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Resource Guide 9 - Managing Information Requirements
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Who should read this?
- Chief Executives
- Public Health Leads
- Commissioning Leads
- Finance & Information Staff
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Before you get started
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How to do it?
- Review the information against the standards in this guidance
- Ensure the Board and decision makers receive clear summary information with written interpretation, NOT reams of detailed numbers
- Ensure the detailed numbers are robust and are agreed/reconciled across the health system.
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Resources/Key Questions
- Are there opportunities to improve information quality and depth bysharing the staff & systems with other organisations?
- Is comparative information from the DoH & the SHA being used toinform decisions.
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Contents
Vision and Strategy
The work to set the broad direction for the future development of servicesin the context of the changing needs of the local population requires a wide range of information and forecasting since it will look 10 or more years ahead.
The main information components are health needs analysis, activity informationon services, Planning and Priorities Framework targets, financial information and risk.
Health Needs Analysis
This will be led by the public health function for most PCTs and may be developed on an individual PCT basis or for a whole health economy. The public health aspects are beyond the scope of this "Commissioning Friend". There are well developed methodologies for assessing the health needs of communities at both a macro and micro level.
The translation of those needs into service strategies and commissioning plans will require commissioning staff to work closely with public health colleagues.
Population information for the PCT and its peer PCTs/ health economy is needed for health needs analysis, strategies, plans, and modernisation. An important source of consistent population information is in the weighted capitation resource allocation information produced by the Department of Health. This reconciles local area forecasts from the Office of National Statistics (produced on a geographic basis) to the GP practice catchment based populations, which form PCTs’ populations.
The weighted capitation populations are analysed into age bands (because different age groups attract differential financial weightings) and are a useful starting point for analysing current use of services and forecasting future needs. These populations can be used at practice level too but caution should be exercised as the problems of variation and "small numbers statistics" increase as analysis gets down to smaller populations.
The nationally produced weighted capitation population figures for PCTs have to adapt the population data taken from Family Health Service computer systems to fit the ONS figures because the Treasury take the ONS figures as the guide when allocating resources to the NHS. The differences vary across the country, partly due to duplicate registration of patients. This is an issue for PCTs when looking at individual practice populations. PCT information and financestaff should reconcile practice population figures to FHS system figures and weighted capitation figures so that apparent differences can be explained.
National targets and standards
The Planning and Priorities Framework sets specific targets for a wide range of services and the need to achieve those targets must be included when forecasting needs and capacity requirements in service strategies. The care standards and service improvement goals in National Service Frameworks must be incorporated into service strategies. The decisions and future work programme of the National Institute for Clinical Excellence on the adoption of new drugs and medical technologies should be included in service strategies. PCTs need to makea financial forecast of future NICE decisions in their financial strategy for the period beyond the current NICE review programme. Much of this information will already have been gathered and put into models to produce the 3 year Local Delivery Plan for 2003/04 to 2005/06.
The use of services
This should be analysed by the care group headings chosen by PCTs for their service strategies. Use should be expressed as a rate per 1,000 population (using the relevant part of the local population e.g. females from 15 to 44 might be used as the divisor for maternity services). The information should be analysed by provider and at practice level as that will be useful for exploring variations and examining the impact on providers of proposed service changes.
Usage rates should be compared to other local PCTs and to national averages.
National Service Frameworks may recommend specific access rates (e.g. for Coronary Heart Disease treatments) and these should be built into forecasts.
The health needs assessment may recommend changes to access rates on publichealth grounds and from knowledge about new medical technologies or internationaltrends (e.g. the rate of knee replacement/resurfacing is likely to overtakethat for hips over the next decade, judging from the Scandinavian experience).
Historic usage rates (PCTs may have to use data at predecessor Health Authority level if it is not available at PCT level) will provide trends for different services, which are useful for forecasting.
The forecast impact of existing approved service development programmes on activity and cost need to be included, for example the effects of reproviding learning disability care in the community or opening a new intermediate care facility.
Simple forecasts of potential future service use can be produced with the above information combined with population forecasts. Those forecasts should be refined by exercising judgement taking account of comparative access rates,changing medical technologies, changing morbidity and new patterns of care likely to result from redesigning care pathways.
This work will create a model with a range of scenarios where PCTs can explore the consequences of changing the underlying assumptions such as access rates,changing referral thresholds, adoption of new medical technologies, care pathway redesign and demand management.
Financial information on the current pattern of expenditure
The financial strategy should show the current pattern of expenditure on each care group, the range of future resource prospects and the future forecast pattern of expenditure on each care group (from the individual service strategies) matched to the resource prospects. It should also note the extent to which it relies on capital investment and efficiency gains.
Financial information should be modelled alongside the activity information,for acute services the advent of national tariffs will simplify that task but other measures are needed to link activity and cost for non acute care.
The key financial components of the longer term vision and strategy work are:
Future resource prospects, with a range of scenarios (high, medium and low) based on weighted capitation populations, using the ONS forecasts and taking account of the distance from target and making judgements about the level of inflation and efficiency targets. PCTs should take advice from their StrategicHealth Authority about possible future resource prospects.
The pattern of expenditure by care group expressed in a simple summary table showing expenditure and the percentage each group is of the total. This should compare the current position with the future proposed position for each of the future scenarios. The expenditure, in the interest of sustainable financial balance, should match the resource prospects. It may assist people working on service strategies to give them initial financial targets to guide their thinking. The final decisions about the allocation of resources to each care group should be driven by the balance of needs and service priorities.
The overall financial strategy information should have a clear reconciliation to the current financial position and contain transparent assumptions about inflation and efficiency. A live policy will guide shorter term decisions and should be updated as major planning, national policy and service changes emerge.
Risk
Long term visions and service strategies have a high degree of risk due to the uncertain nature of the future. That risk must be carefully assessed and managed if the longer term work is to be worthwhile.
The main counters to risk in this approach are:
- Having a starting point based on an accurate picture of current services and costs
- Working on a range of scenarios and selecting solutions that are robust across the widest range, rather than ones which only work in ideal conditions
- Adopting realistic resource assumptions combined with realistic expectations about inflation costs and potential efficiency savings helps to manage expectations and discourage unrealistic bidding for new resources
- The availability of capital resources to deliver new ways of working and the progress of Private Finance Initiative schemes or LIFT schemes can be very difficult to forecast. Those issues need close monitoring in case strategies have to be amended if capital cannot be obtained
- Engagement with partner agencies - providers, local authority, strategic health authority, the public, voluntary bodies and patient interest groups - in developing the vision and in challenging and examining the information and assumptions
- Keeping the work at a high level and avoiding detail will maintain the purpose of the vision and strategy which is to establish a direction of travel understood and owned by those responsible for delivery
- Maintenance - the long term vision should be updated annually keeping the underlying information etc. live to ensure it is kept up to date for real world changes as they emerge
- Major reviews will be needed on a three year cycle to match the government’s comprehensive spending reviews as new resource prospects and policy directions appear
- Longer term service strategies need to be designed with milestones setting out the critical changes and when they are planned to take place. Progress on these milestones should be monitored and reported to the PCT Board as part of regular performance management, which will give early warning of problems so that alternative solutions can be developed.
Planning
Much of the information used for strategies is also useful in planning but plans need to be developed in more detail than strategies so the information has to be drilled down to a lower level.
The main information tool for planning acute care is the demand and capacity model which helps commissioners and providers to meet access targets and meet emergency medical needs. Most of the information for the model will be available from the NHS Wide Clearing Service.
PCTs have the opportunity to supplement the traditional sources of NHS information with information from GP practices subject to local agreement and there is evidence from some health communities of this being a very powerful tool for demand management and service redesign.
The Department of Health produced a demand and capacity model as part of the Capacity Planning initiative in 2002 as a precursor to the 2003 Local Delivery Plans. The model is a useful starting point for assessing the quantity of acute treatment that may need to be provided to meet access targets. The analysis is by specialty but it is often necessary to work at case mix level, for example the orthopaedic waiting list may hold a disproportionate number of patients waiting for hip and knee replacement compared to the usual casemix of the specialty and that will impact on the type of capacity that needs to be purchased.
The model has generally been used on a PCT basis to assess demand but the supply aspects have usually been on provider catchment area basis rather than PCT by PCT. The supply statistics may be more reliable at that level since the problems of small numbers statistics increase when analysing smaller populations. The model is more robust for high volume specialties and for a PCT’s major providers. The main counters to the problems of small numbers statistics are to either collaborate with other PCTs and share the risks together (provided the risks do not always fall in one direction) or to look at several years' information to judge the longer term average level of demand.
The key components are:
- Demand
- Referral rates and the trend, the effects if trends change can be explored.
- Conversion rates, how many referrals require further treatment after the first outpatient attendance.
- The existing waiting list, its time profile and case mix.
- The access targets
Supply
The quantity of activity provided in the base year and its case mix. This should be reconciled to the previous year’s out turn and to the current service level agreement. Adjustments need to be made for non recurring initiatives.
The Gap
The model will compare the demand with the supply and the targets and identify the shortfall against targets (or excess supply).
An iterative process to explore the effects of different options will help the PCT and provider to determine a range of referral rates and activityprovision that can deliver the targets.
It is important to distinguish non recurring extra capacity needs (to clear waiting list backlogs) from the underlying recurring demand. Even if the non recurring need will continue for two or three years as the PCT works toward the longer term access targets there are dangers in signing up to excess recurring capacity as it is hard to retract from once in place. National initiatives including the independent sector and NHS Treatment Centres and accessing treatment in the European Community will provide access to one off capacity and avoid distorting long term recurring priorities.
Evidence from the work of the Modernisation Agency and a number of StrategicHealth Authorities shows that access can be improved where PCTs work closely with their major providers on capacity forecasts to ensure there is a clear understanding of the capacity each consultant can generate (and some comparison of those output rates) taking account of the mix of procedures carried out and the cases admitted but removed from lists without treatment. Waiting lists should be modelled, taking account of the proportion of elective care each clinician deems urgent and assuming that non urgent waiting list patients are seen strictly in date order. This work is a step beyond the existing model but will improve the forecasts on the supply side.
PCTs can influence referral rates and redesign care pathways which may avoid planning to meet all the needs with extra capacity. Some PCTs operate peer comparison of referral rates between practices and are appointing Practitioners with special interests to resolve more care needs within primary care. The impact of that service modernisation should be included in the demand and capacity model.
Information will increasingly be needed at practice level as part of planning.
The model should be updated with the forecast effect of plans, business casesand modernisation proposals to ensure the Local Delivery Plan (and its annual updates) will meet the access targets.
Emergency medical admissions trends require close analysis in many PCTs where the rate of admissions has been increasing above the usual expected levels.It is essential to work closely with providers (including the ambulance service) to identify the causes of unusual rates of increase. The objective of the work is to determine a realistic rate of increase for planning so that unplanned emergencies will not displace elective patients and extend waiting times.
Service Level Agreements
The information for service level agreements (SLAs) will be drawn from that used to establish strategies and plans.
It has to be expressed in detail in the activity and finance schedules that support SLAs and in further detail in the analyses that support the monthly monitoring of performance against the SLAs.
Acute care activity and resources need to be analysed by:
- Provider
- Specialty (and case mix using national HRG weightings)
- Healthcare Resource Group (HRG)
- Emergency/Elective care
- Inpatient/day cases
- Outpatients (first attendance)
- Outpatients (follow ups)
- Regular day attendances
- Open access services e.g. X Ray referrals by GPs
In some health communities much of that information has routinely been collated in commissioner databases for managing cost and volume service agreements.In other health communities the move to block agreements after the abolition of the internal market in 1997 meant that such data was either no longer collated or if collated was not regularly used for managing agreements.
The introduction of choice and tariffs require commissioners to use cost and volume commissioning for all acute care where variations from agreement will result in financial adjustments between commissioners and providers.
One effect of choice, increasing diversity of providers and tariffs is to make commissioning information much more complex. The volumes of data, the different views and reports required from that data and the increasing frequencyof reporting will require the use of a database rather than spreadsheets.The updating and reporting from that database needs to be as automated as possible with user configurable reports to deal with ad hoc queries.
The PCT’s system for producing activity and cost schedules for agreements and for monitoring those agreements during the year needs to be integrated for the sake of efficiency and accuracy. The reports need to be summarised to give the PCT Board and other decision makers and stakeholders a clear view of the shape of the agreement and the impact of variations without inundating them with tables of information.
It is a requirement of the NHS Financial Governance Regime that the effect of variations be forecast to predict the year end position and that action be taken as significant variations emerge. Many PCTs commission via consortia and delegate substantial authority to the lead commissioner. There is still a requirement to report to each PCT Board every month on the position and the forecast outturn of that PCT’s share of the consortium contracts.
Resources
Resource Guide 4 Key Changes to Service Level Agreements
Case Study 2 Strategic Population Health Planning Birmingham and Black Country Strategic Health Authority
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