Enhanced Services- Programme Budgeting and Marginal Analysis

1. Enhanced Services-Programme Budgeting and Marginal Analysis Health Economics Team

2. Contents • Introduction • Literature Review • PBMA Process • Feedback • Conclusion

3. Introduction • NHS Ayrshire & Arran provide a number of Enhanced Services to its patients • Enhanced Service is provided by the GP in addition to their core contract • Usually reimbursed through a per item fee – set tariff • However issues around allocation of the Enhanced Services budget

4. Introduction • Requires a prioritisation exercise assessing the relative value for money of the services • PBMA a technique which can support decision making regarding prioritisation • Identify areas for investment through disinvestment • Real life NHS resource allocation problem with multiple stakeholders

5. Literature Review • Prior to starting project commissioned a literature review examining theory and implementation of technique • Identified the stages of a PBMA which formed structure of the project (Mitton and Donaldson, 2004) • Some variation in the literature but appeared to follow a similar process • Kemp and Fordham (2007) Norfolk example as one of particular relevance

6. PBMA Key Stages • Stakeholder Group • Enhanced Services for Review • Programme Budget • Criteria • Evidence Packs • Scoring and Evaluating the Services • Analysis and Prioritisation

7. Stakeholder Group • Existing Enhanced Services Group made up of Primary Care Managers, Finance Managers, Public Health, GPs • Included Secondary Care colleagues for wider scope • Also included members of the public • Recruited through appropriate department and an advert to patient groups through practice managers

8. Services to Evaluate • Diabetes • Medicines Reconciliation • H Pylori Eradication • Adults with Learning Disabilities • Contraceptive Implants • A&E Frequent Attendees • Service for Carers • Ring Pessary Fitting & Maintenance • Minor Injuries • Specialist Dermatology Service

9. Programme Budget

10. Programme Budget

11. Criteria • Variation in services in terms of outcomes and how they are delivered • Need to determine a ‘global’ measure of benefit which allows comparison to be made • Can be achieved through developing a common set of relevant criteria to judge the options against • Can be developed either through top down or bottom up approach

12. Criteria • How important are these criteria? • Effectiveness • Patient Experience • Practicality • Impact on Sec. Care • Sustainable

13. Criteria Weights 12 10 11 7 10 • How important are these criteria? • Effectiveness • Patient Experience • Practicality • Impact on Sec. Care • Sustainable

14. Evidence Pack • Next stage in the process is where all participants score each service against our criteria • To do this need evidence/information prepare participants for scoring session • Particularly members of the public who are reliant on information for scoring • Coherent and systematic approach for generating pack and compiling evidence

15. Scoring

16. All group results

17. All group results

18. Cost value ratio • Allocation of resources across the services very different and need to standardise for comparison • Calculated a cost per “beneficiary” for each service under review • Divide the cost per beneficiary by the number of points of each service • This gives you a cost per benefit point (cost value ratio) which is a measure of cost-effectiveness

19. All group results

20. All group results

21. Discussion • Results generated much discussion regarding prioritisation, disinvestment, methodology, redesign, public involvement and GP re-imbursement • Reflect upon results and re-review at a future Enhanced Services meeting • Potential aim to agree a few services for investment or disinvestment • Inform further piece of work regarding “impact assessment” outwith PBMA process

22. Feedback • Primary care expressed that technique prompted in depth discussion regarding prioritisation • Expressed view to use technique differently to prioritise larger parts of the Primary Care budget • Process generalisable and interest expressed in using it to prioritise other funding decisions • Well received within NHS Ayrshire & Arran and Senior Directors

23. Conclusion • Real life resource allocation problem requiring a prioritisation process • PBMA provided a direction of travel regarding future allocation of resource • Challenging piece of work and time consuming/intensive • However information provided unique and process enables a degree of transparency in decision making

24. Sub-group scores

25. GP results

26. Public results

27. NHS Managers results