July 2010 NHS Calderdale Health Investment slide pack QIPP Right Care Important: Please note this health investment slide pack may differ from other SHA’s as it was created as part of the initial pilot scheme

22 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

3 Overview We will:- Examine DH Programme Budget Spreadsheet and SPOT Identify a programme area to review in more depth Explore this programme area in the Programme Budget Atlases and NHS Comparators Develop a clearer picture of areas for further investigation

4 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.

5 23 Programme Budgeting Categories 1Infectious Diseases 2Cancers & Tumours 3Blood Disorders 4Endocrine, Nutritional and Metabolic Problems 5Mental Health Problems 6Learning Disability Problems 7Neurological System Problems 8Eye/Vision Problems 9Hearing Problems 10Circulation Problems (CVD) 11Respiratory System Problems 12Dental Problems 13Gastro Intestinal System Problems 14Skin Problems 15Musculo Skeletal System Problems (excludes Trauma) 16Trauma & Injuries 17Genito Urinary System Disorders (except infertility) 18Maternity & Reproductive Health 19Neonates 20Poisoning 21Healthy Individuals 22Social Care Needs 23Other Conditions What is Programme Budgeting?

6 2007/08 and 2008/09 Programme Level Expenditure for England

7 Information Available for PCTs This pack will provide an update on the products available to commissioners including: Programme Budgeting Spreadsheet; Spend & Outcome Tool (SPOT); 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; These tools are a starting point for the process of making health investment decisions.

8 Programme Budgeting Spreadsheet: Calderdale PCT Expenditure

9 Programme Budgeting Spreadsheet – Calderdale PCT Expenditure per 100,000 population (weighted by age, sex and need) – 2008/9 rank column shows PCT is a high spender on Respiratory, Social care and Other categories; Respiratory was a low spend in 2006/07. Note: Calderdale has a high proportion of spend in category 23x ‘Other Miscellaneous’. This may result in low reported expenditure in disease specific categories.

10 Programme Budgeting Spreadsheet – Calderdale PCT Expenditure per 100,000 population (weighted by age, sex and need) on Problems of the Respiratory System category – Green circle shows that the PCT has higher spend than most PCTs, both nationally (blue diamonds), and in similar PCT cluster (purple triangles)

11 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.

12 [2008/09] Each diamond represents a disease category and shows spend and outcome compared to the national average – In Calderdale PCT Respiratory has a higher spend with worse outcome when compared to other PCTs nationally. Mortality from all circulatory diseases: Under 75s Mortality from all cancers: Under 75s, Cancers was a high spend area in 2007/08 Patients on enhanced CPA receiving early FU Mortality from bronchitis, emphysema, COPD

13 [2007/08] Each diamond represents a disease category and shows spend and outcome compared to the national average – In Calderdale PCT Respiratory also had a higher spend with worse outcome when compared to other PCTs nationally. Mortality from all circulatory diseases: Under 75s Mortality from all cancers: Under 75s Patients on enhanced CPA receiving early FU Mortality from bronchitis, emphysema, COPD

14 Summary of DH PB Expenditure and SPOT data Expenditure Budget Spreadsheet –Spending on Respiratory was low in 2006/07 but has risen to became the 5 th highest category spend in 2008/09; –In 2006/07 its spend was 138 th across England, in 2008/09 it was 15 th ; Rank –Calderdale was the 5 th highest spender on Respiratory systems in 2008/09 within its own cluster; SPOT –Respiratory appears in the Higher Spend/Worse Outcome quadrant in both 2007/08 and 2008/09 data sets; The following slides will now look at Respiratory in more depth for Calderdale PCT.

15 Programme Budgeting Atlases (1) 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

16 Programme Budgeting Atlases (2) Atlases include a vast array of data configured in terms of: Expenditure Data. Expenditure per 100,000 population (weighted for age, sex and need) Expenditure per 100,000 population (weighted for age, sex and need) filtered by ONS Cluster Expenditure per 100,000 population (weighted for age, sex and need) filtered by SHA Output Data Primary care prescribing – number of items and expenditure; Admissions/ALOS/Beddays (total, non-elective, elective ordinary, daycase); Day case rates. Prescription expenditure Prescription Volume Outcome Data Expenditure on Respiratory Family health services prescribing per 100,000 population Prevalence data from QOF; Emergency readmissions data;

17 [2007/08] Programme Budget Atlas – Respiratory Expenditure per 100,000 population (weighted for age, sex and need) – Darker areas represent higher spend – Calderdale spend is above average.

18 [2007/08] Programme Budget Atlas - Respiratory Expenditure per 100,000 population (weighted for age, sex and need) filtered by ONS Cluster (Centres with Industry) – Darker areas represent higher spend – Calderdale is above average compared to similar PCTs

19 [2007/08] Programme Budget Atlas – Respiratory per 100,000 population (weighted for age, sex and need) filtered by SHA – Darker areas represent higher spend – Calderdale has an above average spend within the Yorkshire & Humber SHA

20 [2007/08] Programme Budget Atlas – Respiratory Mortality data - Years of life lost under 75 years per 10,000 population (weighted for age, sex and need) – Darker areas represent more years of life lost – Calderdale is average nationally.

21 [2007/08] Programme Budget Atlas – Scatterplot shows Respiratory Expenditure and Mortality data from previous slides on the same graph – Calderdale (highlighted by blue dot) has a high spend (vertical axis) and below average mortality (horizontal axis) – PCTs can use the chart to identify PCTs with good outcomes (and can filter by SHA and ONS similar PCT cluster)

22 [2007/08] Programme Budget Atlas – Expenditure on Respiratory Family Health Services Prescribing per 100,000 population (weighted for age, sex and need) SHA – Darker areas represent higher spend – Calderdale PCT spend is average nationally

23 [2007/08] Programme Budget Atlas – Prescribing Volume on Respiratory Family Health Services per 100,000 population (weighted for age, sex and need) SHA – Darker areas represent higher spend – Calderdale PCT spend is average nationally

/2008 Programme Budget Atlas – Prevalence of COPD (QOF); Percent, all ages FY, Calderdale PCT has slightly above average prevalence of COPD

/2008 Programme Budget Atlas – Fev1 checks for patients with COPD (QOF); Percent, all ages – Calderdale PCT has a below average level of checks for patients with COPD

/2008 Programme Budget Atlas – Vaccination against influenza for patients with COPD (QOF) Patients all ages – Calderdale PCT has a low vaccination rate against influenza for patients with COPD

27 [2007/08] Programme Budget Atlas – Respiratory Elective Hospital Admissions per 100,000 population (weighted for age, sex and need) – Darker areas represent higher number of admissions – Calderdale PCT has an average number of Elective Admissions than the national average

28 [2007/08] Programme Budget Atlas – Respiratory Non-Elective Hospital Admissions per 100,000 population (weighted for age, sex and need) – Darker areas represent higher number of admissions – Calderdale PCT has an average number of Non-Elective Admissions

29 [2007/08] Programme Budget Atlas – Respiratory Non-Elective Average Length of Stay per spell in hospital – Darker areas represent higher LOS Calderdale PCT has an average Length of Stay per spell in hospital

30 [2007/08] Programme Budget Atlas – Respiratory Emergency Readmissions to hospital within 28 days of discharge – Darker areas represent higher number of readmissions – Calderdale PCT has an average number of Respiratory Emergency Readmissions

31 [2007/08] Programme Budget Atlas – Deaths within 30 days of admission for all respiratory system problems – Darker areas represent higher number of deaths – Calderdale has a low number of deaths (but there are very large confidence intervals so caution must be used when interpreting this data)

/2008 Programme Budget Atlas – SCATTERPLOT – Vaccination against influenza for patients with COPD vs Hospitalisation: Respiratory system: Non elective admissions, Calderdale PCT has a below average number of patients hospitalised and an average number of patients vaccinated

33 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

34 [2008/09] NHS Comparators - Expenditure on all admissions covered by PBR tariff (age and sex adjusted rate) - Comparison with other PCTs – Calderdale has slightly higher expenditure than national average

35 [2008/09] NHS Comparators – GP Practice Level Comparison of Expenditure on Respiratory Emergency Admissions – Large variation between spend at practice level in Calderdale PCT Easy to identify high and low spending practices. Can compare practices within groups based on need of population

36 [2008/09] NHS Comparators – GP Practice Level Comparison of Average Length of Stay of Respiratory Emergency Admissions – Large variation at practice level in Calderdale PCT

37 [2008/09] NHS Comparators - Quarterly Time Series of Calderdale PCT Expenditure on Emergency Admissions for Respiratory – The PCT admissions rate is higher than the National average rate PCT has over the last three years been constantly high spending for respiratory. Peaks due to seasonality.

38 [2008/09] NHS Comparators - Managing variation in surgical thresholds – Expenditure at GP Practice level on the six Better Care Better Value procedures identified as low clinical value - Large variation at practice level in Calderdale PCT

39 [2008/09] NHS Comparators - Quarterly Time Series of Calderdale PCT Outpatient First Attendances – The PCT rate is higher than SHA and National average rate – Breakdown by source of referral is also available

40 [2008/09] NHS Comparators – Includes FHS Prescribing data (volume and cost of prescriptions) – Calderdale PCT has an average proportion of low cost Statins

41 [2008/09] NHS Comparators – Breakdown of Actual and Expected Expenditure on admissions by Programme Budget or Disease Category – 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.

42 ONS Cluster Variation The following three slides demonstrate further ways of looking at variation within programme areas. The first slide shows total variation in expenditure by programme, compared with cluster comparator. The next two slides show quadrant charts comparing expenditure and outcome for the PCT compared with other PCTs in its cluster.

43 Programme Budgeting Spreadsheet – Calderdale PCT Expenditure per 100,000 population (weighted by age, sex and need) on all categories compared to cluster average – Calderdale has large variations on Social Care needs and Other when compared with similar PCTs

44 [2007/08] Each diamond represents a disease category and shows spend and outcomes compared to the ONS Cluster average – In Rotherham PCT Cancer has higher spend with better outcome when compared to other PCTs in the same ONS Cluster

45 [2008/09] Each diamond represents a disease category and shows spend and outcomes compared to the ONS Cluster average – In Calderdale PCT Mental Health, Circulation and Cancer have lower spend and better outcome when compared to other PCTs in the same ONS Cluster

46 Conclusion We have:- Examined DH Programme Budget Spreadsheet and SPOT Identified a programme area to review in more depth Explored this programme area in the Programme Budget Atlases and NHS Comparators Developed a clearer picture of areas for further investigation

47 Next Steps Visit the Health Investment Network website: 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: 47