1. Potential excess acute costs at XYZ PCT Dr Rod Jones Statistical Advisor Healthcare Analysis & Forecasting

2. Key Issues Capitation formula is linear but true relationship is sigmoid Low deprivation areas are under funded Gap is mainly NEL (£14M) of which £3M is excess zero day emergency Some EL (mix of counting & intervention) (£9M) PCT is attempting to recover a general gap against specific HRG Is this likely to be a successful strategy? Need to benchmark against the best West Berkshire and the RBH

3. Key Issues (contd) Three acute sites with different counting & coding issues LA data shows different levels of excess OP & IP A FT highest level of Plastic Surgery DC in the UK AAA LA Wycombe highest level of Gynaecology admissions BBB LA (M09, M05, N12) High levels of other first attendance at B NHS Trust CCC LA

4. Suggestions Segment all output areas (OA) into site catchments for EL, NEL and OP and performance manage by catchment Will make demand management more pro- active by virtue of focus Able to calculate expected/desirable demand at OA level, hence, specific & measurable targets for each catchment

5. Efficiency Measures 16% excess bed days within trim points 3% excess NEL bed days > upper trim point 1.4 FCE per Spell for NEL respiratory conditions (1.1 at RBBH) Highest level of transfers to residential care in South Central Surgical DC performance is OK Poor performance only in Ophthalmology 1,440 fewer DC Highest % DC in SCHA in C04 (minor mouth), C22 (nose), H22 (minor T&O), L98 Chemo Check to see if these are outpatient procedures counted as DC

6. Implications Beds occupied hence poor A&E performance Contract should state will not pay for excess bed days above national average Cost saving of 4,300 excess bed days £130,000 at £300 per excess day Benchmark: RBH 4,700 lower than expected Residential care & alternatives

7. Other Cost Pressures Number to be cleared from the waiting list in Bucks is highest in South Central relative to level of capitation funding Legacy issue with high impact in 07/08 and 08/09 However, this tied funding is released in 09/10

8. Outpatient First Attendance Considerable overlap between Plastic Surgery (£130)[1] & Dermatology (£115);[1] Gynaecology (£135) & Obstetrics (£154); Medical group (£161 to £260); Orthopaedics (£144), Neurosurgery, Plastic Surgery (£130), Anaesthetics (£187); General Surgery (£151) and Urology (£157). Specify acceptable proportions in contract [1][1] The 06/07 PbR tariff for outpatient first attendance is given in brackets

9. Excess First Attendance Local AuthorityPopulationExcess Excess per 1,000 head Excess relative to 'best' AAA61,9452,583425,575 BBB165,7416,5093914,515 CCC162,105-4,394-273,436 DDD89,226-3,223-361,087 Reading143,097-6,912-480 Wokingham150,211-7,475-50

10. First Attend by Group (excess per 1000 head) Local AuthorityAllMedical Orthopaedic Overlap Plastic & Dermatol Surgery & Urology AAA4235102 BBB39115 7 CCC-27-4-55-3 DDD-36-6-84-4 Reading-48-7-4-6-7 Wokingham-50-8-4-7

11. 6 in top 15 LSOA in TVHA (no link with IMD implies GP practice related) LSOAWardIMDAllMedical Ortho Olap Plastic & Derm Surg & Urol E01017656Coldharbour227434474126 E01017828Iver Village1215623 1213 E01017805 Burnham Church1915114121820 E01017809 Burnham Lent161337221311 E01017709Southcourt2413122122214 E01017694 Marsh Gibbon812814241521

12. Catchment Area Behaviour SpecialtyTypeWexmStokeWycbeMKGHORH All SpecialtiesGP114%102% 86%105% All SpecilatiesAll110%114%88%111%110% Medical GroupGP92%135%105%96%109% Medical GroupAll92%127%81%170%114% Orthopaedic GroupGP143%98%80%90%88% Orthopaedic GroupAll114%108%86%118%107% Plastic Surgery & DermatologyGP147%133%131%81%100% Plastic Surgery & DermatologyAll142%156%117%85%115% Count of max 88154

13. Conclusions Counting of other is an issue Specify acceptable ratio of GP to Other Very high first attendance in specific OA May be function of GP practice Acute site catchment areas show high/low general patterns Allocate all OA to a site catchment and performance manage as a group Maximum possible saving of 24,600 first attend £5M at 07/08 tariff Possible early stage savings of £1.8M in SB and AV

14. Inpatient Identify all HRG lines with excess cost > £20,000 p.a. £14 M NEL and £9M EL

15. Elective >5,300 excess zero day elective High likelihood of minor procedures counted as DC £5.3M less alternative cost as RDA or OP Some specialist lines are high HRG C35 Major maxillo-facial Proportion of 0 & 1 day too high Coding issue?

16. Non-elective £1.8M is zero day NEL £0.9M of which from Wycombe LA Specify in contract that zero day NEL will be paid up to national average Any HRG ending 99 (Complex Elderly) May be a coding issue

17. SEPHO Atlas of conditions HES data 98/99 to 02/03 Spell per person Relative rate per person Adjusted for age, sex and IMD http://www.uhce.ox.ac.uk/Epidembase2 /Atlases_admissions.html#catalogue

18. Spell per person Rheumatoid Arthritis Wyc 1.46, SB 1.38, AV 1.27, Chilt 1.21 Gynaecology SB 1.09; all others 1.02

19. Relative rates (person based) Knee Arthroplasty Wyc 120%, AV 110% Mastectomy & Lumpectomy AV 120%, Chilt 111%, Wyc 107%, SB 103% Squint AV 114%, Wyc 109%, SB 82%, Chilt 80% Hysterectomy Wyc 88%, Chilt 82%, AV 79%, SB 67% Cholecystectomy AV 102%, Chilt 100%, Wyc 97%, SB 86% Peptic Ulcer AV 136%, Wyc 69%, SB 62%, Chilt 48% CABG Wyc 113%, SB 102%, Chilt 97%, AV 90%

20. Programme Budgeting Links programme expenditure and outcomes over 23 programmes Uses ICD-10 codes to group http://www.dh.gov.uk/programmebudgeting http://nww.nchod.nhs.uk

21. High Expenditure AAA LA(GI, Trauma & Injury, Mental Health, Musculo-skeletal BBB LA (Trauma & Injury) CCC LA ((Trauma & Injury, Circulatory)