Respiratory Benchmarking Packs

1. Respiratory Benchmarking Packs South East Coast September 2010

2. Respiratory Benchmarking Packs We have taken two approaches to looking for unwarranted variation in respiratory health care • Benchmarking of all South East Coast PCTs against selected indicators • Health investment analysis for selected PCTs using programme budgeting tools

3. Purpose of Benchmarking Packs The key purpose of the packs is to help engage local commissioners and clinicians in reducing unwarranted variation Reducing unwarranted variation will improve outcomes for patients and reduce healthcare costs

4. Unwarranted Variation Some variation may be accounted for by local population characteristics, but much is unwarranted and due to the different ways services are organised and delivered. What is achievable for patients in one area should be possible in all areas. Unwarranted variation in respiratory healthcare wastes resources and adversely affects an individual’s chance of receiving timely and accurate diagnosis, of being offered appropriate treatment, of requiring emergency admission to hospital and of recovering after an exacerbation.

5. Questions will Generate Answers By triangulating data from a number of sources, this analysis draws on a wide evidence base. But the main purpose of the benchmarking packs is not to provide answers. By highlighting unwarranted variation, the packs can be used to stimulate local dialogue about the quality of care that is commissioned and delivered. Their value lies in helping us to formulate robust questions that clinicians and commissioners will want to address.

6. How do our Systems Compare with the Best? So where expenditure is relatively high and outcomes relatively poor, where there are high rates of mortality, admission and length of stay compared with socio-demographically similar PCTs….. Commissioners and clinicians will want to know whether local providers have similar systems and offer similar services to the best performing providers. Your Director of Public Health, Quality Observatory and Public Health Observatory will be able to assist in interpreting the data and framing the questions.

7. Some Questions about Service Quality • Is there a local programme of case finding for COPD • to ensure early diagnosis, to optimise proactive management and to minimise risk of expensive hospital admission • Do GP practices and community providers offer: • quality-assured diagnosis • support for self-management • quality clinical review in line with NICE guidance • appropriate referral for LTOT assessment and pulmonary rehab • Appropriate assessment and review of oxygen requirement • Do hospitals offer: • access to specialist respiratory care • early measurement of blood gas status and assessment for NIV • optimal management of co-morbid conditions • early supported discharge or hospital at home

8. 1. Local PCT Benchmarkingfor selected indicators Analysis by Julian Flowers for ERPHO/APHO

9. Five Measures of Variation Burden and Detection • Prevalence and gap between observed and expected prevalence Admission Rates • Per 1000 COPD registered patients Hospital Utilisation • Emergency bed days/1000 PCT residents, Quality Indicators • Readmission rates, hospital mortality Cost • In patient cost per 1000 population

16. QIPP Right Care 2. Health Investment Analysis For Selected PCTs Commissioning Analysis and Intelligence Team Department of Health

17. Health Investment slide packs - Respiratory The following Health Investment slides use programme budgeting tools to highlight variation in health care at PCT and practice level. For each SHA region, respiratory slide packs have been produced for selected PCTs where the evidence suggests that there may be significant variation in spend and outcome.

18. Respiratory Health Investment PacksSouth East Coast The following selected slides illustrate some of the key findings for two PCTs in the South East Coast: • NHS Eastern and Coastal Kent • NHS West Kent The full slide packs for each PCT are available separately.

19. QIPP Right Care NHS Eastern and Coastal Kent Health investment analysis

20. Summary • These slides use Programme Budgeting tools to show thatEastern and Coastal Kent PCT has; • Increased expenditure on Respiratory problems in the last three years but relatively low inpatient spend • High Mortality rates from COPD • Low Prescribing expenditure on Respiratory system problems • High Prevalence of COPD in QOF • High Non elective admissions with low spell length of stay • Large variations in Respiratory admissions at practice level.

21. 2008/2009 APHO ONS Cluster Average – Each diamond represents a disease category and shows spend and outcomes compared to the ONS Cluster group Eastern and Coastal Kent PCT has higher than average spend and a worse outcome for Respiratory problems when compared to PCTs within the same cluster. Mortality from bronchitis Under 75s

22. Years of life lost due to mortality from bronchitis, emphysema and other COPD Directly age-standardised rate per 10,000 population, less than 75 years, all persons 2005-2007 filtered by PCT relevant ONS cluster 2007/2008 Eastern and Coastal Kent PCT has a high rate of years of life lost due to mortality from bronchitis, emphysema and other COPD rate when compared to similar PCTs (Prospering Smaller Towns)

23. Years of life lost due to mortality from bronchitis, emphysema and other COPD Directly age-standardised rate per 10,000 population, less than 75 years, all persons 2005-2007 filtered by SHA 2007/2008 Eastern and Coastal Kent PCT high rate of years of life lost due to mortality from bronchitis, emphysema and other COPD rate when compared to PCTs in South East coast SHA

24. FHS Prescription expenditure: Respiratory system per 100,000 population (weighted for age, sex and need) FY 2007/8 filtered by PCT relevant ONS cluster 2007/2008 Eastern and Coastal Kent PCT has a low FHS prescription expenditure when compared to PCTs (Prospering Smaller Towns)

25. FHS Prescription Volume: Respiratory system per 100,000 population (weighted for age, sex and need) FY 2007/8 filtered by PCT relevant ONS cluster 2007/2008 Eastern and Coastal Kent PCT has a low FHS prescription volume when compared to similar PCTs (Prospering Smaller Towns)

26. Prevalence of COPD (QOF); Percent, all ages: FY 2007/8 filtered by PCT relevant ONS cluster 2007/2008 Eastern and Coastal Kent PCT has an above average prevalence of COPD when compared to similar PCTs (Prospering Smaller Towns)

27. Prevalence of COPD (QOF); Percent, all ages: FY 2007/8 filtered by SHA 2007/2008 Eastern and Coastal Kent PCT has an above average prevalence of COPD when compared to PCTs in South East coast SHA

28. Vaccination against influenza for patients with COPD (QOF) Patients all ages, FY 2007/8 filtered by PCT relevant ONS cluster 2007/2008 Eastern and Coastal Kent PCT has a below average number of vaccinations against Influenza for patients with COPD when compared to similar PCTs (Prospering Smaller Towns)

29. Hospitalisation: Respiratory system problems. All Non-elective admissions, indirectly age-standardised rate per 100,000 population, all ages FY 2007/2008 filtered by PCT relevant ONS cluster 2007/2008 Eastern and Coastal Kent PCT has an above average number of Non elective admissions when compared to similar PCTs (Prospering Smaller Towns)

30. Spell length of stay: Respiratory system problems. Non-Elective admissions, indirectly age-standardised geometric mean LOS (days) per spell, all ages FY 2007/2008 filtered by PCT relevant ONS cluster 2007/2008 Eastern and Coastal Kent PCT has a low spell length of stay for Non-elective admissions when compared to similar PCTs (Prospering Smaller Towns)

31. 2009/10 Quarter 1 NHS Comparators – GP Practice Level Comparison of Expenditure on Problems of Respiratory Admissions 2009/10 Quarter 1: Eastern and Coastal Kent PCT has a large variation in Respiratory admissions at practice level. Easy to identify high and low spending practices. Can compare practices within groups based on need of population

32. QIPP Right Care NHS West Kent PCT Health investment analysis

33. Overview • These slides use Programme Budgeting tools to show that, compared to similar PCTs, West Kent has; • Average expenditure on Respiratory problems • High rate of mortality from COPD • Below average prescription expenditure on Respiratory problems • High reported prevalence of COPD and a high ratio of reported to expected prevalence of COPD • Below above average flu vaccinations for patients with COPD • Spend of £500,000 more than the national average for inpatient admissions for Respiratory problems adjusting for age, sex and need of population 33

34. 2008/2009 APHO ONS Cluster Average – Each diamond represents a disease category and shows spend and outcomes compared to the cluster average West Kent PCT has average spend and worse outcome for Respiratory compared to similar PCTs Mortality from bronchitis, emphysema, COPD

35. Mortality from bronchitis, emphysema and other COPD: Directly age-standardised rate per 100,000 population, all ages, all persons 2005-2007 West Kent PCT has the highest mortality rate from bronchitis, emphysema and other COPD when compared to similar PCTs

36. Emergency readmission to hospital within 28 days of discharge: Respiratory system. Admissions excluding day cases, indirectly age-standardised percent, all ages. 2007/2008 West Kent PCT has a high rate of emergency readmissions for Respiratory problems when compared to similar PCTs

37. Prevalence of COPD (QOF), Percent, all ages, 2007/2008 West Kent PCT has high reported prevalence of COPD compared to similar PCTs

38. FHS prescription expenditure: Respiratory system: Thousand pounds per 100,000 unified weighted population, 2007/2008 West Kent PCT has below average FHS prescribing expenditure on Respiratory compared to similar PCTs

39. Vaccinations against influenza for patients with COPD (QOF); Percent, all ages, 2007/2008 West Kent PCT has below above average flu vaccinations for patients with COPD compared to similar PCTs

40. NHS Comparators – Expenditure on Obstructive Airways Disease emergency admissions – Comparison with similar PCTs West Kent PCT has high expenditure on Obstructive Airways Disease emergency admissions compared to similar PCTs

41. NHS Comparators – Expenditure on Respiratory emergency admissions – GP Practice level West Kent PCT has a large variation at GP practice level for expenditure on Respiratory emergency admissions Easy to identify high and low spending practices. Can compare practices within groups based on need of population

42. IVET: PCT inpatient expenditure above or below the benchmark for diseases in 2008-09. West Kent PCT spend £500,000 more than the national average on Respiratory inpatient admissions adjusting for age, sex and need of population

43. Conclusion Benchmarking suggests there is significant unwarranted variation in the respiratory healthcare received by patients in South Central What is achievable for patients in one area should be possible in all areas By highlighting unwarranted variation, the packs can be used to stimulate local dialogue about the quality of care that is commissioned and delivered. Their value lies in helping us to formulate robust questions that clinicians and commissioners will want to address.

44. Conclusion • Where expenditure is relatively high and outcomes relatively poor, where there are high rates of mortality, admission and length of stay compared with socio-demographically similar PCTs….. • Commissioners and clinicians will want to know whether local providers have similar systems and offer similar services to the best performing providers.