Programme Budgeting – Testing The Approach in Scotland

5. Discussion

41. This work has identified that it is possible to generate programme budgets from both a top down and a bottom up approach.

42. Section 3 presents estimates of activity and spend associated with three risk factors which are amenable to change through policy intervention - smoking, obesity and excessive alcohol consumption. The three programme budgets developed using the bottom up approach are limited because there are no other such programmes with which to compare them. They were effectively generated using a "cost of illness" approach. However they do represent the NHS resources associated with particular risk factors. By impacting on these risk factors there is the potential to reduce the resources required to treat particular disease categories, albeit with a time lag. For example, in the identified expenditure in section 4, problems of circulation accounted for over 9%, a substantial proportion of NHS resources. Literature used to support the bottom up analyses suggests that 24% of Ischaemic Health Disease, 15% of strokes and 62% of aortic aneurysms are smoking related: over a third of hypertension is related to obesity.

43. Mental Health is second only to problems of circulation in terms of the proportion of the identified expenditure that it represents. Admissions for mental and behavioural disorders due to use of alcohol accounted for over 3,250 hospital episodes in 2007. This represents over a quarter of such episodes that year. Approximately 17% of intentional self harm in men and 12% in women can be attributed to alcohol.

44. Cancers are identified as responsible for around 6% of spend. Over 80% of lung cancers can be attributed to smoking. It is estimated that 31% of male and 27% of female oesophageal cancer morbidity and mortality can be attributed to alcohol consumption: as can approximately 20% of breast cancer mortality and morbidity. Just less than 30% of colon cancer is obesity related.

45. We know that the diseases and conditions generating most activity and subsequent cost are not distributed evenly across the population. Inequalities are demonstrable in the conditions related to the largest areas of spend across NHSScotland. If these could be reduced then again, there would be both an increase in health for the affected population and a reduction in resource use. The 2008 Scottish Health Survey showed a clear relationship between deprivation and prevalence of CHD or stroke with 5.1% prevalence among men in the least deprived areas compared to 12.7% in the most deprived areas. The equivalent figures for women were 4.1% and 10.6%. The relationship with income was even stronger, with prevalence among women on the lowest incomes more than four times that of the highest income women.

46. In 2006, adults under 75 in the most deprived decile were 1.5 times more likely to be diagnosed with cancer than those in the least deprived decile. There are, however, different patterns for different cancers. There is a very steep social gradient for cervical and lung cancer incidence and mortality for example, but other cancers e.g. prostate cancer and skin cancer show higher incidence among the least deprived areas. For others, there are no apparent differences in incidence and mortality by socioeconomic group; these include colorectal, breast and brain cancers^[17].

47. For smoking rates a social gradient is well established and increasing as more affluent groups give up in greater numbers. For obesity there is a clear gradient by income, but not by deprivation, albeit a different relationship for each sex. (Obesity prevalence was lowest among men with the lowest incomes but, for women, obesity was lowest among those with the highest incomes.) For determinants such as participation in sport, there is a social gradient.

48. Inequalities in first admissions to hospital relating to alcohol are substantial - those in the most deprived decile are 5.5 times more likely to be admitted than those in the least deprived decile. In 2007 those from the most deprived decile were 13.5 times more likely to die from alcohol-related conditions than those in the least deprived.

49. Programme budgeting allows analysis of resource use by specific disease categories. If demand associated with resource intensive programmes has a social patterning then it suggests that targeting those groups could release resources and reduce inequalities.

50. Further, programme budgeting may help to identify pattern of spend in Scotland and compare the proportional differences in spend in identified problem areas with average proportional spend in other regions (e.g. England & Wales), or changes in spending patterns over times, set against changes in inequality outcomes.

51. Section 4 shows the comparative spend across the Programme Budgeting categories from a top down approach. These are predominantly defined by broad disease categories. Broad comparisons among programmes show that the areas of highest proportions of expenditure are mental health, problems of circulation and cancer, which corresponds to national priority areas.

52. It is acknowledged, however, that there are a number of limitations with the top down approach as it is currently presented:

• Not all activity is able to be allocated to the appropriate programme. This is a particular issue for community and A&E services, where no diagnostic information is routinely collected. In addition, prevention activity, such as general health improvement activities and cancer screening programmes, are not able to be included with the relevant programme and appears under the heading 'other'. This may diminish the potential for reallocation within programmes.
• As has been demonstrated for the diabetes sub programme, the reliance on first diagnostic place for grouping of activity may lead to a significant under reporting of activity levels against some programmes
• The sub programme generated by the top down approach (which provide information by diagnostic groups and type of care) may not be most appropriate for all programmes. For example, in cancer it might be more appropriate to have disaggregation by stage of care (diagnosis, treatment and palliation) and by age group. This may require disaggregation at sub programme level to differ among various programmes.
• There are limits to the value of single year comparisons. A time series, reviewing changes in the relative proportions of spend and outcomes achieved among and within programmes would be more useful for decision makers.
• In order to fully implement the PBMA approach work would be required to agree the most appropriate process and intermediate outcome measures to be used.