Expenditure Review 2009/10-2013/14 & Planning to 2015/16 ... · November 2015 NI HSC Financial Overview Expenditure Review 2009/10-2013/14 & Planning to 2015/16 ... complex health

November 2015

NI HSC Financial Overview Expenditure Review 2009/10-2013/14 &

Planning to 2015/16

HSCB Finance

1

Preface

In recent years, despite austerity and the associated financial constraints, the HSC has

continued to respond effectively to the challenge of an ageing population with increasingly

complex health and social care needs. At the same time, new technologies, drugs and

treatments have been implemented which have improved both life expectancy and quality

of life for many in our local population.

Since its inception the HSCB has sought to balance the challenges of commissioning safe and

sustainable services which meet the emerging and changing needs of local populations with

the financial resource constraints and the aim of ensuring resources available are

maximised.

In order to plan and monitor progress a range of detailed reports are produced by HSC

organisations. This report highlights some of the key findings that can be drawn from the

various reports to answer a number of important questions such as:

What resources are available for Health and Social Care in NI and where are they spent?

What are the main challenges impacting on the financial resources wellbeing of the NI

population?

The Public is naturally concerned about change, particularly when it is being managed in a

time where resources are constrained. This overview provides evidence of significant

improvements in productivity, outcomes and strategic shifts in services in line with the

transformation agenda. All of this is only possible through the hard work, dedication and

innovation of staff across the HSC.

Looking to the foreseeable future, the significant financial challenges will continue.

Nevertheless, reviewing past performance provides reassurance of achievements delivered

for HSC in NI and the organisation’s capacity to respond to these challenges ahead.

Paul Cummings

Director of Finance

What resources are available for Health and Social Care in NI and where are they spent?

What are the main challenges impacting on the financial resources available?

How has the HSC responded to addressing this financial challenge?

How can HSC performance demonstrate the progress achieved to date in meeting this

significant financial challenge:

- Efficiencies delivered

- Financial trends demonstrating targeted investment and shift of services

- Strategic change by Programme of Care

What real improvements in outcomes have been achieved for the health and wellbeing of the

NI population?

What have been the key developments in recent years and consideration of future trends?

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SECTION 1: WHAT RESOURCES ARE AVAILABLE FOR HEALTH & SOCIAL CARE IN NI AND

WHERE ARE THEY SPENT?

The Health and Social Care Board (HSCB) and its Local Commissioning Groups (LCGs) are

responsible for the commissioning of a comprehensive range of Health and Social Care

Services for the population of Northern Ireland.

MAP –by LCG area with population numbers

The Health and Social Care Board (HSCB) receives over £4 billion of resources from the

DHSSPS. This represents a significant proportion of the total resources available for NI public

sector funding (approx. 46% of non-ring fenced resource funding in 2015/16).

Flow of funds and responsibilities of organisations are set out below.

Note: Indicative figures shown in line with plans 2015/16 – may be subject to change.

NI Executive Revenue Funding £10+billion

Other NI Executive Departments

DHSSPS Policy & Strategy

£4.5+bn

NI Fire & Rescue Service

HSCB & PHA Commissioning,

performance and planning £4+bn

Central DHSSPS

Family Health Services

£1bn

NI Trusts 5 HSC Provider Trusts & NI Ambulance Service

Delivery of services £3+bn

Other HSC Providers including:

HSCB, PHA, BSO & Voluntary

Organisations

3

Planned Utilisation of Commissioning Resources 2015/16 The HSCB commissions services across a range of health groups (programmes of care, POC)

and from a number of providers including local Trusts, Family Health Services, NI Ambulance

services and Community and Voluntary organisations.

HSC Provider Trusts (excluding NIAS)

Family Health Services

We have significant resources available for HSC in NI – with some of the key areas where

this money is spent highlighted below.

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1.8 million Total NI population

We have significant resources for HSC in NI:

£4+ billion

To enable the delivery of Health & Social Care (HSC) services to the population of NI

we commit:

£12m every 24 hours £84m per week

54K HSC Staff (WTE)

Hospital Activity

1.8m Inpatient days

2.6m Outpatient attendances

737k A&E attendances

300k+ Day Case attendances

2013/14 Hospital activity (annual total) as reported through Trust Financial Returns

Community & Personal Social Services Activity

15.5m Domiciliary Care hours

(hours of care delivered to people in their own homes)

2.9m Nursing contacts (includes District Nursing, Health Visiting, Specialist & other nursing)

1.7m Allied Health Professional (AHP)

contacts

100k+ Social Work cases (children, teenagers, adults)

2013/14 activity (annual total) as reported through Trust Financial Returns

18,400+ Nurses (including midwifery, health

visiting & nursing support)

3,800+ Doctors

6,700+ Social services (Including social workers &

social care staff)

7,200 Professional & Technical staff (Including Allied Health

Professionals, pharmacists, radiographers)

All staff WTEs at March 14 per

DHSSPS Workforce Census

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A wide range of services are provided within NI Hospitals and Community settings

including provision of Personal Social Services.

The top expenditure categories within these areas are highlighted below (Source: TFR

2013/14).

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SECTION 2: WHAT ARE THE MAIN CHALLENGES IMPACTING ON THE FINANCIAL

RESOURCES AVAILABLE?

Health and Social Care in Northern Ireland has faced a period of unprecedented challenge in

recent years, with increasing demand for services as our population has grown, particularly

the elderly population, and needs also becoming more complex, with an increasing

prevalence of chronic, long term conditions.

Alongside the service pressures within the HSC system there has been an increasingly

challenging financial environment, with growing cost pressures and resource funding

constraints.

HSC Pressures and Areas of Investment

There have been and continue to be significant, inescapable pressures for HSC. Some of

these key areas which have driven pressure on HSC resources are represented below.

Demographics

HSC PRESSURES / INVESTMENTS

REQUIRED

Service Pressures / Developments

Specialist Hospital - Catheterisation Labs - Paediatric intensive care - Neurosurgery Other - Pseudomonas - Children with disabilities - Looked after children - Adult safeguarding - Resettlements - Health Promotion - Out of hours

New NICE approved drugs & growth in

existing Including:

- Cancer - HIV - MS - Biologic therapies -

New technologies

- Electronic Care Record - Theatre & bed management

systems - Cancer patient pathways - Electronic Prescribing - Assistive technologies (for

physical / sensory impaired) - Telecare, telemonitoring

Increasing Complexity

- Co-morbidities - Dementia - Later in life

pregnancies

Long term conditions

- Diabetes - COPD - Asthma - Stroke - Palliative Care

Pay & Inflation

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NI Changing Demographics

Changing demographics have impacted the demand for health and social care services and

resources required to meet those increasing demands. The chart below represents the

proportion of the total NI population by main age band groupings, compared against the

proportion of total NI HSC financial resources required for each age group (for 2013/14).

As expected, the older population consumes significantly more resources than other age

groups.

Population growth from 2009/10 to 2013/14 was 3% in total terms, with over 1.8m people

in NI in 2013/14. The older population (65+ age group) increased the most, by 10% to

266,000 people, and within this the 85+ age group increasing by 14%.

This has driven an increasing overall demographic pressure in recent years (6% cumulatively

from 2009/10 to 2013/14) which will only increase more rapidly as the older population

continues to grow - from 2015-2023 the number of people aged 65+ is estimated to increase

by over 26% (to 353,000 older people).

It is important to note that children and the elderly population have their own dedicated

programmes of care (Family and Child Care and Elderly Care respectively), however these

populations also receive HSC services across other healthcare programmes.

For graphics (people / other):

We invest significant HSC resources across the total population of NI.

These are the average spends per head of population (per 2013/14 Age Cost Curve, DHSSPS

Info & Stats):

0-15 years age group – we spend on average £1.2k per head Within this group the youngest children (0-4 years) spend is on average £1.8k per head & the 5-15 years age group spend per head is approx. £0.9k 16-64 years age group – we spend on average £1.2k per head 65+ years age group – we spend on average £5k+ per head Within this 65+ group the oldest population (85+ years) spend is on average £13k per head

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The Financial Challenge for HSC

The impact of these challenges and pressures to the HSC system in Northern Ireland in

financial terms equates to a pressure of approximately 6% per annum in cash terms, against

average additional resources available each year of up to 3% - creating a significant funding

gap year on year. This reflects a trend similar to the rest of the UK, where government

expenditure on HSC has been increasing at a much slower rate in recent years.

SECTION 3:

The impact of these pressures, and the savings and efficiencies required to be delivered to

ensure HSC continues to live within the constrained resources available are demonstrated

below. These reflect the financial challenge for HSC in NI in 2015/16.

Scales

Annual Cash Pressures 6% v Budget Increases 3%

Funding gap identified in McKinsey’s ‘Reshaping the System’ from 2011-2015: based on average annual budget increases of up to 3% against annual cash pressures of 6%

£302M TOTAL PRESSURES

Pay & Inflation

£37M

Demography £26M

Trust Accumulated Pressures

£131M

FHS & Primary Care

£28M

£80M

£80m

£302M SOURCES REQUIRED

Additional DHSSPS Funding

£150M

Trust Savings £85M

FHS Savings (Including prescribing)

£22M

In year easements (commencement delays)

£23M

Service Pressures

£80M

£80M

£80m

Reduction in planned elective funding

£22M

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SECTION 3: HOW HSC HAS RESPONDED TO ADDRESSING THIS FINANCIAL CHALLENGE?

The HSC has been faced with the impact of these significant financial pressures over a

number of years.

This has meant providing more for less, whilst maintaining safety and improving quality,

through measures including new ways of working, reform of services and productivity. This

has only been made possible with the hard work, dedication and innovation of staff across

the HSC.

Plans are developed across HSC organisations on an annual basis, including the financial

plan, which seeks to address the funding gap for HSC through a combination of cash savings,

productivity and easements where services have been phased in at a slower pace than

planned.

In order to help fund the pressures facing HSC and deliver financial stability, the HSCB has

had to set challenging savings targets each year.

Difficult choices have had to be made, however through careful planning the HSC has tried

to concentrate on achieving its savings through areas which have the lowest impact on

service users. Targeted savings measures have been set with this objective. By addressing

the challenge of savings and delivering productivity alongside a longer term reform strategy

we have improved effectiveness and health outcomes as well as efficiency.

£400m+

Total cash and productivity savings targets for HSC Trusts

From 2010/11 – 2014/15

£130m+

Efficiency savings targets for Pharmacy from 2010/11 – 2013/14 with the

implementation of the Pharmaceutical Clinical Effectiveness Programme

strategy

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Maximising technology

- Telecare &

telemonitoring

- Electronic Prescribing

Targeted Early

Intervention

Supporting people at home &

avoiding hospital admissions

- Management of long term

conditions

- Reablement

- Rapid Response Nursing

Targeting efficiency through COST SAVINGS &

IMPROVED PRODUCTIVITY

Maximising

Productivity

Earlier discharge from

hospital (reducing length

of stay)

- Reducing readmissions

- Targeting DNAs

- Increased Day cases

Targeted Reductions

Staff Skill mix

Staff sickness

Avoiding excess travel

REFORM can also drive efficiency

and effectiveness

Procurement Strategy

Improving value for money

- Economies of scale

- Centralised purchasing

Health Promotion &

Prevention

To improve health and also

saving costs in the long term

- New screening &

vaccination programmes

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SECTION 4: HOW CAN HSC PERFORMANCE DEMONSTRATE THE PROGRESS ACHIEVED TO

DATE IN MEETING THIS SIGNIFICANT FINANCIAL CHALLENGE?

The financial agenda for HSC has been taken forward to address the rising service and cost

pressures – by maximising efficiencies and productivity across all services in order to ensure

we live within our resources and deliver financial break even. At the same time the HSC

through its longer term transformation agenda has sought to ensure services are not only

efficient but also effective in delivering improved health and social care outcomes.

Financial and activity information over time can provide evidence of the combined impact of

all these on expenditure patterns.

Information reported in the annual Board, Department and Trust financial and activity

returns provides performance data across a wide range of resource areas. Actual

expenditure is available 6 months after the financial year end (latest available is 2013/14).

In order to allow for comparisons of spend year on year the reported expenditure (‘Cash

Terms’) has been adjusted to take account of inflationary costs, by applying the UK GDP

deflator1 – allowing the ‘Real Terms’ comparative spend to be identified.

The chart below represents HSC expenditure reported for the main service providers in

Northern Ireland to 2013/14.

Total expenditure in 2013/14 was £4.36bn – an increase in cash terms of 11% over the four

year period from 2009/10, i.e. an average annual increase in cash terms of over 2.6%.

In real terms, after accounting for the impact of inflation, this means the increase in

expenditure has been managed to just 2% in real terms in total across the review period

from 2009/10 to 2013/14.

1 See Appendix 3 GDP Deflator (Inflation Adjustment Factor)

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Efficiencies Delivered

(HSC Trusts 2009/10 – 2013/14)

Community Efficiencies Activity Increases Unit Cost Savings District Nursing +13% -15%

Health Visiting +8% -13%

Physiotherapy +49% -10%

Speech & Language +21% -10% Therapy

Activity (contacts) and unit cost savings (costs per contact) in 2013/14 compared to 2009/10

Hospital Efficiencies Length of Stay Savings Unit Cost Savings

General Medicine - 30% - 26%

General Surgery -11% - 1%

Trauma & Orthopaedics -9% - 9%

Savings in Average Length of Stay (inpatient days) and costs per Finished Consultant Episode (FCE) from 2009/10 to 2013/14

Activity Based Funding

Hospital reference cost comparisons v

England still show scope for

improvement, but do demonstrate a

significant improvement to 2013/14

19%

11%

The cost variation of NI reference costs

compared to England has reduced from circa 19% in 2009/10 to 11%

in 2013/14 – an improvement of over £50m in cash terms

Other Improvements

Domiciliary Care lower cost provision (Expenditure increases have been managed to 3%

in real terms compared to an increase of 8% in activity (domiciliary hours of care) from 2009/10 to

2013/14)

Management of corporate spend (Real terms reduction in Hospitals overhead spend

from 2009/10 to 2013/14)

Hospital Improvements

Day Case Rates Increased from 74.2% (2010/11) to 77.8% (2013/14)

Outpatient DNA (Did Not Attend) Rates Reduced from 10.4% (2010/11) to 9.1% (2013/14)

Source: NISRA Annual HSC Statistics

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Financial Trends - demonstrating targeted investment and shift in services

Investment has been targeted in recent years to ensure care is delivered in the most

appropriate settings, promoting choice, independence and focussing on early intervention

and prevention.

A consistent theme has been the need to reduce our reliance on hospital and institutional

care, while focusing investment on prevention, early intervention and the development of

more responsive and individualised care closer to home - with the benefits of some of these,

such as investment into health promotion being realised into the longer term.

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This can be evidenced through some of the key trends in NI HSC Trusts’ expenditure from

2009/10 to 2013/14, including:

The shift of some services from Acute hospitals to more accessible and appropriate

community settings;

The shift from inpatient to outpatient services, reflecting modernisation in the

delivery of care;

Reducing residential care, and moving to supporting people at home with increasing

domiciliary and other home / community based care services;

Modernisation of diagnostic and labs services enabling access in localised settings.

Hospital Services transition:

Inpatients -2% Outpatients +6% Day Cases +7%

Movement in real terms expenditure by Patient Class from 2009/10 to 2013/14

18% increase

In real terms expenditure for A&E services from 2009/10 to 2013/14

Community & Personal Social Services

Movement in real terms expenditure from 2009/10 to 2013/14 reflecting the transition

to community / home settings

GP Direct Access Services +87% Supported Living +56% Direct Payments +50%

Personal Social Services

Movement in activity delivered from 2009/10 to 2013/14:

Residential Care -6% Nursing Home Care +7% Domiciliary Care +8%

HSC Services - shift in expenditure:

Hospital Services -4%

Community & Personal Social Services +4%

Expenditure as % of total Trusts’ spend in 2013/14 compared to 2009/10

44% increase (additional £53m)

In real terms Drugs expenditure from

2009/10 to 2013/14

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Strategic Change - Trends by Programme of Care 2009/10-2013/14*

Reviewing the trends in expenditure from 2009/10 to 2013/14 also reflects the progress

made in taking forward the strategic change agenda, and how this has been evidenced

across individual programmes of care.

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*See Appendix 2 for more details of Programme of Care expenditure

• Shift from Inpatients to Outpatient and Day Case services

• Transition of diagnostics and labs services from Hospitals to Community settings

• Increased investment in unscheduled care (A&E spend up 18% over 5 years to 2013/14)

Acute Services

• Investment in midwifery led care

• Efficiencies achieved in reducing Obstetrics' inpatients average length of stay (per finished consultant episode) - saving 17% v 2009/10

Maternity &

Child Health

• Increases in family centres, social work, foster care & legislation payments (incl.adoption)

• Reduction in institutional care (residential care spend down 9% v 2009/10)

Family &

Child Care

• Spend up in community nursing, social work, step up / down facilities and supported living

• Domiciliary care activity increasing; shift to independent sector provision.

• Reduced reliance on Hospital based services (expenditure reduction of 4% v 2009/10)

Elderly Care

• Investment into Community services - resettlements, consultant led outreach

• 11% reduction in Hospital services spend Mental Health

• Increases in supported living and domiciliary care reflecting shift to community / home

• Hospital spend down 17% (mainly long stay)

Learning Disability

• Increased spend in supporting home based care - domiciliary care, AHPs, supported living

• Expenditure reflecting shift from traditional Nursing and Residential Care (-10%) & Hospital services (-3%) to the Community

Physical &

Sensory Disability

• Increasing expenditure over 5 years - additional screening programmes, investment in community development teams

Health Promotion & Disease Prevention

• Greatest programme of care spend increase over 5 years (up 53% v 2009/10)

• Reflects transition of services from Hospital setting to the Community - increasing GP direct access services (treatment services, diagnostics)

Primary Health &

Adult Community

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SECTION 5: WHAT REAL IMPROVEMENTS IN OUTCOMES HAVE BEEN ACHIEVED FOR THE

HEALTH AND WELLBEING OF THE NI POPULATION?

The only way we can continue to have sustainable, safe and high quality services is to

transform how we plan and deliver our care.

The HSC transformation agenda has been and continues to be committed to improving

patient experience and outcomes of care by placing the patient, carer and community at the

heart of care and by thinking more innovatively about our ways of working.

Despite the financial constraints and challenging situation around waiting times for a

number of specialties, there have been real, demonstrable improvements in health

outcomes for the people of Northern Ireland, some of which are outlined below.

Life Expectancy

At a regional level the life expectancy for both males and females has increased in recent

years, with the chart below reflecting the increase over the five year period to 2012 (based

on most recent average trend data to 2012). Males living 1.4 years longer and females

almost 1 year longer compared to the average life expectancy ages in 2006-08.

Source: HSC Inequalities Monitoring System

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Reviewing the trend in life expectancy by area (in terms of level of deprivation) below, the

greatest improvement over the five year period to 2012 for both males and females has

been within the most deprived areas of Northern Ireland. This highlights progress achieved

in reducing the inequality gap in recent years – with the age gap in life expectancy between

the most and least deprived areas reducing from 7.7 years to 7.3 years for males, and

reducing from 4.5 to 4.3 years for females (comparing 2008 to 2012).

Population Health Improvements

Reductions in Standardised Death Rates: (Per 100,000 NI population)

Respiratory -6% (reduction in death rate from 2008 to 2012)

Cancer -5% (reduction in death rate from 2008 to 2012)

Smoking -7% (reduction in death rate from 2008 to 2012)

Other Improvements:

Childhood Obesity -7% (reduction in NI % P1 children

categorized as obese - 2009/10 to 2012/13)

Teenage Births -20% (reduction in NI rate per 1,000 births

from 2008 to 2012) Source: HSC Inequalities Monitoring System

Source: HSC Inequalities Monitoring System

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SECTION 6: WHAT HAVE BEEN THE KEY DEVELOPMENTS IN RECENT YEARS AND

CONSIDERATION OF FUTURE TRENDS?

The last number of years have seen significant challenges across Health and Social Care as

we continue to operate under a climate of decreasing budgets and increasing pressure on

resources.

The Donaldson Report reaffirms our belief that Transforming Your Care (TYC) is the right

approach and direction although difficult decisions will have to be made to ensure the

system is fit for purpose in the long term.

To date, over half of the 72 recommendations in TYC which the Board is responsible for,

have been implemented or built into our how we plan and deliver services.

These include:

Reablement

Reablement is about promoting and maximising independence to allow people to remain in

their own home as long as possible. It is designed to enable people to gain or regain their

confidence, ability and necessary skills to live independently, especially after having

experienced a health or social care crisis, such as illness or injury.

Reablement has clear benefits for patients and across the health service. In 2013, the

regional audit of Reablement showed a reduced dependence on domiciliary care packages,

saving about £7m over a period of three years.

During the current 2014/15 financial year:

5,517 people started Reablement

77% were discharged within 6 weeks

43.5% of those reabled were discharged without the need of a further care package

Care Pathways Reform

Care Pathways are a road map which clearly sets out what care and treatment a patient will

receive.

We are currently working with a wide range of stakeholders in the development of regional

Care Pathways for Asthma (Acute Paediatric) and Heart Failure.

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By adopting a regional approach to developing Care Pathways, it will shorten

inpatient/outpatient stay, reduce acute hospital pressures, free up clinician time, drive

efficiencies and reduce both waste and the variability of approach and delivery of care for

patients around Northern Ireland.

Outpatient Reform

Outpatient reform is about ensuring that outpatient services are appropriate, provided in

the right place at the right time, maximising the use of technology. We are currently

establishing four specialty-based multi-disciplinary work streams in General Surgery &

Gastroenterology, Gynaecology, Rheumatology and ENT.

By reforming outpatient services and better use of technology, we expect to reduce waiting

times and acute hospital pressure, free up clinician time, reduce the need for face-to-face

appointments and enhance the role of nurses, AHP and GPs.

Integrated Care Partnerships (ICPs)

ICPs are a new, more collaborative way of working, bringing together doctors, nurses,

pharmacists, social workers, hospital specialists, other healthcare professionals and the

voluntary and community sectors, as well as service users and carers, to design and

coordinate local health and social care services.

ICPs have been responsible for developing the ‘Acute Care at Home’ service, which provides

older people with expert medical and social care in their own home to manage conditions

such as chest infections, urinary tract infections, cellulitis and dehydration without the need

for attending the emergency department, or being admitted to hospital.

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Investment in Reform

The Health and Social Care Board continues to invest in reform and the shift in expenditure

from hospital services to the community sector as detailed Section 4 – Financial Trends. This

can be measured by the:

1) Reallocation of resources from Hospitals to Community and Primary Care services 2) Recurrent transformational investment in community services 3) Hospital activity averted

Figures and Forecast

Source: Estimations per report to DHSSPS (June 2015); 2015/16 per ‘Benefits Report’

MOVING FORWARD

Reviewing past performance provides a sound foundation and reassurance of achievements

delivered for HSC in NI, but it is important to recognise the significant challenges ahead, with

the elderly population estimated to grow rapidly over the coming years (increasing by 26%

from 2015-2023), presenting even greater demography and cost pressures.

The HSC is committed to ensuring that the people of Northern Ireland continue to have

timely access to high quality, safe and sustainable services. Significant progress has been

achieved to date, but on-going reform and modernisation of services, underpinned by the

Transforming Your Care agenda, will be essential in order to deliver quality health and social

care into the future.

£44m - 2014/15 Transition of resources from hospital services to community sector

£52m - 2015/16 estimated

•Bamford resettlement at £27m

•new recurrent investment in transformational services at £18m

•hospital activity averted at £7m

£66m - 2017/18 predicted

•£10.5m is estimated to arise from projects funded through TYC transitional money:

•ICPs (£5m)

•all others (£5.5m)

£83m - Target shift

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APPENDICES

Appendix 1

1.0 Expenditure by Service

5 HSC Trusts (Trust Financial Returns, 2009/10-2013/14)

Cash Terms Real Terms Real Terms

EXPENDITURE £M 2009/10 2009/10 2013/14 Variance %

Hospital Services General medicine 202 219 217 -2 -1%

General surgery 168 182 173 -9 -5%

Trauma & Orthopaedic surgery 110 119 121 2 1%

A&E 84 91 107 16 18%

Obs. & Gynae. (Obstetrics) 87 95 97 2 2%

Geriatric medicine 86 93 94 1 1%

Cardiology 80 87 93 6 7%

Mental Illness (incl. Acute & rehab.) 96 104 88 -17 -16% Medical Oncology (incl. chemo /radiotherapy) 44 48 50 3 6% Gynaecology (excl. IVF/other fertility treatments) 50 55 48 -7 -12%

Other Hospital specialties / services 652 708 726 18 3%

Total 1,659 1,800 1,814 14 1%

Community & Personal Social Services Nursing / Residential Homes 424 459 467 8 2%

Domiciliary Care 200 217 223 6 3%

Nursing 151 164 165 1 1%

Social Work 128 139 144 5 4%

GP Direct Access Services 65 71 133 62 87%

AHPs 77 84 101 17 20%

Day care 76 82 86 3 4%

Supported and other accommodation 27 30 46 17 56%

Community medical / dental expenditure 35 38 40 2 4%

Other services 215 233 246 13 6%

Total 1,399 1,517 1,650 133 9%

TOTAL HSC TRUSTS TFR EXPENDITURE 3,058 3,317 3,464 147 4%

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Appendix 2

2.0 Expenditure by Programme of Care

5 HSC Trusts (Trust Financial Returns, 2009/10-2013/14)

Cash

Terms Real Terms Real Terms

EXPENDITURE £M 2009/10 2009/10 2013/14 Variance %

POC 1: Acute Services 1,289 1,399 1,437 38 3%

POC 2: Maternity and Child Health 145 157 157 0 0%

POC 3: Family and Child Care 188 204 213 8 4%

POC 4: Elderly Care 708 768 782 14 2%

POC 5: Mental Health 225 245 234 -11 -4%

POC 6: Learning Disability 228 248 267 19 8%

POC 7: Physical and Sensory Disability 101 109 111 2 2% POC 8: Health Promotion and Disease Prevention 47 51 56 5 10% POC 9: Primary Health and Adult Community 125 136 208 72 53%

TOTAL EXPENDITURE BY PROGRAMME 3,058 3,317 3,464 147 4%

Caveats:

1. POC 1 & 4: Elderly Care total has been restated in the table above and in the following detailed POC

reviews to include NHSCT Mid Ulster Hospital Geriatric Medicine inpatient expenditure (previously

reported under Acute Services, General Medicine specialty).

2. POC 2: The overall expenditure position for this programme is impacted by the reclassification of part

of total Trusts’ Health Visiting nursing spend - out of Maternity and Child Health and into the Health

Promotion programme from 2013. The increase in the Maternity and Child Health programme

expenditure would increase to over 4% (over the five year review period) adjusting for the impact of

this cost reclassification.

3. POC 5: Trusts complete TFRs on a fully costed methodology that incorporates fixed, variable and

overhead costs. Within Mental Health services people are resettled from long stay mental health

hospital wards to community facilities. In the past, the older hospital buildings that provided the care

services attracted a larger proportion of corporate overheads (e.g. costs of central administrative

departments such as Human Resources, Finance, and Corporate Services). However, as these

buildings are becoming vacant with ward closures, the share of corporate overheads previously

assigned to these buildings are reapportioned across other services and other programmes of care –

i.e. no longer included within Mental Health programme expenditure. A reduction in expenditure may

therefore be seen, but in reality there has been no impact on the service to the patient. A significant

element of the reduction in Hospital expenditure in the Mental Health programme (from 2009/10-

2013/14) relates to the impact of reassigning these overhead / non-direct costs.

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2.1 POC 1 - Acute Services

This Programme of Care includes all inpatient, outpatient, daycase and daycare activity in an

acute hospital setting, covering emergency and non-emergency services, across a range of

specialty areas.

In the period under review, the HSC has evidenced a strategic shift in the delivery of some

services from acute settings to more appropriate community settings. Within the hospital, a

shift from inpatient to daycase and outpatient settings has reflected modernisation in the

clinical delivery of care. A number of services have been reconfigured to centralise skills and

maximise capacity. Modernisation of diagnostic and lab services has enabled a range of

services to be accessed locally and ensured drugs and therapies are delivered closer to the

patient. A significant additional investment has been made to ensure safe and effective

unscheduled care services can be delivered.

Total expenditure in the Acute Services programme was £1,437m in 2013/14, an increase of

3% (£38m) in real terms over the five years from 2009/10.

Expenditure £m 2009/10 Real Terms 2013/14 Variance

Medical Specialties 607 633 26

Surgical Specialties 534 525 -9

A&E 91 107 16

Critical Care 93 96 3

Independent Sector/Waiting List Initiatives 61 63 2

Nurse Clinics & Other 13 12 -1

Total 1,399 1,437 38

The main expenditure increases within Medical Specialties were for Thoracic

medicine, Haematology Chemotherapy drugs, Palliative medicine, Gastroenterology

and Cardiology – all increasing in real terms by £5-7m+ over the five year period.

The reduction in Surgical specialties expenditure was mainly within BHSCT, and

included decreases in General Surgery, Gynaecology and ENT spend across the five

years, reflecting the impact of average length of stay and other savings.

25

2.2 POC 2 - Maternity & Child Health

This Programme of Care includes all Obstetrics inpatient and outpatient activity, and

community activity (contacts) for any health professionals, where contacts are primarily for

maternity or child health reasons. Health visiting activities are split between health

promotion and maternity and child health programmes.

Over the past five years the strategy has placed a greater emphasis on midwifery led care

and also ensuring consultant led care for women with more complex pregnancies. The

volume of deliveries has slightly reduced over the five year period to 2013/14 (down 2.6%),

with a reduction also in the number of caesareans.

Total reported expenditure in the Maternity and Child Health programme has remained

constant in real terms over the five years from 2009/10 to 2013/14, at £157m.


Obs. & Gynae. (Obstetrics) Inpatient 75 77 2

Obs. & Gynae. (Obstetrics) Outpatient 19 20 1

Community Nursing 31 27 -4

AHPS 18 20 1

Other* 14 14 0

Total 157 157 -0

* Other includes: Grants, goods/services, Obstetrics day cases, & Community medical/dental

Note The overall programme expenditure position for this programme is partly impacted by the

reclassification of nursing expenditure (see Caveat (2), page 23).

26

2.3 POC 3 - Family & Child Care

This Programme of Care includes activity and resources relating to the provision of Social

Services support for families and / or children, for example looked after children, adoption,

fostering, day care and family centres. The programme also includes community activity

where contacts relate to family or child care issues.

The key strategy for the programme has been to reduce reliance on institutional care, and

to increase the placements of children with families.

Total expenditure in the Family and Child Care programme was £213m in 2013/14, an

increase of 4% (just over £8m) in real terms over the five years from 2009/10.

The chart below reflects the increase in expenditure across the main service categories.


Social Work 78 81 4

Residential Homes 33 30 -3

Payments under legislation 15 18 3

Other * 79 83 5

Total 204 213 8

*Other includes Lakewood, Family Day centres, Community medical/dental, Nursing, AHPs, Domiciliary and

Day care, Assessment Centres and other goods & services.

Social work expenditure includes Early Years, Aftercare, family placements and family

support services – with the greatest increases in expenditure across the five years within

Aftercare and family placements (for looked after children).

The greatest reduction in spend reflects the strategic transition from Residential Home

care (statutory provision) – down 9% compared to 2009/10.

Payments under legislation have increased significantly over the five years to 2013/14 –

mainly in respect of increases in adoption allowances (£2.6m).

27

Family and Child Care Programme - continued

Foster care payments account for the greatest proportion of ‘Other’ expenditure –

almost £36m in 2013/14. Spend on foster care has increased by 4% in real terms over

the five years to 2013/14.

Family Day Centres (also included under ‘Other’ expenditure above) has been another

area of increased expenditure by Trusts over the five years - up from just under £2m in

real terms in 2009/10 to £5m in 2013/14. This is anticipated to be an increasing cost

pressure area as Trusts are required to respond to Court directives for supervised

contact.

The expenditure increases across the family and childcare programme reflect the

increasing need for services for children in care and family support, as the number of

looked after children and the legislative responsibilities for young people (including

Leaving and Aftercare legislation) continue to increase.

The average weighted spend per head in 2009/10 was £185, increasing to £193 in

2013/14 (4% increase).

28

2.4 POC 4 - Elderly Care

This Programme of Care includes all community health and social services for those aged 65

and over (except where the service provision is due to mental illness or learning disability).

The programme also includes all activity, and resources used, by any health professional,

relating to an inpatient episode where the consultant in charge of the patient is a specialist

in Geriatric Medicine or Old Age Psychiatry.

The strategy for this programme has been to increase the health and wellbeing of the

Elderly population, reducing unnecessary stays in hospital and improving long term

outcomes - through early supported discharge with enhanced therapeutic interventions. A

range of support mechanisms and services have been introduced to help maintain people in

their own homes e.g. telemonitoring, telecare, direct payments and reablement.

Total expenditure in the Elderly programme of care was £782m in 2013/14, an increase of

2% (£14m) in real terms over the five years from 2009/10.



Nursing & Residential Homes 318 324 7

Domiciliary Care 169 165 -4

Hospital Services: Geriatric Med.; Old Age Psychiatry 129 124 -5

Community Nursing 50 53 3

AHPs 29 29 0

Social Work 24 27 3

Daycare 16 17 1

Other* 34 43 9

Total 768 782 14

*Other includes Step up/down, meals, supported living, grants & community medical / dental)

29

Elderly Programme – Key Points

The greatest reduction in expenditure (Hospital Services) is mainly in respect of Old Age

Psychiatry (down 16% over the five years to 2013/14), with a 1% increase in Geriatric

medicine.

Nursing and Residential care has increased by just 2% in real terms (against a 65+

population increase of 10% over the same period), and Domiciliary Care expenditure has

reduced in total terms (reflecting lower cost provision efficiencies).

Supported accommodation and step up / step down facilities (both increasing by 100%+)

are the main categories driving the greatest increase – under ‘Other’ services.

Expenditure per head of weighted population has reduced by 7% in the Elderly

programme – from £3,174 in 2009/10 to £2,943 in 2013/14.

It is also important to note that the Elderly age group also receive services from other

programmes of care, particularly within the Acute programme and for prescribing (within

Family Health Services).

In total, it is estimated that 42% of all services, approximately £1.4bn, is spent on the Elderly

population in Northern Ireland (the elderly age group currently accounting for 15% of the

total NI population).

30

2.5 POC 5 - Mental Health

This Programme of Care includes all inpatient, outpatient, day case and day care activity and

resource, where the consultant responsible is a specialist in Mental Illness or Psychiatry. It

also includes community activity (contacts) for any health professionals, where contacts are

primarily for mental health reasons (excluding dementia which is included within the Elderly

programme).

This programmes’ strategy continues to focus on prevention and early intervention,

reducing reliance on institutional care and investing in resettlements, providing consistent

pathways with local community services and specialist secondary care services for those

most in need - all aiming to improve and protect the mental health and wellbeing of the NI

population in line with the Bamford strategy and Transforming Your Care.

Total expenditure in the Mental Health programme of care was £234m in 2013/14, a

decrease of 4% in real terms over the five years from 2009/10.



Hospital Services (incl. Psychotherapy) 117 104 -13

Consultant led Outreach teams 15 16 1


Supported Accommodation, Domiciliary Care, Meals

18 20 2

Nursing & Residential Homes 18 17 -1

Social Work 11 10 0

Other 47 45 -2

Total Reported 245 234 -11

Adjustment: funding now with PHA -4 0 4

Adjusted Total 241 234 -7

*Other incl. AHPs, Daycare, nursing & community medical/dental, addictions and intensive treatment teams. NOTE: An adjusted total has also been included for comparative purposes - to reflect the impact of expenditure in 2009/10 for Lifeline – funding subsequently transferred to PHA (regional contract).

31

Mental Health Programme – Key Points

Hospital services spend has reduced by 11% (almost £13m), reflecting the transition of

care from long stay wards to community based resettlements. See note below.

Domiciliary care expenditure increased 44% (up £2m) over the five years to 2013/14,

with a 22% reduction in residential care spend (decreasing by £1.8m).

Expenditure increased by almost £8m in other community services including nursing,

AHPs, community addictions teams (up £1.5m) and community medical / dental services

(also up £1.5m).

Transition of service provision

The charts below also reflect the shift in expenditure and transition of service provision

within the Mental Health programme comparing 2013/14 to 2009/10 at a headline level for

the main service categories – with expenditure in Community services increasing by over

10% in real terms, now accounting for 30% of total programme spend.

Note A significant element of the reduction in Hospital expenditure (from 2009/10-2013/14)

relates to the impact of reassigning overhead / non-direct costs as people have been

resettled from long stay mental health hospital wards to community facilities (see Caveat

(3), page 23).

32

2.6 POC 6 - Learning Disability

This Programme of Care includes all inpatient, outpatient, day case and day care activity and

resource, where the consultant responsible for the patient is a specialist in Learning

Disability. It also includes community activity (contacts) for any health professionals, where

the primary reason for the contact is in respect of Learning Disability.

This programmes strategy continues to promote personalisation, choice and independence

with investment in supported living programmes, day care and respite services, direct

payments and with a focus on early years support and relevant, integrated services as

people transition into adult and old age. This strategy, similarly to Mental Health, aligns with

the direction set out in Bamford and Transforming Your Care.

At a regional level, expenditure in the Learning Disability programme increased by 8%

(£19m) in real terms over the five year period to 2013/14.

The chart below reflects the increases in expenditure across the main service categories.


Nursing & Residential Homes 75 82 7

Daycare 48 50 2

Supported & Other Accommodation 16 28 12

Domiciliary Care 16 21 5

Hospital Services 46 38 -8

Community AHPs, Nursing, Social Work 27 29 1

Other* 19 19 -1

Total 248 267 19

*Other includes community medical/dental, step up / step down facilities, grants, goods & services

The most significant expenditure increase in Supported accommodation (an increase

of £12m), against the greatest decrease of almost £8m in real terms in Hospital

Services (long stay), again reflects the transition to resettlements in the community.

The next largest increase, in domiciliary care expenditure, also reflects a shift to

home based care – increasing by 34%, compared to an increase in Nursing /

Residential homes spend of 9% (mainly Nursing and Children’s Residential care).

33

2.7 POC 7 - Physical & Sensory Disability

This Programme of Care includes a range of services provided for those with a physical or

sensory disability. Patients and clients aged 65+ are included within the Elderly programme.

The strategy for this programme focuses on providing a person centred model - promoting

positive health, well-being and early intervention, providing better services to support

independent lives and providing support to carers and families.

Expenditure totalled over £111m for the Physical & Sensory Disability programme in

2013/14 - up £2m (2%) in real terms compared to 2009/10.

The chart below reflects the increases in expenditure across the main service categories.


Domiciliary Care, Supported Accommodation, Meals

28 31 3

Nursing & Residential Homes 16 14 -2

Hospital Services 14 14 0

AHPs 8 10 2

Social Work 13 12 -1

Daycare 8 8 0

Other* 22 23 0

Total 109 111 2

*Other includes complex cases, community nursing, medical & dental, and other grants, goods & services

Regionally, expenditure has increased in community and home based care –AHPs,

domiciliary care and supported accommodation – against reductions in spend for

hospital services and traditional nursing and residential home care provision.

The increase in AHPs is mainly driven by Occupational Therapy spend - increasing by

over £1m (up to £6m in 2013/14).

Within the ‘Other’ category, reported complex cases expenditure has increased by

almost £5m over the five years to 2013/14.

34

2.8 POC 8 - Health Promotion and Disease Prevention

This Programme of Care includes health promotion activities, including screening services,

for the whole population of NI.

The health promotion strategy is mainly led by the Public Health Agency (PHA), with support

from the HSCB. A wide range of initiatives have been spearheaded by the PHA over the

period of this review to tackle health inequalities and to protect and improve the population

health. Additional investment has been targeted accordingly, however many of the benefits

will be demonstrated over the longer term.

Total expenditure in the Health Promotion and Disease Prevention programme increased by

10% (almost £5m) in real terms over the five year period to 2013/14.

The chart below represents the increases in expenditure by main service category for the

programme – comparing 2013/14 against 2009/10 spend.

The main areas generating increased expenditure by Trusts in the programme have included

additional screening programmes (increasing almost £2m) and further investment in

community development teams (increasing over £1.1m) over the five year period.



Screening Services 8 10 2

Community development teams 6 7 1

Community medical / dental 7 1 -6

Other* 7 8 1

Total 51 56 5

*Other includes AHPs and other grants, goods & services

Note: The overall programme expenditure increase is partly impacted by the reclassification

of some Health Visiting nursing spend (included under ‘Community Nursing’) within the

Health Promotion programme from 2013 (previously included in POC 2). However, this is

mainly offset by a similar reduction in Community medical / dental where spend reporting

across programmes has also improved in recent years.

35

2.9 POC 9 - Primary Health & Adult Community

This Programme of Care includes expenditure within Trusts for the adult community, in

primary health settings. Specific funding for Family Health Services is shown separately.

This programmes’ strategy also reflects the wider HSC emphasis – focussing on providing

services closer to the people’s homes.

The greatest increase in expenditure over the five year period to 2013/14 has been in the

Primary Health and Adult Community programme of care – increasing by 53% (£72m) in real

terms compared to 2009/10.

The expenditure increases by main service category are reflected in the chart below,

highlighting the investment into GP direct access services –as treatment and diagnostic

services have transitioned from Hospital services settings into the Community. This reflects

the specific policy to provide direct access including drug therapies in a community setting.

The chart below represents the increases in expenditure by main service category for the programme.


GP direct access services – Diagnostics 51 56 5

GP direct access services – Treatment Services * 20 77 57

AHPS 15 25 10

Community Nursing 28 25 -3

Other (incl. grants, goods & services) 22 25 4

Total 136 208 72

*Includes provision of specialist drugs (red amber drugs)

Increased spend in Physiotherapy of £6m+ in real terms (up to over £15m in

2013/14) is the main driver of the significant increase in AHPs expenditure.

The reduction in Community Nursing expenditure has been partly impacted by the

reclassification of some Treatment Room services under the Health Promotion

programme of care.

36

Appendix 3

GDP Deflator (Inflation Adjustment Factor)

The GDP deflator can be viewed as a measure of general inflation in the domestic economy

(a measure of price changes over time).

The deflator is usually expressed in terms of an index as per the most recent published

series as reported in the table below. Percentage changes on the previous year are also

shown.

For comparative purposes the 2013/14 expenditure included within this report remains

unchanged (100%), with expenditure reported in previous years adjusted by the respective

GDP inflation factor – i.e. adjusted to ‘real terms’ expenditure, removing the effect of

inflation.

Financial year

2013-14 = 100 % change on

previous year 2009-10 92.194 2.59

2010-11 94.745 2.77

2011-12 96.441 1.79

2012-13 97.997 1.61

2013-14 100.000 2.04 Source: UK HM Treasury GDP Deflators at Market Prices & Money GDP – March 2015 (Quarterly National Accounts)

37

Appendix 4

4.1 Glossary of Terms

AHP(s) Allied Health Professional(s)

BHSCT Belfast Health & Social Care Trust

CSIs Community Service Indicators

FCE(s) Finished Consultant Episode(s)

FHS Family Health Services

HPSS Health & Personal Social Services

HSC Health and Social Care

HSCB Health and Social Care Board

HRG(s) Healthcare Resource Group(s)

ICP(s) Integrated Care Partnership(s)

NHSCT Northern Health & Social Care Trust

NIAS Northern Ireland Ambulance Service

NICE National Institute for Health and Care Excellence

PFI Private Finance Initiative

PHA Public Health Agency

POC Programme of Care

SEHSCT South Eastern Health & Social Care Trust

SHSCT Southern Health & Social Care Trust

TFRs Trust Financial Return(s)

TFR E&S Trust Financial Returns Expenditure & Salaries and Wages

TFR H, C & PSS Trust Financial Returns Hospital, Community and Personal Social

Services

WHSCT Western Health & Social Care Trust

38

4.2 Definitions

Acute care– Traditionally refers to services provided in a major hospital setting including unscheduled (or emergency) care, elective (or planned) care and specialist services.

Chronic / long term conditions – illnesses such as diabetes or heart disease that can affect people over long periods of their lives and which need regular treatment and medication.

Commissioning – is the term used to describe all the activities involved in assessing and forecasting the health and social care needs of the population, links investment to agreed desired outcomes, considering options, planning the nature, range and quality of future services and working in partnership to put these in place. Joint commissioning is where these actions are undertaken by two or more agencies working together (in this case the HSCB and PHA), typically health and local government, and often from a pooled or aligned budget.

Commissioning Plan Direction – A document published by the Minister on an annual basis which outlines the key messages, targets and indicators of performance for the year ahead.

Community and Voluntary Organisations – the collective name for a range of independent organisations which support the delivery of health and social care but are not publicly funded.

Community Service Indicators (CSIs) - a range of unit costs and other indicators reflecting

the key community and personal social services areas delivered by Trusts.

Chronic / long term conditions – illnesses such diabetes or heart disease that can affect

people over long periods of their lives and which need regular treatment and medication.

Demography - the study of statistics such as births, deaths, income, or the incidence of

disease, which illustrate the changing nature of a country’s population.

Excess Bed Day – each Healthcare Resource Group has a maximum expected length of stay

(upper trim point) and any stay in hospital which exceeds this upper trim point is defined as

an excess bed day.

Health and Social Care Board (HSCB) – the HSCB role is to commission services, working in partnership with Trusts to deliver services and manage the annual budget given by the NI Executive.

Healthcare Resource Groups (HRGs) – standard groupings of clinically similar treatments

which use comparable levels of healthcare resource, and are determined from diagnostic

and procedural codes. HRGs are grouped into clinically relevant ‘chapters’ - for one or more

body system, for example the Nervous System, Digestive System, Obstetrics.

39

Local Commissioning Groups – committees of the regional Health and Social Care Board and are comprised of GPs, professional health and social care staff and community and elected representatives. Their role is to help the Board arrange or commission health and social care services at local level.

Looked after children - the term ‘looked after children and young people’ is generally used

to mean those looked after by the state, according to relevant national legislation. This

includes those who are subject to a care order or temporarily classed as looked after on a

planned basis for short breaks.

Primary Care – the care services that people receive while living at home in the community

from people such as their GP, district nurse, physiotherapist or social worker.

Public Health Agency (PHA) – the role of the PHA is described under its four primary

functions; health and social wellbeing improvement, health protection, public health

support to commissioning and policy development, research and development.

Reablement - range of services focused on helping a person maximise their independence by learning or re-learning the skills necessary for daily living and the confidence to live at home.

Specialty Costs - unit costs for hospital medical and surgical specialties, which can be

calculated by hospital site and by Trust – e.g. cost per patient day or attendance.

Transforming Your Care – this is a strategic assessment across all aspects of health and social care services examining the present quality and accessibility of services.

Trust Delivery Plans – in response to the Commissioning Plan and Local Commissioning Plans, the six Trusts detail how they plan to deliver the Ministerial targets, key themes and objectives outlined for the year ahead.

Trust Financial Returns (TFRs) – the TFRs and BFRs (Board Financial Returns) are submitted annually to HSCB, post-financial year end, and reflect the actual expenditure incurred by Health and Social Care Trusts and other organisations including Family Health Services.

Expenditure Review 2009/10-2013/14 & Planning to 2015/16 ... · November 2015 NI HSC Financial Overview Expenditure Review 2009/10-2013/14 & Planning to 2015/16 ... complex health

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