This document summarizes government spending by department from 2007-2008, with the largest allocations going to social security (27%) and health (16%). Planned spending increases from 2008-2011 are also shown, with the largest increases for health, social security, and education. The document then discusses reasons for optimism in the NHS, including improved quality of services, but also reasons for concern like increasing demand, a tighter financial regime, and rising prescription drug costs. Areas for scrutiny of the NHS are identified as budget areas, productivity, and outcomes. The document argues for actions that motivate at multiple levels from individual practitioners to centralized policy through guidance, financial incentives, and infrastructure like IT.

1. Financially challenged
Dr Jennifer Dixon
Nuffield Trust
1

2. Government Spending by Department
(FY2007/08)
Other
14% Social
Security
Debt Interest 27%
5%
Home Office
3%
Local Govt
6%
Defence
7%
Health
16%
Scotland,
Wales and NI Education
9% 13%
Sources: HM Treasury (Roger Bootle) 2

3. Planned Increases in Government
Spending by Department
(Nominal, £bn, FY2007/08-2010/11)
Social Security 29
Health 19
Other 14
Education 13
Debt Interest 10
Scotland, Wales and NI 6
Local Govt. 4
Defence 2
Home Office 2
Sources: HM Treasury Total 98 3

4. Reasons to be cheerful (1)
4

5. Use of Resources
05/06-07/08
Source: Annual Health check 2007/8, Healthcare Commission 5

6. Financial Performance of Strategic
Health Authorities
2006-07 2007-08
Financial Management in the NHS: Report on the NHS Summarised Accounts 2007-08
6

7. Financial Performance of Primary Care
Trusts
2006-07 2007-08
Financial Management in the NHS: Report on the NHS Summarised Accounts 2007-08
7

8. Financial Performance of NHS Trusts
2006-07 2007-08
Financial Management in the NHS: Report on the NHS Summarised Accounts 2007-08
8

9. Financial position of NHS (England)
2008/9 Quarter 3
2005/06 to 2009/9 (Q3 Forecast)
Source: The Quarter, DH
9

10. Reasons to be cheerful (2)
10

11. Healthcare Commission
Annual Health Check: Quality of services
Source: annual health check
11

12. Reasons to be not so cheerful…
• Financial regime tighter
• Demand rising
12

13. Demand rising: inpatient
Summary HES inpatient data by month of activity*
Source: NHS Information Centre * 2008-09 data provisional
13

14. Demand rising: outpatients
Summary HES outpatient data by month of activity*
Source : NHS Information Centre * 2008-09 data provisional
14

15. Demand rising: consultations in
general practice
Number of consultations in general practice 1995-2006
350,000,000
300,000,000
250,000,000
200,000,000 Total GP
Consultations
150,000,000 Total
100,000,000
50,000,000
0
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Source: NHS Information Centre Financial Year
15

16. Demand rising: drugs
Expenditure on prescription drugs has increased over
the last decade
From: National Audit Office report: Prescribing costs in primary care, 2007. 16

17. The answer?
17

18. NHS Production Pathway
Source: King’s Fund
18

19. Areas for scrutiny
• Budget areas
19

20. Number of NHS activity categories and estimates
shares of NHS spending, 2005/6
Source: King’s Fund 20

21. Local variations in NHS spending priorities
Figure 1: Total spending* by PCTs on programmes in 2004/5
* An additional category, 'Other', is not included in the figure. This captures around £15.5 billion of
spending out of the £53 billion for 2004/5. Source: King’s Fund 21

22. Areas for scrutiny
• Budget areas
• Productivity
22

23. Trends in Emergency and Elective admissions per
Consultant (FTE*) 1999 /2000 to 2005/6
•Full time equivalent
•Source: King's Fund analysis; Hospital Episode Statistic 2007; Information Centre 2007 23

24. Ranked Activity (case mix adjusted)* per
consultant in General Surgery, 2004/5 data
ANONYMOUS HOSPITAL NHS TRUST
Source: Delivering Quality and Value: Consultant Clinical Activity - University of York and Department of Health 24

25. Potential prescribing efficiency savings in primary
care, by PCT (England) 2007
25

26. Areas for scrutiny
• Budget areas
• Productivity
• Outcomes
26

27. Age-sex standardised admission rate for COPD
(ICD-10 J40 to J44) by PCT – emergency
admissions only – 2000/01 to 2001/02
27

28. Preventable admissions
Month of Acute
LOS ICD10 Diagosis
Admission Trust
APR 2002 11 J440 Chronic obstruct pulmonary dis with acute lower resp infec Hospital E
MAY 2002 4 J441 Chron obstruct pulmonary dis wth acute exacerbation unspec Hospital E
JUL 2002 8 J440 Chronic obstruct pulmonary dis with acute lower resp infec Hospital E
AUG 2002 3 I500 Congestive heart failure Hospital F
AUG 2002 2 J449 Chronic obstructive pulmonary disease unspecified Hospital F
OCT 2002 3 J440 Chronic obstruct pulmonary dis with acute lower resp infec Hospital F
OCT 2002 2 J441 Chron obstruct pulmonary dis wth acute exacerbation unspec Hospital G
OCT 2002 2 J441 Chron obstruct pulmonary dis wth acute exacerbation unspec Hospital G
NOV 2002 4 J441 Chron obstruct pulmonary dis wth acute exacerbation unspec Hospital F
DEC 2002 4 J441 Chron obstruct pulmonary dis wth acute exacerbation unspec Hospital G
DEC 2002 5 J441 Chron obstruct pulmonary dis wth acute exacerbation unspec Hospital G
JAN 2003 1 J441 Chron obstruct pulmonary dis wth acute exacerbation unspec Hospital G
FEB 2003 3 J441 Chron obstruct pulmonary dis wth acute exacerbation unspec Hospital G
28

29. Where and how to act?
System
Organisation
Piecemeal Comprehensive
Team
Practitioner
29

30. Where and how to act?
Guidance
System
Organisation
Piecemeal Comprehensive
Team
Practitioner
30

31. Where and how to act?
On ground
Guidance
System help
Organisation
Piecemeal Comprehensive
Team
Practitioner
31

32. Where and how to act?
On ground
Guidance Motivators
System help
Organisation
Piecemeal Comprehensive
Team
Practitioner
32

33. Where and how to act?
On ground
Guidance Motivators
System help
Central directive
Regulation
Financial
Organisation
incentives
(threat)
Piecemeal Team Comprehensive
Practitioner
33

34. Where and how to act?
On ground
Guidance Motivators
System help
IT infrastructure
Organisation
Piecemeal Comprehensive
Team
Practitioner
34

35. Individualised data to guide
appropriate intervention
Ongoing, individualised,
real time data analysis to
guide intervention:
Utilisation and demand
management
Care coordination
Risk factor reduction
Source: Humana UK
35

36. Proactive Care Gap Checklist
Gaps in the patients care are identified through the use of flags.
If there is a “Y”, an action is needed.
Member
Information
Source: Kaiser Permanente, SC
36

37. What would be evidence of not
coping?
• Deficit
• Reduced access (geographic,
socioeconomic)
• More preventable ill health and mortality
37

38. www.nuffieldtrust.org.uk