Programme Budgeting in NHSScotland

Appendix B: NHSScotland Programme Budgeting Methodology 2011/12 data

1. This document is intended to be read alongside the NHSScotland Programme Budgeting analysis showing estimated expenditure by Programme Budgeting category for 2011/12.

B1 Background

2. The Department of Health describes Programme Budgeting as follows:

The aim of the project is to develop a source of information, which can be used by all bodies, to give a greater understanding of where the money is going and what we are getting for the money we invest in the NHS.

The three main drivers of this are:

a way of monitoring where NHS resources are currently invested, e.g. for the purpose of

monitoring expenditure against National Service Frameworks a way of assisting in evaluating the effectiveness of the current pattern of resource

deployment a tool to support and improve the process for identifying the most effective way of commissioning NHS services for the future.

3. At a basic level the exercise involves collating and presenting NHS expenditure on the basis of programmes of care rather than on the basis of inputs or accounting conventions.

This would track expenditure on patient care regardless of setting and therefore would cut across secondary, primary and community care.

4. Scotland does not currently collect programme level cost information from NHS Boards. The principal cost data collection is the Scottish Health Service Costs Book which reports expenditure on the basis of specialty or service (e.g. Family Health Services (FHS)).

5. Programme Budgeting expenditure for Acute, Geriatric Long Stay (GLS), Mental Health & Learning Difficulties and Accident & Emergency services has been estimated using the IRF (Integrated Resource Framework) Patient Level Costing Information System (PLICS) costing methodology. The PLICS costing methodology was developed for the IRF mapping and is now the accepted method of costing for NHS Scotland. PLICS apportions hospital site and specialty specific direct costs to individual patient records on admission, per day, for theatre time and specific high cost items e.g. prosthetics. As with other costing methodology, PLICS will continue to be developed as and when more appropriate information becomes available, for example high cost items, average theatre times for elective and non-elective patients, etc. More information on the IRF PLICS costing methodology can be found in the paper published on the TAGRA website or from the IRF analytical team at NSS.isdIRF@nhs.net.

6. For Family Health Services, cost information is collected by ISD as part of the payments process which produces more detailed cost information for FHS prescribing and General Dental and General Ophthalmic Services.

B2 Datasets and analysis

7. In Scotland the approach taken to allocate costs to Programme Budgeting Categories (PBC) varied depending on the breadth and quality of the information available nationally. For example, acute inpatient and day case activity is now routinely costed as part of the IRF PLICS costing methodology, whereas within the Outpatient data collection system, there is little information on procedure and diagnoses to allow direct mapping of a PBC code. Wherever possible the most robust method for costing data has been used with a view to enhancing the methodology as the data becomes more readily available.

8. The 2011/12 Scottish Health Service Costs Book was used as the primary data source, with much of the programme budgeting category distribution based on analysis conducted using nationally available datasets.

9. Expenditure in this analysis has been mapped to the Scottish Health Service Costs Book 2011/12 (Report R300), excluding resource transfer.

10. The specific data used and approach taken is detailed in the sections below. More information on the data inclusions/exclusions, as well as additional notes can be found in Appendix C.

B3 Hospital Sector

B3.1 Acute Services

11. In order to calculate Acute services expenditure by PBC, the 2011/12 SMR01 IRF costed file was run through the Health and Social Care Information Centre 2011/12 Healthcare Resource Group (HRG) Reference Costs grouper v4 which assigns an HRG and PBC code to each record. Once the PBC codes were attached to the file, the data was aggregated by PBC to obtain the sum of the costs for each PBC category.

12. The difference between the SMR01 IRF costs and the combined Inpatient, Day Case and Day Patient figures reported in the 2011/12 Costs Book (Reports R310;R330;R370) was apportioned based on the distribution of the SMR01 IRF based expenditure.

B3.2 Geriatric Long Stay

13. Similar to Acute services, Geriatric long stay expenditure by PBC was estimated using the 2011/12 SMR01_E IRF costed file. A PBC was assigned using the 2011/12 HRG Reference Costs grouper v4; the file was then aggregated to obtain a cost for each PBC.

14. The difference between the expenditure reported in the 2011/12 Costs Book (R360) for Inpatient and Day Patient and the SMR01_E IRF costs was apportioned based on the distribution of the SMR01_E IRF based expenditure.

B3.3 Maternity Services

15. The Maternity datasets (SMR02 & Scottish Birth Record (SBR)) have not yet been investigated in terms of mapping to PBC. The figures reported in the tables have been taken directly from the 2011/12 Costs Book (Report R320) for Inpatients and Daycases and allocated to the “Maternity and Reproductive Health” PBC category. The figures reported in the Costs Book for Maternity Services include Special Care Baby Units.

B3.4 Mental Health & Learning Disabilities

16. PBC codes were matched on to the 2011/12 SMR04 IRF costed file using the HRG grouper software and aggregated to obtain a cost per PBC as per the Acute and Geriatric Long Stay analysis. The difference between the expenditure reported in the 2011/12 Costs Book (R340;R350) for Inpatient and Day Cases and the SMR04 IRF costs was apportioned using the distribution of the SMR04 IRF based expenditure.

B3.5 Outpatients

17. The SMR00 Outpatient dataset contains limited information on diagnosis and procedures for outpatient attendances; therefore cost data was taken from the 2011/12 Costs Book (Report R04opX) at Outpatient specialty level. The specialties were mapped to PBCs using the Department of Health’s UNIFY2 Non Admitted Patient Care (NAPC) mapping file.

18. As the analysis was at specialty level only, it meant that much of the data was categorised into the “Other” PBC, as some specialties (e.g. General Surgery) cover numerous PBC categories rather than falling into one (e.g. Dental, Obstetrics). The complete list of specialties included in “Other‟ PBC is outlined in Appendix E.

19. The Costs Book Outpatient Specialty report (R04opX) excludes Allied Health Professional Costs & Activity, as they cannot be broken down by specialty. As these costs and activity cannot be accurately allocated to specific PBC codes, the AHP expenditure outlined in Costs Book report R046X was added to the “Other‟ PBC category.

20. The remaining difference between the combined total of reports R04opX and R046X and the R300 tables (based on sub-contracting fees not included in specialty level data) was allocated to PBC’s based on the activity specialty proportions.

B3.6 Accident and Emergency

21. The figures for Accident and Emergency services are based on the non elective costs from the IRF SMR01 file using the same methodology as per the Acute, Geriatric Long Stay and Mental Health and Learning Difficulties. Similarly, the difference between non elective costs in the SMR01 IRF file and the 2011/12 costs book (Report R310) for Accident and Emergency patients was apportioned using distribution of costed activity. For any future analysis the possibility of using activity data from the A&E datamart would be investigated further as it may allow a breakdown by PBC category.

B1 Background

2. The Department of Health describes Programme Budgeting as follows:

The aim of the project is to develop a source of information, which can be used by all bodies, to give a greater understanding of where the money is going and what we are getting for the money we invest in the NHS.

The three main drivers of this are:

a way of monitoring where NHS resources are currently invested, e.g. for the purpose of

monitoring expenditure against National Service Frameworks a way of assisting in evaluating the effectiveness of the current pattern of resource

deployment a tool to support and improve the process for identifying the most effective way of commissioning NHS services for the future.

3. At a basic level the exercise involves collating and presenting NHS expenditure on the basis of programmes of care rather than on the basis of inputs or accounting conventions.

This would track expenditure on patient care regardless of setting and therefore would cut across secondary, primary and community care.

4. Scotland does not currently collect programme level cost information from NHS Boards. The principal cost data collection is the Scottish Health Service Costs Book which reports expenditure on the basis of specialty or service (e.g. Family Health Services (FHS)).

5. Programme Budgeting expenditure for Acute, Geriatric Long Stay (GLS), Mental Health & Learning Difficulties and Accident & Emergency services has been estimated using the IRF (Integrated Resource Framework) Patient Level Costing Information System (PLICS) costing methodology. The PLICS costing methodology was developed for the IRF mapping and is now the accepted method of costing for NHS Scotland. PLICS apportions hospital site and specialty specific direct costs to individual patient records on admission, per day, for theatre time and specific high cost items e.g. prosthetics. As with other costing methodology, PLICS will continue to be developed as and when more appropriate information becomes available, for example high cost items, average theatre times for elective and non-elective patients, etc. More information on the IRF PLICS costing methodology can be found in the paper published on the TAGRA website or from the IRF analytical team at NSS.isdIRF@nhs.net.

6. For Family Health Services, cost information is collected by ISD as part of the payments process which produces more detailed cost information for FHS prescribing and General Dental and General Ophthalmic Services.

B2 Datasets and Analysis

7. In Scotland the approach taken to allocate costs to Programme Budgeting Categories (PBC) varied depending on the breadth and quality of the information available nationally. For example, acute inpatient and day case activity is now routinely costed as part of the IRF PLICS costing methodology, whereas within the Outpatient data collection system, there is little information on procedure and diagnoses to allow direct mapping of a PBC code. Wherever possible the most robust method for costing data has been used with a view to enhancing the methodology as the data becomes more readily available.

8. The 2011/12 Scottish Health Service Costs Book was used as the primary data source, with much of the programme budgeting category distribution based on analysis conducted using nationally available datasets.

9. Expenditure in this analysis has been mapped to the Scottish Health Service Costs Book 2011/12 (Report R300), excluding resource transfer.

10. The specific data used and approach taken is detailed in the sections below. More information on the data inclusions/exclusions, as well as additional notes can be found in Appendix C.

B3 Hospital Sector

B3.1 Acute Services

11. In order to calculate Acute services expenditure by PBC, the 2011/12 SMR01 IRF costed file was run through the Health and Social Care Information Centre 2011/12 Healthcare Resource Group (HRG) Reference Costs grouper v4 which assigns an HRG and PBC code to each record. Once the PBC codes were attached to the file, the data was aggregated by PBC to obtain the sum of the costs for each PBC category.

12. The difference between the SMR01 IRF costs and the combined Inpatient, Day Case and Day Patient figures reported in the 2011/12 Costs Book (Reports R310;R330;R370) was apportioned based on the distribution of the SMR01 IRF based expenditure.

B3.2 Geriatric Long Stay

13. Similar to Acute services, Geriatric long stay expenditure by PBC was estimated using the 2011/12 SMR01_E IRF costed file. A PBC was assigned using the 2011/12 HRG Reference Costs grouper v4; the file was then aggregated to obtain a cost for each PBC.

14. The difference between the expenditure reported in the 2011/12 Costs Book (R360) for Inpatient and Day Patient and the SMR01_E IRF costs was apportioned based on the distribution of the SMR01_E IRF based expenditure.

B3.3 Maternity Services

15. The Maternity datasets (SMR02 & Scottish Birth Record (SBR)) have not yet been investigated in terms of mapping to PBC. The figures reported in the tables have been taken directly from the 2011/12 Costs Book (Report R320) for Inpatients and Daycases and allocated to the “Maternity and Reproductive Health” PBC category. The figures reported in the Costs Book for Maternity Services include Special Care Baby Units.

B3.4 Mental Health & Learning Disabilities

16. PBC codes were matched on to the 2011/12 SMR04 IRF costed file using the HRG grouper software and aggregated to obtain a cost per PBC as per the Acute and Geriatric Long Stay analysis. The difference between the expenditure reported in the 2011/12 Costs Book (R340;R350) for Inpatient and Day Cases and the SMR04 IRF costs was apportioned using the distribution of the SMR04 IRF based expenditure.

B3.5 Outpatients

17. The SMR00 Outpatient dataset contains limited information on diagnosis and procedures for outpatient attendances; therefore cost data was taken from the 2011/12 Costs Book (Report R04opX) at Outpatient specialty level. The specialties were mapped to PBCs using the Department of Health’s UNIFY2 Non Admitted Patient Care (NAPC) mapping file.

18. As the analysis was at specialty level only, it meant that much of the data was categorised into the “Other” PBC, as some specialties (e.g. General Surgery) cover numerous PBC categories rather than falling into one (e.g. Dental, Obstetrics). The complete list of specialties included in “Other‟ PBC is outlined in Appendix E.

19. The Costs Book Outpatient Specialty report (R04opX) excludes Allied Health Professional Costs & Activity, as they cannot be broken down by specialty. As these costs and activity cannot be accurately allocated to specific PBC codes, the AHP expenditure outlined in Costs Book report R046X was added to the “Other‟ PBC category.

20. The remaining difference between the combined total of reports R04opX and R046X and the R300 tables (based on sub-contracting fees not included in specialty level data) was allocated to PBC’s based on the activity specialty proportions.

B3.6 Accident and Emergency

21. The figures for Accident and Emergency services are based on the non elective costs from the IRF SMR01 file using the same methodology as per the Acute, Geriatric Long Stay and Mental Health and Learning Difficulties. Similarly, the difference between non elective costs in the SMR01 IRF file and the 2011/12 costs book (Report R310) for Accident and Emergency patients was apportioned using distribution of costed activity. For any future analysis the possibility of using activity data from the A&E datamart would be investigated further as it may allow a breakdown by PBC category.

B4 Community Sector

22. Currently community sector costs and activity are unable to be accurately allocated to programme budgeting categories. Therefore all community expenditure reported in the 2011/12 Costs Book has been allocated to the “Other” PBC category, except community dental (Report R820) which can be explicitly identified. The “Other” PBC category will include Community Midwifery, Community Psychiatric teams, Learning Disabilities services and Community Nursing and Health Visiting teams.

B5 Pharmaceutical Services

B5.1 Prescribing (Prescribing Information System (PIS))

23. Prescription Cost Analysis 2011/12 data was obtained from the ISD prescribing website and the “Total for Chemical names‟ sheet extracted, which lists the number of items prescribed and Gross Ingredient cost (GIC) by individual chemical names. The data was allocated to PBC’s using the Department of Health’s British National Formulary (BNF) to PBC mapping file and an additional excel mapping file which detailed the percentage share of the total for each drug for each relevant PBC. Some drugs can be used to treat more than one type of condition, therefore the analysis needed to take this into account when allocating expenditure in order to sufficiently reflect activity & cost by programme budgeting category. An example of the allocation mapping methodology is detailed in Table B1.

B5.2 Other Pharmaceutical Services

24. The outstanding pharmaceutical expenditure reported in the 2011/12 Costs Book (Report R390) was apportioned to PBC based on the distribution of the allocated drug expenditure.

Table B1 : example of prescribing mapping tool.

SECTION	SUB-SECTION	PARAGRAPH	CHEMICAL SUBSTANCE	PBC	Level (for matching to Prescribing Data)	BNF subsection	BNF Chemical Name	Paragraph	1A	2F	2G	2H	4B	18X	23X	Total
8.3 Sex hormones and hormone antagonists in malignant disease																0
	8.3.1 Oestrogens			2H / 2F (90:10)	sub-section	080301				10		90				100
	8.3.2 Progestogens															0
			MEDROXYPROGESTERONE ACETATE	2F / 2G / 2H (20:60:20)	chemical sub	080302	Medroxyprogesterone Acetate			20	60	20				100
			MEGESTROL ACETATE	2F / 2G (40:60)	chemical sub	080302	Megestrol Acetate			40	60					100
			NORETHISTERONE	2F / 18X (10:90)	chemical sub	080302	Norethisterone			10				90		100
	8.3.3 Androgens			?	sub-section	080303										0
	8.3.4 Hormone antagonists															0
		8.3.4.1 Breast cancer		2F	paragraph			08030401		100						100
		8.3.4.2 Prostate cancer and gonadorelin analogues														0
			BICALUTAMIDE	2H	chemical sub	080304	Bicalutamide					100				100
			BUSERELIN	2H	chemical sub	080304	Buserelin					100				100
			CYPROTERONE ACETATE	2H	chemical sub	080304	Cyproterone Acetate					100				100
			FLUTAMIDE	2H	chemical sub	080304	Flutamide					100				100
			GOSERELIN	2H / 4B / 2F	chemical sub	080304	Goserelin			34		33	33			100
			LEUPRORELIN ACETATE	2H / 4B	chemical sub	080304	Leuprorelin Acetate					50	50			100
			TRIPTORELIN	2H / 4B	chemical sub	080304	Triptorelin					50	50			100
		8.3.4.3 Somatostatin analogues		4B	paragraph			08030403					100			100

B6 Family Health Sector

B6.1 Practice Team Information (PTI) estimated consultations

25. General Practice surgeries use a different diagnostic coding system to the hospital setting, using Read codes rather than ICD10 diagnostic codes. As PBC mapping relies on ICD10 codes, this involved mapping Read codes to ICD10 codes before mapping to PBC categories.

26. ISD's PTI team carried out an appropriate mapping of PTI data and provided GP Practice consultation estimates by PBC for 2011/12. Unlike with SMR submissions, Practice staff tend not to use a “main diagnosis” code, but rather list all relevant codes for the individual consultation. This means that one consultation may be counted in more than one PBC as no assumptions can be made regarding which is the “main‟ diagnosis. The method described below was applied to the data to account for this.

27. Costs were apportioned using the percentage distribution of PBC’s (using the sum of the individual PBC consultations rather than the total number of consultations, as this was the greater figure). Expenditure was taken from the 2011/12 Costs Book (Report R390 – General Medical Services).

28. The difference between the total number of estimated consultations from PTI and the sum of the individual PBC’s was calculated and this excess distributed among the PBC’s using the percentage distribution calculated previously. The calculated excess was then subtracted from the estimated no. of consultations for each PBC category in order to obtain a total for each PB category which, when summed, matched the total estimated no. Of consultations from PTI.

B6.2 General Dental Services & General Ophthalmic Services

29. General Dental & General Ophthalmic Services 2011/12 costs have been taken directly from the 2011/12 Costs Book (Reports R820 & SFR8

Correspondence and enquiries

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