QIPP Right Care
NHS Sheffield
Health Investment slide pack
July 2010
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
About this health investment pack
QIPP Right Care
• 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
2
Overview
QIPP Right Care
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
3
What is Programme Budgeting?
QIPP Right Care
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.
4
What is Programme Budgeting?
QIPP Right Care
23 Programme Budgeting Categories
1
2
3
4
5
6
7
8
9
10
11
12
13
Infectious Diseases
Cancers & Tumours
Blood Disorders
Endocrine, Nutritional and Metabolic
Problems
Mental Health Problems
Learning Disability Problems
Neurological System Problems
Eye/Vision Problems
Hearing Problems
Circulation Problems (CVD)
Respiratory System Problems
Dental Problems
Gastro Intestinal System Problems
14 Skin Problems
15 Musculo Skeletal System Problems
(excludes Trauma)
16 Trauma & Injuries
17 Genito Urinary System Disorders
(except infertility)
18 Maternity & Reproductive Health
19 Neonates
20 Poisoning
21 Healthy Individuals
22 Social Care Needs
23 Other Conditions
5
QIPP Right Care
Programme Level Expenditure: 2007/08 - 2008/09
6
Information Available for PCTs
QIPP Right Care
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.
7
Programme Budgeting Spreadsheet: Sheffield PCT Expenditure
Sheffield PCT
QIPP Right Care
Expenditure on own population (£000s)
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
All
Programme Budgeting Category
Infectious Diseases
Cancers and Tumours
Disorders of Blood
Endocrine, Nutritional and Metabolic
Mental Health Disorders
Problems of Learning Disability
Neurological
Problems of Vision
Problems of Hearing
Problems of Circulation
Problems of the Respiratory System
Dental Problems
Problems of Gastro Intestinal System
Problems of the Skin
Problems of Musculo Skeletal System
Problems due to Trauma and Injuries
Problems of Genito Urinary System
Maternity and Reproductive Health
Conditions of Neonates
Adverse effects and poisoning
Healthy Individuals
Social Care Needs
Other
Total
2006-07
10,059
48,417
9,982
19,014
103,896
22,304
30,146
14,947
4,033
66,317
36,935
35,690
41,466
16,886
31,441
31,664
33,113
24,882
6,742
5,537
11,472
18,082
134,678
757,703
2007-08
11,177
46,630
11,519
20,820
116,415
23,745
34,151
17,526
4,701
69,092
43,121
39,146
44,843
17,889
36,525
33,135
37,549
31,364
8,048
7,358
19,198
11,279
135,047
820,278
2008-09
11,194
50,732
11,641
22,348
118,091
22,586
37,347
18,898
4,809
73,444
51,989
41,981
47,643
18,683
39,005
32,873
42,947
30,447
7,898
8,503
17,294
11,745
156,211
878,309
% change from
2007-08
0%
9%
1%
7%
1%
-5%
9%
8%
2%
6%
21%
7%
6%
4%
7%
-1%
14%
-3%
-2%
16%
-10%
4%
16%
7%
8
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
Sheffield PCT
PCT Selected
Selected Cluster details
Population (as per Allocations)
QIPP Right Care
Dist from Target £'000 (Under/Over)
Dist from Target % (Under/Over)
1 SUPER (7 groups)
Cities and Services
2006/07
2007/08
2008/09
543,960
543,775
549,402
29,923
4.32%
30,704
4.08%
32,381
4.08%
EXPENDITURE ON OWN POPULATION
£ per 100,000 population
Programme Budgeting Category
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
23
Social Care Needs
Other
3,324,140
24,758,794
41
30
2,074,202
24,835,075
103
53
2,137,780
28,432,934
100
19
3%
14%
All
Total
139,293,818
150,848,712
159,866,474
6%
9
QIPP Right Care
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)
10
QIPP Right Care
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.
11
QIPP Right Care
[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.
Patients on
enhanced
CPA receiving
early FU
Mortality from all
cancers: Under 75s
Mortality
from
bronchitis,
emphysema,
COPD
Mortality from
all circulatory
diseases:
Under 75s
12
QIPP Right Care
[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.
Patients on
enhanced
CPA receiving
early FU
Mortality from all
cancers: Under 75s
Mortality
from
bronchitis,
emphysema,
COPD
Mortality from
all circulatory
diseases:
Under 75s
13
Summary of DH PB Expenditure and SPOT data
•
Expenditure Budget Spreadsheet
–
QIPP Right Care
•
Rank
–
•
In 2006/07 its spend was 59th across England, in 2008/09 it was 11th;
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.
14
QIPP Right Care
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
15
Programme Budgeting Atlases (2)
QIPP Right Care
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;
16
QIPP Right Care
[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.
17
QIPP Right Care
[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
18
QIPP Right Care
[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
19
QIPP Right Care
[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.
20
QIPP Right Care
[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)
21
QIPP Right Care
[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
22
QIPP Right Care
[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
23
QIPP Right Care
[2007/08] Programme Budget Atlas – Prevalence of COPD (QOF); Percent, all
ages, Sheffield PCT has an above average prevalence of COPD
24
QIPP Right Care
[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
25
QIPP Right Care
[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
26
QIPP Right Care
[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
27
QIPP Right Care
[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
28
QIPP Right Care
[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
29
QIPP Right Care
[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
30
QIPP Right Care
[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)
31
QIPP Right Care
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
32
NHS Comparators
QIPP Right Care
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
QIPP Right Care
[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
34
QIPP Right Care
[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
35
QIPP Right Care
[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
36
QIPP Right Care
[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
37
QIPP Right Care
[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
38
QIPP Right Care
[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
39
QIPP Right Care
[2008/09] NHS Comparators – Includes FHS Prescribing data
(volume and cost of prescriptions) – Sheffield PCT has an average
proportion of low cost Statins
40
QIPP Right Care
[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.
41
ONS Cluster Variation
QIPP Right Care
• 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.
42
QIPP Right Care
[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
43
QIPP Right Care
[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
44
QIPP Right Care
[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
45
Conclusion
QIPP Right Care
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
46
QIPP Right Care
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
47