QIPP Right Care
NHS Cambridgeshire
Health investment slide pack
July 2010
QIPP Right Care
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
2
Cambridgeshire PCT Summary
QIPP Right Care
Programme Budgeting tools show that, compared to similar PCTs,
Cambridgeshire has;
• Higher spend on Endocrine, Nutritional and Metabolic problems
• Worse outcome in terms of diabetic patients whose last HbA1c was less than
7.5
• Higher rate of mortality from Diabetes
• Highest FHS prescription expenditure on Endocrine, Nutritional and Metabolic
problems
• Above average FHS prescription expenditure on Diabetes
• Above average prevalence of Diabetes and highest ratio of reported to
expected prevalence
• Below average rate of Blood pressure lower than 145/85 in patients with
diabetes
• Highest number of admissions for Diabetes
3
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 Musculoskeletal 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
4
QIPP Right Care
2007/08 and 2008/09 Programme Level Expenditure for England
5
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.
6
Programme Budgeting Spreadsheet – Cambridgeshire PCT
Cambridgeshire 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
7,623
40,908
10,279
27,178
81,127
17,167
32,118
16,161
3,423
48,704
34,402
26,098
35,558
18,440
34,780
18,775
36,111
26,242
8,845
7,879
62,358
7,906
95,247
697,329
2007-08
7,651
46,756
11,906
28,394
68,573
19,863
24,327
16,256
3,591
64,574
35,273
27,291
38,862
12,679
36,949
28,738
33,407
32,198
16,052
7,880
30,507
3,223
128,352
723,302
2008-09
7,022
52,933
10,640
28,587
72,402
21,633
28,530
19,081
4,843
70,708
41,898
30,232
38,189
17,230
36,973
36,354
37,761
29,480
9,855
8,908
11,486
2,843
135,521
753,109
% change from
2007-08
-8%
13%
-11%
1%
6%
9%
17%
17%
35%
9%
19%
11%
-2%
36%
0%
27%
13%
-8%
-39%
13%
-62%
-12%
6%
4%
7
Programme Budgeting Spreadsheet – Expenditure per 100,000 population (weighted by age, sex and need)
Cambridgeshire has high spend on Endocrine, Nutritional and Metabolic
compared to PCTs nationally, adjusting for age, sex and need of population
C a m b r id g e s h ir e P C T
P C T S e le c t e d
QIPP Right Care
S e le c t e d C lu s t e r d e t a ils
1 S U P E R (7 g ro u p s )
P r o s p e r in g U K
2006/07
2007/08
P o p u la t io n ( a s p e r A llo c a t io n s )
4 9 9 ,5 8 2
5 0 4 ,9 6 5
5 1 0 ,1 9 0
D is t f r o m T a r g e t £ '0 0 0 ( U n d e r / O v e r )
D is t fr o m T a r g e t % ( U n d e r / O v e r )
( 1 3 ,1 4 7 )
- 2 .0 7 %
( 1 4 ,5 0 2 )
- 2 .0 7 %
( 1 5 ,2 9 4 )
- 2 .0 7 %
2008/09
E X PE N D ITU R E O N O W N P O P U LA TIO N
£ p e r 1 0 0 ,0 0 0 p o p u la t io n
P r o g ra m m e B u d g e tin g C a te g o r y
2 0 0 6 -0 7
Rank
2 0 0 7 -0 8
Rank
2 0 0 8 -0 9
Rank
% Change
01
I n fe c tio u s D is e a s e s
1 ,5 2 5 ,8 7 7
105
1 ,5 1 5 ,1 5 5
105
1 ,3 7 6 ,3 5 1
124
-9 %
02
C a n ce rs a n d T u m o u rs
8 ,1 8 8 ,4 5 3
67
9 ,2 5 9 ,2 5 6
58
1 0 ,3 7 5 ,1 5 9
37
12%
-1 2 %
03
D is o r d e r s o f B lo o d
2 ,0 5 7 ,5 2 2
42
2 ,3 5 7 ,7 8 7
31
2 ,0 8 5 ,4 9 8
57
04
E n d o c r in e , N u tr it io n a l a n d M e ta b o lic
5 ,4 4 0 ,1 5 3
3
5 ,6 2 2 ,9 6 4
2
5 ,6 0 3 ,2 0 9
3
0%
05
M e n t a l H e a lt h D is o r d e r s
1 6 ,2 3 8 ,9 9 0
78
1 3 ,5 7 9 ,7 5 3
146
1 4 ,1 9 1 ,1 9 0
147
5%
06
P r o b le m s o f L e a r n in g D is a b ilit y
3 ,4 3 6 ,2 7 6
124
3 ,9 3 3 ,5 4 0
124
4 ,2 4 0 ,1 8 7
114
8%
07
N e u r o lo g ic a l
6 ,4 2 8 ,9 8 0
28
4 ,8 1 7 ,5 6 2
131
5 ,5 9 2 ,0 3 7
121
16%
08
P r o b le m s o f V is io n
3 ,2 3 4 ,9 0 7
36
3 ,2 1 9 ,2 3 3
59
3 ,7 3 9 ,9 8 1
25
16%
09
P r o b le m s o f H e a r in g
6 8 5 ,1 7 3
60
7 1 1 ,1 3 8
83
9 4 9 ,2 5 5
51
33%
10
P r o b le m s o f C ir c u la tio n
9 ,7 4 8 ,9 5 9
138
1 2 ,7 8 7 ,8 1 7
65
1 3 ,8 5 9 ,1 5 7
37
8%
11
P r o b le m s o f t h e R e s p ir a t o r y S y s t e m
6 ,8 8 6 ,1 6 3
53
6 ,9 8 5 ,2 3 7
63
8 ,2 1 2 ,2 3 8
53
18%
12
D e n ta l P r o b le m s
5 ,2 2 3 ,9 7 2
83
5 ,4 0 4 ,5 3 3
110
5 ,9 2 5 ,6 3 8
95
10%
13
P r o b le m s o f G a s t r o I n t e s t in a l S y s t e m
7 ,1 1 7 ,5 5 7
86
7 ,6 9 5 ,9 7 9
73
7 ,4 8 5 ,2 5 4
98
-3 %
14
P r o b le m s o f t h e S k in
3 ,6 9 1 ,0 8 9
14
2 ,5 1 0 ,8 6 7
126
3 ,3 7 7 ,1 7 5
55
35%
15
P r o b le m s o f M u s c u lo S k e le t a l S y s te m
6 ,9 6 1 ,8 2 6
58
7 ,3 1 7 ,1 4 1
85
7 ,2 4 6 ,9 1 1
96
-1 %
16
P r o b le m s d u e t o T r a u m a a n d I n ju r ie s
3 ,7 5 8 ,1 4 5
140
5 ,6 9 1 ,0 8 8
69
7 ,1 2 5 ,5 8 4
36
25%
17
P r o b le m s o f G e n it o U r in a r y S y s t e m
7 ,2 2 8 ,2 4 9
52
6 ,6 1 5 ,7 0 6
83
7 ,4 0 1 ,3 6 4
71
12%
18
M a te r n ity a n d R e p r o d u c tiv e H e a lth
5 ,2 5 2 ,7 9 6
99
6 ,3 7 6 ,2 8 4
54
5 ,7 7 8 ,2 4 2
89
-9 %
19
C o n d it io n s o f N e o n a te s
1 ,7 7 0 ,4 8 2
38
3 ,1 7 8 ,8 3 4
4
1 ,9 3 1 ,6 3 4
50
-3 9 %
20
A d v e r s e e f fe c t s a n d p o is o n in g
1 ,5 7 7 ,1 2 0
48
1 ,5 6 0 ,5 0 4
73
1 ,7 4 6 ,0 1 7
86
21
H e a lt h y I n d iv id u a ls
1 2 ,4 8 2 ,0 4 6
1
6 ,0 4 1 ,4 0 9
8
2 ,2 5 1 ,3 1 9
131
-6 3 %
22
23
S o c ia l C a r e N e e d s
O th e r
1 ,5 8 2 ,5 2 4
1 9 ,0 6 5 ,3 5 5
112
80
6 3 8 ,2 6 2
2 5 ,4 1 8 ,0 0 0
145
48
5 5 7 ,2 4 4
2 6 ,5 6 2 ,8 6 1
145
32
-1 3 %
5%
A ll
T o ta l
1 3 9 ,5 8 2 ,6 1 3
1 4 3 ,2 3 8 ,0 4 8
1 4 7 ,6 1 3 ,5 0 3
12%
3%
8
2008/2009 Programme Budgeting Spreadsheet – Endocrine Expenditure per 100,000 population (weighted by age, sex and need)
QIPP Right Care
Green circle shows Cambridgeshire PCT has third highest spend on Endocrine
nationally (blue diamonds) and the highest expenditure when compared to
similar PCTs (purple triangles)
9
2008/2009 Programme Budgeting Spreadsheet – Diabetes Expenditure per 100,000 population (weighted by age, sex and need)
QIPP Right Care
Green circle shows Cambridgeshire PCT has a high expenditure for Diabetes
nationally (blue diamonds) and the highest expenditure when compared to
similar PCTs (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
2008/2009 APHO Spend and Outcomes Tool – Each diamond represents a disease category and shows spend and outcomes compared to the national
average
QIPP Right Care
Cambridgeshire PCT has a higher spend and worse outcome for
Endocrine, Nutritional and Metabolic when compared to PCTs
nationally
diabetic patients
whose last HbA1c
was < 7.5
12
2008/2009 APHO Spend and Outcomes Tool - ONS Cluster Average – Each diamond represents a disease category and shows spend and
outcomes compared to the cluster average
QIPP Right Care
Cambridgeshire PCT has a higher spend and worse outcome for
Endocrine, Nutritional and Metabolic when compared to similar PCTs
diabetic
patients
whose last
HbA1c was <
7.5
13
QIPP Right Care
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
Programme by population expenditure: Endocrine: Million pounds per 100,000 unified weighted population 2007/2008
QIPP Right Care
Cambridgeshire PCT has high expenditure on Endocrine compared to
PCTs nationally
15
Programme by population expenditure: Endocrine: Million pounds per 100,000 unified weighted population filtered by PCT relevant ONS cluster
2007/2008
QIPP Right Care
Cambridgeshire PCT has the highest expenditure when compared to
similar PCTs (Prospering Southern England)
16
Programme by population expenditure: Endocrine: Million pounds per 100,000 unified weighted population filtered by SHA 2007/2008
QIPP Right Care
Cambridgeshire PCT has the highest expenditure when compared to
PCTs within the SHA
17
Years of life lost due to mortality from diabetes: (Directly age-standardised rate per 10,000 population <75 years, persons ) FY 2005 -2007
QIPP Right Care
Cambridgeshire PCT has a high rate of years of life lost due to mortality from
diabetes when compared to similar PCTs (NB – large confidence intervals
though)
18
Prevalence of diabetes (QOF); Percent, 17+ years: FY 2007/8
QIPP Right Care
Cambridgeshire PCT has a low prevalence of Diabetes compared to
PCTs nationally
19
Prevalence of diabetes (QOF); Percent, 17+ years: FY 2007/8
QIPP Right Care
Cambridgeshire PCT has an above average prevalence of Diabetes
compared to similar PCTs
20
Blood pressure <= 145/85 in patients with diabetes (QOF): Percent 17+ years, FY 2007/8 (Directly age-standardised rate per 10,000 population
<75 years, persons ) FY 2005 -2007
QIPP Right Care
Cambridgeshire PCT has a below average rate of Blood pressure lower than
145/85 in patients with diabetes compared to PCTs nationally
21
Blood pressure <= 145/85 in patients with diabetes (QOF): Percent 17+ years, FY 2007/8 (Directly age-standardised rate per 10,000 population
<75 years, persons ) FY 2005 -2007
QIPP Right Care
Cambridgeshire PCT has a below average rate of Blood pressure lower
than 145/85 in patients with diabetes when compared to similar PCTs.
22
FHS Prescription expenditure: Diabetes: Thousand pounds per 100,000 population (weighted for age, sex and need) FY 2007/8
QIPP Right Care
Cambridgeshire PCT has an above average FHS prescription
expenditure compared to PCTs nationally
23
FHS Prescription expenditure: Diabetes: Thousand pounds per 100,000 population (weighted for age, sex and need) FY 2007/8
QIPP Right Care
Cambridgeshire PCT has an above average FHS prescription
expenditure on Diabetes compared to similar PCTs.
24
Hospitalisation: Diabetes. All admissions, indirectly age-standardised rate per 100,000 population, all ages,
FY 2007/2008 Filtered by ONS cluster
QIPP Right Care
Cambridgeshire PCT has the highest number of admissions for Diabetes
compared to similar PCTs
25
Hospitalisation: Diabetes: . All Non-elective admissions, indirectly age-standardised rate per 100,000 population, all ages FY 2007/2008
QIPP Right Care
Cambridgeshire PCT has a high rate of non elective admissions for
Diabetes compared to similar PCTs
26
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
27
NHS Comparators –Diabetes Reported vs Expected Prevalence Aged > = 17 - Comparison with similar PCTs
QIPP Right Care
Cambridgeshire PCT has a below average ratio of reported to expected
prevalence of Diabetes compared to PCTs nationally
28
NHS Comparators –Diabetes Reported vs Expected Prevalence Aged > = 17 - Comparison with similar PCTs
QIPP Right Care
Cambridgeshire PCT has the highest ratio of reported to expected prevalence of
Diabetes compared to similar PCTs
29
NHS Comparators – Expenditure on Endocrine FHS Prescribing – Comparison with similar PCTs
QIPP Right Care
Cambridgeshire PCT has the highest expenditure on Endocrine FHS prescribing
compared to similar PCTs
30
NHS Comparators - Expenditure on Endocrine FHS Prescribing - Comparison at GP Practice level
QIPP Right Care
Cambridgeshire PCT have a large variation in expenditure on Endocrine FHS
Prescribing at GP Practice level
Easy to identify high and low
spending practices. Can compare
practices within groups based on
need of population
31
NHS Comparators – Expenditure on Diabetes FHS Prescribing – Comparison with similar PCTs
QIPP Right Care
Cambridgeshire PCT has an above average expenditure on Diabetes FHS
Prescribing compared to similar PCTs
32
NHS Comparators - Expenditure on Diabetes FHS Prescribing - Comparison at practice level
QIPP Right Care
Cambridgeshire PCT have a large variation in expenditure on FHS Prescribing for
Diabetes at GP Practice level
Easy to identify high and low
spending practices. Can compare
practices within groups based on
need of population
33
NHS Comparators – Elective Diabetes Admissions per 100 Patients on Disease Register - Comparison by Cost
QIPP Right Care
Cambridgeshire PCT has an above average expenditure on elective diabetes
admissions per 100 patients on the disease register compared to PCTs
nationally
34
NHS Comparators – Elective Diabetes Admissions per 100 Patients on Disease Register – Comparison by Time series
QIPP Right Care
Cambridgeshire PCT on average has a higher expenditure on elective diabetes
admissions per 100 patients on disease register when compared to the National
and SHA average
35
NHS Comparators – Elective Diabetes Admissions per 100 Patients on Disease Register - Comparison at GP Practice level
QIPP Right Care
Cambridgeshire PCT has a large variation between GP Practice expenditure on
elective diabetes admissions per 100 patients on the disease register
Easy to identify high and low
spending practices. Can compare
practices within groups based on
need of population
36
NHS Comparators – Breakdown of Actual and Expected Expenditure on admissions by Programme Budget or Disease Category– Also available
for FHS Prescribing Expenditure
QIPP Right Care
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.
37
Inpatient Variation Expenditure Tool (IVET)
QIPP Right Care
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 userdefined 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
IVET: PCT inpatient expenditure above or below the benchmark for diseases in 2008-09.
QIPP Right Care
The recently launched Inpatient Variation Tool (IVET) allows PCTs to compare
inpatient expenditure at Disease and Procedure level with a user defined benchmark.
Further diseases and interventions will be added subsequent to feedback from PCTs
39
IVET: Cambridgeshire PCT inpatient expenditure for selected disease/intervention compared to a user defined
benchmark.
QIPP Right Care
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.
40
Conclusion
QIPP Right Care
Programme Budgeting tools show that, compared to similar PCTs,
Cambridgeshire has;
• Higher spend on Endocrine, Nutritional and Metabolic problems
• Worse outcome in terms of diabetic patients whose last HbA1c was less than
7.5
• Higher rate of mortality from Diabetes
• Highest FHS prescription expenditure on Endocrine, Nutritional and Metabolic
problems
• Above average FHS prescription expenditure on Diabetes
• Above average prevalence of Diabetes and highest ratio of reported to
expected prevalence
• Below average rate of Blood pressure lower than 145/85 in patients with
diabetes
• Highest number of admissions for Diabetes
41
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
42