Programme Budgeting – Testing The Approach in Scotland

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

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