Potential excess acute costs at XYZ PCT Dr Rod Jones Statistical Advisor Healthcare Analysis & Forecasting.

Potential excess acute costs at XYZ PCT

Dr Rod JonesStatistical Advisor

Healthcare Analysis & Forecasting

Key Issues Capitation formula is linear but true

relationship is sigmoid Low deprivation areas are under funded Gap is mainly NEL (£14M) of which £3M is

excess zero day ‘emergency’ Some EL (mix of counting & intervention) (£9M)

PCT is attempting to recover a general gap against specific HRG

Is this likely to be a ‘successful’ strategy? Need to benchmark against the best

West Berkshire and the RBH

Key Issues (contd) Three acute sites with different counting

& coding issues LA data shows different levels of ‘excess’ OP

& IP A FT highest level of Plastic Surgery ‘DC’ in

the UK AAA LA Wycombe highest level of Gynaecology

admissions BBB LA (M09, M05, N12) High levels of ‘other’ first attendance at B

NHS Trust CCC LA

Suggestions

Segment all output areas (OA) into site catchments for EL, NEL and OP and performance manage by catchment Will make demand management more

pro-active by virtue of ‘focus’ Able to calculate expected/desirable

demand at OA level, hence, specific & measurable targets for each catchment

Efficiency Measures 16% excess bed days within trim points 3% excess NEL bed days > upper trim point 1.4 FCE per Spell for NEL respiratory conditions

(1.1 at RBBH) Highest level of transfers to residential care in

South Central Surgical DC performance is OK

Poor performance only in Ophthalmology 1,440 fewer DC Highest % DC in SCHA in C04 (minor mouth), C22 (nose),

H22 (minor T&O), L98 Chemo Check to see if these are outpatient procedures counted as

DC

Implications Beds occupied hence poor A&E

performance Contract should state ‘will not pay for

excess bed days above national average’ Cost saving of 4,300 excess bed days £130,000 at £300 per excess day Benchmark: RBH 4,700 lower than expected

Residential care & alternatives

Other Cost Pressures

Number to be cleared from the waiting list in Bucks is highest in South Central relative to level of capitation funding Legacy issue with high impact in

07/08 and 08/09 However, this tied funding is released

in 09/10

Outpatient First Attendance Considerable overlap between

Plastic Surgery (£130)[1] & Dermatology (£115); Gynaecology (£135) & Obstetrics (£154); Medical group (£161 to £260); Orthopaedics (£144), Neurosurgery, Plastic Surgery

(£130), Anaesthetics (£187); General Surgery (£151) and Urology (£157).

Specify acceptable proportions in contract

[1] The 06/07 PbR tariff for outpatient first attendance is given in brackets

Excess First Attendance

Local Authority

Population Excess

Excess per 1,000 head

Excess relative to 'best'

AAA 61,945 2,583 42 5,575

BBB 165,741 6,509 39 14,515

CCC 162,105 -4,394 -27 3,436

DDD 89,226 -3,223 -36 1,087

Reading 143,097 -6,912 -48 0

Wokingham 150,211 -7,475 -50  

First Attend by Group(excess per 1000 head)

Local Authority All MedicalOrthopaedic

Overlap Plastic & Dermatol

Surgery & Urology

AAA 42 3 5 10 2

BBB 39 11 5 11 7

CCC -27 -4 -5 5 -3

DDD -36 -6 -8 4 -4

Reading -48 -7 -4 -6 -7

Wokingham -50 -8 -4 -7 -7

6 in top 15 LSOA in TVHA(no link with IMD implies GP practice related)

LSOA Ward IMD AllMedica

lOrtho O’lap

Plastic &

Derm

Surg &

Urol

E01017656Coldharbou

r 2 274 34 47 41 26

E01017828 Iver Village 12 156 23 23 12 13

E01017805Burnham

Church 19 151 14 12 18 20

E01017809Burnham

Lent 16 133 7 22 13 11

E01017709 Southcourt 24 131 22 12 22 14

E01017694Marsh

Gibbon 8 128 14 24 15 21

Catchment Area Behaviour

Specialty Type Wex’m Stoke Wyc’be MKGH ORH

All Specialties GP 114% 102% 102% 86% 105%

All Specilaties All 110% 114% 88% 111% 110%

Medical Group GP 92% 135% 105% 96% 109%

Medical Group All 92% 127% 81% 170% 114%

Orthopaedic Group GP 143% 98% 80% 90% 88%

Orthopaedic Group All 114% 108% 86% 118% 107%

Plastic Surgery & Dermatology GP 147% 133% 131% 81% 100%

Plastic Surgery & Dermatology All 142% 156% 117% 85% 115%

Count of max 8 8 1 5 4

Conclusions Counting of ‘other’ is an issue

Specify acceptable ratio of GP to Other Very high first attendance in specific OA

May be function of GP practice Acute site catchment areas show high/low

general patterns Allocate all OA to a site catchment and performance

manage as a group Maximum possible saving of 24,600 first

attend £5M at 07/08 tariff Possible early stage savings of £1.8M in SB and AV

Inpatient

Identify all HRG lines with excess cost > £20,000 p.a.

£14 M NEL and £9M EL

Elective >5,300 excess zero day elective

High likelihood of minor procedures counted as DC

£5.3M less alternative cost as RDA or OP

Some specialist lines are high HRG C35 Major maxillo-facial Proportion of 0 & 1 day too high Coding issue?

Non-elective

£1.8M is zero day NEL £0.9M of which from Wycombe LA Specify in contract that zero day NEL

will be paid up to national average Any HRG ending 99 (Complex

Elderly) May be a coding issue

SEPHO Atlas of conditions

HES data 98/99 to 02/03 Spell per person Relative rate per person Adjusted for age, sex and IMD http://www.uhce.ox.ac.uk/

Epidembase2/Atlases_admissions.html#catalogue

Spell per person

Rheumatoid Arthritis Wyc 1.46, SB 1.38, AV 1.27, Chilt 1.21

Gynaecology SB 1.09; all others 1.02

Relative rates (person based) Knee Arthroplasty

Wyc 120%, AV 110% Mastectomy & Lumpectomy

AV 120%, Chilt 111%, Wyc 107%, SB 103% Squint

AV 114%, Wyc 109%, SB 82%, Chilt 80% Hysterectomy

Wyc 88%, Chilt 82%, AV 79%, SB 67% Cholecystectomy

AV 102%, Chilt 100%, Wyc 97%, SB 86% Peptic Ulcer

AV 136%, Wyc 69%, SB 62%, Chilt 48% CABG

Wyc 113%, SB 102%, Chilt 97%, AV 90%

Programme Budgeting

Links programme expenditure and outcomes over 23 programmes

Uses ICD-10 codes to group http://www.dh.gov.uk/programmebudgeting http://nww.nchod.nhs.uk

High Expenditure

AAA LA(GI, Trauma & Injury, Mental Health, Musculo-skeletal

BBB LA (Trauma & Injury) CCC LA ((Trauma & Injury,

Circulatory)