Programme Budgeting – Testing The Approach in Scotland

Appendix C: NHSScotland Programme Budgeting Methodology 2007/08 data

1. This document is intended to be read alongside the NHSScotland Programme Budgeting analysis showing estimated expenditure by Programme Budgeting category for 2007/08.

C1 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. This means that for acute hospital activity, Programme Budgeting expenditure will need to be estimated using central data sets based on a methodology similar to that used to cost activity for the Scottish National Tariffs.

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.

C2 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 routinely costed as part of the Scottish National Tariff work, whereas within the Outpatient data collection system, information is only just being introduced to record diagnoses which allow the mapping of a PBC code. Wherever possible the most robust method for costing data has been used with this initial data run, with a view to enhancing the methodology as the data becomes more readily available.

8. The 2007/08 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 2007/08 (Report R300), excluding resource transfer.

10. The specific data used and approach taken is detailed in the sections below.

C3 HOSPITAL SECTOR

C3.1 Acute Services

11. In order to calculate Acute services expenditure by PBC, a costed 2007/08 activity extract was taken from the SMR01 Acute Inpatients and Day Cases dataset. This file was run through the Information Centre for Health and Social Care 2008 Healthcare Resource Group (HRG) Local Payment grouper v3.5^[21] which assigns an HRG and PBC code to each activity record. Once the PBC codes were attached to the file, the data was aggregated by PBC to obtain the sum of the costs and activity data for each PBC category.

12. The difference between the SMR01 costs and the combined Inpatient, Day Case and Day Patient figures reported in the 2007/08 Costs Book (Reports R310;R330;R370) was apportioned based on the distribution of the allocated costs using the SMR01 dataset.

13. Although the Scottish National Tariff uses a cost per spell within specialty methodology, this particular analysis has been calculated using SMR01 episodes, in order to align with data in the Costs Book. For future programme budgeting analysis this approach would need to be refined. Unlike the expenditure figures in the table, the corresponding activity data detailed by Programme Budgeting category reflects Inpatient and Day Case activity only and excludes Day Patients, as these are counted in terms of attendances rather than number of cases.

C3.2 Geriatric Long Stay

14. Geriatric long stay activity for 2007/08 was extracted from the SMR01_E (formally SMR50) Geriatric Long Stay dataset and Programme Budgeting categories were matched on to the records using an ICD10 to PBC mapping file obtained from the Department of Health website^[22]. The net Inpatient cost per week (Costs Book 2007/08 report R04LSX) was mapped onto the file and the cost per episode calculated (number of weeks stay x cost per week). The file was then aggregated to obtain cost and activity data for each PBC.

15. The difference between the expenditure reported in the 2007/08 Costs Book and the SMR based analysis was apportioned to the PBC's based on the distribution of the expenditure calculated using the SMR01_E file. The difference between the activity data extracted from SMR01_E and the Costs Book report (R040LSX) was also apportioned in a similar way.

C3.3 Maternity Services

16. At the time of writing, 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 2007/08 Costs Book (Report R320) and allocated to the 'Other' PBC category until further investigations into the data have been completed. The figures reported in the Costs Book for Maternity Services include Special Care Baby Units.

C3.4 Mental Health & Learning Disabilities

17. Activity data for 2007/08 was extracted from the SMR04 Mental Health dataset and PBC codes were matched on using the HRG grouper software as per the Acute SMR01 analysis.

18. Preliminary costing of the activity data used inpatient expenditure figures and costs per inpatient week from the 2007/08 Costs Book Long Stay Specialty report (R04LSX). The cost per inpatient week per specialty was matched on to the SMR04 file and length of stay in weeks calculated from admission & discharge dates. This figure was then multiplied by the specialty specific cost per week and aggregated by PBC and specialty to obtain costs per PBC for each specialty. The difference between the net expenditure figure quoted in the 2007/08 Costs Book (Report R04LSX) and that calculated using the SMR04 file was then apportioned amongst the PBC's using the distribution of the calculated expenditure. The figures for each specialty were then summed to obtain the total by PBC.

19. The difference between the specialty specific expenditure from R04LSX and the combined total using R340 (General Psychiatry) and R350 (Learning Difficulties) Inpatient & Day Case figures was apportioned using the distribution of the total specialty specific expenditure. This difference is due to sub-contracting figures which are included in the R300 Costs Book tables.

20. The activity data from the SMR04 file was aggregated by PBC to obtain the activity distribution for the PBC codes; again the difference between the reported activity (Costs Book Report R040LSX) and the SMR04 activity was distributed in a similar way to the expenditure data.

C3.5 Outpatients

21. The SMR00 Outpatient dataset contains limited information on diagnosis and procedures for outpatient attendances; therefore cost and activity data was taken from the 2007/08 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.

22. 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 the appendix.

23. 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 can not be accurately allocated to specific PBC codes, the AHP expenditure outlined in Costs Book report R046X was added to the 'Other' PBC category.

24. 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.

C3.6 Accident and Emergency

25. The figures for A&E services were taken from the 2007/08 Costs Book (Report R04opX) and allocated to the 'Other' PBC category. 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.

C4 COMMUNITY SECTOR

26. Currently community sector costs and activity are unable to be accurately allocated to programme budgeting categories. Therefore all community expenditure reported in the 2007/08 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.

C5 PHARMACEUTICAL SERVICES

C5.1 Prescribing (Prescribing Information System (PIS))

27. Prescription Cost Analysis 2007/08 data was obtained from the ISD website, http://www.isdscotland.org/isd/5015.html, 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 file² 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 C1.

28. Activity data was obtained using same methodology and using 'number of items prescribed' rather than cost per item from the same data source.

C5.2 Other Pharmaceutical Services

29. The outstanding pharmaceutical expenditure reported in the 2007/08 Costs Book (Report R390) was apportioned to PBC based on the distribution of the allocated drug expenditure.

30. The activity detailed on the 'Activity' tables is based on the number of prescribed items alone.

Table C1: Example of Prescribing mapping tool

SECTION	SUB-SECTION	PARAGRAPH	CHEMICAL SUBSTANCE	PBC	Level (for matching to Prescribing Data)	BNF section	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

C6 FAMILY HEALTH SECTOR

C6.1 Practice Team Information (PTI) estimated consultations

31. 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.

32. ISD's PTI team carried out an appropriate mapping of PTI data and provided GP Practice consultation estimates by PBC for 2007/08. 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.

33. 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 2007/08 Costs Book (Report R390 - General Medical Services).

34. 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 PBC category which, when summed, matched the total estimated no. of consultations from PTI.

C6.2 General Dental Services & General Ophthalmic Services

35. General Dental & General Ophthalmic Services 2007/08 costs and activity have been taken directly from the 2007/08 Costs Book (Reports R820 & SFR8.4).