QIPP Right Care
NHS Leicester City
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
Overview
QIPP Right Care
We will use the Programme Budgeting tools to show that when compared to similar PCTs
Leicester City PCT has;
• High expenditure on Respiratory system problems
• Low FHS prescription expenditure and below average FHS prescription volume for Respiratory system
problems when compared to similar PCTs
• Low reported prevalence of COPD (QOF)
• Low percentage of asthma review for patients with asthma when compared to similar PCTs
• An above average number of years of life lost due to mortality from COPD when compared to similar
PCTs
• A high number of non-elective admissions for Respiratory system problems
• An above average number of elective admissions for Respiratory system problems
• An above average number of Respiratory emergency readmissions
• A low ratio of reported to expected prevalence of Asthma
• A large variation at practice level for prescription of inhaled corticosteroids
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
2007/08 and 2008/09 Programme Level Expenditure for England
6
Information Available for PCTs
QIPP Right Care
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.
7
Programme Budgeting Spreadsheet – Leicester City PCT
Expenditure
QIPP Right Care
Leicester City Teaching PCT
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
3,655
28,138
3,095
12,656
50,872
16,162
19,870
8,645
2,278
43,152
25,858
16,616
26,660
7,845
16,951
15,598
18,190
29,720
612
5,036
21,191
4,270
48,178
425,248
2007-08
7,613
15,569
4,347
14,444
59,429
19,675
16,539
9,713
2,856
31,960
18,791
21,596
17,672
7,154
17,147
12,352
21,131
20,851
4,850
4,139
11,657
2,999
113,795
456,279
2008-09
9,048
25,472
5,039
18,912
65,455
22,826
26,818
11,579
2,868
36,947
27,114
21,158
22,232
11,324
21,445
13,435
22,688
20,268
6,959
6,646
12,816
5,856
65,895
482,800
% change from
2007-08
19%
64%
16%
31%
10%
16%
62%
19%
0%
16%
44%
-2%
26%
58%
25%
9%
7%
-3%
43%
61%
10%
95%
-42%
6%
8
Programme Budgeting Spreadsheet – Leicester City PCT Expenditure per 100,000 population (weighted by age, sex and need) –
2008/09 rank column shows PCT has a rank of 38 for Respiratory system
problems compared to 121 in 2007/08
L e ic e s t e r C it y T e a c h in g P C T
P C T S e le c te d
QIPP Right Care
S e le c te d C lu s te r d e ta ils
1 S U P E R (7 g ro u p s )
C it ie s a n d S e r v ic e s
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 )
3 1 7 ,1 4 3
3 1 6 ,7 8 8
3 2 0 ,0 6 6
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 6 ,5 1 0 )
- 4 .0 9 %
( 1 3 ,8 5 7 )
- 3 .1 6 %
( 1 4 ,6 1 4 )
- 3 .1 6 %
2008/09
E X P E 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 r a 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 t io u s D is e a s e s
1 ,1 5 2 ,4 7 8
140
2 ,4 0 3 ,1 8 1
34
2 ,8 2 6 ,9 1 5
31
18%
02
C a n ce rs a n d T u m o u rs
8 ,8 7 2 ,3 4 8
37
4 ,9 1 4 ,6 3 6
150
7 ,9 5 8 ,3 5 3
127
62%
03
D is o r d e r s o f B lo o d
04
E n d o c r in e , N u t r it io n a l a n d M e t a b o lic
05
M e n ta l H e a lth D is o r d e r s
06
P r o b le m s o f L e a r n in g D is a b ilit y
9 7 5 ,9 0 2
135
1 ,3 7 2 ,2 0 9
122
1 ,5 7 4 ,3 6 2
113
15%
3 ,9 9 0 ,6 3 3
37
4 ,5 5 9 ,5 1 0
20
5 ,9 0 8 ,7 7 8
2
30%
1 6 ,0 4 0 ,7 3 1
83
1 8 ,7 5 9 ,8 3 8
59
2 0 ,4 5 0 ,4 5 6
49
9%
5 ,0 9 6 ,1 2 9
64
6 ,2 1 0 ,7 6 9
42
7 ,1 3 1 ,6 5 0
23
15%
07
N e u r o lo g ic a l
6 ,2 6 5 ,3 1 9
33
5 ,2 2 0 ,8 3 4
118
8 ,3 7 8 ,8 9 1
14
60%
08
P r o b le m s o f V is io n
2 ,7 2 5 ,9 0 3
69
3 ,0 6 6 ,0 8 4
73
3 ,6 1 7 ,6 8 9
35
18%
09
P r o b le m s o f H e a r in g
7 1 8 ,2 8 9
51
9 0 1 ,5 4 8
54
8 9 6 ,0 6 5
58
-1 %
10
P r o b le m s o f C ir c u la t io n
1 3 ,6 0 6 ,4 9 5
26
1 0 ,0 8 8 ,7 5 2
137
1 1 ,5 4 3 ,5 4 9
112
14%
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
8 ,1 5 3 ,4 2 9
9
5 ,9 3 1 ,7 1 9
121
8 ,4 7 1 ,3 7 2
38
43%
12
D e n t a l P r o b le m s
5 ,2 3 9 ,2 8 3
82
6 ,8 1 7 ,1 6 8
33
6 ,6 1 0 ,5 0 7
62
-3 %
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
8 ,4 0 6 ,3 1 2
27
5 ,5 7 8 ,4 8 6
141
6 ,9 4 6 ,0 6 3
127
25%
14
P r o b le m s o f t h e S k in
2 ,4 7 3 ,6 5 0
106
2 ,2 5 8 ,2 8 9
141
3 ,5 3 8 ,0 1 8
38
57%
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 t e m
5 ,3 4 4 ,9 1 3
120
5 ,4 1 2 ,7 6 0
131
6 ,7 0 0 ,1 7 6
118
24%
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
4 ,9 1 8 ,2 9 1
102
3 ,8 9 9 ,1 3 2
142
4 ,1 9 7 ,5 6 9
143
8%
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
5 ,7 3 5 ,5 8 9
120
6 ,6 7 0 ,3 8 2
80
7 ,0 8 8 ,5 3 3
92
6%
18
M a t e r n it y a n d R e p r o d u c t iv e H e a lt h
9 ,3 7 1 ,1 7 7
3
6 ,5 8 1 ,9 9 5
46
6 ,3 3 2 ,4 4 0
62
-4 %
19
C o n d it io n s o f N e o n a t e s
1 9 2 ,9 7 3
150
1 ,5 3 0 ,9 9 0
70
2 ,1 7 4 ,2 3 8
35
42%
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 8 7 ,9 2 9
46
1 ,3 0 6 ,5 5 0
120
2 ,0 7 6 ,4 4 5
38
59%
21
H e a lt h y I n d iv id u a ls
6 ,6 8 1 ,8 5 1
3
3 ,6 7 9 ,7 4 3
42
4 ,0 0 4 ,1 7 2
58
22
23
S o c ia l C a r e N e e d s
O th e r
1 ,3 4 6 ,3 9 7
1 5 ,1 9 1 ,2 7 1
119
130
9 4 6 ,6 8 9
3 5 ,9 2 1 ,4 4 8
142
3
1 ,8 2 9 ,6 2 1
2 0 ,5 8 7 ,9 2 8
106
106
A ll
T o ta l
1 3 4 ,0 8 7 ,2 9 1
1 4 4 ,0 3 2 ,7 1 2
1 5 0 ,8 4 3 ,7 9 2
9%
93%
-4 3 %
5%
9
2008/2009 Programme Budgeting Spreadsheet – Leicester City PCT Expenditure per 100,000 population (weighted by age, sex and need) on
Problems of Respiratory category
QIPP Right Care
Green circle shows that this PCT has above average expenditure compared to PCTs
both nationally (blue diamonds), and compared to similar PCTs (purple triangles) for
respiratory
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
Leicester City PCT has higher spend and worse outcome for Respiratory
problems when compared to PCTs nationally.
Patients on
enhanced
CPA receiving
early FU
Mortality
from all
circulatory
diseases,
Under 75s
Mortality
from
bronchitis
Under 75s
Mortality
from all
cancers
Under 75s
12
2008/2009 Each diamond represents a disease category and shows spend and outcomes compared to the ONS Cluster average –
QIPP Right Care
Leicester City PCT has high rank for spend and low rank for outcome for
Respiratory problems when compared to similar PCTs
Mortality
from
bronchitis
Under 75s
13
QIPP Right Care
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
14
2007/2008 Programme Budget Atlas – Prescription volume on Respiratory per unified population, Filtered by ONS cluster
QIPP Right Care
Leicester City PCT has a below average FHS prescription volume for
Respiratory system problems when compared to similar PCTs (Centres
with Industry)
15
FHS Prescription expenditure: Respiratory system: Thousands pounds per 100,000 unified weighted population, FY 2007/08, Filtered by ONS
cluster
QIPP Right Care
Leicester City PCT has a low FHS prescription expenditure for Respiratory
system problems when compared to similar PCTs
16
2007/2008 Programme Budget Atlas – Prevalence of COPD (QOF); Percent, all ages FY, 2, Filtered by ONS cluster
QIPP Right Care
Leicester City PCT has a low reported prevalence of COPD when compared to
similar PCTs
17
2005/2007 Programme Budget Atlas – Years of life lost due to mortality from COPD. Directly age-standardised rate per 10,000 population, less
than 75 years, all persons, Filtered by ONS Cluster
QIPP Right Care
Leicester City PCT has an above average number of years of life lost due to
mortality from COPD when compared to similar PCTs
18
2007/2008 Programme Budget Atlas – Fev1 checks for patients with COPD (QOF); Percent, all ages, Filtered by ONS Cluster
QIPP Right Care
Leicester City PCT has an average level of Fev1 checks for patients with COPD
compared to similar PCTs
19
2007/2008 Programme Budget Atlas – Asthma review aomong patients with asthma (QOF):Percent, all ages, FY 2007/08, filtered by ONS Cluster
QIPP Right Care
Leicester City PCT has a low percentage of asthma review for patients with
asthma when compared to similar PCTs
20
2007/2008 Programme Budget Atlas – Respiratory Elective Hospital Admissions per 100,000 population (weighted for age, sex and need), Filtered by
Cluster
QIPP Right Care
Leicester City PCT an above average number of elective admissions for
Respiratory system problems when compared to similar PCTs
21
2007/2008 Programme Budget Atlas – Respiratory Non-Elective Hospital Admissions per 100,000 population (weighted for age, sex and need),
Filtered by cluster
QIPP Right Care
Leicester City PCT has a high number of non-elective admissions for Respiratory
system problems when compared to similar PCTS
22
2007/2008 Programme Budget Atlas – Respiratory Emergency Readmissions to hospital within 28 days of discharge – Darker areas represent
higher number of readmissions, Filtered by ONS Cluster
QIPP Right Care
Leicester City PCT has an above average number of Respiratory Emergency
Readmissions compared to similar PCTs
23
NHS Comparators
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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
24
NHS Comparators – Asthma Reported vs Expected Prevalence, Period/Year: Rolling Year - 2008/2009; Activity; Applied Group: Centres
with Industry
QIPP Right Care
Leicester City PCT has a low ratio of reported to expected prevalence of
Asthma when compared to similar PCTs
25
Leicester City PCT - Inhaled Corticosteroids per STAR PU, Period/Year: Rolling Year - 2009/2010; Activity
QIPP Right Care
Leicester City PCT has a large variation at practice level for prescription of
Inhaled Corticosteroids
Easy to identify high and low
spending practices. Can compare
practices within groups based on
need of population
26
Emergency Admissions per 1000 Population, Period/Year: Rolling Year - 2009/2010; Cost; Applied Filters: 11: Problems of the respiratory
system (Programme Budget Category); Applied Group: Centres with Industry
QIPP Right Care
Leicester City PCT a high spend on Respiratory emergency admissions
compared to similar PCTs
Drill down to disease level
Table shows activity, expected
activity based on national
averages, and the resulting %
difference, for PCT and SHA
27
NHS Comparators – Total Elective (IP+DC) Admissions per 1000 Population, Period/Year: Rolling Year - 2009/2010; Cost; Applied Filters:
11: Problems of the respiratory system (Programme Budget Category); Applied Group: Centres with Industry
QIPP Right Care
Leicester City PCT has a low spend on all elective admissions when
compared to similar PCTS
28
NHS Comparators - Quarterly Time Series of Leicester City PCT Expenditure on Respiratory Admissions –
QIPP Right Care
Leicester City PCT has a consistently higher emergency Respiratory
admissions rate than the SHA and National average
29
QIPP Right Care
NHS Comparators – Breakdown of Actual and Expected Expenditure on
admissions by Programme Budget or Disease Category for Leicester City
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.
30
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
31
IVET: PCT inpatient expenditure above or below the benchmark for diseases in 2008-09.
QIPP Right Care
Leicester City PCT spent £1 million more on Respiratory inpatient
procedures than the national average (adjusted for age, sex and need)
32
IVET: PCT inpatient expenditure for selected disease/intervention compared to a user defined benchmark.
QIPP Right Care
Leicester City PCT is spending more the national average on Respiratory
Inpatients. Decreasing activity from 7,541 to 6,787 would bring the spend in line
with the national average
33
Conclusion
QIPP Right Care
We have used the Programme Budgeting tools to show that when compared to similar PCTs Leicester
City PCT has;
High expenditure on Respiratory system problems
Low FHS prescription expenditure and below average FHS prescription volume for Respiratory system
problems when compared to similar PCTs
Low reported prevalence of COPD (QOF)
Low percentage of asthma review for patients with asthma when compared to similar PCTs
An above average number of years of life lost due to mortality from COPD when compared to similar
PCTs
A high number of non-elective admissions for Respiratory system problems
An above average number of elective admissions for Respiratory system problems
An above average number of Respiratory emergency readmissions
A low ratio of reported to expected prevalence of Asthma
A large variation at practice level for prescription of inhaled corticosteroids
34
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
35