1. NHS Eastern and Coastal Kent Health investment slide pack July 2010 QIPP Right Care

2. 2 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. 3 Summary These slides use Programme Budgeting tools to show that Eastern and Coastal Kent PCT has; Increased expenditure on Respiratory problems in the last three years but relatively low inpatient spend High Mortality rates from COPD Low Prescribing expenditure on Respiratory system problems High Prevalence of COPD in QOF High Non elective admissions with low spell length of stay Large variations in Respiratory admissions at practice level.

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. 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. 6 2007/08 and 2008/09 Programme Level Expenditure for England

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. 8 Programme Budgeting Spreadsheet – Eastern and Coastal Kent PCT

9. 9 2008-09 Programme Budgeting Spreadsheet –Expenditure per 100,000 population (weighted by age, sex and need) Eastern and Coastal Kent PCT has a high rank nationally for Learning Disability problems. Respiratory system problems ranking has increased from 107 to 69 since 2006/07

10. 10 2008/2009 Programme Budgeting Spreadsheet –Expenditure per 100,000 population (weighted by age, sex and need) Green circle shows Eastern and Coastal Kent PCT having a above average ranking for expenditure on Respiratory problems both nationally (blue diamonds), and compared to similar PCTs (purple triangles)

11. 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. 12 2008/2009 APHO ONS Cluster Average – Each diamond represents a disease category and shows spend and outcomes compared to the ONS Cluster group Eastern and Coastal Kent PCT has higher than average spend and a worse outcome for Respiratory problems when compared to PCTs within the same cluster. Mortality from bronchitis Under 75s

13. 13 Programme Budgeting Atlases Provided on our behalf by the National Centre for Health Outcomes Development, under contract to the NHS Information Centre. 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

14. 14 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 2005-2007 filtered by PCT relevant ONS cluster 2007/2008 Eastern and Coastal Kent PCT has a high rate of years of life lost due to mortality from bronchitis, emphysema and other COPD rate when compared to similar PCTs (Prospering Smaller Towns)

15. 15 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 2005-2007 filtered by SHA 2007/2008 Eastern and Coastal Kent PCT high rate of years of life lost due to mortality from bronchitis, emphysema and other COPD rate when compared to PCTs in South East coast SHA

16. 16 FHS Prescription expenditure: Respiratory system per 100,000 population (weighted for age, sex and need) FY 2007/8 filtered by PCT relevant ONS cluster 2007/2008 Eastern and Coastal Kent PCT has a low FHS prescription expenditure when compared to PCTs (Prospering Smaller Towns)

17. 17 FHS Prescription Volume: Respiratory system per 100,000 population (weighted for age, sex and need) FY 2007/8 filtered by PCT relevant ONS cluster 2007/2008 Eastern and Coastal Kent PCT has a low FHS prescription volume when compared to similar PCTs (Prospering Smaller Towns)

18. 18 Prevalence of COPD (QOF); Percent, all ages: FY 2007/8 filtered by PCT relevant ONS cluster 2007/2008 Eastern and Coastal Kent PCT has an above average prevalence of COPD when compared to similar PCTs (Prospering Smaller Towns)

19. 19 Prevalence of COPD (QOF); Percent, all ages: FY 2007/8 filtered by SHA 2007/2008 Eastern and Coastal Kent PCT has an above average prevalence of COPD when compared to PCTs in South East coast SHA

20. 20 Fev1 checks for patients with COPD (QOF); Percent, all ages, FY 2007/8 filtered by PCT relevant ONS cluster 2007/2008 Eastern and Coastal Kent PCT has a slightly above average number of Fev1 checks for patients with COPD when compared to similar PCTs (Prospering Smaller Towns)

21. 21 Fev1 checks for patients with COPD (QOF); Percent, all ages, FY 2007/8 filtered by SHA 2007/2008 Eastern and Coastal Kent PCT has a high number of Fev1 checks for patients with COPD when compared to PCTs within South East Coast SHA

22. 22 Vaccination against influenza for patients with COPD (QOF) Patients all ages, FY 2007/8 filtered by PCT relevant ONS cluster 2007/2008 Eastern and Coastal Kent PCT has a below average number of vaccinations against Influenza for patients with COPD when compared to similar PCTs (Prospering Smaller Towns)

23. 23 Hospitalisation: Respiratory system problems. All elective admissions, indirectly age-standardised rate per 100,000 population, all ages, FY 2007/2008 filtered by PCT relevant ONS cluster 2007/2008 Eastern and Coastal Kent PCT has an average number of elective admissions when compared to similar PCTs (Prospering Smaller Towns)

24. 24 Hospitalisation: Respiratory system problems. All elective admissions, indirectly age-standardised rate per 100,000 population, all ages, FY 2007/2008 filtered by SHA 2007/2008 Eastern and Coastal Kent PCT has a below average number of elective admissions when compared to PCTs in South East coast SHA

25. 25 Hospitalisation: Respiratory system problems. All Non-elective admissions, indirectly age-standardised rate per 100,000 population, all ages FY 2007/2008 filtered by PCT relevant ONS cluster 2007/2008 Eastern and Coastal Kent PCT has an above average number of Non elective admissions when compared to similar PCTs (Prospering Smaller Towns)

26. 26 Hospitalisation: Respiratory system problems. All Non-elective admissions, indirectly age-standardised rate per 100,000 population, all ages FY 2007/2008 filtered by SHA 2007/2008 Eastern and Coastal Kent PCT has an above average number of Non elective admissions when compared to PCTs in South East coast SHA

27. 27 Spell length of stay: Respiratory system problems. Non-Elective admissions, indirectly age-standardised geometric mean LOS (days) per spell, all ages FY 2007/2008 filtered by PCT relevant ONS cluster 2007/2008 Eastern and Coastal Kent PCT has a low spell length of stay for Non-elective admissions when compared to similar PCTs (Prospering Smaller Towns)

28. 28 Spell length of stay: Respiratory system problems. Non-Elective admissions, indirectly age-standardised geometric mean LOS (days) per spell, all ages FY 2007/2008 filtered by SHA 2007/2008 Eastern and Coastal Kent PCT has a low spell length of stay for Non-elective admissions when compared to PCTs in South East Coast SHA

29. 29 Emergency readmission to hospital within 28 days of discharge: Respiratory system. Admissions excluding day cases, indirectly age- standardised percent, all ages. FY 2007/2008 filtered by PCT relevant ONS cluster 2007/2008 Eastern and Coastal Kent PCT has an average number of emergency readmissions to hospital when compared to similar PCTs (Prospering Smaller Towns)

30. 30 Emergency readmission to hospital within 28 days of discharge: Respiratory system. Admissions excluding day cases, indirectly age- standardised percent, all ages. FY 2007/2008 filtered by SHA 2007/2008 Eastern and Coastal Kent PCT has an average number of emergency readmissions to hospital when compared to PCTs in South East Coast SHA

31. 31 Scatter plot: Prevalence of COPD (QOF) All ages FY 2007/08 VS Years of life lost due to mortality from Emphysema, Bronchitis and Other COPD filtered by PCT relevant ONS cluster 2005-2007 Eastern and Coastal Kent PCT has a higher mortality rate than most similar PCTs with the same Prevalence of COPD (Prospering Smaller Towns)

32. 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

33. 33 NHS Comparators - Expenditure on all admissions covered by PBR tariff (age and sex adjusted rate) - Comparison with other PCTs Drill down to disease level Table shows activity, expected activity based on national averages, and the resulting % difference, for PCT and SHA 2009/2010 Quarter 1-3: Eastern and Coastal Kent PCT is below the national average for total Respiratory admissions (adjusted for age and sex)

34. 34 2009/10 Quarter 1 NHS Comparators – GP Practice Level Comparison of Expenditure on Problems of Respiratory Admissions Easy to identify high and low spending practices. Can compare practices within groups based on need of population 2009/10 Quarter 1: Eastern and Coastal Kent PCT has a large variation in Respiratory admissions at practice level.

35. 35 NHS Comparators - Quarterly Time Series of Outpatient First Attendances Since 2006/07 Eastern and Coastal Kent PCT has a consistently higher spend on Thoracic medicine outpatient first attendances compared to PCTs within South East Coast SHA

36. 36 2008/09 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 – Also available for FHS Prescribing Expenditure.

37. 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

38. 38 IVET: PCT inpatient expenditure above or below the benchmark for diseases in 2008-09. Eastern and coastal Kent PCT spent £2 million less on Respiratory inpatient procedures than the national average (adjusted for age, sex and needs) Further diseases and interventions will be added subsequent to feedback from PCTs

39. IVET: PCT inpatient expenditure above or below the benchmark for Respiratory diseases and interventions in 2008-09. Eastern and Coastal Kent PCT spend £2 million less than the National Average on Respiratory inpatients and £0.5 million more than the national average on HRG D99

40. 40 IVET: Eastern and Coastal Kent PCT inpatient expenditure for selected disease/intervention compared to a user defined benchmark. Eastern and Coastal Kent are spending below the national average on Respiratory Inpatients compared to PCTs Nationally.

41. 41 Conclusion We have used Programme Budgeting tools to show that Eastern and Coastal Kent PCT has; Increased expenditure on Respiratory problems in the last three years but relatively low inpatient spend High Mortality rates from COPD Low Prescribing expenditure on Respiratory system problems High Prevalence of COPD in QOF High Non elective admissions with low spell length of stay for Respiratory problems Large variations in Respiratory admissions at practice level.

42. 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 42