Managing Scarcity: Experience from
Tayside
Setting
Priorities
Delivering
Best Value
Danny Ruta
The doctor-manager divide
‘In a resource allocation context, doctors (can be)
caricatured as taking the role of patient advocate
while managers take the corporate, strategic
view. Delivery of efficient (and in the case of the
NHS, equitable) health care requires doctors to
take responsibility for resources and to consider
the needs of populations while managers need to
become more outcome and patient centred.’
Ruta, Mitton, Donaldson et al, BMJ 2005, in press
Programme Budgeting & Marginal
Analysis (PBMA)



How resources are spent
Costs andPBMA
benefitsasks
of changes
in spending
five simple
Can operate
at microabout
or macro
level
questions
resource
use
Programme Budgeting & Marginal
Analysis (PBMA)
1.
2.
3.
What are the total resources available for
a programme?
On which services are these resources
currently spent?
What services are candidates for
receiving more or new resources (and
what are the costs and potential benefits
of putting resources into such growth
areas)?
Programme Budgeting & Marginal
Analysis (PBMA)
4.
5.
Can any existing services be provided as
= so
effectively, Questions
but with fewer 1&2
resources,
releasing resources
fund
the to
PB
bititems on the growth
list?
If some growth areas still cannot be funded, are
Questions
there any services
which 3,4,5
should=receive fewer
resources, or even
stopped,
thebeMA
bit because greater
benefit would be reached by funding the growth
option as opposed to the existing service?
The ‘seven steps’ of PBMA
1.
2.
3.
4.
Determine the aim and scope of the
exercise
Compile a programme budget (map of
current activity and expenditure)
Form a marginal analysis advisory panel
and stakeholder advisory groups
Determine locally relevant decision
making criteria with input from decision
makers and stakeholders
The ‘seven steps’ of PBMA
5. Advisory panel identifies options in
terms of:
- Areas for service growth
- Areas for resource release through
producing same level of output (or
outcomes) but with less resources
- Areas for resource release through
scaling back or stopping some services
The ‘seven steps’ of PBMA
6. Advisory panel makes recommendations in
terms of:
- Funding growth areas with new resources
- Decisions to move resources released
through increased productivity to areas of
growth
- Trade-off decisions to move resources from
one service to another if relative value is
deemed greater
The ‘seven steps’ of PBMA
7. Validity checks with additional
stakeholders and final decisions to
inform budget planning process
1. Determine aim & scope of exercise
Example – Tayside Drugs & Alcohol
• Population < 500,000
• Dundee, Angus, Perth
& Kinross councils
• 3 DAATs
• from NHS to LA led
1. Determine aim & scope of exercise
Example – Tayside Drugs & Alcohol
Aim:
“To examine current provision of drug and alcohol
services across Tayside; and to propose
opportunities for management, service and
financial benefits or improvements.”
1. Determine aim & scope of exercise
Example – Tayside Drugs & Alcohol
Scope:
• Covering only drugs and alcohol services
specifically for people with drugs and alcohol
problems;
• Covering services delivered by Community Planning
partner organisations across Tayside;
• Not including those services that are not specifically
targeted at people with drugs and alcohol problems
2. Compile Programme Budget
• Broad patterns expenditure &
activity
• Clinically meaningful programme
of services
• Raise questions about value for
money
2. Compile Programme Budget
Example 1 – Tayside Drugs & Alcohol
3. Form advisory panel & stakeholder
groups
• Responsibility for developing
criteria
• Generating options for change
• Assessing marginal benefits
3. Form advisory panel & stakeholder
groups
Example – Tayside Drugs & Alcohol
Advisory Panel
CEO P&K Council
3 DAAT Chairs
Trust Medical Director
Mental Health Commissioner
3. Form advisory panel & stakeholder
groups
Example – Tayside Drugs & Alcohol
Advisory Panel
CEO P&K Council
3 DAAT Chairs
Trust Medical Director
Mental Health Commissioner
Professional Advisory Group
Consultant Psychiatrist (chair)
20 Frontline service providers
3. Form advisory panel & stakeholder
groups
Example – Tayside Drugs & Alcohol
Advisory Panel
CEO P&K Council
3 DAAT Chairs
Trust Medical Director
Mental Health Commissioner
Professional Advisory Group
Scottish Drugs Forum
Consultant Psychiatrist (chair)
6 Service User Focus
Groups
20 Frontline service providers
3. Form advisory panel & stakeholder
groups
Example – Tayside Drugs & Alcohol
Project Team
Advisory Panel
CEO P&K Council
3 DAAT Chairs
Trust Medical Director
Mental Health Commissioner
Me
Psychiatrist
Nurse
3 DAAT Co-ordinators
Professional Advisory Group
Finance manager
Consultant Psychiatrist (chair)
Community pharmacist
20 Frontline service providers
Scottish Drugs Forum
6 Service User Focus Groups
4. Determine locally relevant decision
making criteria
• Criteria to assess benefits
gained/lost
• Relative weights for criteria
importance
4. Determine locally relevant decision
making criteria
Example – Tayside Drugs & Alcohol
• Quality & Length of Life
• Quality of Service
• Feasibility
• Policy & Strategy
4. Determine locally relevant decision
making criteria
Example – Tayside Drugs & Alcohol
5. Advisory panel identify the options
• Areas for service growth;
• Areas for resource release through producing
the same outcomes with fewer resources;
• Areas for resource release through scaling
back or stopping services;
• Areas where growth and resource release
occur simultaneously
5. Advisory panel identify the options
Example – Tayside Drugs & Alcohol
• Professional advisory group generated
options
• Assessed options against Quality/length of
life & Quality of service criteria
• Project team collated evidence
5. Advisory panel identify the options
Example 1 – Tayside Drugs & Alcohol
• 23 Service Investment Candidates
5. Advisory panel identify the options
Example 1 – Tayside Drugs & Alcohol
• 23 Service Investment Candidates
• 31 Service Disinvestment Candidates
6. Panel makes recommendations
Example – Tayside Drugs & Alcohol
Benefit-cost ratio = (weighted benefit
x no. client beneficiaries) / cost
7. Validity Checks with additional
stakeholders
Example – Tayside Drugs & Alcohol
Lessons from Tayside PBMA Study



It is feasible to apply PBMA in practice
Potential to bridge doctor-manager divide
Addresses root cause of problem of
managing scarcity – shared appreciation of
opportunity cost (balance clinical autonomy &
financial responsibility)
Lessons from Tayside
“A Scottish NHS without
market competition but
with PBMA, result
happiness. A Scottish
NHS without a market and
without PBMA, result
misery”