Post on 24-Dec-2015
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%