Enhanced Services- Programme Budgeting and Marginal Analysis

Enhanced Services-Programme Budgeting and

Marginal Analysis

Health Economics Team

Contents

1. Introduction

2. Literature Review

3. PBMA Process

4. Feedback

5. Conclusion

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

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

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

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

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

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

Programme Budget

Service Allocation

Diabetes 500,000

H Pylori 140,000

Medicines Reconciliation 96,442

Learning Disabilities 90,000

Contraceptive Implants 76,000

Dermatology 66,000

Service for Carers 40,000

Ring Pessary 35,000

Minor Injuries 32,000

A&E Frequent Attendees 0

Programme Budget

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

Criteria

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

Criteria Weights

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

12

10

11

7

10

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

Scoring

Service Effective-ness

Patient Exp.

Practical. Imp on Secondary

Care

Sustain.

Diabetes

Patient Safety

H-pylori Eradication

All group results

Service Weighted Benefit Score

Diabetes 415

Contraceptive Implants 405

H Pylori 402

Ring Pessary 383

Minor Injuries 372

Dermatology 370

Learning Disabilities 348

Medicines Rec. 344

Service for Carers 318

A&E Frequent Attend. 196

All group results

Service Weighted Benefit Score Current Allocation

Diabetes 415 47%

Contraceptive Implants 405 7%

H Pylori 402 13%

Ring Pessary 383 3%

Minor Injuries 372 3%

Dermatology 370 6%

Learning Disabilities 348 8%

Medicines Rec. 344 9%

Service for Carers 318 4%

A&E Frequent Attend. 196 0%

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

All group results

Service Cost value ratio

Medicines Rec. 0.47

Service for Carers 1.66

H Pylori 6.22

Diabetes 6.89

Contraceptive Implants 6.94

Learning Disabilities 12.69

Ring Pessary 13.04

Minor Injuries 14.33

Dermatology 29.77

A&E Frequent Attend. 95.46

All group results

Service Cost value ratio Current Allocation

Medicines Rec. 0.47 9%

Service for Carers 1.66 4%

H Pylori 6.22 13%

Diabetes 6.89 47%

Contraceptive Implants 6.94 7%

Learning Disabilities 12.69 8%

Ring Pessary 13.04 3%

Minor Injuries 14.33 3%

Dermatology 29.77 6%

A&E Frequent Attend. 95.46 0%

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

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

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

Sub-group scores

GP results

Service Cost value ratio Current Allocation

Medicines Rec. 0.47 9%

Service for Carers 1.46 4%

H Pylori 6.42 13%

Diabetes 6.66 47%

Contraceptive Implants 6.71 7%

Ring Pessary 11.65 3%

Learning Disabilities 12.04 8%

Minor Injuries 14.87 3%

Dermatology 30.84 6%

A&E Frequent Attend. 92.21 0%

Public results

Service Cost value ratio Current Allocation

Medicines Rec. 0.50 9%

Service for Carers 1.77 4%

H Pylori 6.20 13%

Diabetes 6.99 47%

Contraceptive Implants 7.15 7%

Learning Disabilities 13.13 8%

Ring Pessary 13.83 3%

Minor Injuries 15.05 3%

Dermatology 35.11 6%

A&E Frequent Attend. 78.47 0%

NHS Managers results

Service Cost value ratio Current Allocation

Medicines Rec. 0.46 9%

Service for Carers 1.68 4%

H Pylori 6.10 13%

Contraceptive Implants 6.86 7%

Diabetes 6.93 47%

Learning Disabilities 12.37 8%

Ring Pessary 12.94 3%

Minor Injuries 13.63 3%

Dermatology 26.17 6%

A&E Frequent Attend. 115.75 0%