1. NHS West Kent PCT Health investment slide pack July 2010 QIPP Right Care

2. 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. QIPP Right Care 33 Overview These slides use Programme Budgeting tools to show that, compared to similar PCTs, West Kent has; Average expenditure on Respiratory problems High rate of mortality from COPD Below average prescription expenditure on Respiratory problems High reported prevalence of COPD and a high ratio of reported to expected prevalence of COPD Below above average flu vaccinations for patients with COPD Spend of £500,000 more than the national average for inpatient admissions for Respiratory problems adjusting for age, sex and need of population

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 – West Kent PCT

9. QIPP Right Care 9 Programme Budgeting Spreadsheet – Expenditure per 100,000 population (weighted by age, sex and need) West Kent PCT has average spend on Respiratory compared to PCTs nationally adjusting for age, sex and need of population

10. QIPP Right Care 10 2008/2009 Programme Budgeting Spreadsheet – Respiratory Expenditure per 100,000 population (weighted by age, sex and need) Green circle shows West Kent PCT has average expenditure on Respiratory both nationally (blue diamonds) and when compared to similar PCTs (purple 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 2008/2009 APHO Spend and Outcomes Tool – Each diamond represents a disease category and shows spend and outcomes compared to the national average West Kent PCT has average spend and better outcome for Respiratory compared to PCTs nationally Mortality from bronchitis, emphysema, COPD

13. QIPP Right Care 13 2008/2009 APHO ONS Cluster Average – Each diamond represents a disease category and shows spend and outcomes compared to the cluster average West Kent PCT has average spend and worse outcome for Respiratory compared to similar PCTs Mortality from bronchitis, emphysema, COPD

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 Mortality from bronchitis, emphysema and other COPD: Directly age-standardised rate per 100,000 population, all ages, all persons 2005-2007 West Kent PCT has the highest mortality rate from bronchitis, emphysema and other COPD when compared to similar PCTs

16. QIPP Right Care 16 FHS prescription expenditure: Respiratory system: Thousand pounds per 100,000 unified weighted population, 2007/2008 West Kent PCT has below average FHS prescribing expenditure on Respiratory compared to similar PCTs

17. QIPP Right Care 17 Prevalence of COPD (QOF), Percent, all ages, 2007/2008 West Kent PCT has high reported prevalence of COPD compared to similar PCTs

18. QIPP Right Care 18 Fev1 checks for patients with COPD (QOF), Percent, all ages, 2007/2008 West Kent PCT has a high rate of Fev1 checks for patients with COPD compared to similar PCTs

19. QIPP Right Care 19 Vaccinations against influenza for patients with COPD (QOF); Percent, all ages, 2007/2008 West Kent PCT has below above average flu vaccinations for patients with COPD compared to similar PCTs

20. QIPP Right Care 20 Emergency readmission to hospital within 28 days of discharge: Respiratory system. Admissions excluding day cases, indirectly age- standardised percent, all ages. 2007/2008 West Kent PCT has a high rate of emergency readmissions for Respiratory problems when compared to similar PCTs

21. QIPP Right Care 21 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

22. QIPP Right Care 22 NHS Comparators – Expenditure on Respiratory emergency admissions – Comparison with similar PCTs West Kent PCT have an average expenditure on Respiratory emergency admissions compared to similar PCTs

23. QIPP Right Care 23 NHS Comparators – Expenditure on Obstructive Airways Disease emergency admissions – Comparison with similar PCTs West Kent PCT has high expenditure on Obstructive Airways Disease emergency admissions compared to similar PCTs

24. QIPP Right Care 24 West Kent PCT has a large variation at GP practice level for expenditure on Respiratory emergency admissions Easy to identify high and low spending practices. Can compare practices within groups based on need of population NHS Comparators – Expenditure on Respiratory emergency admissions – GP Practice level

25. QIPP Right Care 25 NHS Comparators – COPD Reported vs Expected Prevalence – Comparison with similar PCTs West Kent PCT has a high ratio of reported to expected prevalence of COPD compared to similar PCTs

26. QIPP Right Care 26 NHS Comparators – Breakdown of Actual and Expected Expenditure on admissions by Programme Budget or Disease Category for Barking & Dagenham PCT – 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 West Kent PCT – Also available for FHS Prescribing expenditure

27. QIPP Right Care 27 Inpatient Variation Expenditure Tool (IVET) The tool provides PCTs with: inpatient expenditure data (2008/9) 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

28. QIPP Right Care 28 IVET: PCT inpatient expenditure above or below the benchmark for diseases in 2008-09. West Kent PCT spend £500,000 more than the national average on Respiratory inpatient admissions adjusting for age, sex and need of population

29. QIPP Right Care 29 IVET: PCT inpatient expenditure for selected disease/intervention compared to a user defined benchmark. The Inpatient Variation Tool allows PCTs to select a high cost disease or procedure, choose a benchmark level (e.g. median, lowest 10%) and view potential savings.

30. QIPP Right Care 30 Conclusion These slides used Programme Budgeting tools to show that, compared to similar PCTs, West Kent has; Average expenditure on Respiratory problems High rate of mortality from COPD Below average prescription expenditure on Respiratory problems High reported prevalence of COPD and a high ratio of reported to expected prevalence of COPD Below above average flu vaccinations for patients with COPD Spend of £500,000 more than the national average for inpatient admissions for Respiratory problems adjusting for age, sex and need of population

31. QIPP Right Care 31 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 31