Published: 22/04/2002, Volume II4, No. 5902 Page 38 39

A PCT in the heart of Sussex has been calling on the help of all its healthcare staff in a pilot scheme to track spending more closely. Emma Forrest reports

A former cottage hospital in the genteel commuter town of Haywards Heath may not seem the most obvious place for a revolution. But It is here that the offices of Mid-Sussex primary care trust are witnessing a financial revolution. For the trust is one of three that in 2003 took on the task of piloting programme budgeting, the system by which it is hoped the NHS will be able to track, for the first time, exactly how much it is spending and on what.

Mid Sussex, which covers a relatively affluent area of pleasant commuter towns, villages and rural areas, was considered an appropriate area to test programme budgeting within the boundaries of community care.

Concentrating on the community care aspect of the PCT's£110m budget has meant close collaboration with director of public health Peter Hayward, who now sits on the Department of Health's programme budgeting board. PCT finance manager Carol Nelson has been key to the project.

'The concept is very simple: we look at our activity and map it against costs, ' says Mr Hayward.

'We wanted to see if we were matching spend with what we know about health in the community.'

'We saw it as an opportunity to be involved from day one, ' adds finance director Richard Hathaway. 'This is not just a financial envelope. It is a clinical process.'

Collecting information has been the mainstay of the project.

Community staff - including district nurses, school nurses, therapists and health visitors - were asked to record the number of visits and consultations; the primary diagnosis that arose from a visit; time spent on admin, planning, meetings and travel;

time spent on meetings that were cancelled; and the numbers of contacts made with existing and new patients. Every condition noted by the worker was coded, allowing the PCT to map time spent by condition within its boundaries and by type of worker.

'Coding is as important with programme budgeting as it is with payment by results, ' says Mr Hathaway. Although this has meant considerable amounts of paperwork for those involved, he was pleasantly surprised by the levels of co-operation from across the trust.

'Though some staff needed persuading, some were very enthusiastic, which is unusual for something that could be seen as a finance issue. It is important to make sure that everyone understands the motivation behind it.'

But while the message may be getting through in Mid Sussex, and despite the potentially enormous consequences for the service, programme budgeting has until recently had a comparatively low profile across the country.

'There was a danger that it would get rather lost between the eagerness to prepare for other things, such as patient choice and payment by results, but it does seem to increasingly be on people's agendas, ' says Mr Hathaway.

'One of the dangers with programme budgeting currently is that a lot of people still see it as an exercise for PCTs only. One of the messages we are trying to get across is that it needs the involvement of all trusts; it needs input from GPs and acute and mental health trusts, too.'

Mr Hayward has his eyes fixed on what programme budgeting will mean for health planning in the future; what it may offer in terms of determining what needs to be spent on illness prevention and how much on treatment.

'The real power is what happens when you combine this information with other data. Once we know what the spends, are we can see if the balance is right. It will allow us to make decisions on prevention and treatment. Are we spending on the right organisations or the right disease?'

He continues: 'We are increasingly getting better health outcomes data and will be able to match these against diagnosis in a way that has not been standard before.'

Comparisons with other trusts in a continual process of benchmarking should also be possible.

Mr Hathaway warns that such measures are five years down the line, and that the data being collected now still needs to be treated with caution. But the possibilities are there.

Both say that the pilot has thrown up some surprises; the large amounts of time spent by nurses on certain situations or conditions have provided an opportunity to look at patterns of behaviour.

As Mr Hayward points out, if district nurses are spending large amounts of time treating pressure sores, for example, can something be done to help patients avoid getting the sores in the first place and what effect could that have on budgets and planning?

'The first thing to ask is, is it appropriate behaviour? If the answer is no, then we can start changing patterns of service delivery. We need to match what we need to what the service is delivering, ' says Mr Hathaway.

For him, this has been the most useful part of the pilot. 'We can sit down with all the clinicians and managers and look at how we can change the service. It has never been possible to look at the service in this way. It will focus discussions in a way we have never done before.'

Both are still clearly enthusiastic for the project. But it has been a tight timetable.

Another team member - programme budgeting analyst Steve Beal - has been working with the finance team while it develops the project, but both Mr Hathaway and Mr Hayward say fitting the programme budgeting alongside their day jobs has been difficult.

'Having Steve on the team has enabled us to spend more time engaging staff in this process.

Without that and Carol's investment, we would not have been able to do this, ' says Mr Hathaway.

The trust's work has already contributed to a programme budgeting manual, and outcomes from Mid Sussex's work and the two other pilots will be published by the Department of Health in October. Then Mid-Sussex will be able to start gauging the extent to which their work will shape national financial planning for the health service.