by the IC on the NHS net; nww.nhscomparators.nhs.uk • Holds data at England, SHA, PCT and Practice level; • Data are timely and frequent – every quarter up to Q3 2009/10 • Various sources of data including: • total admissions – activity and expenditure; • non-elective admissions – activity and expenditure • elective admissions – activity and expenditure • prescribing – items and expenditure • better care better value metrics – including low cost statin prescribing • Very powerful for showing variation, and time series – which allows to track change over time • Outpatient referrals by GP
NHS Comparators – Expenditure on Respiratory emergency admissions – Comparison with similar PCTs West Kent PCT have an average expenditure on Respiratory emergency admissions compared to similar PCTs
NHS Comparators – Expenditure on Obstructive Airways Disease emergency admissions – Comparison with similar PCTs West Kent PCT has high expenditure on Obstructive Airways Disease emergency admissions compared to similar PCTs
NHS Comparators – Expenditure on Respiratory emergency admissions – GP Practice level West Kent PCT has a large variation at GP practice level for expenditure on Respiratory emergency admissions Easy to identify high and low spending practices. Can compare practices within groups based on need of population
NHS Comparators – COPD Reported vs Expected Prevalence – Comparison with similar PCTs West Kent PCT has a high ratio of reported to expected prevalence of COPD compared to similar PCTs
NHS Comparators – Breakdown of Actual and Expected Expenditure on admissions by Programme Budget or Disease Category for Barking & Dagenham PCT – Also available for FHS Prescribing Expenditure NHS Comparators – Breakdown of actual and expected expenditure on admissions by Programme Budget or disease category for West Kent PCT – Also available for FHS Prescribing expenditure This table is available at SHA, PCT, and Practice level, on a quarterly or annual basis. The table shows for inpatient admissions in each disease area, actual spend, expected based on national averages, and expenditure differences in absolute and % terms. Because expenditure is calculated as activity multiplied by tariff, the table is less useful where tariff is less well developed – e.g. Mental Health.
Inpatient Variation Expenditure Tool (IVET) The tool provides PCTs with: • inpatient expenditure data (2008/9) on different diseases and interventions; • Inpatient expenditure per 1000 population, standardising for age, sex and need; • The change in inpatient expenditure and activity required to meet a user-defined benchmark for each disease and intervention; • Comparative data to other PCTs – allowing variation between PCTs to be seen. • A novel feature of this tool is that the standardisation accounts for age, sex and needs - with needs (e.g. deprivation) built up to PCT level from the Person Based Resource Allocation at practice level
IVET: PCT inpatient expenditure above or below the benchmark for diseases in 2008-09. West Kent PCT spend £500,000 more than the national average on Respiratory inpatient admissions adjusting for age, sex and need of population
The Inpatient Variation Tool allows PCTs to select a high cost disease or procedure, choose a benchmark level (e.g. median, lowest 10%) and view potential savings. IVET: PCT inpatient expenditure for selected disease/intervention compared to a user defined benchmark.
Conclusion • These slides used Programme Budgeting tools to show that, compared to similar PCTs, West Kent has; • Average expenditure on Respiratory problems • High rate of mortality from COPD • Below average prescription expenditure on Respiratory problems • High reported prevalence of COPD and a high ratio of reported to expected prevalence of COPD • Below above average flu vaccinations for patients with COPD • Spend of £500,000 more than the national average for inpatient admissions for Respiratory problems adjusting for age, sex and need of population
Next Steps • Visit the Health Investment Network website: www.networks.nhs.uk/nhs-networks/health-investment-network • Use the E guides to understand how the tools use in this slidepack work and to gain a better understanding of expenditure and associated outputs and outcomes. • Produce versions of this slidepack for other programme budgeting categories. • Download the annual population value review which provides a contextual guide to the health investment process. • Access a video learning module that explores the definitions, tools and practical application of Programme Budgeting Marginal Analysis (PBMA) • Find Useful links to other tools, data sources, reports and guidance. • Further information regarding QIPP Right Care can be found at: www.rightcare.nhs.uk 31