1. Enhanced Services- Programme Budgeting and Marginal Analysis Health Economics Team

2. Contents 1.Introduction 2.Literature Review 3.PBMA Process 4.Feedback 5.Conclusion

3. Introduction NHS Ayrshire & Arran provide a number of Enhanced Services to its patients Enhanced Service is provided by the GP in addition to their core contract Usually reimbursed through a per item fee – set tariff However issues around allocation of the Enhanced Services budget

4. Introduction Requires a prioritisation exercise assessing the relative value for money of the services PBMA a technique which can support decision making regarding prioritisation Identify areas for investment through disinvestment Real life NHS resource allocation problem with multiple stakeholders

5. Literature Review Prior to starting project commissioned a literature review examining theory and implementation of technique Identified the stages of a PBMA which formed structure of the project (Mitton and Donaldson, 2004) Some variation in the literature but appeared to follow a similar process Kemp and Fordham (2007) Norfolk example as one of particular relevance

6. PBMA Key Stages 1.Stakeholder Group 2.Enhanced Services for Review 3.Programme Budget 4.Criteria 5.Evidence Packs 6.Scoring and Evaluating the Services 7.Analysis and Prioritisation

7. Stakeholder Group Existing Enhanced Services Group made up of Primary Care Managers, Finance Managers, Public Health, GPs Included Secondary Care colleagues for wider scope Also included members of the public Recruited through appropriate department and an advert to patient groups through practice managers

8. Services to Evaluate Diabetes Medicines Reconciliation H Pylori Eradication Adults with Learning Disabilities Contraceptive Implants A&E Frequent Attendees Service for Carers Ring Pessary Fitting & Maintenance Minor Injuries Specialist Dermatology Service

9. Programme Budget ServiceAllocation Diabetes500,000 H Pylori140,000 Medicines Reconciliation96,442 Learning Disabilities90,000 Contraceptive Implants76,000 Dermatology66,000 Service for Carers40,000 Ring Pessary35,000 Minor Injuries32,000 A&E Frequent Attendees0

10. Programme Budget

11. Criteria Variation in services in terms of outcomes and how they are delivered Need to determine a ‘global’ measure of benefit which allows comparison to be made Can be achieved through developing a common set of relevant criteria to judge the options against Can be developed either through top down or bottom up approach

12. Criteria How important are these criteria? –Effectiveness –Patient Experience –Practicality –Impact on Sec. Care –Sustainable

13. Criteria Weights How important are these criteria? –Effectiveness –Patient Experience –Practicality –Impact on Sec. Care –Sustainable 12 10 11 7 10

14. Evidence Pack Next stage in the process is where all participants score each service against our criteria To do this need evidence/information prepare participants for scoring session Particularly members of the public who are reliant on information for scoring Coherent and systematic approach for generating pack and compiling evidence

15. Scoring ServiceEffective- ness Patient Exp. Practical.Imp on Secondary Care Sustain. Diabetes Patient Safety H-pylori Eradication

16. All group results ServiceWeighted Benefit Score Diabetes415 Contraceptive Implants405 H Pylori402 Ring Pessary383 Minor Injuries372 Dermatology370 Learning Disabilities348 Medicines Rec.344 Service for Carers318 A&E Frequent Attend.196

17. All group results ServiceWeighted Benefit ScoreCurrent Allocation Diabetes41547% Contraceptive Implants4057% H Pylori40213% Ring Pessary3833% Minor Injuries3723% Dermatology3706% Learning Disabilities3488% Medicines Rec.3449% Service for Carers3184% A&E Frequent Attend.1960%

18. Cost value ratio Allocation of resources across the services very different and need to standardise for comparison Calculated a cost per “beneficiary” for each service under review Divide the cost per beneficiary by the number of points of each service This gives you a cost per benefit point (cost value ratio) which is a measure of cost-effectiveness

19. All group results ServiceCost value ratio Medicines Rec.0.47 Service for Carers1.66 H Pylori6.22 Diabetes6.89 Contraceptive Implants6.94 Learning Disabilities12.69 Ring Pessary13.04 Minor Injuries14.33 Dermatology29.77 A&E Frequent Attend.95.46

20. All group results ServiceCost value ratioCurrent Allocation Medicines Rec.0.479% Service for Carers1.664% H Pylori6.2213% Diabetes6.8947% Contraceptive Implants6.947% Learning Disabilities12.698% Ring Pessary13.043% Minor Injuries14.333% Dermatology29.776% A&E Frequent Attend.95.460%

21. Discussion Results generated much discussion regarding prioritisation, disinvestment, methodology, redesign, public involvement and GP re-imbursement Reflect upon results and re-review at a future Enhanced Services meeting Potential aim to agree a few services for investment or disinvestment Inform further piece of work regarding “impact assessment” outwith PBMA process

22. Feedback Primary care expressed that technique prompted in depth discussion regarding prioritisation Expressed view to use technique differently to prioritise larger parts of the Primary Care budget Process generalisable and interest expressed in using it to prioritise other funding decisions Well received within NHS Ayrshire & Arran and Senior Directors

23. Conclusion Real life resource allocation problem requiring a prioritisation process PBMA provided a direction of travel regarding future allocation of resource Challenging piece of work and time consuming/intensive However information provided unique and process enables a degree of transparency in decision making

24. Sub-group scores

25. GP results ServiceCost value ratioCurrent Allocation Medicines Rec.0.479% Service for Carers1.464% H Pylori6.4213% Diabetes6.6647% Contraceptive Implants6.717% Ring Pessary11.653% Learning Disabilities12.048% Minor Injuries14.873% Dermatology30.846% A&E Frequent Attend.92.210%

26. Public results ServiceCost value ratioCurrent Allocation Medicines Rec.0.509% Service for Carers1.774% H Pylori6.2013% Diabetes6.9947% Contraceptive Implants7.157% Learning Disabilities13.138% Ring Pessary13.833% Minor Injuries15.053% Dermatology35.116% A&E Frequent Attend.78.470%

27. NHS Managers results ServiceCost value ratioCurrent Allocation Medicines Rec.0.469% Service for Carers1.684% H Pylori6.1013% Contraceptive Implants6.867% Diabetes6.9347% Learning Disabilities12.378% Ring Pessary12.943% Minor Injuries13.633% Dermatology26.176% A&E Frequent Attend.115.750%