Introduction
This programme covers diseases such as diabetes (lack of insulin), thyroid and other endocrine gland disorders, malnutrition, obesity and other nutritional disorders. The complications of diabetes are wide ranging and have an impact on other programmes, especially the circulatory system (programme 10), kidneys (programme 17) and eyes (programme 8). The full cost of diabetes is therefore not captured in this chapter alone in the Department of Health’s programme budget spreadsheet, which deals only with diabetes itself as the principal reason for contact with the NHS. Similarly, obesity has an impact on other programmes such as circulatory diseases (programme 10) and musculoskeletal problems (programme 15).
This is a good example of a programme where the determinants of ill health lie outside the domain of the NHS, yet need to feature prominently in the programme’s aims and objectives. It requires discussion and coordination with local strategic partnerships and there is a major role for local initiatives that promote physical activity in transport policy, school activities, sport and recreational opportunities and so on. There may be a case for investment of NHS funds in schemes like ‘referral to fitness’ and similar projects, which aim to help people move more and eat less. The role of the NHS is often detection and lifestyle advice, and avoiding complications.
The other nutritional and endocrine abnormalities are rarer but often need specialist investigation and management.
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 questions to think about:
- What are the main health issues in each programme?
- Who are the major players (including patients every time, 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 in the patient pathway—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 to get a better fit between resources and objectives. (Start by looking within programmes before looking between programmes.)
Programme objectives for diabetes and obesity
Examples of aims, objectives and actions are based on those from 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 reduce preventable and treatable diabetes and obesity | 1.1 Diabetes: in primary care achieve a year on year reduction in the average HbA1c for the practice population (a summary measure of blood glucose control) 1.2 Obesity: agree a local strategic partnership strategy for reducing childhood obesity with the local authority by the year end | 1.1.1 Develop and implement a strategy for diabetes in the locality, with a combination of health promotion, early detection, primary care based chronic disease management, specialist outreach and hospital care, and more efficient management of diabetes in hospital patients, where it often features as a complication in other patients admitted for surgery, heart attack, renal failure, peripheral vascular disease, vision problems or pregnancy 1.2.1 Establish baseline obesity prevalence in schoolchildren in the locality. Introduce opportunities for greater physical activity in the journey to school, during school, after school 1.2.2 Establish partnership with local ‘Football in the Community’ at championship football club and draw on club’s resources for schools promotions and out of school activities | - |
| 2: To develop care pathways which tell all the participants, especially the patient, who does what and where. The ‘contracts’ for care should be for a pattern of care, not just an episode of care | 2.1 Diabetes: in hospital care, achieve a reduction in average lengths of stay for all patients where diabetes is a factor—for example, in patients with diabetes undergoing surgery, and give attention to groups with special needs such as adolescents, expectant mothers and those with complex associated medical conditions | 2.1.1 Appoint a diabetes liaison nurse in surgery, maternity and general medicine 2.1.2 Relocate paediatric dietetic clinic to football club to improve attendance and compliance and to reduce stigma (as has been done in Norwich, for example) | - |
| 3. To continue patient and professional education | 3.1 Specify local learning objectives for defined professional groups for the current appraisal year | - | - |
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.