Publication - Progress report

Programme Budgeting – Testing The Approach in Scotland

Published: 18 Apr 2012
Part of:
Health and social care
ISBN:
9781780457468

This paper describes the pilot application of Programme Budgeting and Marginal Analysis (PBMA) in Scotland. Within the Health Care Quality Strategy for NHSScotland one of the three quality ambitions is concerned with providing a more efficient and effective health service. This paper supports this ambition by discussing how outcome measures could be used, along with cost data disaggregated in this way, to inform discussions around the value for money associated with different programmes.

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40 page PDF

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Contents
Programme Budgeting – Testing The Approach in Scotland
4. Preliminary findings - top down approach

40 page PDF

655.1 kB

4. Preliminary findings - top down approach

Activity

27. NHSScotland activity was allocated to the 21 programmes, with the exception of A&E, community, and prevention activity and expenditure, which it was not possible to disaggregate at this time. Total activity by programme is disaggregated and shown in Table A1 in Appendix A.

Expenditure

28. Overall, all NHS Scotland expenditure was allocated to the 21 programmes (Table A2 in Appendix A). The biggest category was 'other', which incorporates much of the community activity in Scotland as well as other activity that cannot be allocated by diagnostic category. The high level (estimated) results are shown in Table 4.1 with proportions from the English PB exercise included for comparison.

Table 4.1: Programme budgeting categories & associated estimated spend

Programme Budgeting Category All Services Percentage % from
English PB
exercise
All Other £2,363,206,181 29.3% 31.4%
Problems of circulation £756,720,451 9.4% 7.8%
Mental Health Disorders £728,254,492 9.0% 11.0%
Problems of the respiratory system £508,300,584 6.3% 4.0%
Problems of the gastro intestinal system £481,524,197 6.0% 4.4%
Cancers and Tumours £475,299,004 5.9% 5.3%
Neurological £437,592,278 5.4% 3.7%
Dental problems £374,083,410 4.6% 3.2%
Problems due to Trauma and Injuries £357,432,705 4.4% 3.3%
Problems of Genito Urinary system £314,612,189 3.9% 3.9%
Problems of the Musculo skeletal system £290,808,712 3.6% 4.4%
Problems of the Skin £203,331,806 2.5% 1.8%
Endocrine, Nutritional and Metabolic problems £195,824,862 2.4% 2.6%
Problems of Vision £185,093,353 2.3% 1.7%
Infectious diseases £85,184,967 1.1% 1.4%
Adverse effects and poisoning £89,540,357 1.1% 0.9%
Maternity and Reproductive Health* £77,496,004 1.0% 3.2%
Disorders of Blood £65,608,322 0.8% 1.3%
Problems of Learning Disability £49,220,106 0.6% 3.0%
Problems of Hearing £24,565,963 0.3% 0.5%
Conditions of neonates* £1,989,574 0.0% 1.0%
Total expenditure £8,065,689,520 100% 100%

* the majority of these data are currently included in the other category
Data source: ISD data request

29. A few of the estimates presented are worthy of comment. At the time of analysis it was not possible to map maternity spend and as a result the majority of the data is in the "other" category. This problem is being resolved. We are aware of data quality and completeness issues with LD data across both hospital and community care, so this category should be treated with caution and the low percentage will be one of the resulting effects. Conversely dental spend may seem high, in relative terms, because it was possible to map comprehensively from existing datasets to the programme budgeting category.

30 Table A2 in the Appendix further disaggregates the spend shown in Table 4.1, allowing comparison across programmes in terms, for example, of acute services, out patients, GP attendances or primary care prescribing.

Figure 1

Figure 1: Proportional spend on Programme Budgeting Categories

32 Figure 1 is a graphical representation of some of the data in Table 4.1. It shows the relative proportion of total spend across the programme budget categories in England and Scotland. Although not presented here, a similar analysis could be done for elements of the total spend such as GMS or prescribing or acute care. Also, within a programme budget, the data shows the distribution of spend across different care settings. The availability of time series would enable analysis of any shifts in these.

Detailed programme budgets

33. Four programme budgets were identified for further examination - mental health, cancer services, diabetes and stroke. Information and expenditure relating to A&E and community services were unable to be allocated to individual programmes. For the diabetes and stroke sub programmes, it was not possible to allocate outpatient activity and costs.

4.1 Mental health

34. Mental health disorders form a programme budget category in their own right. Total expenditure was estimated to be £728 million, which represents 9% of total NHSScotland expenditure. The programme budget is subdivided into 5 separate sub programmes - substance misuse, organic mental disorders, psychotic disorders, child & adolescent (C&A) mental health disorders and other mental health disorders. Table 4.2 shows the activity associated with these sub programmes and with the different service provision.

Table 4.2: Mental health estimated activity

Sub
programme
Acute
services
episodes
Geriatric
long stay
episodes
Mental
health &
learning
disabilities
episodes
OP
attendances
Pharmaceutical
items
dispensed
GMS
visits
Substance misuse 5,323 17 3,566 - 816,808 184,365
Organic MH disorders 3,208 599 3,657 - 95,819 21,959
Psychotic disorders 297 4 8,829 - 693,301 25,079
Child and Adolescent MH disorders[16] 24 - 12 27,259 71,794 788
Other MH disorders 1,863 21 8,055 252,191 5,949,285 767,671
All 10,714 641 24,119 279,450 7,627,007 999,863

Data source: ISD data request

Note: these figures have been apportioned across all activity to ensure they cover the activity figures reported in the Costs Book

The associated expenditure is shown in table 4.3

Table 4.3: Mental health estimated expenditure

Total
(£)
Acute
services
episodes (£)
Geriatric
long stay
episodes (£)
Mental
health &
learning
disabilities
(£)
OP services
(£)
Pharma-
ceutical
items
dispensed
(£)
GMS visits
(£)
Substance misuse 63,882,023 7,014,704 188,296 28,629,093 0 22,083,882 5,966,048
Organic MH disorders 169,203,520 19,332,568 16,087,125 12,1717,842 0 11,355,377 710,608
Psychotic disorders 239,842,417 776,063 57,007 203,349,257 0 34,848,537 811,553
Child and Adolescent MH disorders 11,058,935 68,354 0 746,637 5,984,579 4,233,858 25,507
Other MH disorders 244,267,596 4,389,840 361,292 118,967,816 38,674,192 57,032,602 24,841,855
All 728,254,492 31,581,529 16,693,721 473,410,644 44,658,771 129,554,256 32,355,571

Data source: ISD data request

Outcomes associated with mental health services

Process outcomes

  • Early diagnosis and treatment of dementia
  • Alcohol brief interventions delivered
  • Readmissions within 28 / 133 days

Intermediate outcomes

  • Reduced suicide rates / 1000 population

4.2 Cancer services

35. Cancer is a programme budgeting category in its own right and is split into 8 sub programmes, reflecting the major tumour sites. Cancer services estimated expenditure was £475 million, representing 5.9% of total NHSScotland budget. This excludes cancer screening programmes, which are included in the 'other' category. Additionally we know that activity and cost associated with radiotherapy may not well captured by the data.

Table 4.4: Cancer services estimated activity

Sub programme Acute
services
episodes
Geriatric
long stay
episodes
OP
services
Pharmaceutical
items
dispensed
GMS
visits
Cancer, Head and Neck 5,354 9 2,739
Cancer, Upper GI 14,504 56 - 9,878
Cancer, Lower GI 23,030 76 74 8,030
Cancer, Lung 18,166 95 - 11,844
Cancer, Skin 5,885 2 - 5,334
Cancer, Breast 24,223 35 140,441 10,422
Cancer, Gynaecological 10,590 15 4,091 2,636
Cancer, Urological 13,583 67 32,802 18,606
Cancer, Haematological 27,179 41 - 5,753
Cancers and Tumours 45,627 121 976,206 120,120
All 188,141 517 144,624 1,153,614 195,363

Data source: ISD data request

Table 4.5: Cancer services estimated expenditure

Total (£) Acute
services
episodes (£)
Geriatric
long stay
episodes
(£)
OP
services (£)
Pharmacy
items
dispensed
(£)
GMS visits
(£)
Cancer, Lower GI 60,978,784 59,683,596 1,010,581 24,753 259,853
Cancer, Lung 47,939,226 46,216,400 1,339,545 0 383,282
Cancer, Skin 9,553,213 9,337,406 43,187 0 172,620
Cancer, Breast 47,632,653 34,210,952 1,228,245 11,856,203 337,253
Cancer, Gynaecological 18,996,935 18,704,807 83,166 123,667 85,294
Cancer, Urological 39,065,959 30,356,771 1,205,788 6,901,309 602,092
Cancer, Haematological 51,530,511 50,528,473 815,869 0 186,170
Cancers and Tumours 146,101,588 88,274,471 2,050,777 26,832,657 3,887,085
All 475,299,004 389,749,741 8,432,124 25,056,598 45,738,589 6,321,952

Data source: ISD data request

Outcomes associated with cancer services

36. There are a range of outcome measures, including morbidity and mortality data, and comparative data with EUROCARE. This is collected and published by the Scottish Cancer Registration Scheme, managed by ISD. Information about the process of cancer care is collected by the cancer networks on an individual cancer basis.

4.3 Diabetes

37. Diabetes is not a programme budget category in its own right, but comes under the programme 'endocrine, nutritional and metabolic problems' which together account for an estimated £196 million expenditure (2.4% total budget). Within this, diabetes accounts for total expenditure of £93 million, or 1.2% of the NHSScotland budget.

Table 4.6: Diabetes estimated activity

Acute services
episodes
Geriatric long stay
episodes
Pharmaceutical
items dispensed
GMS visits
5,996 71 2,620,120 451,692

Data source: ISD data request

Table 4.7: Diabetes estimated expenditure

Total (£) Acute services
episodes (£)
Geriatric long stay
episodes (£)
Pharmaceutical
items dispensed
(£)
GMS visits (£)
93,000,152 11,964,874 1,906,408 64,512,096 14,616,774

Data source: ISD data request

Outcomes associated with diabetes services

Process outcomes

  • Attendances at retinal screening
  • Attendances at structured education
  • Use of intensive insulin therapy
  • Attendances at foot screening

Intermediate outcomes

  • Reduced incidence of sequelae, including nerve/ eye/ kidney/ cardiovascular disease

Comment

38. This is likely to be a significant underestimate of the cost of diabetes to NHSScotland. For example, the Department of Health's advisory body, NHS Diabetes estimates that care of people with diabetes consumes around 5-8% of the UK NHS budget, while Diabetes UK estimate the cost is around 10%.

39. There are a number of reasons why this may be the case, including:

  • the use of first diagnostic place for hospital data as the determinant of programme budget, as many diabetes related admissions would be categorised according to the complication or co-morbidity rather than diabetes.
  • the inability to allocate outpatient and community activity (the majority of diabetes care occurs in primary care) and expenditure to this programme budget.

4.4 Stroke

40. Like diabetes, stroke forms part of a larger programme budget grouping, in this case, 'problems of circulation', which together accounts for an estimated £757 million expenditure (9.4% of total) and forms the largest clinical programme budget group. Within this programme, estimated stroke expenditure is £146 million, or 1.8% of total NHSScotland expenditure.

Table 4.8: Stroke estimated activity

Acute services
episodes
Geriatric long stay
episodes
Mental health &
learning
disabilities
Pharmaceutical
items dispensed
GMS visits
20,671 792 1 1,095,584 259,420

Data source: ISD data request

Table 4.9: Stroke estimated expenditure

Total (£) Acute services
episodes (£)
Geriatric long
stay episodes
(£)
Mental
health &
learning
disabilities
(£)
Pharmaceutical
items dispensed
(£)
GMS visits
(£)
146,453,319 104,629,685 24,438,551 8,344 8,891,918 8,394,821

Data source: ISD data request

Outcomes associated with stroke services

Process outcomes

  • Use of primary and secondary prevention
  • Administration of thrombolysis
  • Admission to stroke units
  • Access to imaging

Intermediate outcomes

  • TIAs and strokes prevented
  • Improved 30 day survival
  • Reduced long term disability

Contact

Email: Marjorie Marshall