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Potential excess acute costs at XYZ PCT

Potential excess acute costs at XYZ PCT. Dr Rod Jones Statistical Advisor Healthcare Analysis & Forecasting. Key Issues. Capitation formula is linear but true relationship is sigmoid Low deprivation areas are under funded Gap is mainly NEL (£14M) of which £3M is excess zero day ‘emergency’

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Potential excess acute costs at XYZ PCT

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  1. Potential excess acute costs at XYZ PCT Dr Rod Jones Statistical Advisor Healthcare Analysis & Forecasting

  2. Key Issues • Capitation formula is linear but true relationship is sigmoid • Low deprivation areas are under funded • Gap is mainly NEL (£14M) of which £3M is excess zero day ‘emergency’ • Some EL (mix of counting & intervention) (£9M) • PCT is attempting to recover a general gap against specific HRG • Is this likely to be a ‘successful’ strategy? • Need to benchmark against the best • West Berkshire and the RBH

  3. Key Issues (contd) • Three acute sites with different counting & coding issues • LA data shows different levels of ‘excess’ OP & IP • A FT highest level of Plastic Surgery ‘DC’ in the UK  AAA LA • Wycombe highest level of Gynaecology admissions  BBB LA (M09, M05, N12) • High levels of ‘other’ first attendance at B NHS Trust CCC LA

  4. Suggestions • Segment all output areas (OA) into site catchments for EL, NEL and OP and performance manage by catchment • Will make demand management more pro-active by virtue of ‘focus’ • Able to calculate expected/desirable demand at OA level, hence, specific & measurable targets for each catchment

  5. Efficiency Measures • 16% excess bed days within trim points • 3% excess NEL bed days > upper trim point • 1.4 FCE per Spell for NEL respiratory conditions (1.1 at RBBH) • Highest level of transfers to residential care in South Central • Surgical DC performance is OK • Poor performance only in Ophthalmology 1,440 fewer DC • Highest % DC in SCHA in C04 (minor mouth), C22 (nose), H22 (minor T&O), L98 Chemo • Check to see if these are outpatient procedures counted as DC

  6. Implications • Beds occupied hence poor A&E performance • Contract should state ‘will not pay for excess bed days above national average’ • Cost saving of 4,300 excess bed days • £130,000 at £300 per excess day • Benchmark: RBH 4,700 lower than expected • Residential care & alternatives

  7. Other Cost Pressures • Number to be cleared from the waitinglist in Bucks is highest in South Central relative to level of capitation funding • Legacy issue with high impact in 07/08 and 08/09 • However, this tied funding is released in 09/10

  8. Outpatient First Attendance • Considerable overlap between • Plastic Surgery (£130)[1] & Dermatology (£115); • Gynaecology (£135) & Obstetrics (£154); • Medical group (£161 to £260); • Orthopaedics (£144), Neurosurgery, Plastic Surgery (£130), Anaesthetics (£187); • General Surgery (£151) and Urology (£157). • Specify acceptable proportions in contract [1] The 06/07 PbR tariff for outpatient first attendance is given in brackets

  9. Excess First Attendance

  10. First Attend by Group(excess per 1000 head)

  11. 6 in top 15 LSOA in TVHA(no link with IMD implies GP practice related)

  12. Catchment Area Behaviour

  13. Conclusions • Counting of ‘other’ is an issue • Specify acceptable ratio of GP to Other • Very high first attendance in specific OA • May be function of GP practice • Acute site catchment areas show high/low general patterns • Allocate all OA to a site catchment and performance manage as a group • Maximum possible saving of 24,600 first attend • £5M at 07/08 tariff • Possible early stage savings of £1.8M in SB and AV

  14. Inpatient • Identify all HRG lines with excess cost > £20,000 p.a. • £14 M NEL and £9M EL

  15. Elective • >5,300 excess zero day elective • High likelihood of minor procedures counted as DC • £5.3M less alternative cost as RDA or OP • Some specialist lines are high • HRG C35 Major maxillo-facial • Proportion of 0 & 1 day too high • Coding issue?

  16. Non-elective • £1.8M is zero day NEL • £0.9M of which from Wycombe LA • Specify in contract that zero day NEL will be paid up to national average • Any HRG ending 99 (Complex Elderly) • May be a coding issue

  17. SEPHO Atlas of conditions • HES data 98/99 to 02/03 • Spell per person • Relative rate per person • Adjusted for age, sex and IMD • http://www.uhce.ox.ac.uk/Epidembase2/Atlases_admissions.html#catalogue

  18. Spell per person • Rheumatoid Arthritis • Wyc 1.46, SB 1.38, AV 1.27, Chilt 1.21 • Gynaecology • SB 1.09; all others 1.02

  19. Relative rates (person based) • Knee Arthroplasty • Wyc 120%, AV 110% • Mastectomy & Lumpectomy • AV 120%, Chilt 111%, Wyc 107%, SB 103% • Squint • AV 114%, Wyc 109%, SB 82%, Chilt 80% • Hysterectomy • Wyc 88%, Chilt 82%, AV 79%, SB 67% • Cholecystectomy • AV 102%, Chilt 100%, Wyc 97%, SB 86% • Peptic Ulcer • AV 136%, Wyc 69%, SB 62%, Chilt 48% • CABG • Wyc 113%, SB 102%, Chilt 97%, AV 90%

  20. Programme Budgeting • Links programme expenditure and outcomes over 23 programmes • Uses ICD-10 codes to group • http://www.dh.gov.uk/programmebudgeting • http://nww.nchod.nhs.uk

  21. High Expenditure • AAA LA(GI, Trauma & Injury, Mental Health, Musculo-skeletal • BBB LA (Trauma & Injury) • CCC LA ((Trauma & Injury, Circulatory)

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