1. Phil Wilcock 7 September 2011 Health Investment Tools QIPP Right Care

2. Department of Health 22 Objective Aim is simply to show what the various health investment tools can do and how they can be combined to help create intelligence to support commissioning organisations The tools provide a starting point for the process of making health investment/disinvestment decisions Not to demonstrate how to use each tool but will be an opportunity at end to try them

3. Department of Health 33 Health Investment Tools 1.Background 2.Case study to illustrate: –Demographic tools –Programme Budgeting Benchmarking Tool –Spend and Outcome Tool (SPOT) –Atlases –NHS Comparators –Inpatient Variation Expenditure Tool 3.Further information 4.Next steps 5.Questions

4. Department of Health 44 Policy Context Quality, Innovation, Productivity & Prevention (QIPP) A national programme has been established to achieve optimal health outcomes from reduced funding. There are 12 work streams of which ‘Right Care’ is one Right Care Right Care is a programme designed to increase the value from the resources allocated and directly address variations in spend, activity and outcomes. It will focus on allocative efficiency, aim to reduce variation and increase the use of higher value interventions i.e. doing the right thing as well as doing things right. Better value commissioning The Health Investment Team, based in DH, is focused on ‘better value commissioning’ which is one of the projects within the ‘right care’ work stream. The team has launched a website and produced resources to help commissioners analyse variation in spend, outcome and activity levels by disease area. To help commissioners get started we have produced health investment packs for each PCT. These are available on our website (link at back of pack). The team is now creating a generic pack to support the emerging Clinical Commissioning Groups. NHS Constitution The work supports the NHS Constitution, specifically to provide best value for taxpayers’ money by way of the most effective, fair and sustainable use of finite resources.

5. Department of Health 5 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 eventually, Clinical Commissioner Group 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.

6. Department of Health 6 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? Which is the highest spending programme in England?

7. Department of Health 7 England gross expenditure (£000s) – 2009/10

8. Department of Health 8 Case Study – Hastings & Rother Using NHS Hastings & Rother as an example to illustrate the tools Using an existing PCT rather than emerging clinical commissioning group will enable more tools to be shown At the top of each slide is the source of the tool so that you can recreate the slides for your own organisation All tools can be accessed from our website (details at end)

9. Department of Health 9 Hastings & Rother is located on the South East coast APHO Health Profiles

10. Department of Health 10 Hastings & Rother has a population of 180,000 and an average practice list size of 5,500. It has more elderly and fewer younger people than the England average APHO General Practice Profiles – October 2010

11. Department of Health 11 The health of people living in Hastings is generally worse than the England average APHO Health Profiles – Local Authority level

12. Department of Health 12 The health of people living in Rother is generally better than the England average APHO Health Profiles

13. Department of Health 13 The proportion of the elderly population in Hastings is similar to the UK average but is forecast to grow at a slightly higher rate over the next 20 years ONS Population Forecasting Tool

14. Department of Health 14 The proportion of the elderly population in Rother is almost double the UK average and is forecast to grow at a slightly higher rate over the next 20 years ONS Population Forecasting Tool

15. Department of Health 15 Programme Budgeting Benchmarking Tool The tool is issued annually and is based on the programme budgeting returns submitted by PCTs It allows PCTs to compare their expenditure for each of the 23 Programme Budget disease categories with other PCTs in England and similar PCTs The tool contains a wide range of charts to illustrate the variation across PCTs and programmes

16. Department of Health 16 Expenditure in Hastings & Rother grew from £255m in 2006/07 to £322m in 2009/10 Programme Budgeting Benchmarking Tool – Hastings & Rother PCT Expenditure

17. Department of Health 17 Programme Budgeting Benchmarking Tool – Hastings & Rother PCT Expenditure per 100,000 population (weighted by age, sex and need) Hastings & Rother has spent consistently more per head of population on circulatory problems (CVD) than most PCTs in England over the last 4 reported years (rank 1= highest spend rate, 151=lowest)

18. Department of Health 18 Programme Budgeting Benchmarking Tool – Hastings & Rother PCT Expenditure per 100,000 population (weighted by age, sex and need) on Circulation category Hastings & Rother has high spend (green column) when compared to PCTs nationally (blue columns) and when compared to similar PCTs (purple diamonds)

19. Department of Health 19 Spend and Outcomes tool (SPOT) The Spend and Outcomes tool was designed by DH and 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.

20. Department of Health 20 2009/10 APHO Spend and Outcomes Tool: Each diamond represents a disease category and shows spend and outcomes compared to the national average Hastings & Rother has significantly higher spend and a slightly better outcome for CVD when compared to PCTs nationally Mortality from all circulatory diseases: Under 75s

21. Department of Health 21 2009/10 APHO Spend and Outcomes Tool: Each diamond represents a disease category and shows spend and outcomes compared to the cluster average Hastings & Rother has higher spend and slightly worse outcome for CVD when compared to similar PCTs Mortality from all circulatory diseases: Under 75s

22. Department of Health 22 2009/10 APHO Spend and Outcomes Tool: Each bar represents a disease category and shows spend and outcomes compared to the national average Hastings & Rother has slightly higher spend and a worse outcome for CVD when compared to it’s most similar PCT - East Sussex Downs & Weald Mortality from all circulatory diseases: Under 75s

23. Department of Health 23 Programme Budgeting Atlases The Programme Budgeting Atlases links programme budgeting expenditure data with an array of outcome data. By using mapping software, bar charts and correlation plots, the Atlases provides a user-friendly way of analysing and presenting data. Need to have access to the NHS Network to use the tool

24. Department of Health 24 Hastings & Rother has a high reported prevalence of hypertension when compared to similar PCTs Prevalence of hypertension: % all ages, 2008/09

25. Department of Health 25 Hastings & Rother has a low reported prevalence of CHD when compared to similar PCTs Prevalence of coronary heart disease: % all ages, 2008/09

26. Department of Health 26 Hastings & Rother has the highest FHS prescription expenditure for circulatory diseases when compared to similar PCTs FHS Prescription expenditure: Circulatory system per 100,000 population (weighted for age, sex and need)

27. Department of Health 27 Hastings & Rother has the lowest percentage of low cost statins prescribed when compared to similar PCTs Low cost statins: As a percent of all statins prescribed FY 2008/9 Q4

28. Department of Health 28 Hastings & Rother has an average rate of elective admissions for CVD when compared to similar PCTs Hospitalisation: Circulatory system problems. All elective admissions, indirectly age-standardised rate per 100,000 population, all ages 2008/2009

29. Department of Health 29 Hastings & Rother has the highest rate of non-elective admissions for CVD when compared to similar PCTs Hospitalisation: Circulatory system problems. All Non-elective admissions, indirectly age-standardised rate per 100,000 population, all ages 2008/2009

30. Department of Health 30 Hastings & Rother has an average rate of CVD emergency readmissions within 28 days of discharge when compared to similar PCTs Emergency readmission to hospital within 28 days of discharge: Circulatory system problems. Admissions excluding day cases, indirectly age-standardised percent, all ages. 2007/2008

31. Department of Health 31 Hastings & Rother has a below average rate of deaths within 30 days of admission for CHD when compared to similar PCTs Deaths within 30 days of admission for Coronary Heart Disease: Admissions excluding day cases, indirectly age standardised rate per 100,000 spells, all ages FY 2008/9

32. Department of Health 32 Hastings & Rother has a higher prescription expenditure for CVD than PCTs with a similar indices of deprivation. Scatter plot: shows Indices of deprivation 2007:IMD: Average Score, 2005 vs FHS prescription expenditure: Circulatory system

33. Department of Health 33 Hastings & Rother has a higher non-elective admission rate for CVD than most PCTs with similar indices of deprivation. Scatter plot: shows Indices of deprivation 2007:IMD: Average Score, 2005 vs Non-elective admissions, indirectly age-standardised rate per 100,000 population: Circulatory system, all ages, 2008/09

34. Department of Health 34 NHS Comparators NHS Comparators provided by the IC on the NHS net; nww.nhscomparators.nhs.uk Holds data at England, SHA, PCT, Provider and Practice level; Can combine data to create Clinical Commissioning Groups, PCT and SHA Clusters Various sources of data including: –admissions (elective/non-elective) – activity and expenditure; –prescribing – items and expenditure –better care better value metrics – including low cost statin prescribing –QOF indicators Very powerful for benchmarking and time series

35. Department of Health 35 NHS Comparators – GP Practice Level Comparison of Expenditure on CVD prescriptions Wide variation in spend on CVD drugs across Hastings & Rother Table shows activity, expected activity based on national averages, and the resulting % difference, for PCT and SHA Hastings & Rother England South East Coast SHA

36. Department of Health 36 NHS Comparators – GP Practice Level Comparison of Expenditure on CVD prescriptions Highest spend on CVD drugs is in Rother

37. Department of Health 37 NHS Comparators – PCT Level Comparison of % low cost statins prescribed Wide variation in % low cost statins prescribed across South East Coast SHA – Hastings & Rother and Eastern & Coastal Kent have the lowest % whilst neighbouring West Kent has the highest % Eastern & Coastal Kent Hastings & Rother West Kent

38. Department of Health 38 NHS Comparators – GP Practice Level Comparison of % low cost statins prescribed Wide variation in % low cost statins prescribed across practices in Hastings & Rother Easy to identify high and low spending practices. Can compare practices within groups based on need of population

39. Department of Health 39 NHS Comparators - Expenditure on all CVD admissions covered by PBR tariff (age and sex adjusted rate) - Comparison within ONS cluster Hastings & Rother has the second highest spend on all CVD admissions when compared to similar PCTs (after age and sex adjustment)

40. Department of Health 40 NHS Comparators - Expenditure on all CVD emergency admissions covered by PBR tariff (age and sex adjusted rate) - Comparison within ONS cluster Hastings & Rother has the second highest spend on all CVD emergency admissions when compared to similar PCTs (after age and sex adjustment)

41. Department of Health 41 NHS Comparators - Quarterly Time Series of PCT Expenditure on Emergency Admissions for Circulation Hastings & Rother spend on CVD emergency admissions has been consistently higher than SHA and National average rates for the last three years

42. Department of Health 42 NHS Comparators – GP Practice Level Comparison of Expenditure on Circulation Emergency Admissions Large variation in spend on CVD Emergency Admissions at practice level in Hastings & Rother

43. Department of Health 43 NHS Comparators – GP Practice Level Comparison of Expenditure on Circulation Emergency Admissions Large variation across practices in Hastings & Rother for spend on CVD Emergency Admissions Silver Springs Conquest

44. Department of Health 44 Breakdown of actual and expected expenditure on admissions by programme budget for Hastings & Rother (also available for primary care 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 – Expenditure on inpatient admissions by programme budget category

45. Department of Health 45 Inpatient Variation Expenditure Tool (IVET) The tool provides PCTs with: inpatient expenditure data on different diseases and interventions; 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 unique 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

46. Department of Health 46 IVET: PCT inpatient expenditure above or below the benchmark for diseases in 2008-09. Hastings & Rother is spending over £2m more than the national average on circulation inpatient procedures adjusting for age, sex and need of population

47. Department of Health 47 IVET: PCT inpatient expenditure above or below the benchmark for high spend procedures in 2008-09. Hastings & Rother is spending over £1m more than the national average on three CVD high spend procedures adjusting for age, sex and need of population

48. Department of Health 48 IVET: PCT inpatient expenditure for selected disease/intervention compared to a user defined benchmark. Hastings & Rother is spending more per head on CVD inpatient procedures than most other PCTs in England

49. Department of Health 49 Summary Using programme budgeting tools we have shown that for CVD, when compared to similar PCTs, NHS Hastings & Rother has; high overall spend on CVD slightly higher mortality from all circulatory diseases high reported prevalence of hypertension but low reported prevalence of CHD highest FHS Prescribing spend for CVD lowest percentage of low costs statins prescribed highest rate of non-elective admissions for CVD above average rate of readmissions after 28 days of discharge spent £2m more than the national average on inpatient procedures for CVD (adjusting for age, sex and need of population) Despite the high expenditure on CVD for an ageing population, mortality rates are slightly worse than similar PCTs. The main expenditure pressures appear to be on prescribing and emergency admissions. There appears to be a wide variation across practices too.

50. Department of Health 50 Further Information The Health Investment Network website provides access to all the tools used in this presentation. Registration will give you automatic updates to new resources www.networks.nhs.uk/nhs-networks/health-investment-network The website also contains e-guides to help understand how the tools used in this presentation work and to gain a better understanding of expenditure and associated outputs and outcomes Health Investment Packs are available for all PCTs in England on our website Further information regarding other QIPP Right Care projects, such as shared decision making and lower value interventions, can be found at: www.rightcare.nhs.uk 50

51. Department of Health 51 Further work We are now working with Derbyshire PCT Cluster to create a generic clinical commissioning group version of the PCT packs. Once agreed, we will add to the website together with a training guide We are drawing up a training strategy Tools will be gradually updated with CCG level data 51

52. Department of Health 52 Any questions? Phil Wilcock philip.wilcock@dh.gsi.gov.uk 020 7210 5589 52