Introduction
Cancers and benign tumours account for the third largest programme budget in the NHS (after mental health and circulatory disease) and with a higher proportion seen in hospital than in general practice. They span every organ of the body and every age group and feature in the caseload of pretty well every clinical profession, but especially the specialties of oncology and related diagnostic and therapeutic disciplines. Consequently, it is one of the most complex of the programme budget categories and the one with the widest range of interested parties in setting objectives and matching them to available resources. A multidisciplinary and multispecialty team approach is the norm. Because cancer incidence rises with age, and the disease is more common in those who have smoked, other diseases are common at the same time and can complicate treatment and recovery. Cancer in each body site—for example, skin, breast, lung, is effectively a different subprogramme and this will be reflected in data capture and reporting in the Department of Health’s programme budget spreadsheet.
Points for each programme budget category:
Consider constructing a list or grid like the table below. This table uses examples developed from Norwich PCT and is divided into aims, objectives, actions and costs.
Patients and clinicians should be involved at every level and the tables, as they evolve, should be published—for example, on the PCT website, so that everyone can see their development.
General points to think about
- What are the main health issues in each programme?
- Who are the significant players (always including patients, and often non-NHS agencies) and how will they be engaged?
- What are the programme’s broad aims and specific objectives? (Try to make the objectives ‘SMART’ (specific, measurable, ambitious, realistic, and time-bound.)
- Set objectives at each stage of the treatment, for example: protecting good health, getting a rapid diagnosis and assessment; going for full cure; supporting chronic illness where cure is not possible; easing the passing (a well managed death).
- What are the main unmet needs and any striking inequalities?
- What are the programme inputs (programme budget) at present?
- What outputs are being generated?
- What outcomes are being generated?
- What ideas can be generated for starting and stopping programme activities so as to get a better fit between resources and objectives. (Start by looking within programmes before looking between programmes.)
Programme aim
To reduce the burden of cancer in the locality by a combination of prevention, early detection (including screening), rapid access to treatment, enhanced length and quality of life, and a well managed terminal phase and death at the place of the patient’s choosing.
Programme objectives
- Reduced prevalence of smoking (as recorded by GPs in the Quality Outcomes Framework).
- Higher average uptake rates across all GP practices for cancer screening (breast and cervix) and the new bowel cancer screening when launched.
- Achievement of 2 week waiting time for first appointment of a patient with suspected cancer.
- Rapid access to diagnostic tests: imaging, endoscopy, and pathology.
- Meeting National Institute for Health and Clinical Excellence (NICE) guidance for cancer treatments for all eligible patients.
- Reduced premature mortality rates (‘dying before one’s time’) – currently arbitrarily set at 75 years – for each cancer.
- Allowing patients to die at the place of their choosing—for example, at home.
Programme budget category 2 (example): Cancers and tumours
The table has been simplified, with imaginary issues arising from local discussions, to illustrate.
Resource assumption agreed with PCT Board: a growth in programme budget from £60m to £64.15m—that is, net new investment of £4.15m—to bring the PCT into line with similar PCTs.
| Aims | Objectives | Actions: stopping or starting | Cost (£) +/− |
| TIPS: These should draw on national service frameworks or strategies where they exist. The number should be limited, but should include at least five that cover the steps in the patient pathway | TIPS: These should be drawn directly from the aims. There will usually be more than one objective for each aim. Objectives should be ‘SMART’. | TIPS: These should be drawn from the objectives. There may be more than one and they should relate to disinvestment (cutting back on some areas) and new investment. All these suggested actions should be formulated by a marginal analysis advisory group and be tested for changes in cost and benefit at the margin | TIPS: Every action should be costed whether that means cash releasing (saving), cash neutral or cash requiring. The discipline is to keep the total in the cost column within the programme budget set by the PCT |
| 1: Prevention of cancer | 1.1 Reduce the overall PCT prevalence of smoking, as recorded by GPs, from 28% to 26% by year end | 1.1.1 Set up a joint local strategic partnership initiative on non-smoking day in workplaces | City council funding (neighbourhood renewal fund) |
| - | - | 1.1.2 Cancel order for smoking cessation leaflets | − £1000 (saving) |
| - | - | 1.1.3 Fill two current vacancies in level 3 smoking cessation coordinators | £42 000 |
| - | 1.2 Reduce by 50% the prevalence in smoking among patients awaiting routine surgery | 1.2.1 Deploy one of the new smoking cessation coordinators in the acute hospital elective surgery unit | Already budgeted |
| 2: Diagnosis and assessment of cancer | 2.1 Increase uptake of breast cancer screening from 75% to 80% in a year’s time | 2.1.1 Set up a GP incentive scheme | £2000 |
| - | 2.2 Reduce gap between low uptake areas and the highest from 25% to 10% by year end | 2.2.1 Target low literacy group with visiting theatre company | £1000 – local drama college |
| - | 2.3 Discontinue ineffective opportunistic ‘screening’ activity | 2.3.1 Cancel the PSA (prostate specific antigen) screening pilot in southern part of area | −£4000 (saving) |
| - | 2.4 Deliver 2 week waiting target by year end | 2.4.1 Agree contract with new diagnostic and treatment centre | £150 000 |
| 3: Treatment (attempting full cure) | 3.1 Fund new NICE medicines guidance this year | 3.1.1 Agree new contract with cancer centre for non-tariff medicines | £4 000 000 |
| - | 3.2 Implement new community hospital infusion centre within 6 months | 3.2.1 Complete recruitment for, and refurbishment of, cottage hospital – decrease transport costs - net saving over prior service | −£100 000 (saving) |
| 4: Support continuing care | 4.1 Expand telephone, literature and support group via ‘Big C’ cancer charity | 4.1.1 Increase current grant from £60 000 to £120 000 | £60 000 |
| 5: Easing the passing | 5.1 Increase the percentage of patients dying at place of their choice (eg, at home) by 5% this year and each year until 75% is reached (currently 25%) | 5.1.1 Implement findings of ‘dying with dignity’ local audit. Resource-neutral shift from hospital to domiciliary nursing support, telephone advice service | Neutral |
| 6: Summary outcome aims | 6.1 Reduce the directly standardised under-75 death rate in the Primary Care Trust by x% a year, in line with national average | Summary of activities in objectives 1 to 4 | - |
| - | - | - | New investment – £4 255 000 Disinvestment −£105 000 Net added cost: £4 150 000 |
Author
Dr Peter Brambleby
Dr Peter Brambleby has a clinical background in child health and 20 years’ experience in public health, including five years as Director of Public Health in the former Norwich PCT. He currently serves on the National Programme Budgeting Project Board and related working groups. He has a long-standing interest in trying to match health needs to health spending, and to getting public and clinical engagement in that process. From 1 July 2007, Peter will be the Director of Public Health at North Yorkshire and York PCT.