1. Respiratory Benchmarking Packs Yorkshire and the Humber September 2010

2. Respiratory Benchmarking Packs We have taken two approaches to looking for unwarranted variation in respiratory health care 1. Benchmarking of all PCTs in the SHA against selected indicators 2. Health investment analysis for selected PCTs using programme budgeting tools

3. Purpose of Benchmarking Packs l The key purpose of the packs is to help engage local commissioners and clinicians in reducing unwarranted variation l Reducing unwarranted variation will improve outcomes for patients and reduce healthcare costs

4. Unwarranted Variation l Some variation may be accounted for by local population characteristics, but much is unwarranted and due to the different ways services are organised and delivered. What is achievable for patients in one area should be possible in all areas. l Unwarranted variation in respiratory healthcare wastes resources and adversely affects an individual’s chance of receiving timely and accurate diagnosis, of being offered appropriate treatment, of requiring emergency admission to hospital and of recovering after an exacerbation.

5. Questions will Generate Answers l By triangulating data from a number of sources, this analysis draws on a wide evidence base. l But the main purpose of the benchmarking packs is not to provide answers. l By highlighting unwarranted variation, the packs can be used to stimulate local dialogue about the quality of care that is commissioned and delivered. l Their value lies in helping us to formulate robust questions that clinicians and commissioners will want to address.

6. How do our Systems Compare with the Best? l So where expenditure is relatively high and outcomes relatively poor, where there are high rates of mortality, admission and length of stay compared with socio- demographically similar PCTs….. l Commissioners and clinicians will want to know whether local providers have similar systems and offer similar services to the best performing providers. l Your Director of Public Health, Quality Observatory and Public Health Observatory will be able to assist in interpreting the data and framing the questions.

7. Some Questions about Service Quality 1. Is there a local programme of case finding for COPD  to ensure early diagnosis, to optimise proactive management and to minimise risk of expensive hospital admission 2. Do GP practices and community providers offer:  quality-assured diagnosis  support for self-management  quality clinical review in line with NICE guidance  appropriate referral for LTOT assessment and pulmonary rehab  Appropriate assessment and review of oxygen requirement 3. Do hospitals offer:  access to specialist respiratory care  early measurement of blood gas status and assessment for NIV  optimal management of co-morbid conditions  early supported discharge or hospital at home

8. 1. Local PCT Benchmarking for selected indicators Analysis by Julian Flowers for ERPHO/APHO

9. Five Measures of Variation Burden and Detection Prevalence and gap between observed and expected prevalence Admission Rates Per 1000 COPD registered patients Hospital Utilisation Emergency bed days/1000 PCT residents, Quality Indicators Readmission rates, hospital mortality Cost In patient cost per 1000 population

10. Prevalence

11. COPD Admissions

12. Emergency Bed Days

13. COPD Readmissions

14. In Hospital Mortality

15. In Patient Cost

16. 2. Health Investment Analysis For Selected PCTs Commissioning Analysis and Intelligence Team Department of Health QIPP Right Care

17. 17 Health Investment slide packs - Respiratory The following Health Investment slides use programme budgeting tools to highlight variation in health care at PCT and practice level. For each SHA region, respiratory slide packs have been produced for selected PCTs where the evidence suggests that there may be significant variation in spend and outcome.

18. QIPP Right Care Respiratory Health Investment Packs Yorkshire and the Humber The following selected slides illustrate some of the key findings for two PCTs in the Yorkshire and the Humber: 1. NHS Sheffield 2.NHS Calderdale The full slide packs for each PCT are available separately. 18

19. NHS Sheffield Health Investment analysis QIPP Right Care

20. 20 Programme Budgeting Spreadsheet – Sheffield PCT Expenditure per 100,000 population (weighted by age, sex and need) on Respiratory Systems category – Green circle shows that the PCT has a high spend compared to most PCTs, both nationally (blue diamonds), and in similar PCT cluster (purple triangles)

21. QIPP Right Care 21 [2008/09] Each diamond represents a disease category and shows spend and outcomes compared to the national average – In Sheffield PCT Respiratory and Circulation have a higher spend with worse outcome when compared to other PCTs nationally. Mortality from all circulatory diseases: Under 75s Mortality from all cancers: Under 75s Patients on enhanced CPA receiving early FU Mortality from bronchitis, emphysema, COPD

22. QIPP Right Care 22 [2007/08] Programme Budget Atlas – Respiratory Systems Expenditure per 100,000 population (weighted for age, sex and need) – Darker areas represent higher spend – Sheffield spend is above average.

23. QIPP Right Care 23 [2007/08] Programme Budget Atlas - Respiratory Expenditure per 100,000 population (weighted for age, sex and need) filtered by ONS Cluster (Regional Centres) – Darker areas represent higher spend – Sheffield is above average compared to similar PCTs

24. QIPP Right Care 24 [2007/08] Programme Budget Atlas – Prevalence of COPD (QOF); Percent, all ages, Sheffield PCT has an above average prevalence of COPD

25. QIPP Right Care 25 [2007/08] Programme Budget Atlas – Fev1 checks for patients with COPD (QOF); Percent, all ages – Sheffield PCT has a low level of checks for patients with COPD

26. QIPP Right Care 26 [2007/08] Programme Budget Atlas – Respiratory Non-Elective Hospital Admissions per 100,000 population (weighted for age, sex and need) – Darker areas represent higher number of admissions – Sheffield PCT has a high number of Non-Elective Admissions

27. QIPP Right Care 27 [2007/08] Programme Budget Atlas – Respiratory Non-Elective Average Length of Stay per spell in hospital – Darker areas represent higher LOS – Sheffield PCT has a very high average LOS for Non-Elective Admissions

28. QIPP Right Care 28 [2007/08] Programme Budget Atlas – Respiratory Emergency Readmissions to hospital within 28 days of discharge – Darker areas represent higher number of readmissions – Sheffield PCT has a high number of Respiratory Emergency Readmissions

29. QIPP Right Care 29 [2008/09] NHS Comparators – GP Practice Level Comparison of Expenditure on Respiratory Emergency Admissions – Large variation between spend at practice level in Sheffield PCT Easy to identify high and low spending practices. Can compare practices within groups based on need of population

30. NHS Calderdale Health Investment analysis QIPP Right Care

31. 31 Programme Budgeting Spreadsheet – Calderdale PCT Expenditure per 100,000 population (weighted by age, sex and need) on Problems of the Respiratory System category – Green circle shows that the PCT has higher spend than most PCTs, both nationally (blue diamonds), and in similar PCT cluster (purple triangles)

32. QIPP Right Care 32 [2008/09] Each diamond represents a disease category and shows spend and outcome compared to the national average – In Calderdale PCT Respiratory has a higher spend with worse outcome when compared to other PCTs nationally. Mortality from all circulatory diseases: Under 75s Mortality from all cancers: Under 75s, Cancers was a high spend area in 2007/08 Patients on enhanced CPA receiving early FU Mortality from bronchitis, emphysema, COPD

33. QIPP Right Care 33 [2007/08] Programme Budget Atlas - Respiratory Expenditure per 100,000 population (weighted for age, sex and need) filtered by ONS Cluster (Centres with Industry) – Darker areas represent higher spend – Calderdale is above average compared to similar PCTs

34. QIPP Right Care 34 [2007/08] Programme Budget Atlas – Respiratory Mortality data - Years of life lost under 75 years per 10,000 population (weighted for age, sex and need) – Darker areas represent more years of life lost – Calderdale is average nationally.

35. QIPP Right Care 35 2007/2008 Programme Budget Atlas – Prevalence of COPD (QOF); Percent, all ages FY, Calderdale PCT has slightly above average prevalence of COPD

36. QIPP Right Care 36 2007/2008 Programme Budget Atlas – Fev1 checks for patients with COPD (QOF); Percent, all ages – Calderdale PCT has a below average level of checks for patients with COPD

37. QIPP Right Care 37 2007/2008 Programme Budget Atlas – Vaccination against influenza for patients with COPD (QOF) Patients all ages – Calderdale PCT has a low vaccination rate against influenza for patients with COPD

38. QIPP Right Care 38 [2007/08] Programme Budget Atlas – Respiratory Non-Elective Hospital Admissions per 100,000 population (weighted for age, sex and need) – Darker areas represent higher number of admissions – Calderdale PCT has an average number of Non-Elective Admissions

39. QIPP Right Care 39 [2008/09] NHS Comparators – GP Practice Level Comparison of Expenditure on Respiratory Emergency Admissions – Large variation between spend at practice level in Calderdale PCT Easy to identify high and low spending practices. Can compare practices within groups based on need of population

40. Conclusion l Benchmarking suggests there is significant unwarranted variation in the respiratory healthcare received by patients in this SHA region l What is achievable for patients in one area should be possible in all areas l By highlighting unwarranted variation, the packs can be used to stimulate local dialogue about the quality of care that is commissioned and delivered. l Their value lies in helping us to formulate robust questions that clinicians and commissioners will want to address.

41. Conclusion l Where expenditure is relatively high and outcomes relatively poor, where there are high rates of mortality, admission and length of stay compared with socio-demographically similar PCTs….. l Commissioners and clinicians will want to know whether local providers have similar systems and offer similar services to the best performing providers.