Introduction
This may be an area where the primary care trust (PCT) has been providing a specialist service in partnership with social services. As a ‘provided’ service there may be operational challenges as well as commissioning ones. Those with learning difficulties also experience the full range of issues of all the other programmes. New cases of learning difficulty are relatively low and stable, but the number of existing cases is high because the underlying causes are intrinsically intractable and people with learning difficulty are living longer.
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 aim
Examples of aims, objectives and actions are 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 ensure that the needs of people with learning difficulties are met in a service that is as integrated into the mainstream as possible. This includes educational, employment, recreational, housing and transport needs at all ages. | Obtain evidence of the full range of primary care health promotion, screening, chronic disease management, prescribing and referrals to secondary care for people with learning disability and to ensure that there is no evidence of discrimination or disadvantage | Carry out a survey of educational or learning placements | - |
| 2. To offer all people with learning difficulty a personal, patient held healthcare record and plan containing the names of contact people, to coordinate primary care support. This should include the full range of health promotion, immunisation, screening and other ‘well person’ clinics. | Set up a system to ensure and document that personal, patient held care records and plans are offered to all people with learning difficulties. This should include the full range of immunisation and screening and well person clinics | Work with community pharmacists to supervise use of drugs and supply simple aids to explain dosing schedules | - |
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.