Parallel Session 2.6 (Re)Connecting with Meaning and Motivation

Understanding the potential and evaluating the actual impacts of

change

• Cost Consequence Approach to modelling and evaluating the impact of change

• How CCA is being used nationally

• Some simple techniques for using it in practice to evaluating change

• Challenges in using the approach

• Chance for you to have a go at impact analysis

Today

Introduction to Cost Consequence Analysis

PAIRS EXERCISE

You’ve just moved into a 3 bedroom house that has no central heating, it is heated by plug in electric heaters. Your hot water is via an immersion heater. You expect to stay in this house for about the next 4 years. You need to make a decision whether to progress with getting central heating installed.

In pairs discuss what other information you need to make the decision.

Recurrent costs of the change

Monthly gas and electricity bills prior to change £250

Predicted monthly gas and electricity after making change

£150

Monthly recurrent savings £100

INDIVIDUAL EXERCISE

• You do your sums and work out that if you have it installed, over the next 4 years you will save £4,800 pounds in gas and electricity bills.

• Assume it makes no difference to the value of your house.

• Please write on a piece of paper the maximum amount you would be willing to pay over and above the financial break even point to have central heating installed - including on demand hot water.

• You can have minus figures – so you might say that you would only install it if overall you saved at least £1,000

Non-recurrent costs of change

• Cost of installing central heating (including redecoration) = £6,000

• Costs of hotel room you book for two nights as can’t face the mess = £200

.

So will you make the change?

• Non recurrent costs = £6,200

• Recurrent savings = £100 per month

• Assume that housing market is such that it adds no value to how much your house is worth.

• Assuming inflation is zero, after 4 years you have saved £4,800 in bills giving you a net cost of £1,400

• Who would install the central heating?

Differences in perceived value

• Different people in the room will place a different value on the benefit of being warm and having on-demand hot water.

• Traditional economic analysis puts a financial value on non-financial benefits – fraught with problems.

• CCA doesn’t – it just states non financial and hence enables decision makers to have transparent discussions about the value within their context.

Cost Consequence Analysis

1. Non-recurrent costs of making change

2. Recurrent costs/savings of making change

3. Non-financial impacts of change – both positive and negative - just state – don’t try to put financial figures on

Cost Consequence Analysis

Aspects of CCA Example

Non recurrent costs of making change

• £5,200 costs

Recurrent costs/savings• £100 per month recurrent

savings

Non financial impacts• Warm house• Hot water on demand

QUESTIONS ON OVERALL APPROACH

• Model the potential impacts of changes eg

– Falls bundle– Anticipatory care planning

• Evaluate the actual impacts of changes eg

– Dementia Demonstrators– Poly-pharmacy work

Nationally using CCA to..

Applying it in practice

Scenario Models of the potential impact of changes

Using CCA approach to model impact of adopting new interventions

• Work led by primary,community and outpatients workstream of Quality and Efficiency Support Team

• Developing spreadsheets so NHS Boards/CHPs can scenario model the impact of adopting new interventions

• Exploring models for• Falls Bundles (near to completion)• Anticipatory Care Planning (next priority)• Hospital at Home and Community Assessment

of Intermediate Care• Telehealth for COPD


By quantifying PATIENT BENEFITS now and in future Identify relevant patient groups and events Extract potential clinical benefits from studies Apply to relevant patient groups in Scotland and

measure change in clinical events

By quantifying RESOURCES now and in future Identify resources required under current pathway Identify change in activities with new recommendation Identify resources associated with change, including

disinvestment

By quantifying COSTS now and in future Identify costs of current clinical events Identify potential savings from the reduced clinical

events Identify cost of resources associated with changes


Allows you to answer question of whether potential cost savings exceed cost of implementation and annual operations, and to also play in the clinical

benefits to the discussion

Example from MSK Modelling

Total cost of the pathways

Existing pathway

NHS 24 pathway

Existing pathway

NHS 24 pathway

Savings

GP appointments 109,992 104,726 5,265 £3,959,695 £3,770,141 £189,554

Outpatients 14,995 13,496 1,500 £4,015,759 £3,614,183 £401,576

NHS 24 calls 10,834 -10,834 £167,933 -£167,933Physiotherapy appointmentsof which:

69,760 45,490 24,270 £4,190,276 £2,732,447 £1,457,829

GP referrals 44,160 24,558 19,602 £2,652,560 £1,475,122 £1,177,437

Self referrals 14,080 14,080 £845,744 £845,744

GP suggested 11,520 11,520 £691,972 £691,972

NHS 24 20,932 -20,932 £1,257,325 -£1,257,325

Do not attends 4,378 2,778 1,601 £109,454 £69,440 £40,014

MRI 698 684 15 £150,806 £147,664 £3,142

X-rays 8,333 7,600 733 £546,561 £498,479 £48,083

Prescribed NSAIDs 9,171 9,316 -145 £59,115 £60,053 -£938

Prescribed Analgesics 10,214 9,658 556 £49,687 £46,984 £2,703

Total events and costs of pathways 47,229 13,081,352 11,107,323 1,974,030

Total events

Change in events

Ayrshire & Arran

Total costs (million)

In the CCA modelling will add in the clinical benefits as well as the financial impacts

Applying it in practice Evaluating the impacts of changes

Step OneMap the expected

impact of your change

Increase AZ support worker time

Reduce CPN time providing post diagnostic support

Increased number of people accessing AZ support

Reduce time from referral to individual receiving post diagnostic support

Depending on what we use reduced time for all sorts of potential impacts

Increased number of people accessing assistive technology

Increased number of people with anticipatory care plans

Increased number of people receiving appropriate post diagnostic information

Increased number of people where Talking Points is being used

Increased referrals to locality link offices

Better links to local communities

Benefits of referring for diagnosis improved and more visible to GPs

Individuals better supported in the community

Experience improved satisfaction with service providers

Increased number of referrals to OACMHTs for diagnosis

Increase in number of people diagnosed with dementia

-ve

Increased referrals of people with dementia to lunch clubs

Increased waiting lists for lunch clubs

-ve means has opposite impact to that in box arrow points to so in this case means decrease in no of referrals

Reduction in admissions to care homes and acute hospitals

Spend more money on food

Use more shower gel

Depends on whether water is metered

Costs more

If exercising with others, increased social contact

Initially feel more tired, but longer term more energy

Increase in joint pain

Positive impact on mental wellbeing

Better mental wellbeing

Less time

Take more showers

Increase calorie intake

Giving up working out 5 days a week

Have to stop doing something, impact depends on what stop doing

-ve -ve

Work out 5 days a week

Increase in calories out

A new me
















Increase in number of people diagnosed with dementia

-ve



-ve means has opposite impact to that in box arrow points to so in this case means decrease in no of referrals



Step Two Identify what impacts have measurable financial

consequences attached
















Increase in number of people on Dementia QOF registers

-ve



Green shading = Impact which can be costed.


Recurrent Costs

Issue around impact on hospital and care home admissions

Actual prior to change

Actual at Jul 2012 Difference Comments

Alzheimer Scotland Support Worker Team £51,772 £87,245 -£35,473 Team increased from 1.6 to 2.6 WTE

Costs of increased use of assistive technology -£30,000

Overall use of assistive technology increased by £60,000 over period of project. Attributed 50% of this cost to this change as data showed that 50% of increases in referrals came from AS support workers

band 7 = 4 hoursband 6 = 16 hoursband 5 = 24 hoursband 3 = 26 hours

4 hours4 hours16 hrs8.5 hrs

Same- 12 hrs- 8 hrs- 15.5 hrs

£53,907 £26,021 £27,886Summary of Social care £51,772 £87,245 -£65,473 These are real costsRecurrent Costs Health care £53,907 £26,021 £27,886 This is the value of hours released

Social Care Costs

Health CostsWeekly CPN time spent

on post diagnostic support

This is an esimate of the value of CPN time spent on post diagnostic support prior and after change. These costs may not releasable but highlight how much resource has been released for other work.


Step ThreeIdentify what impacts have non financial

consequences
















Increase in number of people diagnosed

-ve




Non Financial Consequences

Potential non-financial measuresDirection of

expected change

Service user and carer satisfaction with post diagnostic support received Improve

Number of people diagnosed with dementia (as per QOF register) Increase

Number of people receiving post diagnostic support Increase

Number of people with Dementia using assistive technology to maintain independence Increase

Time from referral to individual receiving post diagnostic support Reduce

Number of people with Dementia with anticipatory care plans Increase

Number of referrals to locality link officers Increase

Number of referrals for people with Dementia to lunch clubs Increase

Number of individuals where Talking Points is being used Increase

Number of referrals to Older Adult CMHTs Uncertain


Step Four Identify your non-recurrent costs

Non-recurrent Costs

Hours spent on project

AfC Band (or

equivalent)

Midpoint

Costing (£)1 Comments

Recruitment costs for new post £1,500Includes advertising costs, interview costs etc

Awareness raising with exisitng staff around additional post and how will work

2 hours eachband 7, band 6 x2, band 5,

band 3 £172

Non-recurrent Project manager time 18 hours band 7 £4029 Hours of Health Project Management and 9 Hours of social work project management

Costs Info Analyst - re data for evaluation 7 hours band 6 £131

Finance input re costings 4 hours band 5 £61

Admin time 12 hours band 3 £130

Psychiatrist 2 hoursConsultant

Salary£106

TOTALSummary of non recurrent costs - Health care £801 £801Summary of non recurrent costs - Social Care £201 £1,500 £1,701

Costs associated with staff time spent on project

Other

Staff Role or Pay Banding

Pay Scalemidpoint*

Weeklyrate (£)

Hourly rate (£)

Hourly rate adjusted for

employer costs (24%)

Enter Hours

worked**Total

cost (£)AfC 1 14,008 269 7.16 8.88 0.00AfC 2 14,987 287 7.66 9.50 0.00AfC 3 17,118 328 8.75 10.86 0.00AfC 4 19,933 382 10.19 12.64 0.00AfC 5 24,059 461 12.30 15.26 0.00AfC 6 29,464 565 15.07 18.69 0.00AfC 7 35,184 675 17.99 22.31 0.00

AfC 8a 42,850 822 21.92 27.18 0.00AfC 8b 50,351 966 25.75 31.93 0.00AfC 8c 59,799 1,147 30.58 37.92 0.00AfC 8d 71,642 1,374 36.64 45.43 0.00AfC 9 86,721 1,663 44.35 55.00 0.00

SMgr A 50,873 976 26.02 32.26 0.00SMgr B 58,377 1,120 29.86 37.02 0.00SMgr C 66,989 1,285 34.26 42.48 0.00SMgr D 75,735 1,453 38.73 48.03 0.00SMgr E 86,908 1,667 44.45 55.12 0.00SMgr F 99,729 1,913 51.01 63.25 0.00SMgr G 114,441 2,195 58.53 72.58 0.00SMgr H 131,324 2,519 67.16 83.28 0.00SMgr I 150,696 2,890 77.07 95.57 0.00FHO 1 23,928 459 12.24 15.17 0.00FHO 2 29,763 571 15.22 18.88 0.00

Specialist Reg 38,374 736 19.63 24.34 0.00House Officer 23,928 459 12.24 15.17 0.00

Senior HO 33,416 641 17.09 21.19 0.00Consultant 83,829 1,608 42.87 53.16 0.00

Speciality Doctor 52,546 1,008 26.87 33.32 0.00Associate Specialist 51,667 991 26.42 32.77 0.00

Clinical Medical Officer 38,857 745 19.87 24.64 0.00Sen Clin Med Officer 55,994 1,074 28.64 35.51 0.00

Total (£) 0.00

Bringing it all together

Health Social CareNon-recurrent costs £801 £1,701

Recurrent costs/savings

-£27,886 (productive savings)

£65,473 (actual costs)

Non financial consequences

• 80% of individuals receiving post diagnostic support reporting satisfied or highly satisfied (baseline of 40%)

• 100 more people per year received post diagnostic support (30% increase)

• Reduction in time waiting from diagnosis to support from 4 months to 2 weeks

• Reduction in waiting time for CPN support from 6 months to 1 month

• 10% increase in no of people diagnosed*• 30% increase in no of people with dementia using

assistive technology to support independent living*• 10% increase in no of people with dementia with

anticipatory care plans*• 10% reduction in referrals to OACMHT*

*There are other changes in the system that may have also impacted on this measure.

Not yet able to evaluate

Impact on use of care home beds and acute hospital beds longer term

More detailed analysis should sit behind the summary e.g

Number of Individuals Accessing Post Diagnostic Support

0

10

20

30

40

50

60

70

Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

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New Alzheimer Scotland post

diagnostic support worker started

New model of post diagnostic

support implemented

• Data Reliability

• Proportionality – effort vs benefits of data collection (sampling)

• Costing – access to relevant data

• Non-recurrent costs – difficulties collecting

• Cash releasing vs efficiency gains

• Qualitative as well as quantitative

• Outcomes as well as process measures

• Statistical significance

• When to use CCA for evaluation

Issues

Pairs Exercise (10 mins)

Using CCA to manage and evaluate impacts

Pick a change that one of you is involved with at the moment and have a go at doing an impact map

Discussion/Questions?

Business

Parallel Session 2.6 (Re)Connecting with Meaning and Motivation