1. NHS City and Hackney Health investment slide pack: respiratory disease December 2010 QIPP Right Care Produced by Commissioning Support for London using a template supplied by QIPP Right Care

2. QIPP Right Care 22 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 respiratory disease 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 Directors of Public Health, 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

3. QIPP Right Care 3 Overview Programme Budgeting tools show that, when compared to PCTs within London SHA, City and Hackney PCT has: Lower spend and better outcomes for respiratory problems when compared to similar PCTs A high rate of years of life lost due to mortality from COPD Low reported prevalence of COPD Average rates of Fev1 checks and below average rates of flu immunisation for patients with recorded COPD Low rates of elective admissions and very low rates of non-elective admissions to hospital for respiratory problems Below average rates of expenditure on elective admissions and high rates of expenditure on non- elective admissions to hospital for respiratory problems Low prescription volumes and spend for inhaled corticosteroids

4. QIPP Right Care 4 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.

5. QIPP Right Care 5 23 Programme Budgeting Categories 1Infectious Diseases 2Cancers & Tumours 3Blood Disorders 4Endocrine, Nutritional and Metabolic Problems 5Mental Health Problems 6Learning Disability Problems 7Neurological System Problems 8Eye/Vision Problems 9Hearing Problems 10Circulation Problems (CVD) 11Respiratory System Problems 12Dental Problems 13Gastro Intestinal System Problems 14Skin Problems 15Musculoskeletal System Problems (excludes Trauma) 16Trauma & Injuries 17Genito Urinary System Disorders (except infertility) 18Maternity & Reproductive Health 19Neonates 20Poisoning 21Healthy Individuals 22Social Care Needs 23Other Conditions What is Programme Budgeting?

6. QIPP Right Care 6 2007/08 and 2008/09 Programme Level Expenditure for England

7. QIPP Right Care 7 Information Available for PCTs 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.

8. QIPP Right Care 8 Programme Budgeting Spreadsheet – City and Hackney PCT City and Hackney Teaching PCT Expenditure on own population (£000s) Programme Budgeting Category2006-072007-082008-09 % change from 2007-08 01Infectious Diseases 16,058 19,560 15,657-20% 02Cancers and Tumours 20,185 15,117 18,45122% 03Disorders of Blood 6,988 5,543 7,52236% 04Endocrine, Nutritional and Metabolic 7,892 7,757 10,15831% 05Mental Health Disorders 80,169 76,005 84,87912% 06Problems of Learning Disability 11,802 11,576 12,1995% 07Neurological 11,259 9,874 13,78340% 08Problems of Vision 5,643 4,813 5,56516% 09Problems of Hearing 1,510 2,680 2,226-17% 10Problems of Circulation 22,675 22,220 26,78021% 11Problems of the Respiratory System 11,980 10,969 17,75662% 12Dental Problems 12,469 18,383 12,449-32% 13Problems of Gastro Intestinal System 13,270 11,782 12,8419% 14Problems of the Skin 5,583 8,547 6,826-20% 15Problems of Musculo Skeletal System 11,002 10,523 13,20025% 16Problems due to Trauma and Injuries 10,990 10,390 15,09245% 17Problems of Genito Urinary System 14,450 16,617 19,95920% 18Maternity and Reproductive Health 24,798 22,825 27,17319% 19Conditions of Neonates 8,710 7,392 5,710-23% 20Adverse effects and poisoning 2,906 1,968 3,26066% 21Healthy Individuals 18,281 19,115 12,666-34% 22Social Care Needs 105 455 15-97% 23Other 52,002 93,280 88,288-5% AllTotal370,727407,392432,4556%

9. QIPP Right Care 9 Programme Budgeting Spreadsheet – Expenditure per 100,000 population (weighted by age, sex and need) City and Hackney PCT has high spend on maternity, mental health and infectious disease and low spend on gastro-intestinal, adverse effects & poisoning, cancer, respiratory, neurological, musculoskeletal and dental compared to PCTs nationally, adjusting for age, sex and need of population

10. QIPP Right Care 10 2008/09 Programme Budgeting Spreadsheet – Respiratory Expenditure per 100,000 population (weighted by age, sex and need) Green circle shows City and Hackney PCT has low expenditure on respiratory problems compared to PCTs nationally (blue diamonds) and compared to similar PCTs (pink triangles)

11. QIPP Right Care 11 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.

12. QIPP Right Care 12 2008/09 APHO Spend and Outcomes Tool – Each diamond represents a disease category and shows spend and outcomes compared to the national average City and Hackney PCT has lower spend and worse outcomes for respiratory problems when compared to PCTs nationally Mortality from bronchitis Under 75s

13. QIPP Right Care 13 2008/09 APHO Spend and Outcomes Tool – Each diamond represents a disease category and shows spend and outcomes compared to the cluster average City and Hackney PCT has lower spend and better outcomes for respiratory problems when compared to similar PCTs Mortality from bronchitis Under 75s

14. QIPP Right Care 14 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

15. QIPP Right Care 15 Programme by population expenditure: Respiratory system: Million pounds per 100,000 unified weighted population 2008/09 City and Hackney PCT has low expenditure on respiratory problems when compared to PCTs nationally

16. QIPP Right Care 16 Programme by population expenditure: Respiratory system: Million pounds per 100,000 unified weighted population filtered by SHA 2008/09 City and Hackney PCT has low expenditure on respiratory problems when compared to PCTs within London SHA

17. QIPP Right Care 17 Years of life lost due to mortality from bronchitis, emphysema and other COPD Directly age-standardised rate per 10,000 population, less than 75 years, all persons 2006-2008 City and Hackney PCT has a high rate of years of life lost due to mortality from COPD when compared to PCTs within London SHA

18. QIPP Right Care 18 Prevalence of COPD (QOF); Percent, all ages: FY 2008/09 City and Hackney PCT has a low rate of recorded prevalence of COPD when compared to PCTs within London SHA

19. QIPP Right Care 19 Fev1 checks for patients with COPD (QOF); Percent, all ages, FY 2008/09 City and Hackney PCT an average rate of Fev1 checks for patients with COPD when compared to PCTs within London SHA

20. QIPP Right Care 20 Vaccination against influenza for patients with COPD (QOF) Patients all ages, FY 2008/09 City and Hackney PCT has a below average percentage of COPD patients vaccinated against influenza when compared to PCTs within London SHA

21. QIPP Right Care 21 Hospitalisation: Respiratory system problems. All elective admissions, indirectly age-standardised rate per 100,000 population, all ages, FY 2008/09 City and Hackney PCT has a low rate of elective admissions when compared to PCTs within London SHA

22. QIPP Right Care 22 Hospitalisation: Respiratory system problems. All non-elective admissions, indirectly age-standardised rate per 100,000 population, all ages FY 2008/09 City and Hackney PCT has a very low rate of non-elective admissions when compared to PCTs within London SHA

23. QIPP Right Care 23 Emergency readmission to hospital within 28 days of discharge: Respiratory system. Admissions excluding day cases, indirectly age- standardised percent, all ages. FY 2008/09 City and Hackney PCT has a high rate of emergency readmissions to hospital for respiratory problems when compared to PCTs within London SHA

24. QIPP Right Care 24 Deaths within 30 days of admission for Respiratory system : Admissions excluding day cases, indirectly age standardised rate per 100,000 spells, all ages FY 2008/09 City and Hackney PCT has an average rate of deaths within 30 days of admission for respiratory problems when compared to PCTs within London SHA

25. QIPP Right Care 25 Prevalence of COPD 2008/09 vs Years of life lost due to mortality from bronchitis, emphysema, and other COPD 2006-2008 City and Hackney PCT has a higher rate of years of life lost due to mortality from COPD than PCTs with a similar recorded prevalence of COPD

26. QIPP Right Care 26 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 2008/9 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. QIPP Right Care 27 NHS Comparators: Total Elective (IP+DC) Admissions per 1000 Population: Period/Year: 2009/2010; Cost; Applied Filters: 11: Problems of the respiratory system (Programme Budget Category) City and Hackney PCT has a below average cost of all elective admissions for respiratory problems when compared to PCTs within London SHA

28. QIPP Right Care 28 NHS Comparators - Emergency Admissions per 1000 Population: Period/Year: 2009/2010; Cost; Applied Filters: 11: Problems of the respiratory system City and Hackney PCT has a high expenditure on emergency admissions for respiratory system problems when compared to PCTs in London SHA

29. QIPP Right Care 29 NHS Comparators – GP Practice Level Comparison of Expenditure on Problems of Respiratory Emergency Admissions Easy to identify high and low spending practices. Can compare practices within groups based on need of population City and Hackney PCT has high GP practice level variation for cost of emergency admissions for respiratory problems

30. QIPP Right Care 30 NHS Comparators: Inhaled Corticosteroids per STAR PU: Period/Year: 2009/2010; Activity Table shows activity, expected activity based on national averages, and the resulting % difference, for PCT and SHA City and Hackney PCT prescribes a low number of inhaled corticosteroids when compared to PCTs within London SHA

31. QIPP Right Care 31 NHS Comparators: Inhaled Corticosteroids per STAR PU: Period/Year: 2009/2010; Cost City and Hackney PCT has a low spend on inhaled corticosteroid prescriptions when compared to PCTs within London SHA

32. QIPP Right Care 32 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. NHS Comparators – Breakdown of Actual and Expected Expenditure on admissions by Programme Budget or Disease Category for City and Hackney PCT – Also available for FHS Prescribing Expenditure

33. QIPP Right Care 33 Inpatient Variation Expenditure Tool (IVET) The tool provides PCTs with: inpatient expenditure data (2008/09) 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 user- defined 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

34. QIPP Right Care 34 IVET: inpatient expenditure above or below the benchmark for diseases in 2008-09. The Inpatient Variation Expenditure Tool (IVET) allows PCTs to compare inpatient expenditure at disease and procedure level with a user defined benchmark. City and Hackney PCT spends £700,000 less than the national average on respiratory inpatient admissions adjusting for age, sex and need of population

35. QIPP Right Care 35 IVET: inpatient expenditure for selected disease/intervention compared to a user defined benchmark. The IVET Tool allows PCTs to select a high cost disease or procedure, choose a benchmark level (e.g. median, lowest 10%) and view potential savings. Further diseases and interventions will be added subsequent to feedback from PCTs

36. QIPP Right Care 36 Conclusion Programme Budgeting tools show that, when compared to PCTs within London SHA, City and Hackney PCT has: Lower spend and better outcomes for respiratory problems when compared to similar PCTs A high rate of years of life lost due to mortality from COPD Low reported prevalence of COPD Average rates of Fev1 checks and below average rates of flu immunisation for patients with recorded COPD Low rates of elective admissions and very low rates of non-elective admissions to hospital for respiratory problems Below average rates of expenditure on elective admissions and high rates of expenditure on non- elective admissions to hospital for respiratory problems Low prescription volumes and spend for inhaled corticosteroids

37. QIPP Right Care 37 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 37