Reshaping The System Part 1

CONFIDENTIAL
WORKING DRAFT
Reshaping the System: Transforming Northern

Irelands Health and Social Care Services
Appendix Part 1
Sept 2010
This document is solely for the use of personnel in the Health and Social Care Board and Public Health Agency of Northern Ireland. No part of it may be
circulated, quoted, or reproduced for distribution outside the HSCB or PHA without prior written approval. The document contains extensive material that is
exempt from disclosure under the Freedom of Information Act 2000. It should not be released under the Act without prior consultation with the HSCB.
About this document
This document comprises the analyses done in support of the

accompanying memo, Reshaping the System
It is not a self-standing document and should be read in conjunction

with that memo
Contents of this appendix
1. Where we stand today

2. The trends in health and social care needs and implications
for funding
3. Opportunities to improve productivity and quality
4. Implications for the system: what a new, higher quality and
more efficient service could look like
5. What it will take to transform
6. The pace of delivery
7. Implementation plan: outlines our current (early-stage) plans
for implementation
Quality of care in Northern Ireland has improved in recent years (1/2)

CAGR (average annual % change)
Signs of good quality are increasing . . .
Outcomes
Prevention
a. Life expectancy
at birth, males
0.3%
i. Infant mortality rate
-1.3%
b. Life expectancy
at birth, females
0.2%
ii. Cancer mortality rate
-1.4%
c. % breastfeeding at
discharge from hospital
d. Number of smokers
setting a quit date
e. Immunisation uptake
Safety
in care
. . . and signs of poor quality are reducing
3.0%
Iii. Rate of births to mothers

under <17 years old
-3.4%
9.0%
0.3%
iv. MRSA episodes

v. C-Difficile reports,
inpatients >65 years old
vi. Surgical site infection
rate, orthopaedics
-8.8%
-19.4%
-17.8%
Years (signs of good quality): a, b: 1991-93 to 2005-07; c: 2004 to 2008; d: 2008/09 to 2009/10; e: 2000 to 2009
Years (signs of poor quality): (i), (ii) 1997-01 to 2004-08; (iii) 2001 to 2008; (iv) 2003 to 2009; (v) 2006 to 2009; (vi) 2004 to 2008
* Average of Dip3, Tet3, Pert3, Pol (IPV)3, Hib3
SOURCE: DHSSPS; PHA; Communicable Disease Surveillance Centre Northern Ireland
Quality of care in Northern Ireland has improved in recent years (2/2)

Signs of good quality are increasing . . .
Clinical
effectiveness
. . . and signs of poor quality are reducing
f. % thrombolysis
1.9%
g. Stroke scan 24h
1.6%
h. Primary angioplasty
5.9%
vi. % patients waiting
>13 weeks for inpatient care
Access
-9.0%
vii. % patients waiting

>13 weeks for outpatient care
470.0%
viii. % patients waiting

>13 weeks for diagnostics1
User
experience
i. Patient and client survey
Inequality
16.0%
TBC
ix. Person in deprived area

more likely to die2
x. Infant in deprived area
more likely to die
-0.3%
-2.1%
Years (signs of good quality): f, g, h: 2004/05 to 2008/09

Years (signs of poor quality): (vi), (vii) 2007 (quarters 2-4) to 2010 (quarters 1-2); (viii) 2008 to 2010 (quarters 1-2); (ix), (x) 1997-01 to 2004-08
1 16 tests: Audiology - pure tone audiometry, barium studies; cardiology echocardiography; cardiology - perfusion studies; colonoscopy; computerised tomography;
cystoscopy; dexa scan; flexi sigmoidoscopy; gastroscopy; magnetic resonance imaging; neurophysiology - peripheral neurophysiology; non-obstetric ultrasound; radionuclide imaging; respiratory physiology - sleep studies; urodynamics - pressures and flows;
2 Standardised mortality rate for under 75 years old, deprived areas relative to NI as a whole
SOURCE: DHSSPS; PHA; QOF
Many aspects of Northern Irelands productivity have also increased

Signs of productivity are increasing . . .
Inpatient
1. % all admissions done

as day case
2. Throughput per bed
3. Day of surgery
admissions %
. . . and signs of inefficiency are reducing

4. Average length of stay
1.0%
-4.5%
4.0%
11.0%
Primary
care
5. Growth in primary care

prescribing spend1
-3.0%
Years (signs of productivity): 1, 2. 2003/04 to 2008/09; 3. 2008/09 to 2010/11

Years (signs of inefficiency): 4. 2003/04 to 2008/09; 5. 2004/05 to 2009/10
1 Relative to expected
2 % of complex discharges delayed by more than 48 hours
SOURCE: DHSSPS; PHA; TOR
DHSSPS actual spend
DHSSPS has delivered ~3% p.a.

improvement; HSCNI 2%
DHSSPS spend on existing services after efficiency

savings
HSCNI spend on existing services after efficiency
savings
billion, nominal
DHSSPS Investment
CAGR 2007/082010/11, %
+4 p.a.
4
-3 p.a.
3
-2 p.a.
2
1
0
2007/08
2008/09
2009/10
2010/11
SOURCE: HSCB Finance; DHSSPS
Northern Irelands life expectancy is lower than England, but comparable

to Wales and North East England
Life expectancy at birth, Males
2006-2008, years
Northern
Ireland
76.4
81.3
77.9
England
North East
SHA
Scotland
Wales
Life expectancy at birth, Females

2006-2008, years
82.0
76.5
80.6
75.3
80.0
77.0
81.4
SOURCE: StatsWales; www.scotland.gov; Northern Ireland Neighbourhood Information Service, NCHOD
NI mortality rates are higher than comparators, except for cancer
Age standardised death

rate 2003-07
# per 100,000 population
Northern Ireland
837.6
England
183.7
660.0
Wales
614.7
Unknown
Cancer mortality European

age standardised, 2004-08
265.5
581.9
North East SHA
Scotland
All circulatory disease

mortality age
standardised, 2004-08
201.8
Unknown
Unknown
179.2
173.9
203.9
190.9
206.8
SOURCE: Northern Ireland Neighbourhood Information Service, NASCIS 2008/09, Northern Ireland Cancer Registry, Information Service Division
Scotland (ISD), StasWales, Welsh Cancer Intelligence and Surveillance Unit
Smoking and poor diet could be among the causes of NIs lower life
expectancy and higher mortality rates
Smoking prevalence
(2008)
%
Northern Ireland
24.0
27
24
England
22
Wales
21
Scotland
Adult obesity, 16+,

(2007)1
%
Adults eating
recommended 5 fruit
or veg a day (2006)
%
21.0
25
29
22.0
25.6
Unknown
21
1 Data for Scotland is 2004 (the latest), Obese is defined as BMI>30Kg/m2

SOURCE: Northern Ireland Neighbourhood Information Service, Information Service Division Scotland (ISD), StasWales ,Cancer Research UK, Public
Health Observatory for Wales, International comparisons of Obesity 2008
An increase in the prevalence of chronic diseases (reflecting

the pattern in other parts of the UK) will increase care need . . .
Northern Ireland
England
Prevalence of disease by country

%
4.1
3.5
CHD
12.2
13.1
Hypertension
COPD
Cancer
Mental Health
1.6
1.5
1.1
1.3
0.8
0.8
5.6
5.9
Asthma
Dementia
0.5
0.4
11.3
9.9
Obesity
4.5
5.1
Diabetes
Learning Disabilities
0.5
0.4
SOURCE: Quality Outcomes Framework, 2008/09; Northern Ireland Neighbourhood Information Service; NCHOD
10
NIs population is ageing
Population growth by age group in Northern Ireland

100 = 2008 population
125
80+
120
115
60-79
110
40-59
105
20-39
0-19
100
0
2008
2009
2010
2011
2012
2013
2014
2015
SOURCE: Northern Ireland Neighbourhood Information Service
11
Hospital
Comparison of per capita spend across UK
Community
spend on services (including supplies), 2008/09
Social care
Primary care
Spend per capita across types of care

per capita
Breakdown of Spend
% of total spend (total spend, m)
2,254
2,206
2,066
100% =
3,946
95,311
6,759
51%
48%
7%
10%
2,051
1,901
969
1,090
905
835
264
246
1,078
227
227
157
552
516
476
399
421
399
363
417
Northern
Ireland
Northern
Ireland
(7%
weighting)
44%
Northern England
Ireland
(16%
weighting)
12%
472
25%
22%
21%
464
19%
20%
21%
Wales
Northern
Ireland
England
Wales
SOURCE: HSCNI; Information Service Division Scotland; Wales StatsWales; England Laing and Buisson 2008/09
12
High-level benchmarking suggests the largest productivity

opportunities lie in hospital spend and community prescribing . . .
per need-weighted population
% % reduction opportunity from
NI 16% weighting to England
Northern Ireland (7% weighting)
England
Northern Ireland (16% weighting)
North East SHA
Hospital spend by category

-12%
(61m)
258
-26%
(54m)
110 101
75
238 208
211
Elective inpatient
-18%
(30m)
86
75
Non-elective inpatient
Mental health and learning

disabilities spend
-18%
(53m)
79
65
154 142 116

64
Daycases
Primary care spend
Mental health
56 64
Learning
disabilities
Outpatient
205 189
145
140
126
116 107
33 30
42
-23%
(91m)
125
54 50
35 32 48 50
GP
A&E
Prescribing cost
189 197
85 79
-7%
(6m)
39 36 30
104
Dental
64
N/A
Community
Prescribing
Hospital
Prescribing
SOURCE: Laing & Buisson 2008/09, NHS Information Centre Prescribing Data, HES 2008/09, HSCNI data
13
. . . and significant variations in performance across NI highlight potential

for internal productivity improvements
2009
Standardised Admissions Ratio
Emergency Admissions
100 = NI
95
99
Belfast
Northern
91
108
111
Higher admissions
in the Northern
Trusts appear to be
driven by higher
elective admissions
In the Southern
Trust the higher
ratio is driven by
emergency
admissions
For the Western

Trust higher ratios
for both elective
and emergency are
seen
Standardised Admissions Ratio All

Admissions (including daycases)
100 = NI
95
Belfast
100
Northern
98
104
South SouthEastern ern
104
Western
Western
Standardised Admissions Ratio Elective

Admissions (excluding daycase)
100 = NI
114
106
99
89
88
Belfast
Northern
Western
Note: SARs information is based on the home address of the patient and will not give an accurate reflection of the over- or under-usage of hospital
facilities within a Trust Area, as patients can attend hospitals outside their immediate home areas. The SAR is indirectly standardised and compares the
ratio of observed admissions in an area to those that might have been expected had the area experienced the age specific admission rates of the NI
population.
SOURCE: Northern Ireland Neighborhood Information Service 2009; Department of Health; Social Services and Public Safety
14
There are significant health and social disparities both within and external
to the region, reflecting Appleby and others identification of a need gap
Variation in life expectancy by deprivation quintile
within NI
2004/06, years
Disability living allowances

Allowances per 1,000 population (weighted and
unweighted), as at November 2009
Male life expectancy

Female life expectancy
85
82
80
80
78
NI (at 7%
weighting)
NI (at 16%
weighting)
England
North East
SHA
75
0
Quintile 1
(least
deprived)
Quintile 2
Quintile 3
Quintile 4
Quintile 5
(most
deprived)
102
NI (unweighted)
Scotland
Wales
95
87
49
68
66
80
Appleby and others have identified a need differential between England and NI
Appleby: The judgement of this Review (to be confirmed or
denied in the light of any subsequent results arising
from a UK-wide allocation model) is that a reasonable
need differential between England and Northern
Ireland should be around 7%
Subsequent Identified potential disparity gap of

joint DFP /
up to 14-17%
DHSSPSNI
work1:
1 Taken from internal unpublished report on need comparison compared to England, represents overall increased need for health and social care
2 All analysis in this document considers both 7% and 16% overall need weightings (16% and 36% for social care specific analyses)
SOURCE: NISRA; Independent Review of Health and Social Services Care in Northern Ireland, Kings Fund 2005; DHSSPS unpublished report
15
In 2009/10, Northern Irelands per capita spend on health care

has dropped below that of other regions
Healthcare
per capita, not weighted for need
Northern Ireland
2007/08
North East England
England
Wales
Scotland
1.79
1.63
1.89
1.76
2008/09
n/a
1.95
0.44
0.54
0.64
Northern Ireland
1.68
0.46
UK average
1.66
0.46
1.75
1.97
1.86
1.86
1.78
Social services
2008/09
n/a
2.08 n/a
0.46
1.90
0.58
0.64
0.47
0.48
0.47
2.07
1.96
1.88
1.91
0.60
0.62
0.52
0.49
SOURCE: HM Treasury Public Expenditure Statistical Analyses 2010
16
HSCNI spends less than England when need is taken into account
per capita spend on health and social care, 2009/10
-3%
2,361
-12%
2,400
2,293
2,069
England
Funding
gap
NI unweighted
NI 7%
weighted
NI 16%
weighted
226m
606m
SOURCE: HM Treasury
17

2. The trends in health and social care needs and
implications for funding
for implementation
18
NI-SPECIFIC ANALYSIS
Demographic change, residual demand growth and cost

inflation, unmanaged, would increase spend by ~6% p.a.
Historical/ forecast spend

Forecast do nothing spend
x
Spend gap
b per annum, nominal, total DHSSPS allocation

7
6
5.4
2010/11
savings
3
2006/07
2010/11
2014/15
SOURCE: SRF; DHSSPS; various Northern Ireland historical activity sources for residual growth (see appendix for details)
19
Other regions have assumed residual activity demand growth

above demographic which has been similarly calculated for NI
Compound annual growth rate; 2010/11-2013/14 (England SHA A), 2007/08-2016/17 (England SHA B) or 2010/11-2014/15 (all other)
Demographic
growth3
Wales2
0.5% 0.8%
Northern
Ireland
Scotland
England SHA A2
England SHA B2
Residual
growth1
Unit price
inflation
0.9% 1.3%
1.2% 1.8%
2.2%
1.5%
1+
1.3%
1+
1.9%
0.3% 0.9%
1.8%
1.8%
0.8%
2.7%
2.6
3.9%
N/A
6.0%
2.2%
2.5%
Low case
5.7%
-1
N/A
Base case
Total do-nothing
growth in spend
1.9%
1+
High case
3.5
6.2%
1 Residual growth representing increasing expectations and demand for services, improving access to care, changes in care technology, changes to clinical practice, changes in disease
profile and all other factors which increase demand for care, other than demographics. Details of calculation for Northern Ireland in appendix; calculated at 2.4% incorporating ageing factor
and excluding prescribing (which were then deducted and added respectively to give figure shown above); 2.4% comprises ~4% for acute, ~1% for social care, ~0% for community and
primary healthcare, based on 04/05 08/09 CAGRs; ~0.8% ageing factor and ~0.6% impact of prescribing volume increase are based on DHSSPS assumptions
2 Healthcare only, excludes social care
3 Accounts for growth of whole population (0.7% CAGR for NI, source NISRA) and changes in age profile (0.8% CAGR for NI, source DHSSPS)
NOTE: Total growth in spend CAGR for comparators is accurate; constituent CAGRs are approximate representations of the aggregation of CAGRs applied at service line and organisation
level and then compounded in each year. Differences in methodology mean that figures for different regions are approximately but not precisely comparable
SOURCE: Expert interviews; DHSSPS; Welsh and English SHA QIPP plans
20
On calculating the total size of the challenge
An estimate of likely future growth in required funding has been

developed in terms of three components:
Demographic growth
Residual growth
Cost inflation
NISRA population growth projections (~0.7% p.a.) have been used for
demographic growth with the calculated residual growth factor capturing
all other phenomena (i.e., increasing expectations and demand for
healthcare services, improving access to care, changes in healthcare
technology, changes to clinical practice, changes in disease profile,
ageing of the population)
The methodology for calculating residual growth factor is explained in

detail on subsequent pages
Cost inflation has been developed using an approximate aggregation of

the DHSSPS assumptions on pay and non-pay inflation (including GMS,
pharmacist remuneration), grade drift and growth in prescribing
volumes, using DHSSPS baseline 2009/10 spend assumptions, resulting
in a 2.5% p.a. growth in required funding due to unit cost increases
21
Improvement opportunities
analysed apply to this baseline
Baseline spend figures used
No specific improvement
opportunities analysed apply
million, 2008/09
Inpatient elective
Inpatient non-elective
Outpatient
Daycase
A&E
296
603
258
Non-inpatient (district nursing, health

visiting, etc)
145
78
Other hospital (incl MHLD,

physical/sensory disability)
Community healthcare
Inpatient (community hospitals)
233
219
Nursing care, residential care, statutory

day care, social work, domiciliary care,
meals
196 415
Social care
General practice
Other primary care (dental,
ophthal., pharmacy remun.)
Primary care drugs
784
185 969
Community addiction teams, MHLD

inpatient and hospital daycare, geriatric
medicine inpatient, physical disability
inpatient
222
140
392
Total service spend
3,749
DHSSPS, centrally-funded,
depreciation/cost of capital
292
Small bodies
Total spend
Revenue generated
Total outflow
169
Multiple data sources had to be used to
4,210 reach this level of granularity. As a
result, not all of these figures will match
50
those in any given data source but
these variances should be small
4,160
1 RQIA, HPA, NIPEC, NISCC, NIGALA, NIMDTA, NIFRS, CSA

SOURCE: TFR, Community Indicators, HIS, DHSSPS
22
Population growth is forecast to continue at a similar rate to recent past

Million persons in Northern Ireland
0.7% p.a.
0.8% p.a.
1.70
1.71
1.72
2003
04
05
1.74
1.76
1.78
1.79
1.80
1.82
1.83
1.84
1.85
06
07
08
09
10
11
12
13
2014
SOURCE: NISRA
23
CASE STUDIES
Most English health economies have estimated future

residual growth based on historical plus judgement
Similar approach
adopted by HSCNI
Scenario
Region/project
Low
Baseline
High
Healthcare for
London review
2009
Estimate:
0.5% Medicine
1% Primary Care
0% all other
N/A
Historical growth 00/01 to 07/08

Used national historical rate for inpatients
and primary care, local for other
Healthcare for
London original
2007
Estimate: 1% for areas with higher

historical growth (Medicine, A&E,
Primary Care), 0% for others
Historical 00/01 to 05/06, adjusting for

known one-off phenomena (e.g., A&E
historical residual growth rate of 8% p.a.
halved because impact of 4-hour wait
and improved access not expected to
continue)
Used national historical rate for inpatients
and primary care, local for other
Baseline plus 1% for Medicine (reflecting

greater pace of future development in
technology, drugs and clinical practice)
and plus 1% for Primary Care and 2% for
Outpatients (reflecting continuing
improvements in access through
Polyclinic model and increased patient
expectations)
SHA 3
N/A
Scenarios (varying by PCT) some per

Healthcare for London original 2007 with
some modification (e.g., plus 0.5% for
Obstetrics to reflect greater fertility of
increasing immigrant population); others
per historical local PCT rates
N/A
SHA 4
N/A
As per Healthcare for London review

2009 with some services adjusted to
reflect local historical rates (A&E,
Medicine, Regular Attender, Primary
Care)
N/A
SHA 2
N/A
As per Healthcare for London review

2009 with some local adjustments
N/A
SOURCE: Team Analysis
24
CASE STUDIES
English residual assumptions varied across regions and services

Percent
Scenario
Healthcare for London

Affordability 2009
Healthcare for London

2007
SHA 4 2009
SHA 2 2009
SHA 3 2010
Historical
Historical plus
judgement
High - above historical
Source
Medicine
Surgery
Historical 00/01 to 05/06

except A&E (lower)
Low estimate
Low - below historical
0.5 2.2 2.7
2.7
0.5
0.5
1.5
2.0
1.5
1.3
1.3
1.3
1.3
1.3
0
0.1
1.3
Paediatrics
1.0
Outpatients
2.0
2.1
0
2.1
1.0 3.0 0 4.0
4.0
Community
care
4.2
1.0
0.1
1
3
Per service
line
10
A&E
Primary care
Healthcare for
London, modified
obstetrics for
immigrant pop
1.0 1.7 1.0 3.7
0.5
Obstetrics
Regular
attenders
High historical 00/01 to 07/08
4.3
5.3
3.2
4.0
3.2
1.0 4.2
1.0 3.3
1.3
4.3
1.0 5.3
Mental health
N/A
N/A
NA
Specialised
commissioning
N/A
N/A
NA
Other
N/A
N/A
NA
2.3
2.3
1.3
1
4.3
Per service
line
0
SOURCE: Healthcare for London, expert interviews
25
In aggregate, residual growth will likely increase required funding by

~2.4% p.a.
Spend, m; growth due to residual only (excludes growth due to demographic change)
Considered baseline
spend excludes
~1,587m of other
spend (see previous
baseline spend page)
Residual growth
CAGR, 2008/092014/15
2.4% p.a.
3,032
2,628
Inpatients
Outpatients
A&E
General practice
ECRs
Community healthcare
Social care
1,319
308
85
217
50
221
1,044
258
78
222
24
219
1.5
-0.3
13
784
831
0.2
1
2008/09
2014/15
SOURCE: Trust Financial Returns; HIS
26
Inpatient/ daycase acute activity residual growth is ~4% p.a.

Residual growth relative to previous year
Admissions, %
Historical residual Residual CAGR

CAGR
used for forecasting 2008/09
2004/05 008/09, % 2009/10-2014/15, %
admissions
15
10
5
0
-5
Surgery
4.2
3.2
203,955
Medicine
5.3
5.3
279,405
Mental
Health
-6.4
10,670
Obstetrics
1.6
1.6
40,034
Paediatrics
1.2
1.2
40,749
574,813
-10
-15
-20
2005/06
Variance to
historical rate
2006/07
2007/08
2008/09
Surgery downsized to reflect on-going trend of interventions

moving from surgical to medical. Elective waiting time targets
not adjusted for, on the basis that there has been a steady
growth year on year (3-4%) in elective IPDC activity
Mental health adjusted to 0% on the basis that there is no
reason to believe demand for mental health services is truly
declining; rather, these figures may reflect some shifting of
activity out of acute into the community
Overall CAGR for forecasting
(aggregated using baseline activity)
4%
Note: Regular Attenders and independent sector activity Included

SOURCE: KH03a
27
Outpatient acute activity residual growth is ~3% p.a.

Historical
residual CAGR
2004/05
2008/09, %

Outpatients, %
10
9
8
7
6
5
4
3
2
1
0
-1
-2
-3
2005/06
Residual CAGR
used for
forecasting
2008/09 OP
2009/10-2014/15, % attendances
Surgery
2.9
2.9
41,821
Medicine
3.5
3.5
621,359
Mental
Health
5.5
5.5
56,976
Obstetrics
1.0
1.0
111,644
Paediatrics
1.6
1.6
74,560
1,606,360
2006/07
2007/08
2008/09
Total CAGR for Forecasting

(using baseline activity)
3%
Note: Independent sector activity Included. T&O ICATS figures excluded for 07/08 and 08/09. During 0809 a number of Mental Health OP services were
reclassified to non consultant led, therefore 0809 is excluded from the Mental Health Residual Growth figures
SOURCE: KH09 & QOAR
28
A&E activity residual growth is ~1.5% p.a.

A&E attendances, %
2.5
Historical
residual CAGR
2004/05
2008/09, %
Residual CAGR
used for forecasting 2009/102014/15, %
2008/09 A&E
attendances
1.5
1.5
732,022
2.0
1.5
1.0
0.5
0
2005/06
2006/07
2007/08
2008/09
SOURCE: KH09 Part 2
29
General practice activity residual growth is ~0% p.a.
2.0
Historical
residual CAGR
2004/05
2008/09, %
1.5
-0.3

GP and nurse consultations in general practice, %
Residual CAGR
used for
2008/09
forecasting
consulta2009/10-2014/15, % tions
-0.3
10,323,830
1.0
Negative growth rate in

general practice activity
over and above
population growth may
be due to registration
being over 100% of
population
0.5
0
-0.5
-1.0
-1.5
-2.0
2005/06
2006/07
2007/08
2008/09
SOURCE: Continuous Household Survey
30
ECR spend has been growing ~13% above population

All programmes of care
Extra contractual referrals spend, %
20
Historical
residual CAGR
2004/05
2008/09, %
Residual CAGR
used for
forecasting
2009/10-2014/15, %
2008/09
spend
m
13
13
23.9
15
This analysis is based on annual

growth in costs rather than activity
as comparable historical activity
figures are not readily available
10
0
2006/07
2007/08
2008/09
Note: 08/09 is based on an estimate figure

SOURCE: ECR Regional Report
31
Community healthcare activity residual growth has fluctuated
Historical
residual CAGR
2004/05
2008/09, %
0.2

Community health care contacts, %
Residual CAGR
used for
forecasting
2008/09
2009/10-2014/15, % contacts
0.2
4,064,382
2
1
0
Year to year change (above population

growth) in the number of contacts has been
highly variable over the 3 years for which data
is available. This data has been used
nevertheless because longer-term comparable
historical data was not readily available
-1
-2
-3
-4
2007/08
2008/09
Note: Total number of contacts in the above chart include District Nurses, Community Dental/Midwives/Psychiatric Nursing, AHPs, Health Visitors, LD
Nurses, Family Planning and Clinical Psychology
SOURCE: Trust Financial Returns Community Indicators
32
Social care activity residual growth has varied across services but is
estimated at ~1% p.a. overall
Activity, %
30
25
20
Meals delivered to
client homes growth
rate is erratic,
however impact
limited as total
spend is only 7m
When calculating
costs for
domiciliary care,
direct payments
are included
15
10
5
0
-5
-10
-15
2007/08
2008/09
Historical
residual CAGR
2004/05
2008/09, %
Residual CAGR
used for
forecasting
2008/09
2009/10-2014/15, % activity
Domiciliary
care (hrs
worked)
13,820,318
Meals delivered
to client homes
1,417,936
Nursing Care
(occupied
resident weeks)
411,457
Residential Care
(occupied
resident weeks)
-3
-3
246,093
Social Work
(caseload)
94,808
Statutory
Day Care
(attendances)
-2
-2
1,088,986
Discussions with experts have suggested there

may be an apparent decline in some social care
activity due to the increase in direct payments
Total CAGR for

forecasting (using
baseline spend)
1%
SOURCE: Trust Financial Returns Community Indicators
33
Unit cost inflation assumptions aggregate to ~2.5% p.a. increase in

required funding
Elements of cost inflation, growth relative to preceding year
11/12
12/13
13/14
14/15
Pay inflation HSC

(Pharmacists)
0.0%
3.5%
0.0%
3.5%
1.0%
3.5%
1.0%
3.5%
Superannuation
0.9%
0.0%
0.0%
0.0%
Non Pay inflation
1.9%
2.3%
2.6%
2.7%
Grade Drift HSC
1.0%
1.0%
1.0%
1.0%
Demand Increase
Prescribing1
5.2%
5.2%
5.2%
5.2%
Aggregate effect
2.5%
2.1%
2.8%
2.8%
1 DHSSPS figure of 6.5% minus DHSSPS forecast population growth factor of 1.3%
SOURCE: DHSSPS, Aug 2010; NISRA
34
1 Residual activity demand growth Data-to-analysis explanation

Data
Estimation of future
residual activity demand
growth
IPDC & OP Activity

A&E Attendances
GP & Nurse Consultations
ECR spend
Mid year population estimates
Spend
Community activity and spend
IS activity
Sources
Hospital Statistics Publication by POC (KH03a,

KH09, QOAR)
KH09 part 2
Continuous Household Survey
Extra Contractual Referrals NI HSC Recent
Trends and Issues
NISRA
Trust Financial Returns
Community indicators
IS quarterly activity returns
Approach and assumptions
Approach: Calculate historical residual growth and apply judgement to modify as a proxy for anticipated future residual growth
Historical data was used to measure activity growth for as long a historical period as was available and provide a trendline
For each 1-year period (e.g., 2004/05 to 2005/06), historical population growth as a % was deducted from historical activity growth as a %
to give historical residual growth as a %
The compound effect of this historical residual growth in any given service (e.g., medicine inpatient/ daycase) over the full historical period
examined was calculated as a CAGR (compound annual growth rate)
These service-specific CAGRs were aggregated (by summing 2008/09 activity and 2014/15 activity implied by the CAGR, then calculating
the CAGR between these totals) to give the CAGR for a given setting of care (e.g., inpatient/ daycase). (For social care, where the
various services were too different to meaningfully sum activity, spend was used instead)
The total impact of all of these setting of care specific growth rates on required funding was calculated by applying each to its associated
2008/09 spend to estimate the 2014/15 spend required for each setting of care, then summing the 2008/09 and 2014/15 spend and
calculating the CAGR between these totals
Comments
During 2008/09 a number of Mental Health OP services were reclassified to non consultant led
and therefore 2008/09
is excluded from the Mental Health Residual Growth figures
Inpatients, Daycases and Outpatients treated in the Independent Sector are included in activity
Regular Attenders are included in the Inpatient activity
ICATS activity for T&O during 0708 and 0809 are excluded from outpatient activity
Internal Contacts/Data owners
Laura Smyth (DHSSPS), Christine

Kennedy (DHSSPS), Christine
Frazer (HSCB Finance), Dermot
McAteer (HSCB), Caroline Earney
(HSCB Information), Penny Murray
(Primary Care)
35

2. The trends in health and social care needs and implications
for funding
for implementation
36
CASE STUDY
At country level, extra spend does not seem to drive better health status
Healthcare
spend/head
US $
Life
Expectancy
Years
6,714
USA
Infant
WHO health
Mortality
system rank
Per 1000 live births out of 192
78
France
4,056
81
Canada
3,912
81
Germany
3,669
80
UK
3,361
79
72
7
4
4
5
35
41
4
5
Italy
2,845
81
Japan
2,690
83
24
3
9
SOURCE: WHO SIS (2006)
37
CASE STUDY
and, for example, at hospital-level, increased cost is not associated

with lower mortality
Variation in hospital mortality and cost per patient (sample of US acute care hospitals)
6
Severity adjusted cost (Z-value), 2001
5
4
3
2
1
0
-4
-2
-1
-2
-3
-4
-5
Risk-adjusted m ortality (Z-value), 2001
Note: Data are based on 10 HCUP states. Mortality is a weighted composite of 10 risk-adjusted inpatient mortality rates. Cost adjusted for wage index,
case mix, and severity of illness
SOURCE: Joanna Jiang, Ph.D.; Center for Delivery, Organization and Markets, AHRQ
38
It is therefore possible to both increase quality and decrease cost; some

actions achieve both, others benefit one without affecting the other
Main focus of
this assessment
E.g. Protocols
that minimise the
chance of errors
E.g. New
technology or
drugs that are
more effective
E.g. Improved
procurement
Quality
improvements
Productivity
improvements
39
We have assessed the potential impact of the main quality and

productivity improvement opportunities
Category
Optimise
the care
delivered
(allocative
efficiency)
Reduce the
unit cost of
required care
(technical
efficiency)
Main improvement levers
Hospital
Applies but
not analysed2
Quantified
Community
Primary/
6
healthcare Social care1 FHS
LTC management, early intervention
Decommissioning
Prevention, re-enablement
Referral management, variation in assessment (OP,

NEIP shortstay, social care, diagnostics)
Optimise urgent care
Shift to lower cost settings
Productivity (staff productivity, inpatient ALOS)
Prescribing and pharmacy procurement
10 Procurement of other supplies

3
11 Estates better use of space
12 Patient flows to/ from other regions (RoI, England)
13 Renegotiate unit price or reprocure externally-provided

services
14 Reduce management costs and other administrative
overheads
Y
~
Y
Y
1 Social care content across all levers has been grouped into a single chapter (6) of this document
2 Because either expected size of opportunity is very small, or because sufficiently meaningful data is not available
3 Excluding the implications of other improvement opportunities
40
Methodology has drawn upon experiences from within the NI system,

other UK regions, and internationally
Most analyses are based on centrally-available data from NI, England or external sources it is
not intended to provide specific or local granularity
Opportunities identified through benchmarking against, for example:

England (highest/ lowest quartile)
Wales and Scotland
Between NI HSC Trusts
Opportunities identified, ratified and enhanced using selected international academic research
and case studies of good practice1
Outside-in
analysis
using
benchmarking
and good
practice
augmented by
local insight
to size
potential
for various
scenarios on
need
Interviews with approximately 20 Director-level leaders and senior professionals (from HSCB,
PHA and DHSSPS)
System leaders workshop (~70 participants from HSCB, PHA, DHSSPS, HSC Trusts and LCGs)
Data analysis and collection supported by HSCB, PHA, DHSSPS and HSC Trust information
and finance specialists
Top-down identification of opportunities
Approx size of opportunity shown as a range, assuming full costs can be made variable (e.g.,
wards or sites can be closed where relevant)
Next step: further investigation as part of local implementation planning
Considering 3 both 7% and 16% weighting for overall need relative to England (16% and 36%
for social care specific need)
1 Case studies have been chosen to be as comparable as possible to NI, but differences in system and/or context
making should be taken into account in further work
41
INDICATIVE
Improvement opportunities can be prioritised according to

quality and financial impact and ease of implementation
High Priority
Medium Priority
Lower Priority
Quality impact
Low
LTC management, early intervention
Decommissioning
Prevention
Referral management, variation in assessment
Optimise urgent care
Social care
Shift to lower cost settings
Productivity (staff productivity, inpatient ALOS)
Prescribing and Procurement of Pharmacy
Financial impact
High
Low
Ease of implementation
High
Low
High
Procurement of other supplies

10
11
Estates better use of space
12
Patient flows to/ from other regions
Renegotiate unit price or reprocure services

13
Reduce management costs and other
14
administrative overheads
SOURCE: Workshop 16 August 2010 (70 participants), NI interviews, experience of similar initiatives in England
42
About the pages that follow

In the pages that follow you will find
A covering page for each major improvement opportunity, laying out the estimated size
of the opportunity
Based either on
Attainment of highest/lowest quartile benchmark; or, where unavailable
Review of case studies and clinical literature
Displaying potential financial benefit for each of

The year from which data was used (usually 2008/09)
2014/15
Showing (by means of a range) the impact of whether Northern Irelands population
weighting to reflect deprivation relative to England is 7% or 16%1
NB. The opportunities are shown here on a standalone basis and are not additive. In the
summary sector they have been aggregated so that double-counting has been removed
Supporting pages behind that covering page show greater detail behind the figures
1 7% using Kings Fund Independent Review of Health and Social Services Care in Northern Ireland assessment; 16% using internal HSCNI unpublished
report on need comparison compared to England, which identified 1417% variance
43
Smaller opportunities are detailed in the appendix, and some further

opportunities (beyond the 16) have not yet been assessed
Opportunities assessed in the appendix
Potential opportunities not yet assessed
3 Prevention
Service overlaps: for example, multiple

A&Es in close proximity
10 Procurement of supplies other than drugs
Reconfiguration:
Much of the financial impact of
11 Estates use of space
reconfiguration has been taken into

account (e.g., through using the full cost
of activity to estimate savings from
reduced LOS or fewer LTC admissions)
12 Patient flows
13 Renegotiation of externally-procured
services (GP)
However, other aspects have not yet

been quantified (e.g., rent and
maintenance costs avoided, capital
impact of selling property, where viable)
14 Reduce administrative overheads
Mental health, learning disabilities and nonacute care reconfiguration: reducing ALOS,
centralising
44
Details behind opportunity sizing

1 LTC management, early intervention
2 Decommissioning
3 Prevention
4 Referral management, variation in assessment
5 Optimise urgent care
6 Social care
7 Shift to lower cost settings
8 Productivity (staff productivity, inpatient ALOS)
9 Prescribing and drug procurement
11 Estates - use of space
12 Patient flows to/from other regions
13 Renegotiate unit price or reprocure services
15 Copayment by the service user
45
1 Improving management of long term conditions would

improve quality and could release ~13m1
Re-provision Cost
Opportunity net of
Re-provision cost
Estimate of potential benefits, m

Benchmark to highest/ lowest quartile
Results,
2008/09
Physical Health
10-12
Elderly
Total
Results,
2014/15
Methodology
used
Total
12-16
0
10-12
12-16
13-15
Compared LTC acute admissions per weighted population with

English PCTs lowest quartile
Assumed ~8 community/GP contacts to prevent 1 inpatient spell
(double what used in similar analyses in England, to reflect NIs
strong starting performance)
1 Assumes that Northern Ireland need is 7-16% higher than England

SOURCE: Reference Costs Returns 2008/09, team analysis of HRG 4.0 to 3.5 map, 2008/09 Activity Based Funding Model, Continuous Household Survey, Mid-Year Estimate, HES 2008/09,
DH weighted populations, Healthcare for London; Coye (HealthTech) Transformation In Chronic Disease Management Through Technology
46
1 LTC-related HRGs were allocated to sub-LTC groupings for

benchmarking (1/5)
HRG
Grouping
LTC
A19
Stroke + TIA (A19-23)
Hypertension
A20
Hypertension
A21
Hypertension
A22
Hypertension
A23
Hypertension
A38
Old Age Psychiatry
Mental health
A99
Stroke + TIA (A19-23, A99)
Hypertension
B30
Diabetes - eye surgery (B30)
Diabetes
D12
Pneumonia/Empyema (D12-D14, D41-43)
COPD
D13
COPD
D14
COPD
D21
Asthma (D2122)
Asthma
D22
Asthma (D2122)
Asthma
D39
COPD (D3940)
COPD
D40
COPD (D3940)
COPD
D41
Pneumonia/Empyema (D12D14, D4143)
COPD
D42
COPD
SOURCE: Healthcare for London; interviews with English HES experts
47

benchmarking (2/5)
HRG
Grouping
LTC
D43
COPD
D99
COPD Elderly respiratory (D99)
COPD
E01
Syncopsy, Chest Pain (E0102,09,3132, 3536)
CHD
E02
CHD
E07
Pacemakers, HF, PCI (E07, 1819, 2830, 3839. 99)
CHD
E09
CHD
E11
CABG + AMI + IHD (E4,1115,2223)
CHD
E12
CABG + AMI + IHD (E4,1115,2223)
CHD
E13
CABG + AMI + IHD (E4,1115,2223)
CHD
E14
CABG + AMI + IHD (E4,1115,2223)
CHD
E15
CABG + AMI + IHD (E4,1115,2223)
CHD
E18
Heart Failure (E18E19)
Heart failure
E19
Heart Failure (E18E19)
Heart failure
E22
CABG + AMI + IHD (E4,1115,2223)
CHD
E23
CABG + AMI + IHD (E4,1115,22-23)
CHD
E24
Hypertension (E2425)
Hypertension
E25
Hypertension (E2425)
Hypertension
48

benchmarking (3/5)
HRG
Grouping
LTC
E28
CHD
E29
Cardiac Arrhythmias (E29E30)
CHD
E30
Cardiac Arrhythmias (E29E30)
CHD
E31
CHD
E32
CHD
E35
CHD
E36
CHD
E38
CHD
E39
CHD
E04
CABG + AMI + IHD (E4,1115,2223)
CHD
E99
CHD
F55
Other IBD (F55)
Other non-specific
F99
Frail/Elderly Catch all (F99, L99, S99)
Frail/elderly
H39
Frail/Elderly Falls (H39, 86-87)
Frail/elderly
H86
Frail/elderly
H87
Frail/elderly
J41
Diabetes Other (J41, L09)
Diabetes
49

benchmarking (4/5)
HRG
Grouping
LTC
K11
Diabetes (K11K17, K29)
Diabetes
K12
Diabetes
K13
Diabetes
K14
Diabetes
K15
Diabetes
K16
Diabetes
K17
Diabetes
L01
Renal replacement (L01, L4648)
Diabetes
L09
Diabetes Other (J41, L09)
Diabetes
L46
Diabetes
L47
Diabetes
L48
Diabetes
L49
Renal failure (L4951)
Diabetes
L50
Diabetes
L51
Diabetes
L99
Frail/Elderly Catch all (F99, L99, S99)
Frail/elderly
P29
Diabetes
50

benchmarking (5/5)
HRG
Grouping
LTC
Q12
Endovascular procedures (Q12 & Q15)
Diabetes
Q15
Endovascular procedures (Q12 & Q15)
Diabetes
Q16
Diabetes foot and vascular procedures (Q1619)
Diabetes
Q17
Diabetes
Q18
Diabetes
Q19
Diabetes
51
1 Opportunities have been identified by analysing a range of HRGs

by condition (1/2)
Potential reduction of admissions, in %, 2008/09 compared to English PCTs
HRG Group
Asthma
CABG + AMI + IHD
Cardiac Arrhythmias
Chest pain
COPD - Elderly respiratory
COPD
Diabetes - eye surgery
Diabetes - foot and vascular procedures
Diabetes - Other
Diabetes
Endovascular procedures
Frail/Elderly - Catch all
Frail/Elderly - Falls
Syncopsy, Chest Pain
Heart Failure
Hypertension
Lowest Quartile
0
8-15
28-33
0
0-1
26-31
26-32
0
0
12-18
0
0
0
23-29
31-36
29-34
SOURCE: 2008/09 activity based funding model; continuous household survey; mid-year population estimate; team analysis; HES 2008/09; DH weighted
populations; Healthcare for London
52
1 Opportunities have been identified by analysing a range of HRGs

by condition (2/2)
Potential reduction of admissions, in %, 2008/09 compared to English PCTs
HRG Group
Lowest Quartile
Other - IBD
0-5
Pacemakers, HF, PCI

Pneumonia / Empyema
Renal failure
Renal replacement
Stroke + TIA
23-29
15-21
0-1
0
SOURCE: 2008/09 activity based funding model; continuous household survey; Mid-Year Estimate; HES 2008/09; DH weighted populations; Healthcare
for London
53
1 Minimal correlation between age and long term condition admissions

in benchmark dataset
30 PCTs with lowest LTC admissions per 1,000 weighted
population
Population aged 75 and above

in percent
14
Tower Hamlets
City and Hackney Teaching
Newham
Hammersmith and Fulham
Kensington and Chelsea
Coventry Teaching
Isle of Wight NHS
Greenwich Teaching
North East Essex
Medway
Luton
Barking and Dagenham
Brighton and Hove City
Nottingham City
Brent Teaching
Herefordshire
Plymouth Teaching
Kirklees
North Lincolnshire
Warwickshire
Waltham Forest
Telford and Wrekin
County Durham
Newcastle
Bradford and Airedale
Leeds
Peterborough
Westminster
Wakefield District
Shropshire County
12
10
8
6
4
2
R2=0.114
0
0
20
40
60
80 100 120 140 160
Rank by number of LTC

admissions per 1,000 Weighted Population
In discussions on the foregoing analysis with stakeholders in NI, the question was raised to what extent
the PCTs being used as lowest-quartile comparator were those with the youngest populations (which
would invalidate the comparison). This analysis shows that this is not the case
Note: R2 is the coefficient of determination, a measure of the interdependence of the two metrics, 0 indicating low interdependence,
1 indicating high interdependence
SOURCE: HES 2008/09
54
1 Long-Term Condition Management Data-to-analysis explanation (1/2)

Data
Benchmarking
Sources
Admissions for specified HRGs

Northern Ireland
England
NI unit cost of HRG admissions
England weighted populations
2008/09 Activity Based Funding model

HES 2008/09
2008/09 Reference Costs (HRG 4.0)
DH exposition book

Compare acute admissions per weighted population in LTC-related HRGs
For each LTC, a group of HRGs typically associated was identified
Number of admissions per 1,000 weighted population was compared to English PCTs lowest quartile, for the
above-mentioned group of HRGs
The cost per admission was estimated based on a map of hospital cases coded under both HRG 3.5 and HRG
4.0, since the admissions for English PCTs were only available in HRG 3.5 while the NI unit costs were only
available in HRG 4.0
It was assumed that to prevent each LTC-related admission, it would require two GP consultations and six district
nurse contacts, at a total cost of ~360 shown on the charts as re-provision cost
Comments
PCTs with lowest quartile admissions are not outliers with

regard to their age profile
Given the relative under-investment in mental health in
Northern Ireland, although this analysis could have been
applied to mental health related HRGs, it was not
Contacts/ data owners
Christine Kennedy
55
CASE STUDY
1 With good disease management at primary care level, hospital activity

for long term conditions can be significantly reduced
Condition
Congestive
heart
failure
Intervention
Asthma
COPD
Diabetes
Increase in PC conReduction in acute

sultations required to
unscheduled activity
deliver LTC in London
1
Adm
LOS case example
Core references
Multi-disciplinary
23-85%3
2
managed care
Specialist nurse
58%
interventions
Discharge planning 25%
and post discharge
support
Active case
management4
Specialist asthma
nurses
36%
Early discharge
planning and
hospital-at-home
Multi-disciplinary
pulmonary rehab
for 6-12 weeks
Active disease
management
Specialist primary
care (GPwSIs)
10-30%
x 2.5
54%
x 1.7
10-38%
50%
x 1.8
10-30%
50%
25%
40%
x 2.4
Heart,2005,91,899-906 (74 trials);

JGenInternMed,1999,14 (2), 130-4 (7 trials);
Chest, 2005,127;2042-8 (4yr study)
BMJ,2001;323;715-8 (1 RCT)
JAMA,2004,291,11 (18 RCTs)
CHD NSF Chapter 6
Euro Heart Journal, Guidelines for the
diagnosis and treatment of CHF, 2005
Cochrane,2003(1) (36 trials); BTS
Asthma Guideline, 2004 (25 trials)
DH Compendium of CDM citing
BMJ,2004,328,144;Thorax,2001,56,68790;Pub Health Med,2002;25;258-60
Thorax(NICE),2004,59,39-130 (2 RCTs;
1 for each intervention)
NHS Institute Directory of Ambulatory
Emergency Care for Adults (citing NICE
guidance)
DH CDM Compendium citing Cochrane
(41 RCTs) & 3 RCTs
Diabetes Med, 2003(1),32-8 (1 study)
1 Hospital readmission (inpatient); 2 Best evidence for programmes of 3m including education, lifestyle advice, exercise, home visits, nurse case
managers and regular monitoring; 3 Weighted average = 27%; 4 Including written care plan, supported self-monitoring and regular practitioner reviews
SOURCE: Disease prevalence numbers from QOF data for 2005/6 (applied to GP registered populations for percentage prevalence), NHS Information
Centre; Decision Resources Patient Base for CHF prevalence and severity breakdowns between conditions; Department of Health (for GP
registered populations)
56
CASE STUDY
1 Using a registry to target secondary prevention, Kaiser

reduced hospitalisation rates and reduced mortality by 76%
Background/Context
Cardiovascular disease is the leading cause of
death in the US
There is robust evidence that cholesterol and blood
pressure control reduces mortality
Programme details
All patients with an acute coronary event are
offered enrolment in the KP Colorado programme
12,000 patients enrolled, average age 70
Patients are seen by a nurse within 24 hours and
agree a prevention plan
Education, therapy, medication and monitoring
Nurses, pharmacists and clinicians share an
electronic medical chart and online registry
Highly proactive case management by nurses and
pharmacists to monitor adherence and efficacy
Collaborative approach across clinicians, nurses
and pharmacists, enabled by good IT systems and
integrated care
Resources
Kaiser is currently evaluating total costs
SOURCE: Permanente Journal, Summer 2008, Volume 12 No. 3
Impact
77
100
-76%
24
+250%
22
All-cause mortality % patients at

over 8 years
target LDL
Quality improvements
All cause mortality down
76% over 8 years
Patients at target LDL up
from 22% to 77%
266 less major cardiac
events each year in 12,000
population
Cost improvements
Annualised savings of
$3m/year ($242 per
patient) due to less
hospital activity
57
CASE STUDY
1 Disease registries: Key success factors and replicability
Key success factors
Lessons for adoption in the NHS
Identify appropriate personnel

Nurses skilled in education
Pharmacy medication experts
Kaiser invested 2 to 3 years in

developing the evidence base on
protocols
Build appropriate systems

Identify and track patients
Communicate plans and
problems
Track outcomes and
performance
Significant investment in highquality IT system is necessary
Protocols, once agreed, were made

compulsory for all clinical staff
Productivity dropped in the first year

as need was discovered and the
new system was implemented
Collaborate with clinicians
SOURCE: Permanente Journal, Summer 2008, Volume 12 No. 3,
58
CASE STUDY
1 German national disease management programme (DMP) improved

outcomes and reduced costs of LTCs
Patients in DMP with new cases of diabetic feet
Percent per quarter, adjusted to patients at risk
DMPs achieved
improved medical
outcomes
3.0
2.0
-63%
1.0
0
2
Duration of DMP
Half-years
Costs of care for patients with diabetes
EUR per year, 2006
4,800
665
610
4,177
520
661
Other
1,525
Prescription drugs
1,471
Inpatient care
1,521
2,004
Non-DMP
620
Outpatient care
Higher cost
effectiveness by
Improved treatment
and coordination
DMP
SOURCE: Interviews with DMP experts
59
CASE STUDY
1 Recent English PCT frail/elderly pilot has yielded a 58%

reduction in admissions compared with a control group
Control Group
Registered with the 6 pilot

practices
Identified by PARR++ based
on inpatient records from
2007-2009
PARR++ score of more than
30
Admissions is measured as
total emergency admissions
over 12 weeks for the top
106 patients
Number of emergency admissions

for 106 patients over 12 weeks
Pilot patients
41
-58%
17
Control group Pilot patients
Current patients under the

pilot at the 6 practices
Selected through a
combination of PARR++
analysis and local
intelligence
Patients selected through
PARR++ have median score
of 36. A large percentage of
the original PARR list have
been filtered out through
local intelligence
Admissions is measured as
number of emergency
admissions in first 7 weeks
and projected across 12
weeks
SOURCE: Pilot PCT; PARR++ estimates
60
CASE STUDY
1 Case study of multidisciplinary staff project: Croydon virtual wards

Description and context
Impact to date
Context
~2,600 patients in Croydon with >2 emergency admissions per year due to worsening LTC
Croydon decided that these patients need to be managed better to reduce admissions
Since May 2006

Has saved 1 million
Has resulted in the closing of 100
Acute beds
This caused the introduction of a Virtual Ward, each with 100 beds
Each ward is a team with a community matron, ward clerk, GP attached
Beds are offered to patients with high risk of admission
Ward staff and processes are similar to acute, but patient remains at home
If patients exceed risk factor they are admitted to a real hospital
Local hospitals, GPs and NHS Direct aware of who is in these wards to be available 24/7
Patient selection
Predictive algorithm (PARR) identifies 100 patients most at risk of emergency admission
Usually patients with worsening LTCs
Adjustable boundaries mean wards do not need to be co-terminous with boroughs/PCTs
Enablers and prerequisites for this

change
Organisational structure
Ward staff
Community matron
(ward clerk)
Coordination of ward
staff and specialist
care
Nurse
Health visitor
Pharmacist
Social worker
Physiotherapist
Specialist services
Specialist nurses
Palliative care team
Occupational therapist
Mental health link
Voluntary sector helper
GP
Alcohol service
Dietician
Effective leadership by local

authorities
Pooled funding
The risk management tool which
contained a predictive algorithm
(PARR) created by the Kings Fund
SOURCE: Kings Fund; NHS Institute for Innovation and Improvement
61
CASE STUDY
1 Veterans Health Administration trialled remote patient management

and realised significant savings in admissions and bed days
Background/Context
The VAs Care Coordination Home Telehealth (CCHT)
program began in 2001
A total of 43,430 patients have been enrolled since VHA
implemented CCHT in 2003. VHA will increase these
services 100% above 2008 levels to reach 110,000
patients by 2011 (only 50% of projected need).
Programme details (what was done & how)
Use of health informatics, disease management and home
telehealth technologies to provide routine non-institutional
care (NIC) and chronic care management services to
patients with diabetes, congestive heart failure,
hypertension, posttraumatic stress disorder, chronic
obstructive pulmonary disease and depression
In 85% of cases the technology utilised was
messaging/monitoring services; video-telemonitors 11%;
videophones 3%
VHA attributes the rapidity and robustness of its
implementation to the systems approach taken to
integrate the elements of the program.
Impact
% reduction
25
20
Reduction in
admissions
Reduction
in bed days
Quality improvements
86% mean satisfaction
score rating
Cost improvements
25% reduction in bed days
of care
20% reduction in numbers
of admissions
SOURCE: Coye (HealthTech) Transformation In Chronic Disease Management Through Technology
62
CASE STUDY
1 resulting in dramatic reduction of LTC acute care utilisation

at the Veterans Health Administration
Condition
Number of Patients
% Decrease Utilization
Diabetes
8,954
20
Hypertension
7,447
30
CHF
4,089
26
COPD
1,963
21
PTSD
129
45
Depression
337
56
Other Mental
Health1
653
41
Single Condition
10,885
25
Multiple Conditions
6,140
26
1 Since this applies to acute care settings only, not directly for entirety of Mental Health provision.
SOURCE: VA Care Coordination/Home Telehealth Studies 2004-007, in Darkins et al. Telemedicine and e-Health, Dec 2008 Ratan (MKR-A) | 5/12/2009 |
2009 Robert Bosch LLC and affiliates. All rights reserved.
63
CASE STUDY
1 Healthways Diabetes management programme reduced healthcare

cost per patient by 20%
Summary
Comprehensive disease
management for diabetes
Reduces overall
healthcare costs
Primarily through
hospitalisation reduction
Coordinated series of interventions managing all aspects of the

diabetic patients care
Patients stratified on 20 parameters to determine the appropriate
intensity of support required
Patient care manager assigned to each patient
Pro-active outreach and patient engagement programme
Self-care counselling and support
Regular testing and monitoring
Active management of acute episodes
Planned preventative interventions
All healthcare costs reduced by 17.1% (21.2% for patients staying

continuously on the programme for 1 year)
Hospitalization costs reduced by 15.9% (23.7% 1 year)
Hospital admissions reduced by 15.6% (20.5% 1 year)
Bed days reduced by 21.7% (26.6% 1 year))
Rate of HbA1c testing increased by 21%, from 61% to 74%
HbA1c levels reduced from mean 7.75 to 7.48
Increased rates of
Retinal eye exam
Foot exam
Serum creatinine testing
Cholesterol screening
Approach
Intervention
Healthways Comprehensive
Diabetes Disease
Management Program
Sample size
20,539 patients with
diabetes enrolled in the
Medicare+ program across
the USA.
Follow-up
Patients followed-up for
12 months
Results stratified between
those staying on the
programme continuously
vs intermittently
Impact
SOURCE: American Healthways, American Healthways Comprehensive Diabetes Disease Management Program Improves Health Status for Medicare
Recipients and Reduces Health Care Costs by 17.1 Percent, http://www.americanhealthways.com/articles/outcomes/CDCHandoutFINAL.pdf
64
CASE STUDY
1 Ownhealth in Birmingham proactively manage patient care, delivering

improved outcomes
Example outcomes, %
Overview
% in action or maintenance stage at baseline

% in action or maintenance stage at follow-up
Telephone-based case management service

run by nurse care managers
Covers diabetes, COPD, heart failure

and CVD
Currently operating across 3 PCTs and

serving around 1300 patients (July 2007)
Operates in several languages
70
65
41
36
38
6
Physical activity
Diet
Stop smoking
Baseline
28
Focus on:
Proactivity: outbound calls to patients

at agreed time
20
14
Follow-up
16
12
Patient responsibility: patients set

own goals
Motivation, coaching and support
Heart failure
symptoms
of patients
Angina pectoris Hypoglycaemic

symptoms
Hyperglycaemic
symptoms
Overall patient satisfaction 96% September 2006

good adviceyou are not on your own when you have a care manager
can always ring up and ask a question if you are worried
really educational I am in safe hands with the care manager
reassuring to share my feelings what I was doing right and what I knew I was doing wrong
SOURCE: OwnHealth presentation materials; National Commissioning Conference
65
CASE STUDY
1 Tower Hamlets has negotiated an innovative contract that will

incentivise the right behaviours in procuring care packages
Background
Tower Hamlets derived an innovative contract for commissioning diabetes care from GPs, which
included both requirements for minimum standards of activity and pay for performance to incentivise
behaviour. Over time percentage of payment made for outcomes will increase.
Payment for activity ensures adequate care is provided:
% of payment
Definition
When paid
70%
Undertaking all activity required by the care packages
Quarterly
Payment for performance aligns incentives to improved outcomes:

% of payment
Definition
When paid
10%
Accurate and timely data coding
Year end
5%
Patient satisfaction
Year end
5%
Improvement in HbA1c, BP, Chol.
Year end
5%
All patients have individual care plans
Year end
SOURCE: Tower Hamlets PCT, 2008 (contact Andrew Ridley)
66
CASE STUDY
1 Crisis resolution teams can reduce the need

for mental health inpatient admissions by 4050%
Background/Context
Crisis resolution teams are intended to reduce
psychiatric bed use and provide rapid access to
services. Their roles are to assess everyone for
whom acute admission is considered and,
whenever feasible, to provide intensive home
treatment instead of admission.
No randomised evaluation of this service model
had previously been carried
260 residents of the Inner London borough of
Islington who were experiencing crisis severe
enough for hospital admissions to be considered
Programme details (what was done & how)
Compare admission rates and satisfaction of the
group of 135 who received care from crisis
resolution team (experimental group) vs. the
group of 125 who receive the standard inpatients
services and community mental health teams
support (control group)
Control group
Group supported by CRT
Impact
8 weeks after
the crisis:
Psychiatric
ward
Crisis
House
Overall
6 months after
the crisis:
59
22
67
29
13
19
18
24
69
36
-48%
75
47
-37%
Quality improvement
Care delivered closer to home and reduced
need for hospital admissions
Productivity improvement
Patients in the experimental group were less
likely than those in the control group to be
admitted during the eight weeks after the crisis
SOURCE: NHS
67
CASE STUDY
1 Mental health example: Early intervention in Northumberland reduced

No early intervention (n=114)
bed days due to psychosis by 54%
Number of admissions in the
first 3 years of treatment
Mean number of bed

days in first 3 years of
treatment
99.7
1.9
1.3
0.9
44.9
0.4
Reduction:
Number of
admissions
Number of readmissions
Bed days
52%
69%
54%
Early intervention (n=75)
Study details:
Early intervention in psychosis team was
established in Northumberland (2002) aimed
to take on all individuals with first-episode
psychosis in the county
Participants were service users under 36
years of age who presented between
October 1998 and September 2005
The first group (n=114) were individuals
who presented between October 1998
and September 2002 (i.e. before the
service had been established), but who
would have met the acceptance criteria
for the service.
The other group (n=75) were all
individuals who received treatment from
the service between September 2002
and October 2005
The groups were biased in prognostic
indicators such that the treatment group was
expected to have a worst prognosis
1 Early intervention in psychosis service and psychiatric admissions - Guy Dodgson, Kathleen C Rebbin, Caroline Pickering, Emma Mitford, Alison
Brabban and Roger Paxton - Psychiatric bulletin (2008), 32, 413-416. doi: 10.1192/pb.bp.107.0174 42
SOURCE: Psychiatric bulletin (2008)
68
CASE STUDY
1 Other studies also demonstrate the potential impact of early

intervention/ long-term condition management in
preventing the need for mental health inpatient spells
ILLUSTRATIVE
SAMPLE
Study
Study conclusions
SWL and St George's COPD pilot
83% reduction in admissions (sample size ~40) and 84%

reduction in LOS for those admitted, through use of integrated
physical and mental health community teams
Cochrane, Community mental health teams for people with

severe mental illnesses and disordered personality (Review),
2007, 3
13% reduction in inpatient admissions through use of community

teams
Dupont S Breathlessness Clinic at Hillingdon Hospital
COPD: CBT based interventions significantly reduced health

care utilisation, including accident and emergency attendance,
bed usage, and pharmacy costs, with improvements in
depression and anxiety
Moore RK, Groves DG, Bridson JD, Grayson AD, Wong H,

Leach A, Lewin RJ, Chester MR. A Brief Cognitive-Behavioral
Intervention Reduces Hospital Admissions in Refractory Angina
Patients. J Pain Symptom Manage. 2007 Mar;33(3):310-316.
Lewin B, Cay E, Todd I, Soryal I, Goodfield N, Bloomfield P,
Elton R The angina management programme: a rehabilitation
treatment. British Journal of Cardiology 1995; 2(8): 221-226
Psychological intervention and psycho-education angina

stability improved by 30%, 40% reduction in emergency
admissions for refractory angina
Liverpool and Leeds psychiatric liaison services
Leeds Partnership for Older People Project reduced hospital

admission of people with dementia, leading to over 1000 bed
days saved per annum and cashable savings. An analysis in
Liverpool of 320 cases managed by the liaison team social
worker showed a lowered six month re-admission rate, with 87%
of re-admissions for medical, not mental health or social,
reasons
SOURCE: Various, cited above
69

2 Decommissioning
3 Prevention
6 Social care
70
2 Decommissioning procedures of limited value could

reduce spend by ~12m
Estimate of potential benefits, m
Re-provision cost
Opportunity net of re-provision cost

Results,
2008/09
A Relatively ineffective
interventions
B Potentially
cosmetic interventions
C Effective interventions,
cost-effective alternatives1
D Effective, close
risk-benefit ratio
Results,
2014/15
Methodology
used
4.5-5.0
1.6-1.9
0.4-0.9
3.1-4.2
Total
9.6-12.0
Total
12-15
Comparison of interventions per weighted population with England

Reference cost returns (HRG 4.0) mapped to HRG 3.5 for unit prices
Overcounting for both England and Northern Ireland possible, as analysis was
not conducted at procedure level; results should be seen as indicative
1 30% re-provision cost deducted for spend on alternatives

SOURCE: Reference Costs Returns 2008/09, team analysis of HRG 4.0 to 3.5 map, 2008/09 Activity Based Funding Model, continuous household survey, mid-year population estimate,
London Health Observatory Save to Invest: Developing criteria-based commissioning for planned health care in London; Hospital Episode Statistics 2008/09 2009, Re-used
with the permission of The Health and Social Care Information Centre, DH weighted populations; JAMA 4 Dec 2002 (vol 288) no. 12
71
2 Decommissioning procedures Data-to-analysis explanation (1/2)

Data
Benchmarking
Sources
Admissions for specified HRGs

Northern Ireland
England
Unit costs of admissions
English PCT weighted populations
London Health Observatory Save to

Invest: Developing criteria-based
commissioning for planned health care in
London
2008/09 Activity Based Funding model
Hospital Episode Statistics 2008/09
NI 2008/09 Reference Costs
DH exposition book

Compare admissions per weighted population for interventions of limited clinical value
Based on Save to Invest report, HRGs representing treatments of limited clinical value were identified
Number of admissions per 1,000 weighted population was compared to English PCTs lowest quartile, for the
above-mentioned group of HRGs
The cost per admission was estimated based on a map of hospital cases coded under both HRG 3.5 and HRG
4.0, since the admissions for English PCTs were only available in HRG 3.5 while the NI unit costs were only
available in HRG 4.0
For interventions with more cost efficient alternatives, 30% re-provision cost was assumed
Comments
PCTs with lowest quartile admissions are not outliers with

regard to their age profile
Overcounting for both England and Northern Ireland
comparators is possible, as analysis was conducted at
HRG but not procedure level; results should be seen as
indicative
Christine Kennedy
72
2 We used these HRGs to represent the majority of treatments with

potential for decommissioning
Effective interventions with a

close benefit/risk
balance in mild
cases
Effective interventions where

cost effective
alternatives
should be tried
first
Effective interventions with a

close benefit/risk
balance in mild
cases
Effective interventions where
cost effective
alternatives
should be tried
first
HRG Description
HRG version 3.5
Tonsillectomy
Spinal Cord Stimulation
Back Pain : Injections and Procedures
Grommets
Knee Washouts
Trigger Finger
Dilation and Curettage
Jaw Replacement
Minor Skin Lesions
Inguinal, Umbilical and Femoral Hernias
Incisional and Ventral Hernias
Aesthetic Surgery - Breast
Varicose Veins
Aesthetic Surgery - ENT
Other Hernia Procedures
Aesthetic Surgery - Plastics
Aesthetic Surgery - Opthalmology
Orthodontics
Knees
Primary Hip
Hip and Knee Revisions
Cataract Surgery
Female Genital Prolapse/Stress Incontinence (Surgical)
Wisdom Teeth Extraction
Dupuytrens Contracture
Cochlear Implants
Other Joint Prosthetics
Female Genital Prolapse/Stress Incontinence (Non-Surgical)
Hysterectomy for Menorrhagia
Carpal Tunnel
Anal Procedures
Bilateral Hips
Elective Cardiac Ablation
C58
A03
R03,R04,R07,R09
C55
H10
H14,H20,H16, H17
M05
C25, C35, C45
J33,J34,J35,J36,J37
F73, F74
F71, F72
J01,J04,J05,J06,J07,J50
Q11
C21,C32,C56
F76, F77
J29,J32
B17,B18
C04
H03, H04
H80,H81
H05,H06,H07,H71,H72
B13
M03
C58
H13,H16, H17,H14
C60
H08
M13
M07,M08
H13
F92,F93,F94,F95
H01
E38,E39
Part of service line
Surgery
Medicine
SOURCE: LHO Save to invest: Developing criteria-based commissioning for planned health care in London
73
2 By benchmarking activity per weighted population to England, the

potential reduction in NI activity was identified (1/2)
% potential reduction in number spells if NI moves to English lowest-quartile PCT rate, 2008/09
HRG Group
A
Back Pain : Injections and Procedures

Dilation and Curettage
Relatively
ineffective
interventions
45-49
Grommets
23-29
Jaw Replacement
22-28
Knee Washouts
Spinal Cord Stimulation
Tonsillectomy
Trigger Finger
Aesthetic Surgery - Breast
Aesthetic Surgery - ENT
Potentially
cosmetic
interventions
23-29
Aesthetic Surgery - Opthalmology
Aesthetic Surgery - Plastics
Incisional and Ventral Hernias
Inguinal, Umbilical and Femoral Hernias
Minor Skin Lesions
Orthodontics
Other Hernia Procedures

Varicose Veins
16-22
30-36
SOURCE: 2008/09 activity based funding model; continuous household survey; mid-year population estimate; HES 2008/09; DH weighted populations
74
2 By benchmarking activity per weighted population to England, the

potential reduction in NI activity was identified (2/2)
% potential reduction in number spells if NI moves to English lowest-quartile PCT rate, 2008/09
HRG Group
C
Effective
interventions
where costeffective
alternatives
should be tried
first1
D
Anal Procedures
Bilateral Hips
Carpal Tunnel
For some of these

treatments, Northern
Ireland activity levels
are already below
English comparators
Elective Cardiac Ablation
0-7
0
0
19-26
Hysterectomy for Menorrhagia
4-11
Cataract Surgery
Effective
interventions
with close
benefit-riskbalance in mild
cases
Cochlear Implants
Female Genital Prolapse/Stress
Incontinence (Non-Surgical)
Femal Genital Prolapse/
Stress Incontinence (Surgical)
Hip and Knee Revisions
27-32
0-4
35-40
0
0
Knees
Other Joint Prosthetics
Primary Hip1
55-58
8-15
1 For these treatments we assume a 30% re-provision cost, e.g., for drug-based treatment
SOURCE: 2008/09 activity based funding model; continuous household survey; mid-year population estimate; HES 2008/09; DH weighted populations
75
2 PCTs with lowest levels of this kind of activity tend to have slightly
younger populations but not to extent of discrediting this analysis
These PCTs have the lowest level of interventions with
potential for decommissioning per weighted
population
with a slight bias towards younger populations, but

not sufficiently so to discredit the analysis
% of 2008 population over 75
1. Tower Hamlets PCT

2. Kensington and Chelsea PCT
3. Westminster PCT
4. City and Hackney Teaching PCT
5. Newham PCT
6. Leicester City PCT
7. Camden PCT
8. Heart of Birmingham Teaching PCT
9. North East Lincolnshire CT
10. Hammersmith and Fulham PCT
11. Nottingham City PCT
12. Islington PCT
13. Wandsworth PCT
14. Manchester PCT
15. Liverpool PCT
16. Luton Teaching PCT

17. Brent Teaching PCT
18. North Lincolnshire PCT
19. Stoke on Trent PCT
20. Leeds PCT
21. Bolton PCT
22. Brighton and Hove City PCT
23. Knowsley PCT
24. Barking and Dagenham PCT
25. Middlesbrough PCT
26. Walsall Teaching PCT
27. Darlington PCT
28. Wolverhampton City PCT
29. Salford PCT
30. Ealing PCT
20
15
10
R2 = 0.35
5
0
0
20
40
60
80
100
120
140
160
Spells per 1000 wt pop,

interventions with potential to decommission
In discussions on the foregoing analysis with stakeholders in NI, the question was raised to what extent the
PCTs being used as lowest-quartile comparator were those with the youngest populations (which would
invalidate the comparison). This analysis shows that this is not generally the case
Note: R2 is the coefficient of determination, a measure of the interdependence of the two metrics, 0 indicating low interdependence,
1 indicating high interdependence
SOURCE: LHO Save to invest: Developing criteria-based commissioning for planned health care in London; applied to PCTs using HES 2008/09
76
CASE STUDY
2 Decision aids in the UK have reduced hysterectomy rates by 20% and

total costs by 43% per case
Background/Context
The NHS aims to increase patient participation
in treatment
Decision aids can help, because they
Inform patients better about the tradeoffs in
care choices (probabilities of benefit and
harm)
Clarify individuals values on how the
patient perceives benefit and harm
Offer support through the decision making
process using guidance and prompts
Study details
An information pack and interview were
developed to help women with menorrhagia
894 women in South West England were
randomised to decision aid or usual care
Two year total cost to the payor was recorded
When compared to
standard care, the interview
Reduced hysterectomy
rates by 20%
Reduced costs by 43%
or 780/case1
Increased long-term
satisfaction
Neither information nor
interview had a negative
effect on health status
1 Costs reduced more than the hysterectomy rates because after the interview costs decreased both in women who had hysterectomies and in women
who did not
SOURCE: JAMA Dec 4 2002 vol 288 no 12
77
CASE STUDY
2 Decision aids increase patient engagement

Perspectives
Patients with decision aids

15% higher knowledge scores
40% less passive in decisions
70% more realistic expectations
Decision aids reduce the use of

discretionary surgery without
apparent adverse effects on health
outcomes or satisfaction
Conclusions of Cochrane review
Challenges for adoption in the NHS
Many procedures are unnecessary

Commissioners can avoid
unnecessary procedures by
Decommissioning certain services
Developing service access criteria
Implementing decision aids
Careful value judgements need to be
made in discussion with clinicians
about thresholds for intervention
Examples in the NHS
Croydon PCT has developed common

services access criteria
Decision aids for menorrhagia in
hospitals in South West SHA reduced
hysterectomy rates and costs (see
next page)
SOURCE: OConnor et al., Cochrane Library, 2009
78
CASE STUDY
2 Systematic review finds that decision aids could reduce elective

surgical procedures by 2025%
International surgical review
South West SHA example
Percentage of patients deciding to have a procedure with or without use of

Decision Aids
Background/Context
Decision aids can help increase patient
participation in treatment, because they
Inform patients better about the tradeoffs in
care choices (probabilities of benefit and harm)
Clarify individuals values on how the patient
perceives benefit and harm
Offer support through the decision making
process using guidance and prompts
Study details
An information pack and interview were developed
to help women with menorrhagia
894 women in South West England were
randomised to decision aid or usual care
Two year total cost to the payor was recorded
Impact
When compared to standard care, the interview
Reduced hysterectomy rates by 20%
Reduced costs by 43% or 780/case1
Increased long-term satisfaction
Neither information nor interview had a negative
effect on health status
Standard Care
With decision aid
83%
Prostatectomy (for cancer)
63%
83%
Orchidectomy
56%
58%
Coronary Bypass surgery
41%
40%
Mastectomy
23%
33%
Back surgery
Prostatectomy (for BPH)
26%
14%
8%
1 Costs reduced more than the hysterectomy rates because after the interview costs decreased both in women who had hysterectomies and in women
who did not
SOURCE: OConnor et al., Cochrane Library, 2007 & updated 2009; JAMA Dec 4 2002 vol 288 no 12
79

2 Decommissioning
3 Prevention
6 Social care
80
3 Prevention will be an important driver of long-term quality and

productivity, short-medium term effect will be more limited
SOCIAL CARE ASPECTS
IN CHAPTER 6
Estimation of benefits, m
Case studies/ research
Results,
2008/09
Results,
2014/15
3.6
Savings are estimated using some indicative case study programmes as

examples
Although many studies exist to prove the clinical impact of prevention programs,
exact costs, financial benefits and implementation timelines remain unclear
Given the short-medium term timeline to 2014/15, assumptions have been

conservatively based on:
Alcohol: based on results from English Total Places pilots scaled to NI3
Diabetes: Successful delivery of obesity reduction programme to 2-3% of
diabetics1; with savings per person pro-rated from US Why WAIT case study
Infants breastfed: 10% increase in initiation from post-natal care programme
leading to reduction in otitis media, gastroenteritis, asthma cases and teat
usage (from NICE costing report) (scaled to NI)2
Further savings could be possible from other programme areas for example,
smoking and sexual behaviour
4.6
Scale of savings triangulates to

expected prevention benefits in
other health regions
1 Assuming 65k diabetics in NI (NIAO Obesity and Type 2 Diabetes in NI report, January 2009) with Why WAIT savings pro-rated down by variance in
healthcare spend/head
2 Based on cost-benefit analysis outlined in Postnatal care: routine post-natal care of women and their babies: Cost Report: Implementing NICE guidance
in England, July 2006
3 Based on Total Place pilots in Leicester, Birmingham, South Tyneside, Sunderland and Gateshead; with results scaled to NI
SOURCE: NIAO Obesity and Type 2 Diabetes in NI report, January 2009, Postnatal care: routine post-natal care of women and their babies: Cost
Report: Implementing NICE guidance in England, July 2006; Reference Costs Returns 2008/09; Continuous household survey, mid-year
population estimate; London Health Observatory Save to Invest: Developing criteria-based commissioning for planned health care in London;
Hospital Episode Statistics 2008/09 2009, Re-used with the permission of The Health and Social Care Information Centre
81
3 Preventing health and well-being issues has significant knock-on

impact to broader health issues reducing serious harm in the mid term
NI
Prevalence
Estimated health
impact
Patient action
24%1
(340,000
people)
CHD
Cancer
2,400 smoking
deaths per year
Stop smoking
High quality smoking

cessation services
24%,
(340,000
people)2
62,000
people
(diabetics
Type 2)3
Diabetes
Hypertension
Dyslipidemia
Breathlessness
Sleep apnoea
Gall bladder
disease
5 fruits/vegetables
a day 27%2
compliance
5 days a week
with 30 min
physical activity
30%2 compliance
Programs like
EPODE (France)
Colac (Australia)
MEND (U.S./U.K.)
Package of action
required, including
registration, regional
and local
Smoking
Obesity
Provider action
1 of adults, 15 and above, 2008/09

2 of adults, 15 and above, 2005/06
3 2005
SOURCE: Northern Ireland Continuous Household survey; Northern Ireland Health and Social Wellbeing survey; ERPHO, 200305; NIAO Obesity and
Type 2 Diabetes in NI report, January 2009; Mid-Year Estimate of Population
82
3 It will be critical to ensure spend is targeted towards the highestimpact interventions based on local need, impact and feasibility
Impact
Potential to impact
years of life lost
Social
determinants
High
ENGLAND PCT
EXAMPLE,
ADJUSTED FOR NI
Alcohol
Other health
behaviours (diet,
activity)
Smoking
Better mgmt
of LTCs
Breastfeeding
Sexual behaviour
Immunisation
Low
Screening
Low
High
Feasibility
Ease of implementation, Speed to impact
SOURCE: England PCT; Northern Ireland expert interview
83
3 Prevention Data-to-analysis explanation

Data
Case Example
Estimate
Sources
Total spend Non-Elective, Elective, and

Day Cases
Internal expenditure for Trust and Boards

Northern Ireland Continuous Household
survey
Northern Ireland Health and Social
Wellbeing survey (2008/09)
Research (see slides on case studies)

Approach: Estimate savings potential based on case studies
Given the short-medium term timeline out to 2014/15, assumptions have been conservatively based off:
Diabetes: Successful delivery of obesity reduction programme to 2-3% of diabetics1 ; with savings per person
pro-rated from US Why WAIT case study
Infants breastfed: 10% increase in initiation from post-natal care programme leading to reduction in otitis
media, gastroenteritis, asthma cases and teat usage (from NICE costing report) (scaled to NI)2
Alcohol: based on results from English Total Places pilots scaled to NI3
Comments
None
Internal contacts
Laura Smyth
Bryan Dooley
1 Assuming 65k diabetics in NI (NIAO Obesity and Type 2 Diabetes in NI report, January 2009) with Why WAIT savings pro-rated down by variance in healthcare spend/head
2 Based on cost-benefit analysis outlined in Postnatal care: routine post-natal care of women and their babies: Cost Report: Implementing NICE guidance in England, July 2006
3 Based on Total Place pilots in Leicester, Birmingham, South Tyneside, Sunderland and Gateshead; with results scaled to NI
SOURCE: NIAO Obesity and Type 2 Diabetes in NI report, January 2009, Postnatal care: routine post-natal care of women and their babies: Cost Report: Implementing NICE guidance in
England, July 2006; Reference Costs Returns 2008/09; Continuous household survey, mid-year population estimate; London Health Observatory Save to Invest: Developing
criteria-based commissioning for planned health care in London; Hospital Episode Statistics 2008/09 2009, Re-used with the permission of The Health and Social Care
Information Centre
84
CASE STUDY
3 HM Government and WHO give guidance on successful programs to

combat alcohol abuse
Intervention
Harmful/
Hazardous
Drinkers
Identification and
Brief Advice (IBA) in
GP practices and
A&Es
Outcomes
Dependent
Drinkers
Specialist treatment
Saving
A&E patient journey

time improves
between 6-16%
Individuals consume
on average 3 to 9
fewer alcohol units
per week
1 in 8 individuals
reduce drinking to
low-risk levels
307,250 estimated
1 in 4 treated
individuals report no
continuing alcoholrelated problems
2 in 5 treated
individuals reduced
their alcohol
problems by at least
66%
717,100 estimated
return on investment
for typical PCT
Potential savings of
1300 per individual
per year in averted
health care costs or
premature death
return on investment
for a typical PCT
SOURCE: HM Government: Safe.Sensible. Social. The next steps in the National Alcohol strategy; DH, Alcohol Misuse Interventions: Guidance on
developing a local programme of improvement; WHO-CHOICE study, 2003.
85
CASE STUDY
3 Pilots of smoking reduction and alcohol control services have resulted

in significant savings in England
Alcohol High-Impact Changes

Total Place pilots in Leicester, Birmingham, South Tyneside,
Sunderland and Gateshead showed potential annual savings of up to
an average of 650,000 for a PCT
Services included: alcohol screening to provide higher-risk individuals
with brief advice on alcohol consumption, additional counselling, or an
alcohol health worker to manage dependent drinkers in an acute
setting
See: www.localleadership.gov.uk/totalplace/
NHS Stop Smoking Services

DH analysis of Stop Smoking Services data shows 70,000 lives have
been saved since they were established, with annual potential of
380m across England
See: Beyond Smoking Kills, Protecting Children, Reducing
Inequalities, Action on Smoking and Health (ASH), 2009
SOURCE: NHS 2010-2015: from good to great. Preventative, people-centred, productive, DH (2009)
86
CASE STUDY
3 Government led initiatives, UK

Situation
Impact
What is being done
Experts say that most of the

population in Britain will be
obese by 2050
At present, 30% of children are
obese target is to bring this
back down to 2000 levels of
26% within the next 12 years
(2020)
an 2008 milestone strategy
Healthy Weight, Healthy Lives
will look at using financial
incentives such as payments,
vouchers and other rewards to
encourage individuals to lose
weight
There are 36,000 smokers in

Dundee, about half who live in
poverty
Getting people to participate in
smoking cessation has been a
very difficult task and is costing
the Scottish NHS an enormous
amount of money
Well @ Work joint programme with the

Department of Health and the British
Heart Foundation
1.5m 2 yr programme to pilot ways of
getting England's work places healthier
Programmes are centred around
supportive workplace environments,
education and awareness and
workplace policies
There is no onus on who will fund
financial incentive schemes, but its
likely to fall on the shoulders of
companies who will benefit from a
healthier workforce.
An estimated 600mill invested into
school meals by 2011
Offering the poorest parts of Dundee

150 on groceries if they are able to
give up smoking.
A 12 week scheme (12.50 a week)
where smokers go to a pharmacy and
get a carbon monoxide test to ensure
they are not cheating
This has followed the success of the
100,000 programme aimed at
encouraging pregnant women to stop
smoking by offering them 50 a month
One competition called The Biggest

Loser awarded 130 to the
participants who lost the most weight.
The clinical director of the National
Obesity Forum has voiced there is little
evidence that payments would work
and it would be difficult to check
whether people were taking regular
exercise
In total, the government is investing
372 mill over 3 yrs to implement the
strategy.
Programmes include breastfeeding
initiations, children's centres, school
based programmes, community
intervention, clearer food labelling,
reduced advertising of foods high in
fat, salt and sugar
As these initiatives are in their infancy,
there is little evidence reported on
impact.
The pregnancy scheme helped 100
women to stop smoking at least for the
time the programme was running
SOURCE: http://news.bbc.co.uk/1/hi/scotland/tayside_and_central/7465908.stm http://news.bbc.co.uk/1/hi/scotland/tayside_and_central/5124194.stm
87
CASE STUDY
3 Social marketing and smoking, North West UK

Situation (need):
PCTs across England want
to encourage more
participants to join their
smoking cessation services
to meet national healthcare
targets and improve the
health of its population, thus
reducing the utilisation of
resources
The North West has the
highest number of smokers
in England - accounting for
about 1.5 million of the
population. More than 3,000
people in the region die
each year before the age of
64 because of diseases
caused by smoking.
What was done:

Two projects were
undertaken in collaboration
with Dr Foster Intelligence
a public private partnership:
Oldham PCT and Dr
Foster Intelligence
designed, planned and
implemented a social
marketing campaign
promoting the PCTs stop
smoking programmes
Greater Manchester PCT
introduced a Quit It
campaign with an education
focus. Central to this was
the Quit It bus, which
undertook a 20 day tour,
and then repeated two
months later
Impact (+ cost of
program?):
Oldham PCT achieved
743 on-the-spot sign-ups to
the stop smoking service,
more than 800 requests for
further information, 73 text
messages and more than 20
requests for one-on-one
meetings with stop smoking
advisors
Greater Manchester PCT
The Quit-It bus generated
nearly 2000 referrals to
services across Greater
Manchester, it is estimated
that 40% of these people
are accessing local services
and receiving stop smoking
support.
88
CASE STUDY
3 Breastfeeding has been shown to protect infants from

infections which lead to hospital admission
Background/Context
12% of infants in the UK are hospitalised in the
first eight months of life
Breastfeeding shown in many studies to have a
protective effect on infant mortality and
morbidity as well as on mother/child bonding
Study details
Study compared the hospitalisation and
breastfeeding status of 15,000 infants born in
England between 2000 and 2002
Only 1.2% of English infants exclusively
breastfed for at least six months (vs. 26% in
New Zealand)
Data were adjusted for socio economic status
and other confounders
Study conclusions
Exclusive breastfeeding of all babies for the
first 8 months would prevent
53% of hospitalisations for diarrhoea
27% of hospitalisations for lower respiratory
tract infection (LRTI)
Partial breast feeding would prevent 31% of
diarrhoea and 25% of LRTI admissions
respectively
Comment
Breastfeeding is one of the few preventive

strategies linked to short-term impact
Successful breastfeeding has particular benefit

for underserved groups, and can lessen
inequalities as well as improve overall health
Resources
Resources to encourage breastfeeding not
measured, in Northern Ireland ~240k,
assuming 12 per birth
SOURCE: Pediatrics 2007;119;e837-e842, The Times, July 20th 2009, New Zealand MoH
89
CASE STUDY
3 The Why WAIT program targeted weight loss to control diabetes,

with significant improvements in metabolic and anti-inflammatory
outcomes
1 Background
Region: Massachusetts, U.S.
Health system: Joslin Diabetes Center, a
research organization and clinical care
provider affiliated with Beth Israel Deaconess
Medical Center
The challenge
Rapidly aging population and rising
obesity present a dual challenge
32% of adult Americans are obese

(BMI >30)
10.7% of the U.S. population has

diabetes (2007 estimates)1
Traditional management of diabetes

with oral medications typically leads
to weight gain
A previous program (Look AHEAD2)
demonstrated that lifestyle improvements
targeting weight loss could significantly
improve HbA1c levels in diabetics
4
2 Initiative details
3 Impact
Approach
Joslin Diabetes Center launched a
comprehensive weight-reduction program
called Why WAIT? (weight achievement
and intensive treatment) for type 2
diabetes mellitus (T2DM) patients
Program details
The twelve-week program with 85 patients
involved
adjustments to diabetes medications

to reduce weight
structured diet
group didactic sessions
individualized exercise plan
weekly group behavioralmodification sessions, led by a

psychologist
After the program, follow-up activity
included monthly support sessions over
one year to maintain weight loss
Twelve weeks with a follow up of one year
5 Who could implement this initiative?
Key success factors

Structured interventions with clear, specific options for patients
Use of motivational tools throughout the weight-loss process (e.g.,
cognitive behavioral support)
Convenient and accessible support programs for patients (e.g., group
sessions in evening hours)
Program included providers across several areas of expertise (e.g.,
diabetologist, exercise physiologist)
Quality (after one year)

Weight:
7.7% reduction on average, with 55% of patients

with an average reduction of 12%
HbA1c:
Participants who maintained weight loss also

maintained low HbA1c levels
Cardiovascular risk:
Significant reduction in anti-inflammatory outcomes,

reducing cardiovascular risk
Cost
Given changes in medications, cost savings on diabetic
drugs were $561.37 per patient per year
A previous cost model, in which 1% annual weight loss in
a type 2 diabetic patient decreases total healthcare costs
by $213 ($131 in diabetes-related cost), implies that this
program could save up to $1,619 in total healthcare costs
per patient (including ~$996 in diabetes-related costs)
Time to impact
Elements of the program could be replicated in most settings by providers

(e.g., primary care, community care, integrated care systems), depending on
access to necessary resources (e.g., clinical gym, meal replacements)
Partnerships with different clinical and nonclinical providers (e.g., dieticians
and athletic centers) would be an asset to anyone implementing a similar
program
1 Includes type 1 and type 2 diabetes mellitus

2 Action for health in diabetes
SOURCE: Hamdy O, et al. Current Diabetes Reports 2008 (5): 413-420
90
CASE STUDY
3 Cost-saving implications from Why WAIT and other programs show

that lifestyle interventions have potential for healthcare savings
Why WAIT:
cost savings
Implications
from previous
cost models
Given changes in medications, cost savings on

diabetes drugs were $561 per patient per year
According to a previous cost model, a 1% annual

weight loss in a T2DM patient decreases total
healthcare costs by $213, including $131 or 62%
of the total as diabetes-related cost
Applying this to Why WAIT programme (which
delivered a 7.7% weight reduction) implies total
potential health care savings of $1,619 per
patient per year (including $996 in diabetesrelated costs)
Evidence from other programs suggested that 1%
drop in HbA1c saves $776 per patient, further
suggesting that Why WAIT may produce
significant cost savings
SOURCE: Hamdy O, et al. Current Diabetes Reports 2008 (5): 413-420
91
CASE STUDY
3 Overview: EPODE school-based nutrition and exercise program

reduced prevalence of obesity in Fleurbaix and Laventie, France
1 Background
Initiative details
3 Impact
Region: Fleurbaix and Laventie,

France
EPODE (Together, Lets Prevent Childhood

Obesity) was a longitudinal school-based
program to investigate the determinants of
weight and BMI changes in children
Started with three periods of study over 12
years with 804 (1992), 601 (2000) and 633
1
(2005) children in each period
EPODE was officially launched in 2004,
inspired by work done in the towns of Fleurbaix
and Laventie, as the third phase of the project
Average cost: $2.83/inhabitant
Interventions include:
School-based nutrition program
Health checkups targeting at-risk and obese
children
Town meetings for both children and adults
New sports facilities built
Sport educators employed to promote
physical activity in primary schools
Walking-to-school days organized
Population health
Health system: local towns, split

payor/provider
The challenge
The number of obese and
overweight children in France
has increased threefold since
1980
Prevalence reached 6%-8% in
the 1980s and 13%-15% in end
of 1990s among children aged
5-12
Cost implications
In 2002, annual total cost of
obesity across the whole
population was estimated at
1.5%-4.6% of total health
expenditure in France
4
Key success factors

Targeted intervention for identified overweight and obese children
Emphasis on comprehensive food education across settings (e.g.,
schools, restaurants, community centers, sports centers)
Effective coordination among private and public stakeholders
Experimental adaptive approach in community that was then adapted
nationally over time
France
Obesity prevalence:
From 2000 to 2004, with the launch of
EPODE, prevalence among overweight and
obese girls in Fleurbaix and Laventie (FL)
went down by 47%; boys went down by 30%
BMI:
Among boys and girls, a 2.25% and 2.11%
annual decrease, respectively, was
observed during the same period
Weight:
Weight loss was only significant among girls
in FL, who experienced a 2.1 kilogram
decrease from 2002 to 2004
Cost
No direct cost savings from intervention

reported
Time to impact
One to three years
Who could implement this initiative?
Key to implementing this initiative is community-based involvement

Public organizations (e.g., payors/systems that pay for care,
providers, or integrated systems) are best equipped, but private
organizations may consider partnering with community groups to
implement
1 Number of children varied slightly throughout the years due to varied participation
SOURCE: Emery C. et al., La Presse Medicale, 2007
92
CASE STUDY
3 EPODE is based on key activities to achieve primary and secondary

strategy objectives
Key objective
Key activities
Primary strategy
Secondary strategy
To prevent onset of obesity
To reduce BMI of children identified as

overweight or obese
15-30 minutes of physical exercise per

day during recess
Yearly nutrition and exercise week to

promote fun alongside a balanced diet
Consultations with dieticians for

children identified as overweight or
obese
Individual health plans by dieticians

and general practitioners developed
for those who are overweight or obese
A Taste of Seasons program

promoting different foods every three
months using guidelines from the
national nutrition program
Recipe dissemination to children

through the classroom
Walking to school pedestrian buses

organized by parents
Some schools work with dieticians to

teach children how to have a balanced
breakfast, thereby eliminating the need
for a morning snack
SOURCE: EPODE background Web site
93
CASE STUDY
3 Example set of EPODE communication tools and road maps prepared

for a semester devoted to promoting play and fun through
physical activity
Communication
tools are prepared
by national
coordination team
and delivered
through local
project managers
SOURCE: EPODE background Web site
94
CASE STUDY
3 Over the 3 years of EPODEs implementation, there was a significant

decrease in BMI and obesity prevalence among girls and boys
Girls
BMI (kg/m2)
Boys
17.5
BMI:
Among boys, 2.25% annual
decrease
Among girls, 2.11% annual
decrease
Differences were significant
from the control group in
which obesity was increasing
17.0
16.5
16.0
15.5
15.0
14.5
14.0
2000
Prevalence of
overweight and
obesity (%)
2001
2002
2003
2004
19
Girls
17
Boys
14
10
2000
10
10
N/A
2001
2002
2003
2004
Prevalence
Among girls, 47% total
decrease
Among boys, 30% total
decrease
SOURCE: Romon et al., Public Health Nutrition, 2008; Heude et al., Diabetes and Metabolism, 2003
95
CASE STUDY
3 A range of programmes is important to ensure all groups are

effectively targeted
MUMS
Being
developed
Ages 2-4
Ages 5-7
Ages 7-13
Targeted towards overweight

and obese children
Adults
Facilitated
self-help
programme
Open to all
as well
SOURCE: MEND investor presentation
96

2 Decommissioning
3 Prevention
6 Social care
97
4 Improved referral management and reduced variation

in assessment could release ~25m
Estimation of potential benefits, m
SOCIAL CARE ASPECTS

IN CHAPTER 6

Results,
2008/09
Results,
2014/15
Methodology
used
OP first attendances
OP follow-up attendances
19
Diagnostics
Short-stay nonelective admissions
Total
20
Total
26
Comparison of outpatient attendances/NEL admissions per

weighted population with England
No comparison possible for diagnostics
SOURCE: Reference Costs Returns 2008/09, HRG 4.0 to 3.5 map, 2008/09 Activity Based Funding Model, continuous household survey, mid-year population estimate, London Health
Observatory Save to Invest: Developing criteria-based commissioning for planned health care in London; Hospital Episode Statistics 2008/09 2009, Re-used with the
permission of The Health and Social Care Information Centre
98
4 Referral Management Data-to-analysis explanation (1/4) new

outpatient referrals
Data
Benchmarking and
international good
practice/ research
Sources
Total number of first outpatient referrals:

Northern Ireland
English PCTs
DHSSPS Hospital statistics

HES 2008/09
DH exposition book

Benchmarking: Compare number of referrals per weighted population with English PCTs
Number of new outpatient referrals was divided by weighted population (each of 7% and 16% weighting relative to
England average) for NI
Referrals per weighted population for English PCTs were calculated and the lowest quartile rate identified
Potential reduction in the number of outpatient referrals for NI was calculated by multiplying NI weighted
population by the difference between NI actual and English PCT benchmark referrals per weighted population
This potential reduction in the number of referrals was then multiplied by an average outpatient new attendance
cost of 214 (see comments, below) to calculate the potential reduction in spend
Comments
Cost per new outpatient appointment calculated using

English outpatient costs for first, follow up and all
appointments (178, 90 and 137 respectively), and
applying the ratio between them to the NI all-appointment
cost for outpatients (165)
Data taken directly from publications
99
4 Referral Management Data-to-analysis explanation (2/4) first

to follow-up ratio
Data
Benchmarking and
international good
practice/ research
Sources
Total number of first outpatient referrals:

Northern Ireland
English PCTs
DHSSPS Hospital statistics

HES 2008/09
DH exposition book

Benchmarking: Compare first to follow-up ratio to English PCTs
Number of follow-up attendances was divided by new attendances to calculate first to follow-up ratio for NI
The equivalent calculation was done for England and the lowest quartile rate identified
Number of potentially-avoidable follow-up attendances was calculated by subtracting a target number of followups (England comparator ratio * NI actual number of first attendances) from the number of actual NI follow-ups
This potentially-avoidable number was then multiplied by an average outpatient follow-up attendance cost of 108
(see comments below) to calculate potential reduction in spend
Comments
Cost per new outpatient appointment calculated using

English outpatient costs for first, follow up and all
appointments (178, 90 and 137 respectively), and
applying the ratio between them to the NI all-appointment
cost for outpatients (165)
A more in-depth version could be done at Trust level where
each specialty is examined individually
100
4 Referral Management Data-to-analysis explanation (3/4) diagnostics

Data
Sources
NI diagnostic activity (CT, MRI, nonobstetric ultrasound)

Cost per scan
% reduction possible through demand
management
Case studies/
research
NI Reference Costs, 2007/08

Benchmark to average English PCT
diagnostic rates and English lowestquartile
Apply to NI diagnostic activity the % reduction used for similar assessments in England
Analysis carried out separately for each type of scan
Potential reduction % in diagnostic activity (specific to each type of scan) used for planning in England were taken.
These were based on benchmarking against the median and lowest-quartile scans per 1,000 weighted population.
MRI: 10.7% to median additional 5.6% to lowest quartile; CT: 9.9% to median additional 3.2% to lowest quartile;
US: 9.2% to median additional 6.5% to lowest quartile
These %s were applied to the relevant NI activity baseline (from 2007/08 one-off survey, which may not be
reliable)
The resulting reduction in the number of scans was multiplied by the NI price per scan to calculate the potential
reduction in spend
Comments
Reliable data on current levels of diagnostic activity in NI

was not available, so no benchmark-based analysis was
done
Reference costs 2007/08 was the latest version with
imaging diagnostic activity available
Analysis at Trust level required to refine the size of the
opportunity, given limitations of current data collected

Laura Smyth or Cathy Gillan may be able to help
101
4 Referral Management Data-to-analysis explanation (4/4) nonelective inpatient short-stays

Data
Benchmarking
Sources
Number of non-elective admissions of

duration <48hrs
Northern Ireland
England
Total number of non-elective admissions
Northern Ireland Hospital Statistics

query run by Caroline Earney
HES

Compare NI % of NEIP spells that are short-stay with English comparators
Defined short-stay NEIP spells as 0-48 hours based on midnight stays and excluding Obstetrics, Psychiatry and
regular attenders
Benchmarks were taken from non-tertiary acute hospitals in one English SHA, benchmarking short stay NEIP
spells as a % of all NEIP spells. These were validated by comparison versus evidence from case studies
including PCT A&E audits
The potential reduction in NI short-stay NEIP spells was calculated for the scenarios where NI moved to the
lowest-quartile comparator
Assumed that for every short-stay NEIP avoided, 1 bedday was avoided at a cost of ~300 - 350
Comments
Further refinements to this analysis might include

Performing an audit within NI A&E(s), as done in the
case study to reveal a more accurate picture
Benchmarking between NI hospitals to explore reasons
for variation
Caroline Earney
102
4 Outpatient appointments are slightly high relative to benchmarks,

driven by follow-up rates being high
Number of 1st
attendances per
000 weighted
population (7%),
2008/09
Northern Ireland
Number of 1st
attendances per
000 weighted
population (16%),
2008/09
238
258
England Average
2.31
361
361
England Lowest Quartile
Follow-up/first
ratio,
2008/09
2.23
259
259
Analysis assumes
that outpatient
appointments that
are removed from
the system are
unnecessary
appointments, and
therefore do not
need re-provision
elsewhere in the
system
1.90
-18%
% reduction
18
Savings potential
in 2008/091, m
19
1 Cost calculated using English outpatient costs for first, follow up and overall per outpatient appointment (178, 90 and 137), then applying the ratio to
the NI all-appointment cost per outpatient
SOURCE: HES 2008/09, Northern Ireland Hospital Statistics 2008/09, Outpatient tariff 2009/10
103
CASE STUDY
4 Hampshire and Oxfordshire have had some early success with their
referral incentive schemes
Hampshire: Total referrals to PHT by source by quarter, 2008/09
26,498
Hampshires referral management

programme was introduced in
September 2008
Others
Consultant
follow up
GPs paid ~1.75 per patient per year

to review referrals made within the
practice
Practices share outcomes of

review to allow assurance that it
is working effectively
Practices also incentivised by up to

68p per patient per year for limiting
year on year referral growth
A&E referrals
Consultant
referrals
2,536
24,698
1,190
1,089
2,328
22,957
1,217
1,173
1,813
1,113
1,056
3,700
-14%
21,254
1,574
1,052
1,016
3,521
3,625
GP referrals
17,983
3,083
16,459
15,350
14,529
AprJun
JulSep
OctDec
JanMar
Oxfordshire: Referrals per week, July, October 2008

Oxfordshire provides GPs with 8 processes and outcomes (e.g., a demand
management (DM) audit as well as a DM
target)
Hitting these carries incentives ranging

from 20p to 60p per patient per year,
summing to 3
1,500
1,100
-27%
Others
AprJun
JulSep
SOURCE: NHS Hampshire analysis
104
4 Applying savings potential for diagnostics identified in England

in the NI context suggests potential savings of 1.4m in 2014/15
Total number of three imaging diagnostic
tests in Northern Ireland
#
Additional percentage saved in

England at lowest quartile
Percentage saved in
England at median
Scans still conducted
100% = 5,506
6%
11%
The source of
diagnostic data
in Northern
Ireland is not a
consistent and
reliable source,
rather is from a
one-off survey
38,068
3%
10%
19,834
6%
9%
Assumes same % of total scans can

be demand-managed as in England
when median or lowest-quartile scans
per weighted population are applied
Total number of scans saved in NI:
8,998
84%
87%
84%
MRI
CT
Ultrasound
Potential savings in 2007/8 of 1.2m

(1.3m in 2008/09) assuming
average costs2 of :
353 for MRI
142 for CT
54 for US
1 Calculated from reference costs in 2007/8

2 Average costs from reference costs 2007/08
Note: Reduction in diagnostic imaging was estimated using the same percentages that could be achieved across the whole of England when
benchmarked against the median and top quartile scans per 1000 weighted population: MRI; 10.7% to median additional 5.6% to TQ, CT; 9.9% to
median additional 3.2% to TQ, US; 9.2% to median additional 6.5% to TQ,
SOURCE: Reference Cost 2007/08, DH Diagnostic Statistics 2008/09, QIPP Model
105
4 Reducing short stay non-elective admissions to benchmark could save

~1m
% surg, med, paed

NEIPs that are
shortstay1,
2008/09
Northern Ireland
352
SHA 1 providers average
35
SHA 1 providers lowest quartile
33
Number of non
elective short
stay admissions
could be reduced
by ~6%
Saving potential3
of ~1.1m in
2008/09,
-6%
1 Shortstay defined as 0-48 hours; figures exclude Obstetrics and Psychiatry. Pediatric specialties are classed as: Main specialty codes: 142, 171, 321,
420 and 421. Surgical specialties are classed as; Main specialty codes: 100, 101, 110, 120, 130, 140, 141, 143, 145, 150, 160, 170, 180, and 190.
Medical specialties are classed as: All other main specialty codes excluding: 199, 501, 700, 710, 711, 712, 713, 715
2 Northern Ireland had 58,450 non-elective short stay admissions in 2008/09
3 Saving calculated as if a short stay was avoided, i.e., 1 bedday would be saved, average cost approximately 300350
SOURCE: HSCNI Internal data, HES 2009/10
106
CASE STUDY
4 Data from English PCT audits suggest NI benchmarking

results may be realistic
INDICATIVE ONLY
% of 0-48 hour A&E admissions requiring assessment but not admission to

acute care
Provider 1
Provider 2
47%
NB: Audit results

may be inconsistent,
depending on audit
methodology
26%
1 PCT A&E audits 2009, 2010

SOURCE: Sample of English PCTs
107

2 Decommissioning
3 Prevention
6 Social care
108
5 Better management of care locally could avoid urgent

admissions and release ~25m additional (low need wt only)
7% need weighted
16% need weighted

Results,
2008/09
NEIP spells1 avoided

A&E attendances2
avoided
Total
Results,
2014/15
Methodology
used
Total
18
Low need weighting (7%)

only; in the 16% need
weighting scenario there are
no savings
19
25
Benchmarked NEIP spells per weighted population in NI against

lowest quartile PCTs in England
1 Net of reduction from better long-term condition management (chapter 1)

2 For each admission reduced in NEIP, one A&E attendance is also assumed to be avoided
SOURCE: Hospital Information System, Create an acute GP unit to reduce emergency admissions,; Dr. Rob White, GP in St Agnes, Cornwall; Pulse, 13 Nov 2009
109
Reducing non-elective admissions to benchmark could

increase quality of care but wont release much spend
Non-Elective admissions
Admissions per 1000 weighted
population
Northern Ireland
111.2
7% Weighted Need
16% Weighted Need
Number of admissions avoided

7% weighting
16% weighting
120.6
England average
118.4
4,211
18,665
819
Partly modelled
as part of LTC
management
Fully modelled
as part of LTC
management
-0.4%
England lowest
quartile
Savings potential in 2008/091,

m
110.8
-8%
18
1 Saving calculated on the average unit cost of a non-elective spell from HIS, minus the average cost of re-provision (360 for 6 district nurse and 2 GP contacts), net of
savings already modelled as part of LTC management (chapter 1)
SOURCE: Hospital Episoide Statistics 2008/09, Hospital Statistics Northern Ireland, DH Exposition Book
110
CASE STUDY
5 Urgent and Emergency Care GP- and nurse-led urgent care to reduce
emergency admissions
Description of lever
GPs based in A&E, serving several functions:

Screening patients before they arrive at A&E, by manning phones to consult with GPs making A&E referrals, and
suggesting alternatives when appropriate
Hospital-at-home team
Specialist consultant clinics in GP surgeries
Reassurance that existing care plan is sound
Screening patients upon arrival and before registration, and providing care where required
Evidence for financial impact
Patient impact
Avoided emergency admissions ranging from 10%

(Hammersmith) to 30% (Cornwall)
Costs for co-located GP service (Cornwall)
Setup: 100k, excl. existing facilities to register
patients by phone
Running cost for 5 GPs on shifts: 280k, to cover
phone screening, and in-person screening and
treatments
Costs for UCC are larger and to be determined
Assumptions and calculation of benefit

at English SHA
SHA NEIP spend, 08/09 (m)
Potential reduction in in-patient spells
Implied gross savings for SHA (m)
Deflator1
Revised implied gross savings
Assumed reinvestment required
Implied net savings for SHA (m)
Shorter waiting times for minor injuries

Fewer hospital admissions
Sources
800
30%
240
40%
144
40%
86
Hammersmith & Fulham PCT

Dr. Rob White, GP in St Agnes, Cornwall; Pulse,
13 Nov 2009
HES 08-09
1 To account for avoided admissions being shorter (and therefore

cheaper) than average
SOURCE: English SHA
111
CASE STUDY
5 Urgent and Emergency Care GP-led acute care in Cornwall reduced

non-elective emergency hospital admissions by 30%
Background/Context
Outcomes
Cornwall and the Isles of Scilly PCT (CIOSPCT) had

telephone referral system already in place
Takes calls from GPs to log patient details before they
arrive at A&E
Serves 74 GP practices across the county
On average, GPs divert 16% of attendees

from A&E; have achieved as much as 50%
Reduces overall emergency medical
admissions by 30%
One year pilot with 2 GPs now extended for
2010-11, and expanded to 5 GPs
Programme details
GPs based in medical admissions unit at Royal Cornwall

Hospital
Once details recorded by existing staff, GP takes over the
call to recommend alternatives to admission
hospital-at-home team
hot clinic to see the cardiologist of the week
reassuring the GP their existing plan is sound
Located in 3 rooms at the entrance to the medical
admissions corridor with shared waiting room, clinical room
and office
Startup costs = 100k; annual budget 280k (~1k/day)
Working at the primary-secondary care interface
means it is their job to have better knowledge of
alternatives and so they specialise in seeking out
and developing such services.
Estimated gross saving of 418,320 from

March to August 2009
2,208 per working day net of costs
Conservative estimate using 560 cost
for short-stay admission
For example, the GP has a patient
with pleuritic sounding chest pain, but
is well and cannot find cause. The
acute GP can exclude PE and order
bloods and CXR. It transpires the
patient has a viral infection so a lifethreatening condition is excluded
but under the old system that patient
would have been in, on a ward
waiting to be seen by a chest
consultant.
SOURCE: Create an acute GP unit to reduce emergency admissions,; Dr. Rob White, GP in St Agnes, Cornwall; Pulse, 13 Nov 2009
112
5 Urgent Care Data-to-analysis explanation

Data
Benchmarking
Sources
Total NI expenditure on NEIP (nonelective inpatient) spells

NI unit cost of A&E attendances
NEIP activity levels
Northern Ireland
England
Hospital Information System

Create an acute GP unit to reduce
emergency admissions, Dr. Rob White,
GP in St Agnes, Cornwall
Pulse, 13 Nov 2009
HES 2008/09
DH exposition book

Compare NEIP spells per weighted population in NI with English comparators
Calculate NEIP spells per weighted population for all English PCTs and identify the lowest-quartile rate
Compare this rate to the NI rate and calculate the potential reduction in NI spells if NI moved to the comparator
rate
Deduct from this reduction the NEIP spells already assumed to have been avoided through better long-term
condition management (chapter 1)
Multiply the remaining reduction by the average unit cost of a NEIP in NI (2,612) minus the assumed cost of
preventive care to avoid the admission (2 GP consultations and 6 district nurse contacts, total cost 360)
Comments
None
Internal contacts
Christine Kennedy
113

2 Decommissioning
3 Prevention
6 Social care
114
6 Improvement in social care could release ~288m
Range

Results,
2008/09
Community social care

clients per WP
Institutional care
clients per WP
Community social
cost per client
Institutional care
cost per client
27
131
55
31
244
Total
Results,
2014/15
Methodology
used
Total
288
29 317
Comparison of no of people in care per 1000 weighted population

Average cost per client compared with England
SOURCE: Northern Ireland Neighbourhood Information Services 2008/09, National adult social care intelligence service (NASCIS), Adult Community Statistics 2008/09, NASCIS 2008/09,
NHS Informtion Centre 2008/09, HSCNI financial data, DLA Claimants Statistics, Department for Social Development, The national evaluation of the Individual Budgets pilot
programme, Department of Health, 2008, Expert Interview, Godfrey et al., 2005 Prevention and Service Provision: Mental Health Problems in Later Life, Ellis et al.; 2006
Buying Time II: an economic evaluation of a joint NHS/Social Services residential rehabilitation unit for older people on discharge from hospital
115
6 5 components of social care efficiency have been explored
6a
Decision
whether care
needed
Description
Analysis/ benchmark
The decision whether or not care is
Number of people in care per
needed - are more people given care

compared to benchmarks and good
practice?
If assessed as needing care, what type
weighted population
Ratio of number of people in
of care is most appropriate?
Duration of
care
continue for?
How often, when and how effectively are
they reviewed?
For a given type of care, how do unit
6b
Cost of care
costs/ prices compare?
No data available for
Payment of
care1
Who then pays for the care? What

balance between HSCNI and the client
or others?
benchmarking
Unit cost per person in care

Number of people receiving
6c
137
home care to the number in

residential care
Type of care
How long should a care package
Potential saving
for NI, 2008/09
m
87
both DLA and funded care

Potential impact of individual
budgets
Charging for community

based services
47 791
2241
1 The savings/revenue generated is included in the totals in section 15 not here
116
116% need weighted
6a Northern Ireland has higher levels of clients in community

social care compared to England
136% need weighted
2008 / 2009
Number of clients in
Home help / Domiciliary
care1 per weighted
population
# of clients per 1000 WP
Northern Ireland
9.6
England average
1.7 11.3
3.8
0.7 4.5
+13% 11.2
-17% 3.2
10.9
3.2
England Lowest quartile

Wales
registered daycare2
per weighted
population
8.6
Number of clients
receiving meal service
per weighted
population3
2.1
0.4 2.5
-40% 1.4
1.3
5.3
2.6
% reduction
(vs 136% wt)
17
40
Savings potential
in 2014/154, m
13.7
1.9
1 Domiciliary care client numbers were taken from a different source due to incomplete numbers for home help in the community statistic s publication. A
Domiciliary care survey in Sept 2009 was used as the source within which quoted client numbers from return: cc7b tables 2A, 2B and 3A and 3B.
2 Daycare client numbers could include some double counting due to overlap of POC
3 No separate costs were listed for meal services so the average English cost was used to calculated savings instead
4 Savings calculated on the average spend per client receiving home help (7,116), daycare (7,025) , or meal service (734)
SOURCE: Community statistics 2008/09 Tables 1.16 (daycare) and 1.4 (meal services), National adult social care intelligence service (NASCIS),
Domiciliary Care for Adults 2009 return cc7b tables 2A, 2B and 3A and 3B
117
116% need weighted
6a Northern Ireland has much higher levels of clients

in nursingcare compared to England
136% need weighted
2008 / 2009
Residential care per
weighted population1
Northern Ireland
Nursing care per
weighted population4
3.5
0.4 2.6
2.2
+42%
England average
3.3
3.1
England Lowest quartile
3.3
Wales
0.6 4.1
1.2
-69%
1.1
1.4
% reduction
69
Savings potential
in 2014/153, m
148.6
Nursing care
appears to have 3.5x
the activity than
England and Wales.
The driver appears
to be Elderly patients
with NI having 3 per
1000 weighted
population compared
to Englands 0.16
per 1000 weighted
population
1 Excluding Nursing home beds

2 Savings calculated on the average yearly spend on a client receiving residential care (22,949) or Nursing Care (18,159)
3 Independent free nursing care was excluded from Northern Ireland figures as it was thought to be comparable to continuing care in England which was
unable to be added to the English figures due to lack of reliable data
Residential care includes independent, statutory (Local Authority staffed for England), and residential places in nursing homes.
Nursing care includes, number of residents in registered homes for England and Statutory, Independent and Dual registered nursing beds in NI
SOURCE: Community statistics 2008/09 tables 1.18 (Residential care) and 1.19 (Nursing Care), National adult social care intelligence service (NASCIS)
118
6a If assessments were conducted after a 4 week period of intermediate

care, then 50% fewer clients could be in receipt of social services
Saving
Social Care clients

#
100% = 26,444
Text
Potential clients
for re -enablement
Social Care Costs

m
Re-enablement Costs
100% = 273,745
22%
(61,588)
50%
(13,222)
7%
21%
Other
Clients
50%
(13,222)
NI
Social Care Clients
50%
NI
Changing the assessment could mean

that in the future 50% fewer clients use
social services
Assuming half of the people not entering
social services require intermediate care
at home (at 1,4441) and half need a
rehabilitation unit recovery (at 8,5001),
the potential saving is estimated to be
61.5m in 2008/09
In 2014/15 this is equivalent to 73.9m2
Pilots to these effect are to begin in

Autumn in the Southern Trust, with
expected gross savings of 246k
within 6 months
1 The costs are based on studies reviewed by the Personal Social Services Research Unit in England
2 These savings are included as part of the savings potential within the prior 2 pages
SOURCE: Expert Interview, Godfrey et al., 2005 Prevention and Service Provision: Mental Health Problems in Later Life, Ellis et al.; 2006 Buying Time
II: an economic evaluation of a joint NHS/Social Services residential rehabilitation unit for older people on discharge from hospital
119
6a Northern Ireland has a slightly lower ratio of clients receiving

community social services per resident in institutional care
as compared to England
2008 / 2009
Number of community social
services1 clients per institutional
client2
#
Northern Ireland
2.74
+32%
England
England highest quartile
3.37
3.63
1 Community social services includes meal services, daycare and domiciliary care/homehelp
2 Institutional care includes residential care and nursing care beds, but excludes independent free nursing care beds due to incompatibility to England
SOURCE: Adult Community Statistics 2008/09 tables 1.18, 1.19, 1.4 and 1.16, NHS Information Centre NASCIS 2008/09
120
6b Northern Irelands community based social services1 are provided

at a higher cost than England
2008 / 2009
Adult Social
Services - Daycare
per Client per year
Northern Ireland
7,025.3
England
England
lowest quartile
Savings potential
in 2014/151, m
Adult social services

Home help /
Domiciliary Care
per Client per year
6,403.9
8,063.4
4,340.0
-37%
+12%
7,847.7
4,032.0
The significant cost

differences could
be due to several
factors including:
Productivity, more
generous (higher
value) care
packages, more
complex care
required per client,
or higher unit cost
(cost per hr)
66.7
1 Meal services could not be benchmarked as there is no individual budget line for these services in the LCG financial statements
The two sources used to generate the unit cost were triangulated with a copy of the community indicators 2008/09 to ensure the figures reconciled
SOURCE: Community statistics 2008/09 Tables 1.16 (daycare) , dhsspsni, NHS Information Centre 2008/09 (NISCIS), Local Commissioning Group
financial data,
121
6b Northern Irelands institutional care is provided at a slightly higher

cost than England
2008 / 2009
Unable to
benchmark
childrens
services due to
lack of access
to good quality
comparable
data in England
Adult Social Services

Residential care
per Client per year
Adult social services

Nursing Care
per Client per year
22,949.1
Northern Ireland
21,262.3
24,892.6
England
20,531.0
-6%
-13%
England
lowest quartile
Savings potential
in 2014/15, m
21,497.4
9.4
18,475.8
28.2
SOURCE: Community statistics 2008/09, dhsspsni, NHS Information Centre 2008/09, Local Commissioning Group financial data
122
6b Introducing Individual budgets with a new assessment to take DLA into

account could reduce the cost per client
2008 / 2009
No of clients
receiving Domicilary
care services
#
Belfast
Northern
Southern
South Eastern
Western
Potential saving
2014/153, m
6,214
4,052
4,462
3,908
4,741
Potential saving
if 15% receive
DLA2, 2008/09
m
Potential saving
if 60% receive
DLA2, 2008/09
m
2.0
0.5
Due to
uncertainty
on how many
people are
claiming DLA
and receiving
home help we
have applied
a range
0.3
0.4
0.3
1.3
1.4
1.2
The
implications of
reducing clients
benefits has to
be taken into
account to
ensure clients
incomes are
not being
reduced to
below the
poverty line
1.5
0.4
2.2
9.0
1 Savings calculated on saving the equivalent of the average claim for the care component of DLA a week which is 45.36 as of November 2009, Total
number of DLA claimants in 2008/09 = 176,758, 15% is the number of people between 16-65 that receive intensive domiciliary care, 60% is an estimate
i.e. 4x the low figure
2 Over 65s can no longer claim DLA so we have excluded the activity that is proportional to the amount spent under the Elderly POC (77.5%)
3 These savings are included as part of the savings potential within the prior 2 pages
SOURCE: Domiciliary care for Adults in Northern Ireland 2009, DLA Claimants
Statistics, Department for Social Development
123
6b Procuring home care via individual budgets could reduce unit cost by
20 per week per client
Number of home care clients
2008/09
100% =
21,039
Conventional
Home Care Clients
50%
(10,520)
Potential
IB Clients
50%
(10,520)
If IBs reduced the cost of conventional

social care by 20 per person per week in
Northern Ireland and assuming 50%1 of
current clients would be able to move to
this method, then 10,520 clients in
2008/09 could have benefited from the
improved social care outcomes in addition
to a saving of 10.9m in 2008/09
In 2014/15 this would represent 13.1m2
NI
1 IB has not been fully operational anywhere to get a robust figure on how many clients would choose to move to IBs, the 50% figure has no concrete
evidence base
2 These savings are included as part of the savings potential within the prior pages for 6b
SOURCE: Team analysis, Northern Ireland Neighbourhood Information Services 2008/09
124
6c Charging in community social care services could generate

an additional 47.4 - 79m
The revenue from this analysis is
included in the revenue
generation lever and is not
included in the totals for Social
care
Internal
Provider
Rules
Potential for charging
Home help charging guidance by

DHSPSS applies therefore
over 75s and people on income
support and family credit receive
free services,
others contribute roughly 30-50% of
cost
No written guidance published2 all

assessed to need the service receive
the service for free
Residential care is charged in the

same way as England, clients with
over 23,250 in savings pay the full
costs
Domiciliary
Care / home
help
149.7m
External
Provider
Social Care
633.9m1
Residential
Care
124.1m
Nursing Care
178.9m
Other
181.2m
Potential
area for
charging
Nursing home care is charged in the

same way as residential
Care such as meal services and

daycare, offered as a free service to
those who require it, whereas in
England the same rules apply to
these services as to home care
All domiciliary, meal

service and daycare
service could attract a copayment of 30 50%:
Therefore the home
policy will have to be
amended
People would co-pay
on a scale dependent
on their income / ability
to pay
Potential additional
revenue generated3,
2014/15
79
47
Min (30% of Max (50%

cost
of cost
contributed) contributed)
1 Total cost and revenue potential excludes childrens social services which is an additional 159.2m
2 Not able to find guidance that allows external providers to be provided free of charges, but knowledge gained through interviews with social care Financial Assessments Manager
3 Savings have been calculated assuming 60% of clients could afford the co payment, average cost per client pa was used for home help (7115), meal service (735) and daycare (7025).
SOURCE: Local Commissioning Group Financial Returns, DHSPSS website
125
6a Social Care Data-to-analysis explanation (1/5) Community

social care activity
Data
Number of Clients in
Care (Community
Social care)
Sources
Number of people receiving home help

Number of people receiving meal
services
Number of people registered for Daycare
Weighted population
Northern Ireland Community Statistics,

DHSSPS
NHS Information Centre National Adult
Social Care Intelligence Service
(NASCIS)
Approach 1 : calculate the potential reduction in spend on community social care services
Calculate the number of clients per weighted population for each service, using a range of weighted population
from 7% increased need to 36% (as this is a social care metric)
Benchmarks were calculated from English data for average and top quartile
The number of clients expected at the benchmark levels was calculated by dividing the weighted population of NI
by the benchmark, this was then subtracted from the current number of clients to develop the potential reduction
This was then multiplied by the average cost per client per annum to get the potential saving
Comments
Numbers from England are in the NASCIS

database which requires an account to be set up
No contact, taken directly from the publications

on the DHSSPS website
126
6a Social Care Data-to-analysis explanation (2/5) Institutional

social care activity
Data
Number of Clients in
Care (Institutional
care)
Sources
Number of people in residential care

Number of people in nursing care
Weighted population

DHSSPS
(NASCIS)
Approach 2 : calculate the potential reduction in spend on institutional social care services
The number of clients per weighted population for each service was calculated, using a range of weighted
population from 7% increased need to 36% (as this is a social care metric)
Benchmarks were calculated from English data for average and top quartile
The number of clients expected at the benchmark levels was calculated by dividing the weighted population of NI
by the benchmark, which was then subtracted from the current number of clients to get the potential reduction
Average cost per client per annum was then multiplied to get the potential saving
Comments
Numbers form England are in the NASCIS

Supported living clients could also be
benchmarked (however, numbers were not
available at this time)

127
6b Social Care Data-to-analysis explanation (3/5) Institutional social

care unit costs
Data
Cost per client pa
(Institutional social
care)
Sources
Number of people in residential care

Number of people in nursing care
Total cost of residential care
Total cost of nursing care

DHSSPS
Local Commissioning Group financial
returns
(NASCIS)
Approach 3 : calculate the potential reduction in cost per client in institutional social care services
Calculate the cost per client per annum for each service, calculated by dividing the total cost for the year by the
number of clients in that year
Benchmarks were calculated from English data for average and top quartile, based on the costs and activity by
Governmental office region (GOR)
The reduction in cost per client at the benchmark levels was calculated by subtracting the cost of the benchmark
from the NI cost
This was then multiplied by the number of clients in the service to derive the potential saving
Comments

Supported living clients could also be
benchmarked; however numbers were not
available at this time
No contact, taken directly from publications on

the DHSSPS website
128
6b Social Care Data-to-analysis explanation (4/5) Community social care

unit costs
Data
Cost per client pa
(Community social
care)
Sources

Number of people receiving meal
services
Number of people registered for Daycare
Total cost of services

DHSSPS
Local Commissioning Group financial
returns
(NASCIS)
Approach 4 : calculate the potential reduction in spend on community social care services
The cost per client per annum for each service was calculated by dividing the total cost for the year by the number
of clients in that year
Benchmarks were calculated from English data for average and top quartile, based on the costs and activity by
Governmental office region (GOR)
The reduction in cost per client at the benchmark levels was calculated by subtracting the cost of the benchmark
from the NI cost
This was then multiplied by the number of clients in the service to get the potential saving
Comments


129
6b Social Care Data-to-analysis explanation (5/5) DLA claims

Data
DLA Duplication
Sources

Number and amount claimed for DLA

DHSSPS
Department for Social Development
Approach 5 : calculate the potential saving of taking account of DLA claims when providing social care
services
The number of clients receiving home help and domiciliary care was taken, excluding those over 65 where DLA
does not apply
As the exact numbers claiming DLA and receiving services was not known, a range from 15% (the number under
65 in intensive domiciliary care), up to a high range of 60% was used
The average claim of the care component of DLA was calculated and multiplied by the expected numbers of
people in care receiving DLA, assuming that the DLA claim could be saved on the cost of the care provided
Comments
Analysis recognises that disallowing DLA in the

assessment for services could result in some clients
moving to below the poverty line
The proportion of people claiming DLA and receiving
home help is not known, hence further local analysis
would enable a more precise analysis

on the DHSSPS and DSD websites
130
CASE STUDY
6 Individual Budgets have been shown to provide social care in a

cheaper and improved way for the majority of user groups
CASE STUDY
The Department of Health set up Individual Budget (IB) pilots in 13 English

local authorities, running from November 2005 to December 2007
Successes
Cost Effectiveness Analysis
People receiving an IB were significantly more
likely to report feeling in control of their daily lives

IBs appeared cost-effective for social care
outcomes i.e. they produced better outcomes for
the costs incurred
IB group
Home care
Meals service
Personal assistant
Supporting People
Integrated Community
Equipment
Independent Living Fund
Social worker/care manager
Challenges
Allocating resources was particularly challenging
with no consensus on the best method

Older people reported lower psychological wellbeing with IBs, suggested to be due to the
processes of planning and managing their own
support
IBs were expected to include money from several
funding streams but legal and restrictions on how
resources could be used produced limited success
Implementing IBs required major shifts in staff and
organisational culture, roles and responsibilities
N=268
37
1
100
2
18
8
18
Comparison
group
N=250
701
1
521
4
19
301
11
Pilot concluded that overall the average saving
compared to conventional social care was 20 per

person per week
Home care and independent living fund were the types
of care that were significantly cheaper under IBs
1 Significant difference p<0.001

SOURCE: The national evaluation of the Individual Budgets pilot programme, Department of Health, 2008
131
CASE STUDY
6 Partnerships for Older People Project (POPP) consists of 470 diverse

projects in health and social care integration across 29 pilot sites (1/2)
Context and goals
Approach and implementation
Impact
The project aims to help shifting

resources and culture away from
institutional and urgent hospital
care toward earlier interventions
for older people within community
settings
This is achieved through
supporting local partnership
programmes focusing on the
following:
Providing lower level care
and support in the community
and preventing or delaying the
need for higher intensity and
more costly care
Reducing avoidable,
emergency admissions
and/or bed days for older
people
Supporting more older people
to live in their own home
60m funding provided by the
Department of Health in March
2006 to March 2009
470 projects and within 29 pilot

site areas
Partnerships are led by local
authorities
A wide range of projects:
low level services, eg, lunchclubs
formal preventative
programmes, eg, hospital
discharge and rapid response
services
522 organisations are involved,
including:
The third sector (the largest
category of partners)
Statutory organisations (PCTs,
ambulance trusts, fire service
and police)
Independent/private sector
As only short-term funding is
available form DH, partners have
provide their own financing in order
to sustain the projects that are
successful
Services used by over 264

thousand people
Emergency bed days reduced
resulting in savings: 1.20 saved
for every 1 spent
Hospital admissions reduced by
47%
Use of A&E reduced by 29%
Overall reduction in care use of
2,166 per person
Pro-active case coordination
services resulted in particularly
significant reductions:
60% in A&E visits
48% in hospital admissions
28% in phone calls to GPs
25% in visits to practice
10% in GP appointments
Efficiency gains in health service
use appear to have been achieved
without any adverse impact on the
use of social care resources
Improved partnership relationships
between local authorities and
healthcare
SOURCE: Final evaluation (2010); National Evaluation of POPP (2008); Press articles
132
CASE STUDY
6 POPPs pilots have included 400+ diverse projects for joint working
between local authorities and PCTs
Location
Project
Impact
Southwark
Hospital discharge and

community pathway redesign
Reduction of 12% in placements into

residential and nursing home care
with savings of 511,980
Clients discharged home with
support services increased from
5.3% to 11.2%
Devon
Complex Care Teams
Emergency bed days reduced by 5%
North Yorkshire
Specially trained generic

workers
Net saving of 190,000 and

reduction in emergency hospital
admissions
Kent
Independence through the

voluntary action of Kent elders
(INVOKE)
Reduction in length of stay from 7.5

to 3.7 days. Cost reduction of 161
per person
Brent
Integrated care co-ordination

service
Avoided hospital admissions and

within 2 years will make savings from
229,000 and 2.8 million net
Avoided A&E attendance will save
between 282,000 and 781,000 per
year
SOURCE: Department of Health, North Yorks County Council, www.mylifemychoiceindevon.org.uk, www.endoflifecare.nhs.uk,IdEA website, Kent PSSRU
report; Borough Of Poole social services; Brent council
133

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Reshaping The System Part 1

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CONFIDENTIAL

Reshaping the System: Transforming Northern

About this document

This document comprises the analyses done in support of the

It is not a self-standing document and should be read in conjunction

Contents of this appendix

1. Where we stand today

Quality of care in Northern Ireland has improved in recent years (1/2)

i. Infant mortality rate

ii. Cancer mortality rate

. . . and signs of poor quality are reducing

Iii. Rate of births to mothers

iv. MRSA episodes

Quality of care in Northern Ireland has improved in recent years (2/2)

. . . and signs of poor quality are reducing

g. Stroke scan 24h

vii. % patients waiting

viii. % patients waiting

i. Patient and client survey

ix. Person in deprived area

Years (signs of good quality): f, g, h: 2004/05 to 2008/09

SOURCE: DHSSPS; PHA; QOF

Many aspects of Northern Irelands productivity have also increased

1. % all admissions done

2. Throughput per bed

. . . and signs of inefficiency are reducing

5. Growth in primary care

Years (signs of productivity): 1, 2. 2003/04 to 2008/09; 3. 2008/09 to 2010/11

DHSSPS actual spend

DHSSPS has delivered ~3% p.a.

DHSSPS spend on existing services after efficiency

SOURCE: HSCB Finance; DHSSPS

Northern Irelands life expectancy is lower than England, but comparable

Life expectancy at birth, Females

SOURCE: StatsWales; www.scotland.gov; Northern Ireland Neighbourhood Information Service, NCHOD

NI mortality rates are higher than comparators, except for cancer

Age standardised death

Cancer mortality European

North East SHA

All circulatory disease

Adult obesity, 16+,

1 Data for Scotland is 2004 (the latest), Obese is defined as BMI>30Kg/m2

An increase in the prevalence of chronic diseases (reflecting

Prevalence of disease by country

NIs population is ageing

Population growth by age group in Northern Ireland

SOURCE: Northern Ireland Neighbourhood Information Service

Comparison of per capita spend across UK

spend on services (including supplies), 2008/09

Spend per capita across types of care

High-level benchmarking suggests the largest productivity

Northern Ireland (7% weighting)

Northern Ireland (16% weighting)

North East SHA

Hospital spend by category

Mental health and learning

154 142 116

Primary care spend

. . . and significant variations in performance across NI highlight potential

For the Western

Standardised Admissions Ratio All

South SouthEastern ern

South SouthEastern ern