July 2010

NHS Sheffield Health Investment slide pack

QIPP Right Care

Important: Please note this health investment slide pack may differ from other SHA’s as it was created as part of the initial pilot scheme

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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

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Overview

We will:-

• Examine DH Programme Budget Spreadsheet and SPOT • Identify a programme area to review in more depth

• Explore this programme area in the Programme Budget Atlases and NHS Comparators

• Develop a clearer picture of areas for further investigation

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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.

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23 Programme Budgeting Categories

1 Infectious Diseases2 Cancers & Tumours3 Blood Disorders4 Endocrine, Nutritional and Metabolic

Problems5 Mental Health Problems6 Learning Disability Problems7 Neurological System Problems8 Eye/Vision Problems9 Hearing Problems10 Circulation Problems (CVD)11 Respiratory System Problems12 Dental Problems13 Gastro Intestinal System Problems

14 Skin Problems15 Musculo Skeletal System Problems

(excludes Trauma)16 Trauma & Injuries17 Genito Urinary System Disorders

(except infertility)18 Maternity & Reproductive Health19 Neonates20 Poisoning21 Healthy Individuals22 Social Care Needs23 Other Conditions

What is Programme Budgeting?

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Programme Level Expenditure: 2007/08 - 2008/09

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Information Available for PCTs

This pack will provide an update on the products available to commissioners including:

• Programme Budgeting Spreadsheet;• Spend & Outcome Tool (SPOT);• 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.

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Programme Budgeting Spreadsheet: Sheffield PCT Expenditure

2006-07 2007-08 2008-09% change from

2007-08

01 Infectious Diseases 10,059 11,177 11,194 0%02 Cancers and Tumours 48,417 46,630 50,732 9%03 Disorders of Blood 9,982 11,519 11,641 1%04 Endocrine, Nutritional and Metabolic 19,014 20,820 22,348 7%05 Mental Health Disorders 103,896 116,415 118,091 1%06 Problems of Learning Disability 22,304 23,745 22,586 -5%07 Neurological 30,146 34,151 37,347 9%08 Problems of Vision 14,947 17,526 18,898 8%09 Problems of Hearing 4,033 4,701 4,809 2%10 Problems of Circulation 66,317 69,092 73,444 6%11 Problems of the Respiratory System 36,935 43,121 51,989 21%12 Dental Problems 35,690 39,146 41,981 7%13 Problems of Gastro Intestinal System 41,466 44,843 47,643 6%14 Problems of the Skin 16,886 17,889 18,683 4%15 Problems of Musculo Skeletal System 31,441 36,525 39,005 7%16 Problems due to Trauma and Injuries 31,664 33,135 32,873 -1%17 Problems of Genito Urinary System 33,113 37,549 42,947 14%18 Maternity and Reproductive Health 24,882 31,364 30,447 -3%19 Conditions of Neonates 6,742 8,048 7,898 -2%20 Adverse effects and poisoning 5,537 7,358 8,503 16%21 Healthy Individuals 11,472 19,198 17,294 -10%22 Social Care Needs 18,082 11,279 11,745 4%23 Other 134,678 135,047 156,211 16%All Total 757,703 820,278 878,309 7%

Programme Budgeting Category

Expenditure on own population (£000s)

Sheffield PCT

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Programme Budgeting Spreadsheet – Sheffield PCT Expenditure per 100,000 population (weighted by age, sex and need) – 2008/9 rank column shows PCT is a high spender on Respiratory and Dental categories

PCT Selected

Selected Cluster details

Population (as per Allocations)

Dist from Target £'000 (Under/ Over)Dist from Target % (Under/ Over)

2006-07 Rank 2007-08 Rank 2008-09 Rank % Change

01 Infectious Diseases 1,849,216 67 2,055,445 50 2,037,489 61 -1%

02 Cancers and Tumours 8,900,834 34 8,575,234 86 9,234,046 86 8%

03 Disorders of Blood 1,835,061 58 2,118,338 54 2,118,851 53 0%

04 Endocrine, Nutritional and Metabolic 3,495,476 91 3,828,788 82 4,067,698 96 6%

05 Mental Health Disorders 19,099,925 29 21,408,660 26 21,494,476 34 0%

06 Problems of Learning Disability 4,100,300 99 4,366,694 115 4,111,018 120 -6%

07 Neurological 5,541,949 66 6,280,352 73 6,797,759 67 8%

08 Problems of Vision 2,747,811 67 3,223,023 57 3,439,742 56 7%

09 Problems of Hearing 741,414 46 864,512 60 875,316 66 1%

10 Problems of Circulation 12,191,516 70 12,705,984 68 13,367,998 55 5%

11 Problems of the Respiratory System 6,790,018 59 7,929,930 24 9,462,841 11 19%

12 Dental Problems 6,561,141 17 7,198,930 20 7,641,222 16 6%

13 Problems of Gastro Intestinal System 7,622,984 57 8,246,605 45 8,671,798 32 5%

14 Problems of the Skin 3,104,271 40 3,289,778 42 3,400,609 52 3%

15 Problems of Musculo Skeletal System 5,780,018 108 6,716,929 103 7,099,542 102 6%

16 Problems due to Trauma and Injuries 5,821,014 69 6,093,510 49 5,983,419 80 -2%

17 Problems of Genito Urinary System 6,087,393 104 6,905,242 66 7,817,050 45 13%

18 Maternity and Reproductive Health 4,574,231 124 5,767,824 79 5,541,848 104 -4%

19 Conditions of Neonates 1,239,429 92 1,480,023 77 1,437,564 101 -3%

20 Adverse effects and poisoning 1,017,905 140 1,353,132 113 1,547,684 109 14%

21 Healthy Individuals 2,108,978 94 3,530,503 49 3,147,788 87 -11%

22 Social Care Needs 3,324,140 41 2,074,202 103 2,137,780 100 3%

23 Other 24,758,794 30 24,835,075 53 28,432,934 19 14%

All Total 139,293,818 150,848,712 159,866,474 6%

Sheffield PCT

Cities and Services1 SUPER (7 groups)

543,960 543,775 549,402

29,923 30,704 32,381

2008/ 09

4.08%

Programme Budgeting Category

4.32% 4.08%

£ per 100,000 population

EXPENDITURE ON OWN POPULATION

2006/ 07 2007/ 08

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Programme Budgeting Spreadsheet – Sheffield PCT Expenditure per 100,000 population (weighted by age, sex and need) on Respiratory Systems category – Green circle shows that the PCT has a high spend compared to most PCTs, both nationally (blue diamonds), and in similar PCT cluster (purple triangles)

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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.

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[2008/09] Each diamond represents a disease category and shows spend and outcomes compared to the national average – In Sheffield PCT Respiratory and Circulation have a higher spend with worse outcome when compared to other PCTs nationally.

Mortality from all circulatory diseases: Under 75s

Mortality from all cancers: Under 75s

Patients on enhanced CPA receiving early FU

Mortality from bronchitis, emphysema, COPD

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[2007/08] Each diamond represents a disease category and shows spend and outcomes compared to the national average – In Sheffield PCT Respiratory has a higher spend with worse outcome when compared to other PCTs nationally.

Mortality from all circulatory diseases: Under 75s

Mortality from all cancers: Under 75s

Patients on enhanced CPA receiving early FU

Mortality from bronchitis, emphysema, COPD

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Summary of DH PB Expenditure and SPOT data

• Expenditure Budget Spreadsheet– In 2006/07 its spend was 59th across England, in 2008/09 it was 11th;

• Rank– Sheffield was the 3rd highest spender on Respiratory systems in 2008/09 within its own ONS

cluster type;

• SPOT– Respiratory appears in the Higher Spend/Worse Outcome quadrant in both 2007/08 and

2008/09 data sets;

• The following slides will now look at Respiratory in more depth for Sheffield PCT.

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Programme Budgeting Atlases (1)

• 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

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Programme Budgeting Atlases (2)

Atlases include a vast array of data configured in terms of:

Expenditure Data.• Expenditure per 100,000 population (weighted for age, sex and need) • Expenditure per 100,000 population (weighted for age, sex and need) filtered by ONS Cluster• Expenditure per 100,000 population (weighted for age, sex and need) filtered by SHA

Output Data• Primary care prescribing – number of items and expenditure;• Admissions/ALOS/Beddays (total, non-elective, elective ordinary, daycase); • Day case rates.• Prescription expenditure• Prescription Volume

Outcome Data

• Expenditure on Respiratory Family health services prescribing per 100,000 population• Prevalence data from QOF;• Emergency readmissions data;

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[2007/08] Programme Budget Atlas – Respiratory Systems Expenditure per 100,000 population (weighted for age, sex and need) – Darker areas represent higher spend – Sheffield spend is above average.

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[2007/08] Programme Budget Atlas - Respiratory Expenditure per 100,000 population (weighted for age, sex and need) filtered by ONS Cluster (Regional Centres) – Darker areas represent higher spend – Sheffield is above average compared to similar PCTs

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[2007/08] Programme Budget Atlas – Respiratory per 100,000 population (weighted for age, sex and need) filtered by SHA – Darker areas represent higher spend – Sheffield has an above average spend within the Yorkshire & Humber SHA

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[2007/08] Programme Budget Atlas – Respiratory Mortality data - Years of life lost under 75 years per 10,000 population (weighted for age, sex and need) – Darker areas represent more years of life lost – Sheffield is about average nationally.

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[2007/08] Programme Budget Atlas – Scatterplot shows Respiratory Expenditure and Mortality data from previous slides on the same graph – Sheffield (highlighted by blue dot) has a high spend (vertical axis) and an average mortality (horizontal axis) – PCTs can use the chart to identify PCTs with good outcomes (and can filter by SHA and ONS

similar PCT cluster)

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[2007/08] Programme Budget Atlas – Expenditure on Respiratory Family Health Services Prescribing per 100,000 population (weighted for age, sex and need) SHA – Darker areas represent higher spend – Sheffield PCT spend is about average

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[2007/08] Programme Budget Atlas – Prescribing Volume on Respiratory Family Health Services per 100,000 population (weighted for age, sex and need) SHA – Darker areas represent higher spend – Sheffield PCT volume is above average nationally

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[2007/08] Programme Budget Atlas – Prevalence of COPD (QOF); Percent, all ages, Sheffield PCT has an above average prevalence of COPD

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[2007/08] Programme Budget Atlas – Fev1 checks for patients with COPD (QOF); Percent, all ages – Sheffield PCT has a low level of checks for patients with COPD

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[2007/08] Programme Budget Atlas – Vaccination against influenza for patients with COPD (QOF) Patients all ages – Sheffield PCT has an average rate of vaccination against influenza for patients with COPD

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[2007/08] Programme Budget Atlas – Respiratory Elective Hospital Admissions per 100,000 population (weighted for age, sex and need) – Darker areas represent higher number of admissions – Sheffield PCT has a higher number of Elective Admissions than the national average

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[2007/08] Programme Budget Atlas – Respiratory Non-Elective Hospital Admissions per 100,000 population (weighted for age, sex and need) – Darker areas represent higher number of admissions – Sheffield PCT has a high number of Non-Elective Admissions

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[2007/08] Programme Budget Atlas – Respiratory Non-Elective Average Length of Stay per spell in hospital – Darker areas represent higher LOS – Sheffield PCT has a very high average LOS for Non-Elective Admissions

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[2007/08] Programme Budget Atlas – Respiratory Emergency Readmissions to hospital within 28 days of discharge – Darker areas represent higher number of readmissions – Sheffield PCT has a high number of Respiratory Emergency Readmissions

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[2007/08] Programme Budget Atlas – Deaths within 30 days of admission for all respiratory system problems – Darker areas represent higher number of deaths – Sheffield PCT has an above average number of deaths (but there are very large confidence intervals so caution must be used when interpreting this data)

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2007/2008 Programme Budget Atlas – SCATTERPLOT – Vaccination against influenza for patients with COPD vs Hospitalisation: Respiratory system: Non elective admissions, Sheffield PCT has an above average number of patients hospitalised and an average number of patients vaccinated

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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

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[2008/09] NHS Comparators - Expenditure on all admissions covered by PBR tariff (age and sex adjusted rate) - Comparison with other PCTs – Sheffield has a higher expenditure than national average

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[2008/09] NHS Comparators – GP Practice Level Comparison of Expenditure on Respiratory Emergency Admissions – Large variation between spend at practice level in Sheffield PCT

Easy to identify high and low spending practices. Can compare practices within groups based on

need of population

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[2008/09] NHS Comparators – GP Practice Level Comparison of Average Length of Stay of Respiratory Emergency Admissions – Large variation at practice level in Sheffield PCT

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[2008/09] NHS Comparators - Quarterly Time Series of Sheffield PCT Expenditure on Emergency Admissions for Respiratory – The PCT admissions rate is higher than SHA and National average rate

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[2008/09] NHS Comparators - Managing variation in surgical thresholds – Expenditure at GP Practice level on the six Better Care Better Value procedures identified as low clinical value - Large variation at practice level in Sheffield PCT

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[2008/09] NHS Comparators - Quarterly Time Series of Sheffield PCT Outpatient First Attendances – The PCT rate is higher than SHA and National average rate – Breakdown by source of referral is also available

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[2008/09] NHS Comparators – Includes FHS Prescribing data (volume and cost of prescriptions) – Sheffield PCT has an average proportion of low cost Statins

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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.

[2008/09] NHS Comparators – Breakdown of Actual and Expected Expenditure on admissions by Programme Budget or Disease Category – Also available for FHS Prescribing Expenditure

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ONS Cluster Variation

• The following three slides demonstrate further ways of looking at variation within programme areas.

• The first slide shows total variation in expenditure by programme, compared with cluster comparator.

• The next two slides show quadrant charts comparing expenditure and outcome for the PCT compared with other PCTs in its cluster.

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[2008/09] Programme Budgeting Spreadsheet – Sheffield PCT Expenditure per 100,000 population (weighted by age, sex and need) on all categories compared to cluster average – Sheffield has a large variance on Other when compared with similar PCTs

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[2007/08] Each diamond represents a disease category and shows spend and outcomes compared to the ONS Cluster average – In Sheffield PCT Respiratory has higher spend with better outcome when compared to other PCTs in the same ONS Cluster, Mental Health has higher spend and worse outcome

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[2008/09] Each diamond represents a disease category and shows spend and outcomes compared to the ONS Cluster average – In Sheffield PCT Cancer and Circulation has higher spend with better outcome when compared to other PCTs in the same ONS Cluster

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Conclusion

We have:-

• Examined DH Programme Budget Spreadsheet and SPOT • Identified a programme area to review in more depth

• Explored this programme area in the Programme Budget Atlases and NHS Comparators

• Developed a clearer picture of areas for further investigation

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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

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