Programme Budgeting in NHSScotland

Detailed Programme budgets

12.Detailed examination of 4 of the programme budgets is presented: mental health, cancer, and both circulatory and respiratory disease. These are 4 of the 5 most costly programmes for the NHS. “Gastro intestinal (GI) conditions” is the 5th. Most of that spend on GI conditions is within the acute sector although there is £75m estimated for the spend on pharmaceutical items dispensed in the community.

13.Across all 3 countries whose programme budgeting data are presented in Figure 2, mental health has the largest proportion. There have been problems in Scotland with the completeness of SMR04 data (which is the data set which collects data on Psychiatric inpatients) submitted in recent years. As a result, from 2015, SMR04 has been re-designed and developed.

14.It should be noted that due to the implementation of a new patient management system, information on treatments delivered at NHS Ayrshire & Arran, in the hospital sector for mental health (i.e. from SMR04) in the year 2011/12, is not available. As a result, Scotland level data for mental health are not directly comparable to the previous analysis, or to similar services in the other UK countries. Comparison with England and Wales is further compromised by the inability to attribute community activity and spend across the programmes, including mental health.

15. Mental illness is one of the major public health challenges in Scotland. Around one in three people are estimated to be affected by mental illness in any one year^[8]. As shown in table 3 the spend is distributed across all areas of care with the majority of the identified cost attributed to psychiatric inpatient care although there is also a substantial spend in community prescribing.

Table 3: estimated expenditure for mental health sub programmes (2011/12) NHS Scotland (£m).

* - CAMHS has a separate data gathering exercise

# cells with £0 have less than £100,000 (rounded) spend in the year

16.The majority of cancer spend is in the acute sector, as might be anticipated. Table 4 shows that the greatest spend is on colo-rectal, lung, breast and haematological cancer (e.g. leukaemia and Hodgkins). This reflects both the pattern of incidence and prevalence of the disease within Scotland and the cost of treatment. Colon cancer is the 4th most commonly diagnosed cancer in both men and women: breast cancer is the most common cancer in women in Scotland accounting for almost 30% of all cancers diagnosed. Lung cancer is the most common cause of death from cancer in both men and women^[9]. The cost to GMS (GP visits) is relatively low. Whilst the costs cover both primary and secondary care sectors, the costs presented do not include costs for any of the national screening programmes. Nor do they include the cost of palliative care.

Table 4: estimated expenditure for cancer services ( 2011/12) NHS Scotland (£m).

17.Whilst the spend on mental health and cancer appears to be concentrated in the acute sector, Tables 5 and 6 shows that diseases of circulation and the respiratory system make demands on both the acute sector and family health services where they are the most costly programmes. Diseases of circulation include coronary heart disease and cerebrovascular disease (stroke). The most common causes of death in Scotland are cancer, heart disease and stroke. Although the incidence of coronary heart disease is dropping, and survival rates from a first heart attack have risen over the last 10 years^[10], heart disease remains the second most common cause of death in Scotland.^[11]

Table 5: estimated expenditure for problems of circulation (2011/12) NHS Scotland (£m).

18.Respiratory conditions include Chronic Obstructive Pulmonary Disease (COPD) and asthma. COPD, for which the most significant risk factor is cigarette smoking, is the third most common reason for hospital admission in Scotland and has high re-admission rates. This may be due to the high smoking rates seen 30 - 40 years ago and increased awareness of COPD in primary care. Tables 5&6 also show the level of spend on pharmaceutical services for these groups of conditions. Table 6 includes the estimated cost of £100m on community prescribing for asthma. The UK has some of the highest rates of asthma in Europe. There were over 450,000 consultations for asthma with either a GP or practice nurse in 2011/12.^[12] One in 14 adults and 1 in 13 children in Scotland are receiving treatment for asthma.^[13]

Table 6: estimated expenditure for respiratory disease ( 2011/12) NHS Scotland (£m).

19.The 2012 paper, reporting analysis of the 2007/08 data, reflected that the diseases and conditions generating most activity and subsequent cost were not distributed evenly across the population. For example, although there has been a reduction in mortality from coronary heart disease in all the deprivation quintiles there remains a strong social gradient^[14]. There is a strong link between COPD and deprivation^[15] and mental health is unevenly distributed across the Scottish adult population, with inequalities evident for age, gender, deprivation and socioeconomic status^[16]. For some, but not all, cancers there is a clear social pattern to incidence. Of the most commonly occurring, (prostate, breast, colorectal, trachea, bronchus and lung), cancer of the trachea, bronchus and lung demonstrates the highest levels of inequality.^[17] Similarly there is a link with deprivation for mortality from some cancers but not others. Again, mortality from lung cancer exhibits a high degree of inequality.

20.The Gastro Intestinal category, another significant area of spend, covers a very wide range of conditions and activity. Many of these may have no link to deprivation. Others, such as liver disease, including hepatitis B and C, appear linked to deprivation and poverty.^[18]