PBMAC@H in S&M

Delayed DischargesCurrent NHS Highland Delayed Discharge Position

Opportunity Cost of Delays

24,000 bed days lost to delayed discharge equates to circa £8m OPPORTUNITY COST

PBMA?

Generating options for investment

• Imagine that services for older people will receive a budget increase of 10% next year. This would amount to approximately £X.

• What service areas (either existing or new) would you want to allocate this increase spending to?

Generating options for investment and disinvestment

• Imagine now that there is a budget cut of 10% to service for older people as of next year. Again, this would amount to £X.

• What service areas would you prioritise for:• Design to save resources?• Actual cutbacks?

Marginal Analysis• Define and agree decision criteria • Criteria weighting• List of options for service growth and service reduction• Process supported by business cases. These should

show how each option meets the agreed decision criteria using supporting evidence and expert opinion

• Scoring options against criteria • Scoring of options then allows for each option to be

ranked showing which is the preferred option• This then can allow for resources to be released from the

lowest ranking service reduction option

Doing PBMAPBMA approaches needs assessment by asking five questions

about resources:1. What resources are available in total?

2. In what ways are these resources currently spent?

3. What are the main candidates for more resources and what would be their effectiveness and cost?

4. Are there any areas of care which could be provided to the same level of effectiveness but with less resources, so releasing those resources to fund candidates from (3)?

5. Are there areas of care which, despite being effective, should have less resources because a proposal from 3. is more effective (for £s spent)?

Questions 1 and 2 pertain to the PROGRAMME BUDGETQuestions 3-5 are addressed in MARGINAL ANALYSIS

Marginal Analysis• Define and agree decision criteria • Criteria weighting• List of options for service growth and service reduction• Process supported by business cases. These should

show how each option meets the agreed decision criteria using supporting evidence and expert opinion

• Scoring options against criteria • Scoring of options then allows for each option to be

ranked showing which is the preferred option• This then can allow for resources to be released from the

lowest ranking service reduction option

Criteria weights

Access Equity Improved Outcomes

Effective Practice

Sustainable Culture & Values

9 (15%) 8 (13.3%) 12 (20%) 11 (18.3%) 10 (16.67%) 10 (16.67%)

Business Cases• Mental Health• Virtual Ward• Day Care• Care @ Home......THE WINNER!

2013/14 Care @ Home Position

Hospital unmet need• 40 people @ 10 hours per week• around 400 hours per week / £322k per

annumCommunity unmet need:• 246 people @ 10 hours per week• 2,460 hours per week / £2m per annum

– Estimated cost of current unmet need is £2.3m p.a.

– Market split 60% (in house) / 40% (independent sector)

– In-house provision more expensive– Competition between providers to

recruit– Not all geographical areas of

operation sustainable– Inconsistent (and some poor) quality

of provision

Investment Shift in Care @ Home

• Level playing field, means commissioning across sectors, not protecting in house service.

• Stop the race to the bottom

• Paying (75p) to achieve compliance with Living Wage

• Collaborative zoning, means providers can access cost effective “runs”, not scattered provision

• Disinvest in inefficiencies

• Developing a single tariff for all providers which can be enhanced for rurality and complexity

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Care at Home Gradings 2014IS and In House Care and

Support Gradings July 2014

Independent/Third Sector

In House

Market Changes

Quality of Provision

North Highland Changes in Provision

North Highland Changes in Provision

ExpenditureIndependent Sector: £3.8m (37%)In House: £6.4m (63%)

ClientsIndependent Sector:750 (60%)In-House: 506 (40%)

So 100% could be provided for £6.36m?; saving £3.84m

Unmet need was £2.3m

£1.54m for....

In this climate?

Doing PBMAPBMA approaches needs assessment by asking five questions

about resources:1. What resources are available in total? In house resources included

2. In what ways are these resources currently spent? Reverse 60/40 split

3. What are the main candidates for more resources and what would be their effectiveness and cost? More C@H

4. Are there any areas of care which could be provided to the same level of effectiveness but with less resources, so releasing those resources to fund candidates from (3)? (Independent & Community) C@H

5. Are there areas of care which, despite being effective, should have less resources because a proposal from 3. is more effective (for £s spent)? In House C@H

Questions 1 and 2 pertain to the PROGRAMME BUDGETQuestions 3-5 are addressed in MARGINAL ANALYSIS

Commissioning (Staffside)

• Defend (and seek to expand) numbers of jobs in the in-house services, ensuring that it does not become significantly proportionately smaller in the mix of care providers.

• Defend (and seek to enhance) terms and conditions for staff in the in-house services (including pay/grading, holidays, travel time etc but also access to training, policies and procedures, health & safety, staff governance etc)

• Defend (and seek to enhance) terms and conditions for staff in the private/voluntary sector (including pay/grading – living wage a minimum, holidays, travel time etc but also access to training, policies and procedures, health & safety, staff governance etc)

PBMA• Process• Justification• If not, what’s yours....

North Highland Changes in Provision

ExpenditureIndependent Sector: £3.8m (37%)In House: £6.4m (63%)

ClientsIndependent Sector:750 (60%)In-House: 506 (40%)

So 100% could be provided for £6.36m?; saving £3.84m

Unmet need was £2.3m

£1.54m for....

In this climate?

Thank You

Any questions?