Introduction
This is a major programme dealing with volume of work in general practice, district general hospitals and specialist centres. Circulation problems are a major source of disability and death. The budget for the programme is the second biggest in the NHS. The programme covers such conditions as high blood pressure, angina, heart attack, pulmonary embolism, diseases of the heart muscle, abnormalities of heart rhythm, strokes, aneurysms, peripheral vascular disease and inflammation of blood vessels. It is the domain of the health promotion specialist, general practitioner, cardiologist, stroke specialist, cardiac surgeon and specialist in medicine for older people. There is a particularly close relationship with programme 4 (endocrine, nutritional, and metabolic diseases) – with obesity, diabetes and blood lipids as risk factors. It is also a programme with some of the most rapidly improving survival rates.
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 objectives for circulation problems
Examples of aims, objectives and actions are based on Norwich PCT
| 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. To assess and improve the deployment of staff and resources in prevention of circulatory diseases— in particular, coronary heart disease, strokes and peripheral vascular disease, with particular in regard to inequalities in risk factors | Reduce the overall incidence of smoking in the PCT as recorded by GPs from 28% to 26% by year end Increase work with community groups in deprived areas—for example, in Norwich work with the Norwich Citywide Co-operative aim to bring high quality, low cost healthy food into deprived areas. Increase attempts to reduce obesity in children through working with schools on healthy eating and cooking skills | Joint local strategic partnerships initiative on non-smoking day in workplaces Cancel order for smoking cessation leaflets (eg, from Norwich PCT) | - |
| 2. To assess and improve the deployment of staff and resources in the diagnosis of circulatory diseases, in particular coronary heart disease, strokes and peripheral vascular disease | Investigate effectiveness of GPs with a special interest in cardiology as service providers Investigate cost effectiveness, feasibility and patient acceptability of consultants providing out-reach clinics Review audit of patient care pathways, eg, for myocardial infarction and stroke | Employ practice based pharmacists to conduct drug reviews to ensure safe prescribing that is cost effective in primary care (e.g., from Norwich PCT) Increase proportion of echocardiograms carried out in primary care | - |
| 3. To assess and improve the deployment of staff and resources in the treatment and rehabilitation of circulatory diseases, in particular coronary heart disease, strokes and peripheral vascular disease | Assess availability of acute stroke services and stroke rehabilitation units | Audit stroke care Carry out patient satisfaction surveys of cardiac rehabilitation services | - |
| 4. To identify Indicators of premature mortality (for example, death rates under the age of 75) | Work with the public health department to develop set of indicators for PCT | Publish set of indicators and distribute in annual health report | - |
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.