Programme Budgeting – Testing The Approach in Scotland

3. Preliminary findings - bottom up approach

14. For the three risk factors, smoking, obesity and excessive alcohol consumption, activity and expenditure related directly to secondary prevention^[6] is presented alongside activity and expenditure related to diseases directly resulting from the presence of the risk factor. Use of community and ambulance services could not be estimated. Non NHS service provision was also excluded. Primary prevention to prevent people developing the risk factor in the first place, such as general health improvement activities, smoking in public places legislation etc, is excluded from this analysis.

15. Disease attributable fractions were applied to activity related to the sequelae to generate estimates of the cost to NHSScotland of disease related to the risk factor. Obesity attributable fractions derived from fractions for England (NAO 2001, as used in ScotPHO obesity study 2007)^[7] were applied to total costs for individual specified conditions. Similarly, UK smoking attributable fractions (Statistics on Smoking, The Health and Social Care Information Centre, 2009)^[8] were applied to total costs for the relevant conditions. Note that activity and costs were based on the primary diagnosis used in coding, not a diagnosis in any position.^[9]

16. In each case, costs were made up of inpatient (including daycases), outpatient, and primary care costs as well as prescription charges for each condition (by ICD10 code).

17. Inpatient (including day cases)^[10] and outpatient^[11] activity data were applied to treatment costs given in the Cost Book^[12]. For all other surgical appointments and all medical appointments, pro rata proportions of individual conditions were calculated for inpatient episodes and these fractions were then applied to the main disease categories for outpatients. The number of GP consultations was derived from Practice Team (PTI) sample data for 2007/08. The total cost of primary medical services divided by the total number of face-to-face contacts was used as a proxy for a unit cost per GP visit.

18. For prescription costs for conditions indirectly related to obesity or smoking, volume and cost (Gross Ingredient Cost (GIC)) associated with the main BNF sections for digestive, circulatory, respiratory diseases and cancers were obtained from ISD^[13]. Direct costs for drugs in smoking cessations are available from ISD^[14].

19. Data on activity and cost related to alcohol in Scotland in 07/08 were taken from 'Societal Cost of Alcohol Misuse in Scotland for 2007'^[15] . The information in the report was based on ISD data, enhanced with additional analyses.

Table 3.1: Summary of risk factor activity

Programme	Secondary Prevention Activities	Related disease activity
		Primary care contacts	Prescribing items	OP attendances	IP episodes/ daycases
Smoking	Smoking cessation services Smoking cessation prescribing (244,283 items)	130,131	34,886,390	44,160	32,349
Obesity	Healthy weight community projects Counterweight HEAT target NHS Health HEAL support	925,857	8,211,483	31,872	22,851
Excessive alcohol consumption*	Screening in A&E Brief interventions	470,752	202,373	194,258	19,000

* For consistency only similar data to those presented for obesity and smoking are shown for 2007/08 in this overview.

Table 3.2: Summary of estimated risk factor costs

Programme	Total ( £m)	Secondary Prevention Activities (£m)	Related disease activity (£m)
			Primary care contacts	Prescribing items	OP attendances	IP episodes/ daycases
Smoking	£336.3	18.3 (5.6%)	7.0	62.6	19.2	229.3
Obesity	£190.9	16.4 (8.6%)	29.9	83.0	4.0	57.6
Excessive alcohol consumption	£114.7	10.1 (8.8%)	15.1	1.6	20.9	67.0

3.1 Smoking

20. Tables 3.3 and 3.4 provide a more detailed overview of activity and cost linked to smoking, disaggregated by major disease categories.

Table 3.3: Activity attributable to smoking 2007/08

Programme	Secondary Prevention Activities	Related disease activity
		Primary care contacts	Prescribing items**	OP attendances	IP episodes/ daycases
All diseases of the digestive system		588	5,056,691	449	175
All circulatory diseases		97,887	23,791,257	21,760	19,185
All respiratory diseases		24,758	6,019,723	5,454	6,150
All cancers		4,351	18,719	13,719	5,998
Other*		2,547		2,779	841
Direct smoking cessation prescription items	244,283
Total	244,283	130,131	35,130,673	44,160	32,349

* includes attributable fractions for: age-related cataract; Periodontal disease; Spontaneous abortion; Hip fracture (GP appointments only)
**measured independently from GIC
Data source: ISD data request (2007/08 data) - Inpatient, Outpatient and Daycase activity data (diagnosis); number of GP consultations; prescribing of smoking cessation interventions

Table 3.4: Estimated costs attributable to smoking 2007/08

Programme	Total (£m)	Secondary Prevention Activities (£m)	Related disease activity (£m)
			Primary care contacts	Prescribing items	OP attendances	IP episodes/ daycases
All diseases of the digestive system	10.4		0.2	1.1	1.2	7.9
All circulatory diseases	105.7		3.8	32.7	4.4	64.9
All respiratory diseases	82.2		2.2	28.7	2.7	48.5
All cancers	118.1		0.7	0.05	10.8	106.6
Other*	1.6		0.07		0.2	1.3
Direct smoking cessation prescription costs	7.3	7.3
Smoking Cessation	11.0	11.0
Total	336.3	18.3	7.0	62.6	19.2	229.3

* includes attributable fractions for: age-related cataract; Periodontal disease; Spontaneous abortion; Hip fracture (GP appointments only)
Data source: ISD cost book data (2007/08) R040; R044. R100; ISD data request (2007/08 data) total number of face-to-face GP visits

3.2 Obesity

21. Tables 3.5 and 3.6 provide a more detailed overview of activity and cost linked to obesity, disaggregated by major disease categories.

Table 3.5: Activity attributable to obesity 2007/08

Programme	Related disease activity
	Primary care	Prescribing	OP	IP episodes/ daycases
Direct Obesity	183,456	110,303	1,202	601
All diseases of the endocrine system	297,608	1,214,531	10,096	3,097
All circulatory diseases	410,573	6,307,827	10,031	6,841
All cancers	1,822	627	3,045	7,763
other*	32,398	578,195	7,498	4,549
Total	925,856	8,211,483	31,872	22,851

*includes attributable fractions for: Osteoarthritis, Gallstones and Gout
**measured independently from GIC
Data source: ISD data request (2007/08 data) - Inpatient, Outpatient and Daycase activity data (diagnosis); number of GP consultations; prescribing data for associated disease treatment

Table 3.6: Estimated costs attributable to obesity 2007/08

Programme	Total (£m)	Secondary Prevention Activities (£m)	Related disease activity (£m)
			Primary care contacts	Prescribing items	OP attendances	IP episodes/ daycases
Direct Obesity costs	28.6	16.4	5.9	4.5	0.1	1.6
All diseases of the endocrine system	45.7		9.6	26.9	1.2	8.0
All circulatory diseases	80.7		13.3	48.4	1.5	17.5
All cancers	19.1		0.1	0.0	0.3	18.8
other*	16.8		1.0	3.1	0.9	11.8
Total	190.9	16.4	29.9	83.0	4.0	57.6

*includes attributable fractions for: Osteoarthritis, Gallstones and Gout
Data source: ISD cost book data (2007/08) R040; R044; R042. R100; ISD data request (2007/08 data) total number of face-to-face GP visits

3.3 Alcohol

22. Tables 3.7 and 3.8 provide a more detailed overview of activity and cost linked to alcohol misuse, disaggregated by major disease categories including injuries and other external influences.

23. Note that, as alcohol has a protective effect for coronary heart disease and cholelithiasis (gallstones) at lower levels of consumption, the alcohol attributable fraction (as used in the York study) has a negative value and therefore the estimate is of the number of prevented hospital episodes attributable to alcohol consumption. The negative impact for heart diseases is outweighed by other disease impacts in the circulatory disease category, but the impact for gallstones is the dominating contributor in the digestive disease category. This is represented by a negative prefix in Table 3.7 and a negative cost in Table 3.8 in the digestive disease category.

24. The activity and costs shown in tables 3.7. and 3.8 differ from those in the York study (2007) and this work is not intended to replicate that. In common with the estimates for the other risk factors they omit costs using assumptions from literature such as the cost of ambulance journeys or A&E visits; and are based on primary diagnosis only. The York study uses diagnosis in any position.

Table 3.7: Activity attributable to alcohol misuse 2007/08

Programme	Related disease activity
	Primary care	Prescribing	OP	IP episodes/ daycases
Direct Alcohol misuse ***	109,594	38,680		13,943
Indirect activity
All diseases of the digestive system	2,134			-1,433
All circulatory diseases	323,182			1,203
All cancers	4,454			3,183
other*	27,368			2,104
Injuries and other external	4,020
Total indirect activity***	361,158	163,693		5,057
Total	470,752	202,373	194,258	19,000

*includes attributable fractions for: epilepsy; spontaneous abortion, psioriasis
**prescriptions for direct treatment and dependence, indirect: withdrawal symptoms
***excl OP attendances
Data source: York 2010

Table 3.8: Estimated costs attributable to alcohol abuse 2007/08

Programme	Total (£m )	Secondary Prevention Activities (£m)	Related disease activity (£m)
			Primary care contacts	Prescribing items	OP attendances	IP episodes/ daycases
Direct Alcohol misuse costs***	67.45	10.10	3.51	0.87		52.97
Indirect costs
All diseases of the digestive system	-3.92		0.07			-3.99
All circulatory diseases	13.69		10.34			3.35
All cancers	9.00		0.14			8.85
other*	6.73		0.88			5.85
Injuries and other external	0.13		0.13
Total indirect costs***	26.40		11.56	0.78		14.07
Total	114.7	10.1	15.1	1.6	20.9	67.0

*includes attributable fractions for: epilepsy; spontaneous abortion, Psoriasis
**prescriptions for direct treatment and dependence, indirect: withdrawal symptoms
***excl OP attendances Data source: York 2010

Outcomes for risk factors

25. As with all NHSScotland activity, outcomes should reflect both life years gained and the quality of these years gained. In the absence of such a measure of the effectiveness of prevention, process and intermediate outcomes can be used to describe the outcomes of the programmes. Table 3.9 provides examples:

Table 3.9: programme outcomes

Programme	Process outcomes	Intermediate outcomes
Smoking	Smoking cessation clinic attendances	Smoking cessation rates Lung cancer incidence Incidence of other smoking related conditions
Obesity	Child healthy weight interventions carried out	% population overweight % population obese Incidence of type 2 diabetes
Excessive alcohol consumption	Brief interventions undertaken Number of people screened in A&E Admissions for alcohol related disease	Harmful drinking quit rates Incidence of harmful drinking

26. Such analyses could demonstrate the return on investment from secondary prevention in those with particular risk factors. For example, expenditure of £x million in smoking cessation services, led to y successful quit attempts (at one month post quit). Likewise with time series information, the reduced incidence in lung cancer over time could be presented alongside information on investment in smoking cessation services.