1. Health Economics Tools for JSNA Susan Hamilton Sandra Shcherba

2. Overview Why Health Economics? What is Health Economics? Programme Budgeting –What it is –Data and tools Marginal Analysis NICE costing tools – new developments

3. Why health economics? Major refresh of the local JSNA in 2011 25 chapters in 5 sections –Health & wellbeing, –Children & young people –Safer & stronger – Transport, economy & environment –Overview of health

4. Structure –Why is this important –What are the needs of the population –Current service provision –Community Voice –What works –Challenges for consideration Aprox. 30 authors from PCT and LA Limited guidance given on content

5. What went into the JSNA Overview of health –Contained health profile information –Included results from SPOT tool Provides overview of spend & outcomes Details of disease areas with highest spend & outliers Some references to £ but no consistent approach

6. Questions of £££ Authors questions – Making the economic case for prevention (national documents / NICE costing templates) –Cost-effectiveness / benefits of current service –Evaluating health impact of disinvestment Commissioner questions –What do I put in the acute trust contract? –How do I make a £ case for investment in prevention?

7. National Guidance Local Government Improvement and Development. JSNA a springboard for action “Nevertheless, the potential for JSNA to be at the centre of commissioning decisions has not yet been fully realised. Considerable scope still exists to ensure JSNA informs investment and decommissioning decisions as well as guiding efficiencies in service provision”.

8. Going forward Programme Budgeting –Including in the new JSNA chapter on mental health Guidance –More detailed guidance developed for authors Population needs – inc. impact on health and/or social care or wider societal costs Current service provision – inc. cost benefit –Local H&W board consider issues of cost effectiveness in relation to PH outcomes.

9. Challenges Link with annual commissioning cycle. Political dimension of including £ PCT skills limited in health economics. Technical difficulties of undertaking proper economic assessment. Where to focus first – breadth vs depth? What timescales?

10. What is health economics? Looks at the economic aspects of health and healthcare Uses methods such as epidemiology and economic theories to assess and manage healthcare resources and their impact. EconomicsMedicine Health economics

11. Programme Budgeting- What is it? Programme budgeting is an appraisal of past resource allocation (£££) in specified programmes of care, rather than services, with a view to tracking future resource allocation in those same programmes.

12. Programme Budgeting- What is it for? The aim is to maximise health gain by deploying the available resources to best effect.

13. Programme Budgeting Can help commissioners to assess how they spend their allocation over 23 disease categories and their respective subcategories; how their disease category level expenditure is split across 12 care settings (2010-11 only) and; how their expenditure distribution pattern compares with other commissioners nationally, locally or with similar characteristics

14. 23 Programme Budgeting Categories 1 Infectious Diseases 2 Cancers & Tumours 3 Blood Disorders 4 Endocrine, Nutritional and Metabolic Problems 5 Mental Health Problems 6 Learning Disability Problems 7 Neurological System Problems 8 Eye/Vision Problems 9 Hearing Problems 10 Circulation Problems (CVD) 11 Respiratory System Problems 12 Dental Problems 13 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

15. Programme Budgeting- What is it? All PCTs in England have submitted an annual programme budgeting return since 2003/4. Data is published on Department of Health Website (http://www.dh.gov.uk/en/Managingyourorganisation/Finance andplanning/Programmebudgeting/)

16. Programme Budgeting Outputs- Tools Help to view and analyse PB data, mainly by linking expenditure information with health outcomes Key tools are: 1.Benchmarking tool 2.Programme Budgeting Atlas 3.NHS Comparators 4.Inpatient Variation Expenditure Tool (IVET) 5.Spent and Outcomes Tool (SPOT) 6.Patient Reported Outcome Measures Tool (PROMT) Health Investment Pack (HIP)

17. Health Investment Packs (HIP) Available at: http://www.ic.nhs.uk/services/in- development/right-care/health-investment- packs/south-west

18. 1. Benchmarking tool Commissioner level expenditure data National expenditure Cancer Network level Cardiovascular disease network level

20. Benchmarking tool – Commissioner level expenditure

22. 2. Programme Budgeting Atlas Produces maps of expenditure and outcomes includes health outcomes, Quality Outcome Framework (QOF) data and Hospital Episodes Statistics (HES) data

25. 3. NHS Comparators provides quarterly inpatient activity and expenditure data by programme budget at England, SHA, Commissioner and Practice level. includes: –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 nww.nhscomparators.nhs.uk [NHSNet users only]

27. Inpatient Variation Expenditure Tool (IVET) calculates potential savings by reducing admissions across major disease groups and for interventions with the highest spend.

28. Inpatient Variation Expenditure Tool (IVET) 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 (deprivation); Comparative data to other PCTs Allows PCTs to select a high cost disease or procedure, choose a benchmark level (eg median, lowest 10%) and view potential savings.

29. Inpatient Variation Expenditure Tool (IVET)

30. 5. Spend and Outcome Tool (SPOT) Graphic tool to identify areas for potential investment or disinvestment or service improvement Consists of factsheets and tool The tool contains more details allows different outcome measures for some programmes, which can be displayed on the quadrant chart Available from the YHPHO website http://www.yhpho.org.uk/spot

31. Higher Spend, Worse Outcome Lower Spend, Worse Outcome

32. Higher Spend, Worse Outcome Lower Spend, Worse Outcome

33. 6. Patient Reported Outcome Measures Tool (PROMT) assists health investment decisions by comparing expenditure and patient reported outcomes at local level for: hip and knee replacements groin hernia varicose veins

34. PROMPT –Knee replacement

35. IVET and PROMPT are both available on the NHS Networks website: http://www.networks.nhs.uk/nhs-networks/health- investment-network

36. PBMA Stands for Programme Budgeting and Marginal Analysis Often only Programme Budgeting data used Marginal analysis explicitly assesses the costs and benefits of proposed changes in the delivery of health care For investment as well as disinvestment

37. PBMA PB answers question on what and where money is currently spent MA identifies areas for growth (wish list) and areas for resource release (hit list) Hit List What services can be provided with less resources? What services can be stopped or scaled back? Wish List What services should receive more resources to better meet the need of the population?

38. Very good worked examples and video presentations on PBMA are available on the Health Knowledge (Public Health) website: http://www.healthknowledge.org.uk/interactive- learning/pbma

39. Limitations Coding issues Local definitions programme budgeting input data bit of a mystery for non-finance people Category 23 problem (Other Conditions)

40. NICE COSTING TOOLS

41. Types of NICE costing tools All NICE guidance (except interventional procedures) published since January 2005 has costing tools. Types of NICE costing tools National cost reports -national estimated cost and implementing the guidance. Business case –presents the financial costs and benefits of implementing guidance. Costing statements are used when cost impact is considered to be minimal to explain why the cost impact is not considered to be significant. Cost impact and commissioning assessment for NICE quality standards.

42. Local impact of NICE guidance Costing templates –estimate the local cost of implementing guidance and public health guidelines. –assess the impact guidance will have on local budgets

43. Cost Summary

44. Beware of assumptions

45. New NICE public health tools Shift from cost impact and cost utility measures (QUALY) to Return on Investment methodology First project is for tobacco control, then areas such as obesity Looks at scenarios around different interventions where national cost- effectiveness data may be ignored

46. New NICE public health tools Current methodsFuture approach Live time benefitsShort (1-2yrs), medium (5yrs), longterm outcomes Health outcomesHealth and non-health (eg social care) outcomes NHS view (generally)Costs and benefits for wider society (economy, social care, employment) Takes national evidence for efficacy and cost- benefit Will allow changes and omission of cost-benefit data