Prescribing Programme Budgeting and Prescribing Incentive Scheme

1. Practice Based Commissioning Shaped Prescribing Support Prescribing Programme Budgeting and Prescribing Incentive Scheme Andrew Riley, Head of Medicines Management, NHS Stoke on Trent

2. Scope of presentation • Prescribing Programmes • Prescribing Incentive Scheme • Targeted Support • Prescribing Indicators

3. Moving beyond predicting and monitoring prescribing spend. A framework for improving commissioning and accountability for prescribing at PBC cluster level. Prescribing programme budgeting – allocation broken down into budgeted programmes Influencing and tracking expenditure in each programme at PCT, cluster and practice level. Marginal analysis – an appraisal of the costs and benefits which accrue when resources are deployed in new ways. Prescribing Programme Budgets

4. Letter from DH Director of Finance, Nov 06 “….analysis of expenditure in this way should help PCTs to examine the health gain that can be obtained from investment and will inform understanding around equity and how patterns of expenditure map to the epidemiology of the local population”. Prescribing Programme Budgets

5. Action orientated – PBMA is a way of thinking and working - a way of framing questions and objectives, of measuring, planning, coordinating, communicating, networking and reporting – getting a better fit between needs and resources. i.e. more than a spreadsheet or just a new way of presenting the figures Prescribing Programme Budgets

6. “Delivery of efficient (and in the case of the NHS equitable) health care requires doctors to take responsibility for resources and to consider the needs of populations while managers need to become more outcome and patient centred. … programme budgeting and marginal analysis has the potential to align the goals of doctors and managers and create common ground between them. (Danny Ruta, Craig Mitton, Angela Bate, and Cam Donaldson Programme budgeting and marginal analysis: bridging the divide between doctors and managers BMJ 2005; 330: 1501-1503) Prescribing Programme Budgets

7. “economic studies should be used to facilitate dialogue between stakeholders rather than directing resource decisions. The emphasis should be on facilitating a conversational competence rather than the pursuit of an increasingly methodological one that bares little relationship to the complexities of the real world”. REF: McDonald R. Programme budgeting and marginal analysis: a pragmatic approach to economic evaluation. In: Kernick D (Ed). Getting health economics into practice. Abingdon: Radcliffe Medical Press 2002. Prescribing Programme Budgets

8. Prescribing Programme Budgets • Prescribing budget setting – predicting spend rather than setting a budget • 5 Prescribing programme budgets 75% of the prescribing budget • CVS, CNS, Respiratory, Gastro, Endocrine • Target: manage budget for all 5 areas to within +/- 5% of allocation • Monthly monitoring at practice and PBC cluster level • Aim - • NHS Stoke on Trent - 5 PBC Clusters • To enable GP leads at cluster and practice level to monitor and actively manage “big ticket” high volume, low cost prescribing in each of their programme budgets

9. Infectious disease Cancer and tumours Blood disorders Endocrine, nutritional and metabolic problems Mental health problems Learning disability problems Neurological system problems Eye/vision problems Hearing problems CVD Respiratory system problems Dental problems Gastro-intestinal system problems 14. Skin problems 15. Musculo skeletal system problems 16. Trauma and injuries 17. GUM 18. Maternity and reproductive health 19. Neonates 20. Adverse effects and poisoning 21. Healthy Individuals 22. Social care needs 23. Other conditions 23 Programme budgeting categories

10. Get the right people together for each programme and ask • How much does our PCT/PBC cluster spend on this programme at the moment? • What are our programme objectives for each step along the patient journey from prevention to terminal care? • What activity is being generated at present? • What are our results? • How do all these compare with our peers elsewhere in the NHS? • Could we do better with the resources between us?

14. Practice monthly report The prescribing budget target shows at a glance which of the programmes most influence the budget and what the variance is between the budget and the spend. Also what the projected outturn variance is as a percentage and whether this is out of range = red. Target of 90% compliance with AB formulary Better care, better value indicators Compliance with North Staffs Joint Formulary Seven cost effective targets for formulary compliance, usage compared with non-formulary branded comparator drugs

15. Formulary Choices

17. Healthcare finances Work with finance team Understand their needs and learn their language, aim to achieve confidence in spend – balanced ledger. Reliance on historical data. Get friendly with DoF Raise the profile of the prescribing budget £50M v £450M Understand their issues re reliability of data. Of £450M only £60M has reference costs – biggest contract £35M. Start with high level overview Top 6 prescribing programmes represent 75% of overall prescribing budget. Improve confidence in ability to re-jig the prescribing spend. Provide rationale for unpredicted changes to the forecast in prescribing budget out-turn and help board (Chair and NEDs) to develop their understanding of the key issues. Broaden ownership and understanding

18. Monthly cluster reports which monitor spend in each practice in each programme Focus on a 5 programmes Sub budget for 5 programmes Budget for all 5 programmes Incentive for managing programmes Measuring Improvement

22. Next Steps “The pursuit of efficiency and ownership of opportunity cost, is an ethical imperative for all who work in the NHS. Ultimately, it is the population who pay for inefficiency and the currency in which they pay is avoidable pain, disability and dying before their time” Jackson A Brambleby P Young C. Putting spending on the map. Healthcare Finance Dec 2006 11-13

23. Thank You