Gateshead Local Strategic

Partnership

Shifting ResourcesUpstream

JSNA aimShift from acute to preventive/community care

£

£

2008 Gateshead JSNA

“…strategic commissioning intention expressed by the JSNA…a reallocation of resources…of 5% from acute care to prevention or community based care.”

“to aim for at least 1% transfer in 08-09, leading up to at least 3% by 10-11.”

“reviewed in terms of best outcomes for the health of the population as well as…resource allocation.”(ref. “Our Health, Our Care, Our Say”)

Why “shift resources upstream”?

e.g. Chapter 6: Care Closer to Home

e.g. Primary Care Centres, outpatient clinics into community settings, health checks

e.g. “Helping People to Stay Healthy”

Focus of project

• Tracking expenditure from acute to preventive or community care

• Data identification, access and presentation

• Circulatory disease(similar work also on mental health and musculo-skeletal conditions)

Why track expenditure?

• Lack of evidence showing how JSNA is influencing commissioning

• How do we know JSNA is making a difference?

• To demonstrate that JSNA is a cost-effective exercise

Challenges (1)

• Identifying appropriate data– Definitions of ‘acute’

• Secondary care – hospital-employed nurses in the community

– Acute to preventive/community care is a continuum

• E.g. care in outpatients is more ‘community-based’ than care as an inpatient

– Cross-over effects• Preventive measures affect several conditions e.g.

weight management – heart disease, diabetes etc.

Challenges (2)

• obtaining appropriate data– General

• Information staff and public health staff unavailable to provide or discuss (swine flu management)

– Non-routine data• JSNA is not everybody’s priority

– Routine data• Timeliness• Appropriate level• LA service data and health data not

categorised in same way

Challenges (3)

Programme budgeting• PCT not LSP• Levels of standard breakdown

inappropriate– (lowest level = circulatory disease

subcategories)

• Not even split into secondary/primary care• Standard format is spend per 100,000

weighted head of population – less impact than actual £total

Challenges (4)

• Actual spend or percentage of total?• How to account for injections of funding, as opposed to

transferred money

• Displaying dataQuestions include– where do prescribing data go?– Is outpatients ‘more community-based’ than LA day

care?

• What do data NOT show?– Was expenditure actually transferred?– Were the relative changes coincidental?

Addressing challenges (1)

• Aim to use routinely available data– LA – Personal Social Services Expenditure

(PSSEX) but hope for more on specific long-term conditions (e.g. stroke expenditure)

– Drugs expenditure – prescription costs AND number of items

– Secondary care• Cardiology

– attendances and costs– Elective, non-elective– Inpatient, outpatient

Addressing challenges (2)

Primary care - Programme budgeting– Continue work with finance colleagues

• Identify useful drilling down approachesOngoing (local) work to show – by setting and – by sector

– Use and disseminate use of approach– Obtain £actual not £ per 100k population– Press for national drilling-down requirements

Addressing challenges (3)

• Make assumptions – even if we get it ‘wrong’ but use the same next time, we can still draw year-on-year comparisons

E.g. retain standard classification of hospital heart nurses as secondary care (far from ideal)

Displaying information (1)

Even if chosen approach not ideal, consistency allows comparison

cardiovascular disease, outpatient costs as a proportion of total secondary care costs

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

2005/06 2006/07 2007/08 2008/09

cardiovascular disease - secondary care expenditure as proportion of PCT expenditure

-

0.05

0.10

0.15

0.20

0.25

2005/06 2006/07 2007/08

aimaim

Displaying information (2)

Even if chosen approach not ideal, consistency allows comparison

cardiovascular disease, secondary care expenditure

£0

£500,000

£1,000,000

£1,500,000

£2,000,000

£2,500,000

£3,000,000

£3,500,000

£4,000,000

£4,500,000

£5,000,000

2005/06 2006/07 2007/08 2008/09

outpatients elective noneelective

aim – non-elective

aim – outpatients

aim –elective

aim – health improvement

• Comparing expenditure across all sectors

• Data not yet available for 2008/09 – chart not based on actual figures

Displaying information (3)

Examples of areas of expenditure along the continuum

key year 1

year 2

preventive acute

costs

NB - not based on actual figures - for illustrative purposes only

residential care hospital stayshealth

promotioncommunity care GP surgery care drugs

What has gone well (1)

JSNA steering group

multi-agency

Others invited and informed

Multi-level –

Directors

Information staff

Others invited and informed

PCTincl, public health and information

LA

incl. housing, adult social services,

child social services etcvoluntary

sector

secondary care

What has gone well (2)

• Programme budgeting– Finance colleagues very helpful– Pilot site for local implementation of

“Programme Budgeting” approach– Additional work ongoing

• Other information supply– Colleagues willing to discuss requirements

What has gone well (3)

Linkage with other strategies and plans• Results will link with forecasting for PCT

strategies• Provides evidence for World Class

Commissioning competency 5– evidence for investment and disinvestment decisions

• Results expected to influence LA and LSP plans, e.g.– Adult Care Commissioning Strategy– Housing strategy – needs for people with long-term

conditions– mental health work will influence plans for mental

health services

What to do next?

• Await further data/information• Continue similar work with musculo-skeletal and

mental health conditions• Circulate proposed outputs for comment• Use results as levers:

– to push for changes to ensure resources are shifted upstream

– to push for additional drilling down in programme budgeting

– to link JSNA with other strategies