1. NHS Barking and Dagenham Health investment slide pack: respiratory disease December 2010 QIPP Right Care Produced by Commissioning Support for London using a template supplied by QIPP Right Care

2. QIPP Right Care 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 respiratory disease 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 Directors of Public Health, 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. QIPP Right Care 3 Overview Programme Budgeting tools show that, when compared to PCTs within London SHA, Barking and Dagenham PCT has: Lower spend and worse outcomes for respiratory problems when compared to similar PCTs A high rate of years of life lost due to mortality from COPD A high reported prevalence of COPD High rates of Fev1 checks and flu immunisation for patients with recorded COPD High rates of elective and non-elective admissions to hospital for respiratory problems High rates of expenditure on elective and non-elective admissions to hospital for respiratory problems A high spend on prescriptions for inhaled corticosteroids despite average prescription volumes

4. QIPP Right Care 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. QIPP Right Care 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 15Musculoskeletal 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. QIPP Right Care 6 2007/08 and 2008/09 Programme Level Expenditure for England

7. QIPP Right Care 7 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.

8. QIPP Right Care 8 Programme Budgeting Spreadsheet – Barking and Dagenham PCT Barking and Dagenham PCT Expenditure on own population (£000s) Programme Budgeting Category2006-072007-082008-09 % change from 2007-08 01Infectious Diseases 2,607 4,592 7,56165% 02Cancers and Tumours 13,299 16,416 17,6938% 03Disorders of Blood 1,778 2,397 2,120-12% 04Endocrine, Nutritional and Metabolic 5,865 6,789 9,88946% 05Mental Health Disorders 32,124 36,205 34,537-5% 06Problems of Learning Disability 8,686 8,917 9,83210% 07Neurological 11,167 8,718 10,96326% 08Problems of Vision 3,246 2,929 3,0885% 09Problems of Hearing 905 1,373 153-89% 10Problems of Circulation 20,815 23,663 22,098-7% 11Problems of the Respiratory System 13,445 13,239 15,18515% 12Dental Problems 11,260 13,548 11,413-16% 13Problems of Gastro Intestinal System 13,966 10,893 12,21812% 14Problems of the Skin 3,941 3,934 3,603-8% 15Problems of Musculo Skeletal System 10,116 7,867 11,01940% 16Problems due to Trauma and Injuries 8,943 955 2,064116% 17Problems of Genito Urinary System 9,110 4,500 11,865164% 18Maternity and Reproductive Health 14,466 14,068 15,2859% 19Conditions of Neonates 795 2,723 5,471101% 20Adverse effects and poisoning 3,488 2,691 3,59734% 21Healthy Individuals 1,515 2,402 20,680761% 22Social Care Needs 2,058 2,269 3,16239% 23Other 36,545 51,722 41,508-20% AllTotal230,140242,810275,00413%

9. QIPP Right Care 9 Programme Budgeting Spreadsheet – Expenditure per 100,000 population (weighted by age, sex and need) Barking and Dagenham PCT has high spend on healthy individuals and low spend on vision, hearing, trauma and skin compared to PCTs nationally, adjusting for age, sex and need of population PCT SelectedBarking and Dagenham PCT Selected Cluster details1 SUPER (7 groups)Cities and Services 2006/072007/082008/09 Population (as per Allocations)195,342195,802197,828 Dist from Target £'000 (Under/Over)(12,124)(9,685)(10,214) Dist from Target % (Under/Over)-4.80%-3.50% EXPENDITURE ON OWN POPULATION £ per 100,000 population Programme Budgeting Category2006-07Rank2007-08Rank2008-09Rank% Change 01Infectious Diseases 1,334,585 124 2,345,228 36 3,822,011 1763% 02Cancers and Tumours 6,808,072 130 8,383,986 99 8,943,638 977% 03Disorders of Blood 910,200 141 1,224,197 135 1,071,639 147-12% 04Endocrine, Nutritional and Metabolic 3,002,432 135 3,467,281 120 4,998,793 2244% 05Mental Health Disorders 16,445,034 73 18,490,632 63 17,458,115 98-6% 06Problems of Learning Disability 4,446,568 85 4,554,094 108 4,969,980 919% 07Neurological 5,716,651 55 4,452,461 142 5,541,689 12324% 08Problems of Vision 1,661,704 145 1,495,900 152 1,560,954 1524% 09Problems of Hearing 463,291 103 701,219 86 77,340 152-89% 10Problems of Circulation 10,655,690 123 12,085,177 89 11,170,322 125-8% 11Problems of the Respiratory System 6,882,813 54 6,761,428 78 7,675,869 8714% 12Dental Problems 5,764,260 50 6,919,240 29 5,769,160 106-17% 13Problems of Gastro Intestinal System 7,149,525 85 5,563,277 142 6,176,079 14111% 14Problems of the Skin 2,017,491 141 2,009,174 151 1,821,281 150-9% 15Problems of Musculo Skeletal System 5,178,619 124 4,017,837 150 5,569,996 13939% 16Problems due to Trauma and Injuries 4,578,133 117 487,738 152 1,043,332 152114% 17Problems of Genito Urinary System 4,663,624 149 2,298,242 152 5,997,641 139161% 18Maternity and Reproductive Health 7,405,487 28 7,184,815 32 7,726,418 208% 19Conditions of Neonates 406,979 140 1,390,692 84 2,765,537 1399% 20Adverse effects and poisoning 1,785,590 24 1,374,349 109 1,818,248 7232% 21Healthy Individuals 775,564 149 1,226,750 144 10,453,537 1752% 22Social Care Needs 1,053,539 132 1,158,825 137 1,598,360 11638% 23Other 18,708,248 85 26,415,481 41 20,981,887 98-21% AllTotal117,814,099 124,008,023 139,011,826 12%

10. QIPP Right Care 10 2008/09 Programme Budgeting Spreadsheet – Respiratory Expenditure per 100,000 population (weighted by age, sex and need) Green circle shows Barking and Dagenham PCT has a slightly below average expenditure on respiratory problems compared to PCTs nationally (blue diamonds) and notably lower than that in similar PCTs (pink triangles)

11. QIPP Right Care 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. QIPP Right Care 12 2008/09 APHO Spend and Outcomes Tool – Each diamond represents a disease category and shows spend and outcomes compared to the national average Barking and Dagenham PCT has lower spend and worse outcomes for respiratory problems when compared to PCTs nationally Mortality from bronchitis Under 75s

13. QIPP Right Care 13 2008/09 APHO Spend and Outcomes Tool – Each diamond represents a disease category and shows spend and outcomes compared to the cluster average Barking and Dagenham PCT has lower spend and worse outcomes for respiratory problems when compared to similar PCTs Mortality from bronchitis Under 75s

14. QIPP Right Care 14 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

15. QIPP Right Care 15 Programme by population expenditure: Respiratory system: Million pounds per 100,000 unified weighted population 2008/09 Barking and Dagenham PCT has slightly below average expenditure on respiratory problems when compared to PCTs nationally

16. QIPP Right Care 16 Programme by population expenditure: Respiratory system: Million pounds per 100,000 unified weighted population filtered by SHA 2008/09 Barking and Dagenham PCT has high expenditure on respiratory problems when compared to PCTs within London SHA

17. QIPP Right Care 17 Years of life lost due to mortality from bronchitis, emphysema and other COPD Directly age-standardised rate per 10,000 population, less than 75 years, all persons 2006-2008 Barking and Dagenham PCT has a high rate of years of life lost due to mortality from COPD when compared to PCTs within London SHA

18. QIPP Right Care 18 Prevalence of COPD (QOF); Percent, all ages: FY 2008/09 Barking and Dagenham PCT has a high rate of recorded prevalence of COPD when compared to PCTs within London SHA

19. QIPP Right Care 19 Fev1 checks for patients with COPD (QOF); Percent, all ages, FY 2008/09 Barking and Dagenham PCT has a high rate of Fev1 checks for patients with COPD when compared to PCTs within London SHA

20. QIPP Right Care 20 Vaccination against influenza for patients with COPD (QOF) Patients all ages, FY 2008/09 Barking and Dagenham PCT has a high percentage of COPD patients vaccinated against influenza when compared to PCTs within London SHA

21. QIPP Right Care 21 Hospitalisation: Respiratory system problems. All elective admissions, indirectly age-standardised rate per 100,000 population, all ages, FY 2008/09 Barking and Dagenham PCT has a high rate of elective admissions when compared to PCTs within London SHA

22. QIPP Right Care 22 Hospitalisation: Respiratory system problems. All non-elective admissions, indirectly age-standardised rate per 100,000 population, all ages FY 2008/09 Barking and Dagenham PCT has a high rate of non-elective admissions when compared to PCTs within London SHA

23. QIPP Right Care 23 Emergency readmission to hospital within 28 days of discharge: Respiratory system. Admissions excluding day cases, indirectly age- standardised percent, all ages. FY 2008/09 Barking and Dagenham PCT has a low rate of emergency readmissions to hospital for respiratory problems when compared to PCTs within London SHA

24. QIPP Right Care 24 Deaths within 30 days of admission for Respiratory system : Admissions excluding day cases, indirectly age standardised rate per 100,000 spells, all ages FY 2008/09 Barking and Dagenham PCT has a high rate of deaths within 30 days of admission for respiratory problems when compared to PCTs within London SHA

25. QIPP Right Care 25 Prevalence of COPD 2008/09 vs Years of life lost due to mortality from bronchitis, emphysema, and other COPD 2006-2008 Barking and Dagenham PCT has a higher rate of years of life lost due to mortality from COPD than PCTs with a similar recorded prevalence of COPD

26. QIPP Right Care 26 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 2008/9 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

27. QIPP Right Care 27 NHS Comparators: Total Elective (IP+DC) Admissions per 1000 Population: Period/Year: 2009/2010; Cost; Applied Filters: 11: Problems of the respiratory system (Programme Budget Category) Barking and Dagenham PCT has a high cost of all elective admissions for respiratory problems when compared to PCTs within London SHA

28. QIPP Right Care 28 NHS Comparators - Emergency Admissions per 1000 Population: Period/Year: 2009/2010; Cost; Applied Filters: 11: Problems of the respiratory system Barking and Dagenham PCT has a high expenditure on emergency admissions for respiratory system problems when compared to PCTs in London SHA

29. QIPP Right Care 29 NHS Comparators – GP Practice Level Comparison of Expenditure on Problems of Respiratory Emergency Admissions Easy to identify high and low spending practices. Can compare practices within groups based on need of population Barking and Dagenham PCT has high GP practice level variation for cost of emergency admissions for respiratory problems

30. QIPP Right Care 30 NHS Comparators: Inhaled Corticosteroids per STAR PU: Period/Year: 2009/2010; Activity Table shows activity, expected activity based on national averages, and the resulting % difference, for PCT and SHA Barking and Dagenham PCT prescribes close to the average number of inhaled corticosteroids when compared to PCTs within London SHA

31. QIPP Right Care 31 NHS Comparators: Inhaled Corticosteroids per STAR PU: Period/Year: 2009/2010; Cost Barking and Dagenham PCT has a high spend on inhaled corticosteroid prescriptions when compared to PCTs within London SHA

32. QIPP Right Care 32 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. NHS Comparators – Breakdown of Actual and Expected Expenditure on admissions by Programme Budget or Disease Category for Barking and Dagenham PCT – Also available for FHS Prescribing Expenditure

33. QIPP Right Care 33 Inpatient Variation Expenditure Tool (IVET) The tool provides PCTs with: inpatient expenditure data (2008/09) 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

34. QIPP Right Care 34 IVET: inpatient expenditure above or below the benchmark for diseases in 2008-09. The Inpatient Variation Expenditure Tool (IVET) allows PCTs to compare inpatient expenditure at disease and procedure level with a user defined benchmark. Barking and Dagenham PCT spends £100,000 more than the national average on respiratory inpatient admissions adjusting for age, sex and need of population

35. QIPP Right Care 35 IVET: inpatient expenditure for selected disease/intervention compared to a user defined benchmark. The IVET Tool allows PCTs to select a high cost disease or procedure, choose a benchmark level (e.g. median, lowest 10%) and view potential savings. Further diseases and interventions will be added subsequent to feedback from PCTs

36. QIPP Right Care 36 Conclusion Programme Budgeting tools show that, when compared to PCTs within London SHA, Barking and Dagenham PCT has: Lower spend and worse outcomes for respiratory problems when compared to similar PCTs A high rate of years of life lost due to mortality from COPD A high reported prevalence of COPD High rates of Fev1 checks and flu immunisation for patients with recorded COPD High rates of elective and non-elective admissions to hospital for respiratory problems High rates of expenditure on elective and non-elective admissions to hospital for respiratory problems A high spend on prescriptions for inhaled corticosteroids despite average prescription volumes

37. QIPP Right Care 37 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 37