Thursday, 28 May 2009

Programme Budgeting in Kidney Care : 17B has arrived

The Department of Health (DH) initiated the national Programme Budget Project in 2002 to develop a source of information, which shows ‘where the money is going’ and ‘what we are getting for the money we invest in the NHS’ collected on the basis of International Classification of Disease (ICD).

A focus on medical condition rather than input cost was adopted to forge a closer and more obvious link between expenditure and patient care. Analysis of expenditure in this way has helped Primary Care Trusts (PCTs) examine the health gain that can be obtained from investment such as statin use, expenditure and CHD rates. It will increasingly inform understanding around equity and how patterns of expenditure map to the epidemiology of the local population.

From 2003/4 onwards, PCTs and Strategic Health Authorities (SHAs) reported the totality of their expenditure on a programme basis. Data is collected as part of the annual accounts process and aggregate data is published each Autumn in the DH Resource Accounts, and PCT data is published in the form of an interactive Excel spreadsheet. This spreadsheet allows PCTs to benchmark their expenditure with PCTs nationally, locally, or PCTs with similar characteristics as classified by the Office for National Statistics (ONS).

Programme Budgeting is therefore a way of analysing NHS expenditure by medical condition, based on 23 programmes of care. Renal services were added as a sub-category programme in 2006/07, prior to this, renal costs were included in programme 17 ‘Problems of the genito-urinary system’. Programme expenditure linked to activity and outcomes can be viewed in the Programme Budgeting Atlas and on NHS Comparators. This provides a framework for analysis and evidence to support commissioning decisions.

The analysis shows that £1.3 billion was spent on renal services in England in 2006/07. That equates to 1.5% of the total expenditure of the NHS. Expenditure was predominantely in secondary care - 93%, with only 7% incurred in a primary care setting (of which approximately 4% relates to prescribing). Expenditure is calculated using NHS Trust reference costs using ICD10 primary diagnosis codes to identify episodes of admitted patient care and speciality to identify non-admitted care. The costs cover both dialysis and transplantation. Renal programme costs do not include GMS/PMS expenditure (included in programme 23a) or prevention expenditure (included in programme 21).

The Programme Budgeting Atlas brings together expenditure with specific activity and outcomes data including QOF data on prevalence and management of chronic kidney disease, an analysis of mortality and years of life lost and a range of activity data specific to kidney problems, eg admission rates, bed days, length of stay. We can’t yet map sub-category level expenditure, such as renal services, 17B, but this is planned for the future. NHS comparators links admitted patient care activity with programme budgeting expenditure including subcategory level data, so renal services spend is available using this tool. It is updated quarterly and allows you to drill down to practice level. Prescribing data by programme category will be available soon.

Programme budgeting is dependant on the quality of the financial and clinical activity data. It will need refinement over time . In particular, figures produced in the early years will be a best estimate of expenditure in kidney care, rather than a precise measurement. We know from the review of reference cost returns for dialysis that accounting errors do occur , similarly primary care coding of kidney conditions has historically been incomplete to say the least. However, PRODUCTIVITY is now one of the watch words of the NHS and getting our clinical coding and financial costing right will be vitally important for the delivery of high quality kidney care.