1. Dr Peter Brambleby 01603 307206 peter.brambleby@nyypct.nhs.uk 1. World class commissioning 2. Investing in health (Programme budgeting and marginal analysis) DsPH, Yorks and Humber, 14 Dec 2007

2. Outline World class commissioning – vision and competencies Investing in health (PBMA) in NYYPCT: –Where does the NHS money in NYYPCT go? –What good does it do? –How do we compare with other PCTs? –What might we do better from here on?

4. World class commissioning values Better health and well-being for all –Healthier; longer lives; reduced inequalities Better care for all –Evidence-base; quality; choice; control; personalised Better value for all –Investment decisions informed and considered; improvement within available resources; PCTs looking outwards not just upwards

5. “Competencies” 1.Leadership: PCTs rebranded as “The Local NHS” 2.Work with community partners 3.Engage with public and patients 4.Collaborate with clinicians 5.Manage knowledge and assess needs 6.Prioritise investment 7.Stimulate the market 8.Promote improvement and innovation 9.Secure procurement skills 10.Manage the local health system 11.Make sound financial investment

6. Key phrases Transformational, not just transactional Equity, effectiveness, efficiency Put the “mission” into commissioning Draw legitimacy from local engagement Outcomes: clinical, health, community Not risk-averse: experiment and innovate Adhere to “Standards in Public Life”

7. Professional development List of competencies provides the syllabus for training in commissioning Individual and organisational CPD (Individual and collective competence) Role for educational establishments, FESC (Framework for External Support for Commissioners), improvement agencies eg NHS III. PBC, PCT, SHA level.

8. Health needs assessment is … NICE, 2005, Health needs assessment: a practical guide. “… a systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities.” This fits neatly with programme budgeting and marginal analysis. But the public expects action - a health needs addressment!

9. Definitions Programme Budgeting: a retrospective appraisal of resource allocation in ‘health programmes’ - with a view to influencing and tracking future expenditure in those same programmes to meet the programmes’ stated objectives. Marginal Analysis: an appraisal of incremental changes in costs and benefits when the resources in programmes are deployed in new ways.

10. A verb, not a noun Programme budgeting (verb) is a way of thinking and working – a way of framing questions and objectives, of measuring, planning, coordinating, communicating, networking and reporting – getting a better fit between needs and resources. More than a programme budget (noun) – more than just a spreadsheet or atlas.

11. Letter from DH Director of Finance to all SHA directors of finance, public health and commissioning: 28 November 2006 “Purpose … to ask you to communicate the 2005/06 programme budgeting figures to all PCTs, NHS Trusts and NHS Foundation Trusts within the SHA boundary.” “... Analysis of expenditure in this way should help PCTs examine the health gain that can be obtained from investment, and will help inform understanding around equity and how patterns of expenditure map to the epidemiology of the local population.”

12. It’s not just the map that matters, it’s the journey Programme budget spreadsheets and atlases provide the maps. Marginal analysis informs the direction of travel. Without a map we wouldn’t know where we were coming from or where we were going. We could neither describe the journey to others nor interpret their directions. Public and professional engagement would be merely tokenistic.

13. For each programme: look at investment all along the patient journey, including contributions of agencies outside the NHS Protecting good health Diagnosing ill health Restoring health Adjusting to chronic disability Easing the passing

14. So, get the right people together for each programme and ask: how much does our PCT spend on this programme at the moment? what are our programme objectives for each step along the patient journey from prevention to terminal care? what activity is being generated at present? what are our results? how do all these compare with our peers elsewhere in the NHS? could we do better with the resources between us?

15. The 12 PCTs most like NYYPCT East Riding of Yorkshire PCT East Sussex Downs and Weald PCT Gloucestershire PCT Herefordshire PCT Lincolnshire Teaching PCT Norfolk PCT North East Essex PCT North Somerset PCT Northumberland Care Trust Shropshire County PCT Somerset PCT Suffolk PCT

16. How do we differ from similar PCTs?

17. Where does the money go? NHS Hospital Trusts –YHFT –HDFT –STHT –SNEYT GMS, GDS, GOS GP medicines prescribing PCT provider services Non NHS Providers Other NHS Other £393,975,000 –£141,191,000 –£66,413,000 –£58,852,000 –£56,469,000 £143,743,000 £121,400,000 £130,496,000 £73,960,000 £42,746,000 £30,119,000

18. What were the top 10 programmes in hospitals? Circulation problems Cancers Genitourinary system Gastrointestinal system Musculoskeletal problems Reproduction and childbirth Neurological system problems Trauma and injuries Respiratory system problems Skin problems Eye/Vision problems £49,004,000 £45,548,000 £42,456,000 £38,377,000 £32,111,000 £31,584,000 £29,233,000 £28,702,000 £21,210,000 £13,532,000 £13,042,000

19. Top 10 programmes for GP prescribing? Circulation problems Endocrine problems Respiratory system problems Gastrointestinal system Mental health problems Neurological system problems Cancers Genitourinary system disorders Skin problems Musculoskeletal system Healthy individuals £27,509,000 £14,920,000 £12,723,000 £12,164,000 £10,234,000 £8,231,000 £5,378,000 £5,220,000 £5,184,000 £4,965,000 £4,225,000

20. Top 10 programmes for community services? Mental health problems Social care needs Learning disability Circulation problems Cancers Trauma and injuries Neurological system problems Musculoskeletal system Healthy individuals Dental problems Respiratory system problems £44,053,000 £13,738,000 £8,180,000 £6,431,000 £6,101,000 £5,690,000 £3,852,000 £3,749,000 £3,693,000 £2,981,000 £2,938,000

21. Circulation disorders: how did our spend compare with elsewhere? NYYPCT Cluster average Yorkshire and the Humber SHA average England average £13,479,000 £13,561,000 £12,403,000 £12,221,746 Spend per 100,000 weighted population, (DH)

22. How did our spend compare with elsewhere?

23. Where did the money for circulation go? NHS Hospital Trusts –YHFT –HDFT –STHT –SNEYT GP prescribing PCT provider services Non NHS Providers Other NHS providers Other £49,004,000 £15,492,000 £7,047,000 £10,888,000 £4,440,000 £27,509,000 £6,431,000 £1,739,000 £4,665,000 £2,803,000

24. How do our outcomes compare, eg “dying before our time”?

25. What about inequalities?

26. Inequalities in referrals? Coronary angioplasty by GP practice and deprivation score.

27. Equity, effectiveness, efficiency

28. Other factors Age impact, now and 10 years on Scope for inter-agency action at each step, but especially prevention and end of life. Current and future NICE guidelines Latest stroke guidance etc

29. Summary: redeployment of programme resources at each step in the patient pathway – transformational commissioning Prevention Diagnosis Treatment Chronic care Easing the passing

30. Conclusions 1.All five steps on the patient journey contribute to health and well-being 2.Programme objectives should be the “mission” in “commissioning” 3.PBMA is a world class commissioning competency and provides a framework to: collect evidence on inputs, outputs and outcomes; engage with partners, public, providers be accountable improve health and tackle inequalities stay in financial balance