1. Powerful analysis, influencing decisions 22 April, 2015 Commissioning Analysis and Intelligence Team Andrew Jackson Overview of Tools Analysis to support Commissioning

2. Commissioning Analysis and Intelligence Team 2 22 April, 2015 2 Why Variation Matters - Application to beer ( with thanks to Angela Bate, Newcastle University, Institute of Health and Society!)

3. Commissioning Analysis and Intelligence Team 3 22 April, 2015 3 Application to beer

4. Commissioning Analysis and Intelligence Team 4 22 April, 2015 4 Diminishing Marginal Returns benefit Quantity of beer

5. Commissioning Analysis and Intelligence Team 5 22 April, 2015 5 Quantity of beer benefit Negative Marginal Returns

6. Commissioning Analysis and Intelligence Team 6 22 April, 2015 6 Marginal Analysis Quantity of beer benefit Marginal benefit Quantity of beer – or £ invested

7. Commissioning Analysis and Intelligence Team 7 22 April, 2015 7 What We Do Annual Data Collection each summer from 152 PCTs for 23 PB Categories, plus Sub-Categories. –England level, programme budgeting expenditure published each autumn; –Benchmarked expenditure data at PCT level published each autumn on DH website; –One page linked spend and outcome data published via SPOT tool; –NCHOD site links expenditure data with:  Outcome data – e.g. disease mortality, 75 >YLL, 30 day > hospital mortality;  QOF data – e.g. disease prevalence, disease incidence, blood / cholesterol control;  HES data – e.g. admissions, alos, beddays, day case rate,  FHS Prescribing – expenditure and volume. For PBC activity, using programme budgeting codes we are able to use NHS Comparators to; –Provide a selection (elective / non – elective admissions, plus FHS prescribing) of programme budgeting data more quickly, and more frequently (every quarter); –Data are available at England, SHA, PCT, and individual practice level. Developing additional supporting tools; –Links variation in programme budgeting category with high volume HRGs within the programme – IVET tool available now; –Analysis underway on high growth admissions to question whether clinical thresholds are changing, work being undertaken in partnership with NICE; –Analysis scheduled (and resourced) to take place over the summer analyse PROMS data, but from a commissioner perspective to highlight variation in initial health status i.e. the threshold, and in due course, final health status / improvement in health status. Dissemination to the NHS taken forward jointly via; –The World Class Commissioning Programme; –QIPP ‘Right Care’ programme. wcc.networks.nhs.uk/healthinvestment –Provides links to all material, plus on line training.

8. Commissioning Analysis and Intelligence Team 8 22 April, 2015 8 2008/9 Programme Level Expenditure

9. Commissioning Analysis and Intelligence Team 9 22 April, 2015 Expenditure Variation of Cancer Source – PB Spreadsheet Powerful analysis, influencing decisions

10. Commissioning Analysis and Intelligence Team 10 22 April, 2015 Spend v Outcomes – National Comparison Source – APHO Spot Tool

11. Commissioning Analysis and Intelligence Team 11 22 April, 2015 Spend v Outcomes – Cluster Comparison Source – APHO SPOT tool. Powerful analysis, influencing decisions Arrows show movement from national to cluster picture

12. Commissioning Analysis and Intelligence Team 12 22 April, 2015 12 Programme Budget Atlas – Scatterplot shows CVD Expenditure and Mortality data from previous slides on the same graph – BEN PCT (highlighted by blue dot) have low spend (vertical axis) and high mortality (horizontal axis) – PCTs can use the chart to identify PCTs with good outcomes (and can filter by SHA and ONS similar PCT cluster)

13. Commissioning Analysis and Intelligence Team 13 22 April, 2015 13 Programme Budget Atlas – CVD Non-Elective Hospital Admissions per 100,000 population (weighted for age, sex and need) – Darker areas represent higher number of admissions – BEN PCT has a high number of Non-Elective Admissions

14. Commissioning Analysis and Intelligence Team 14 22 April, 2015 14 Programme Budget Atlas – CVD Non-Elective Average Length of Stay per spell in hospital – Darker areas represent higher LOS – BEN PCT has a low average LOS for Non-Elective Admissions

15. Commissioning Analysis and Intelligence Team 15 22 April, 2015 15 Programme Budget Atlas – CVD Emergency Readmissions to hospital within 28 days of discharge – Darker areas represent higher number of readmissions – BEN PCT has a high number of CVD Emergency Readmissions

16. Commissioning Analysis and Intelligence Team 16 22 April, 2015 NHS Comparators – Range of Activity and Expenditure Data (age and sex standardised) Powerful analysis, influencing decisions Ealing PCT Estimate of the difference between actual and expected spend (based on national average expenditure applied to own population)

17. Commissioning Analysis and Intelligence Team 17 22 April, 2015 NHS Comparators – Admissions data can be broken down by Programme Budget category Powerful analysis, influencing decisions Ealing PCT

18. Commissioning Analysis and Intelligence Team 18 22 April, 2015 NHS Comparators – Variation between GP Practices in a PCT

19. Commissioning Analysis and Intelligence Team 19 22 April, 2015 NHS Comparators – Time series data – Outpatient First Attendances 18% growth in Outpatient First Attendances in 2008/9

20. Commissioning Analysis and Intelligence Team 20 22 April, 2015 NHS Comparators – Reported vs Expected Prevalence – Indication of unmet need

21. Commissioning Analysis and Intelligence Team 21 22 April, 2015 NHS Comparators - Disease (or Programme Budgeting) Level Expenditure on Admissions 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.

22. Commissioning Analysis and Intelligence Team 22 22 April, 2015 NHS Comparators - Disease (or Programme Budgeting) Expenditure on Prescribing This table is available at SHA, PCT, and Practice level, on a quarterly or annual basis. The table shows for each disease area for FHS prescribing, actual spend, expected based on national averages, and expenditure differences in absolute and % terms. Data are only available on NHS net – hence thus are not accessible by pharmaceutical industry!

23. Powerful analysis, influencing decisions 22 April, 2015 Map Additional view Google copyright © Google Highest 20% Lowest 20% Selected area highlighted No gradients within cells Google copyright

24. Powerful analysis, influencing decisions 22 April, 2015 Map Google copyright Highest 20% Lowest 20% Map centralises when selected area when selected

25. Powerful analysis, influencing decisions 22 April, 2015 Map On pin click, show practice name Google copyright Highest 20% Lowest 20% Garforth practice

26. Commissioning Analysis and Intelligence Team 26 22 April, 2015 Cardiac valve procedures – Inpatient expenditure rate, 2008/9 (weighted for age, sex and need - per 1,000 population) Source: DH CAI (using HES) London Some overlap with circulatory 96% of expenditure in analysis Cardiac valve procedures cost £12,343 each. There is a 5-fold variation in expenditure between PCTs (adjusting for age, sex and need). The coefficient of variation is 26.5%. (This takes into account all PCTs, not just the top and bottom PCTs.) The potential savings are £19M (if PCTs with rates higher than the median reduced to this level). Relatively high unwarranted variation so large potential savings. Small drops in activity give large savings

27. Commissioning Analysis and Intelligence Team 27 22 April, 2015 Coronary bypass – Inpatient expenditure rate, 2008/9 (weighted for age, sex and need - per 1,000 population) Source: DH CAI (using HES) London Coronary bypasses cost £8,660 each. There is a 9-fold variation in expenditure between PCTs (adjusting for age, sex and need). The coefficient of variation is 27.3%. (This takes into account all PCTs, not just the top and bottom PCTs.) The potential savings are £14M (if PCTs with rates higher than the median reduced to this level).

28. Commissioning Analysis and Intelligence Team 28 22 April, 2015 Non-transient stroke or cerebrovascular accident >69 – Inpatient expenditure rate, 2008/9 (weighted for age, sex and need - per 1,000 population) Source: DH CAI (using HES) London Non-transient stroke or cerebrovascular accidents >69 cost £4,096 each. There is a 5-fold variation in expenditure between PCTs (adjusting for age, sex and need). The coefficient of variation is 18.7%. (This takes into account all PCTs, not just the top and bottom PCTs.) The potential savings are £14M (if PCTs with rates higher than the median reduced to this level).

29. Commissioning Analysis and Intelligence Team 29 22 April, 2015 Of this £12 million, over £2 million a year can be saved if they reduce Primary Knee Replacements to the national average rate Source – IVET tool.

30. Commissioning Analysis and Intelligence Team 30 22 April, 2015 The benchmarking tool allows PCTs to select a high cost disease or procedure, choose a benchmark level (e.g. median, lowest 10%) and potential savings are displayed. Source IVET tool.

31. Commissioning Analysis and Intelligence Team 31 22 April, 2015 Improvements to Programme Budgeting Data (1) Move to a Commissioner-based return (trial-run for 2009/10 collection and replace Reference Cost based return for 2010/11 collection) This will improve the accuracy of the data in future –Based on actual PCT spend rather than Provider’s cost (e.g. PbR tariff) –Commissioners have greater incentive to ensure data is as accurate as possible This will improve the timeliness of data in future –Benchmarking tools will be available to PCTs sooner –Potential for in-year monitoring and benchmarking This will also reduce the overall burden on NHS in future We are also working to improve the allocation of Outpatients and A&E expenditure to Programme Budget categories

32. Commissioning Analysis and Intelligence Team 32 22 April, 2015 Improvements to Programme Budgeting Data (2) We also propose to develop a template that provides a more detailed breakdown of Programme Budget data The intention is to provide PCTs with the opportunity to compare spend in different areas within a disease category (e.g. Primary Care, Secondary Care, Community Care) The long term aim is for the template to be based on patient pathways (the template will initially include prevention spend for each category) The basis for all our developments is to provide information to PCTs in the most useful way to allow them to make informed health investment decisions We have a data quality group to advise on these developments, but are always seeking feedback from the NHS – if anyone has any comments on this and/or would like to be involved in developing the collection please let us know

33. Commissioning Analysis and Intelligence Team 33 22 April, 2015 Useful Links nww.nhscomparators.nhs.uk wcc.networks.nhs.uk/healthinvestment