1. Programme Budgeting Dawn Godber Commissioning and System Management Directorate

2. Definitions Programme Budgeting: a retrospective appraisal of resource allocation broken down into ‘programmes’ - with a view to influencing and tracking future expenditure in those same programmes. Marginal Analysis: an appraisal of the added costs and added benefits when the resources in programmes are increased, or deployed in new ways. Do the benefits outweigh the costs?

3. NHS Constitution Principles That Guide The NHS. Number 6 - The NHS is committed to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources. Public funds for healthcare will be devoted solely to the benefit of the people that the NHS serves.

4. World Class Commissioning Purpose of World Class Commissioning is to Add Life to Years and Years to Life Programme Budgeting features in the following two of the 11 WCC commissioning Competencies 6 – Prioritise Investment 11 – Make Sound Financial Decisions

5. Investing in Health How do we know that we are ‘maximising years to life and life to years’, at the same time as providing ‘best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources’ How do we know whether we are investing in health? Programme Budgeting provides a framework to help commissioners make and evaluate health investment decisions.

6. From Consumer Intelligence….. Do you know how much you spent on electricity last year? Do you know what activities are driving your electricity expenditure? Can you identify ways in which you can save money…. ….and maintain or improve the level of benefit obtained from having electricity at the same time? How would you decide how to spend the money that you have saved? What sources of intelligence are available to help you with these decisions?

7. ..to Commissioning Intelligence Do you know what you spent on CVD last year? Do you know what activities are driving your CVD expenditure? Can you identify ways in which you can save money…. ….at the same time as maintaining or improving the level of benefit obtained? How would you decide what to spend the money that you have saved? What sources of intelligence are available to help you with these decisions?

8. Programme Budgeting in a nutshell…. Programme Budgeting…. –Tells us what we are spending –Allows us to look at how we are spending it –Lets us see what we are getting for the money we are spending…..

9. How spend data is calculated PCTs already know what they are spending from their annual accounts; But how do they split this expenditure into ‘programmes’ –Providers supply PCTs with expenditure data split by ‘programme’ –The Business Services Authority supplies PCTs with prescribing data by ‘programme’ –PCTs analyse their own data for community care –GMS / PMS expenditure goes to category 23 – other. So what is a ‘programme’?

10. 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 23 Programme Budgeting Categories

11. Which is the biggest Programme? The top three Programmes in no particular order are: Cancer, CVD, and Mental Health. But which is the biggest?

12. Programme Budgeting Category 2006-07 Max/Min 2007-08 Max/Min 2006-07 COV2007-08 COV 01Infectious Diseases 13.522.50.810.87 02Cancers and Tumours 2.53.30.160.18 03Disorders of Blood 6.19.20.330.35 04Endocrine, Nutritional and Metabolic 4.73.20.170.16 05Mental Health Disorders 3.72.90.250.22 06Problems of Learning Disability 16.829.20.33 07Neurological 3.03.50.210.19 08Problems of Vision 6.23.60.260.21 09Problems of Hearing 8.712.00.41 10Problems of Circulation 2.33.60.150.17 11Problems of the Respiratory System 2.82.60.16 12Dental Problems 12.54.00.230.18 13Problems of Gastro Intestinal System 2.63.00.170.18 14Problems of the Skin 2.82.90.220.21 15Problems of Musculo Skeletal System Not Available3.60.280.23 16Problems due to Trauma and Injuries 5.223.00.250.28 17Problems of Genito Urinary System 3.34.50.210.19 18Maternity and Reproductive Health 4.35.30.26 19Conditions of Neonates 51.363.50.480.49 20Adverse effects and poisoning 3.55.40.240.26 21Healthy Individuals 19.915.40.550.45 22Social Care Needs Not Available2,176.41.641.52 23Other 4.54.40.290.26

13. What we Publish (Spend) From 29 October four years worth of benchmarking expenditure data published on DH website: 2003/04 2004/05 2005/06 2006/07 As you’ve seen – the 2007-08 data are in – we are just checking them. Data published on an interactive spreadsheet in terms of levels and changes. Data presented in terms of spend per 100,000 (weighted/unweighted) population. Possible to adjust to take account of distance from target. Spreadsheet enables PCTs to benchmark themselves against PCTs locally or PCTs with similar characteristics. Also publish data for Cancer and CVD networks Data are all available to the General Public. And the press. And the HSJ.

14. BBC News, 8 September 2008

15. Next Steps Expenditure Longer term next steps include: - age specific data? - prevention spend per programme? - expenditure estimates based on tariff not cost? - audited PCT returns?

16. NHS Comparators NHS Comparators can provide data more frequently and at a practice as well as PCT level; Working closely with the NHS comparators team to provide - inpatient admissions / alos / beddays; - outpatient attendances; - FHS prescribing. Also planning to multiplying inpatients and outpatient activity by tariff to provide estimated expenditure. FHS prescribing expenditure data will also be made available at the same level.

17. NHS Comparators

25. Programme Budgeting Atlas Programme Budgeting Atlas brings together Expenditure and Outcomes Data per Programme. Outcomes data are compiled by the National Centre for Health Outcomes Development (NCHOD) Data Published (July ‘06) for Top 6 Programme Budgeting Categories in expenditure terms. Additional Atlases giving 15 in total published December ‘06. New 152 PCT Atlases published October 2008

26. Health Atlas Next Steps Final 303 PCT complete including 2005/6 QOF data. These atlases will then be archived but will remain accessible. 2006/7 atlases on the basis of 152 PCTs also now available. Still looking to include ‘predicted prevalence’ indicators. - uses work from the Public Health Observatories; will allow comparison of recorded (through QOF) prevalence with predicted prevalence – an indicator of unmet need; - in addition predicted prevalence indicators are forward looking through to 2020.

27. Liverpool PCT Cancer Mortality

28. Liverpool PCT – Cancer Incidence

29. Cancer – Incidence vs Mortality

30. YLL Cancer – Liverpool PCT

31. Liverpool PCT – QOF Data Cancer Prevalence

32. Liverpool PCT 2006/7 Cancer Expenditure

33. Liverpool PCT – Cancer FHS Prescribing

34. Cancer – All Admissions

35. Liverpool PCT Cancer Electives

36. Liverpool PCT Cancer Non-Electives – High - But Much Lower Rate – 1 in 6 Cancer Admissions in Liverpool Non-Elective

37. Liverpool PCT Cancer – Elective ALOS

38. Liverpool PCT QOF Data Women With Smear Test

39. Smoking Prevalence

40. Smoking Cessation Advice

41. Recent Articles on Programme Budgeting Ruta D, Mitton C, Bate A, Donaldson C. Programme budgeting and marginal analysis: bridging the divide between doctors and managers. BMJ 2005;330:1501-3 Gray J.A.M. Better value healthcare. Offox Press. Oxford 2006 Jackson A, Brambleby P, Young C. Putting health spending on the map. Health Finance, Dec 2006, p 11-13 Brambleby P, Jackson A, Gray AJM. Better allocation for better health and healthcare. Annual Population Value Review, NHS National Knowledge Service & Commissioning Directorate, DH, Feb 2007, available from: rosemary.lees@dphpc.ox.ac.uk

42. Information/Guidance Website address – Department of Health: http://www.dh.gov.uk/programmebudgeting Or type ‘Programme Budgeting’ into Google! NHS website – Programme Budgeting Atlas: nww.nchod.nhs.uk (N.B. nww prefix not www) Atlases Require Users to Download SVG Viewer Software