2. Today
• 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
4. 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.
5. Recurrent costs of the change
Monthly gas and electricity bills prior to change £250
Predicted monthly gas and electricity after £150
making change
Monthly recurrent savings £100
6. 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
7. 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
8. 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?
9. 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.
10. Cost Consequence Analysis
• Non-recurrent costs of making change
• Recurrent costs/savings of making change
• Non-financial impacts of change – both positive and
negative - just state – don’t try to put financial figures
on
11. Cost Consequence Analysis
Aspects of CCA Example
Non recurrent costs of • £5,200 costs
making change
• £100 per month recurrent
Recurrent costs/savings
savings
• Warm house
Non financial impacts
• Hot water on demand
13. Nationally using CCA to..
• Model the potential impacts of changes eg
– Falls bundle
– Anticipatory care planning
• Evaluate the actual impacts of changes eg
– Dementia Demonstrators
– Poly-pharmacy work
14. Applying it in practice
Scenario Models
of the potential impact of changes
15. 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
16. Using CCA approach to model impact of
adopting new interventions
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
17. Using CCA approach to model impact of
adopting new interventions
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
18. Example from MSK Modelling
Total cost of the
Ayrshire & Arran
pathways
Existing NHS 24 Existing NHS 24
Change Savings
pathway pathway pathway pathway
in events
Total events Total costs (million)
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 -£167,933
Physiotherapy appointments
69,760 45,490 24,270 £4,190,276 £2,732,447 £1,457,829
of which:
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
In the CCA modelling will add in the clinical benefits as well as the
financial impacts
19. Applying it in practice
Evaluating the impacts of changes
Step One
Map the expected
impact of your change
20. Depending on what Reduction in
we use reduced admissions to
time for all sorts of care homes and
potential impacts Individuals acute hospitals
Reduce better
CPN time supported
providing in the -ve means has opposite
post Increased number impact to that in box arrow
community
diagnostic of people points to so in this case
support accessing assistive means decrease in no of
-ve referrals
technology
Increase Increased number Benefits of
Increase
AZ Increased of people with referring Increased
in number
number of anticipatory care for number of
support of people
people plans diagnosis referrals to
worker diagnosed
accessing improved OACMHTs
time with
AZ and more for
dementia
support Increased number visible to diagnosis
of people receiving GPs
appropriate post
Reduce diagnostic Experience
time from information improved
referral to satisfaction with
individual service
receiving Increased number providers
post of people where
diagnostic Talking Points is
support being used
Increased Increased
Better links referrals of waiting
Increased referrals to local people with lists for
to locality link communities dementia to lunch
offices lunch clubs clubs
22. If exercising with
Positive impact on
others, increased
mental wellbeing
social contact
Initially feel more Giving up working out 5
tired, but longer days a week
term more energy
-ve -ve
Increase in joint
pain
Work out
Increase in calories
5 days a out
A new me
week
Increase calorie
intake Spend more money on
food
Costs
Use more shower gel
Take more more
showers Depends on whether
water is metered
Better mental
wellbeing
Have to stop doing something, impact
Less time
depends on what stop doing
23. Depending on what Reduction in
we use reduced admissions to
time for all sorts of care homes and
potential impacts Individuals acute hospitals
Reduce better
CPN time supported
providing in the -ve means has opposite
post Increased number impact to that in box arrow
community
diagnostic of people points to so in this case
support accessing assistive means decrease in no of
-ve referrals
technology
Increase Increased number Benefits of
Increase
AZ Increased of people with referring Increased
in number
number of anticipatory care for number of
support of people
people plans diagnosis referrals to
worker diagnosed
accessing improved OACMHTs
time with
AZ and more for
dementia
support Increased number visible to diagnosis
of people receiving GPs
appropriate post
Reduce diagnostic Experience
time from information improved
referral to satisfaction with
individual service
receiving Increased number providers
post of people where
diagnostic Talking Points is
support being used
Increased Increased
Better links referrals of waiting
Increased referrals to local people with lists for
to locality link communities dementia to lunch
offices lunch clubs clubs
24. Applying it in practice
Step Two
Identify what impacts have measurable financial
consequences attached
25. Depending on what Green shading
we use reduced = Impact which
time for all sorts of can be costed.
potential impacts Individuals
Reduce better
CPN time supported Reduction in
providing in the admissions to
post Increased number care homes and
community -ve
diagnostic of people acute hospitals
support accessing assistive
technology
Increase Increased number Benefits of
Increase
AZ Increased of people with referring Increased
in number
number of anticipatory care for number of
support of people
people plans diagnosis referrals to
worker on
accessing improved OACMHTs
time Dementia
AZ and more for
QOF
support Increased number visible to diagnosis
registers
of people receiving GPs
appropriate post
Reduce diagnostic Experience
time from information improved
referral to satisfaction with
individual service
receiving Increased number providers
post of people where
diagnostic Talking Points is
support being used
Increased Increased
Better links referrals of waiting
Increased referrals to local people with lists for
to locality link communities dementia to lunch
offices lunch clubs clubs
26. Recurrent Costs
Actual prior to Actual at
change Jul 2012 Difference Comments
Alzheimer Scotland
Support Worker Team £51,772 £87,245
-£35,473 Team increased from 1.6 to 2.6 WTE
Overall use of assistive technology
increased by £60,000 over period of
Social Care Costs
project. Attributed 50% of this cost to
this change as data showed that 50% of
Costs of increased use increases in referrals came from AS
of assistive technology -£30,000 support workers
This is an esimate of the value of CPN
band 7 = 4 hours 4 hours Same time spent on post diagnostic support
Weekly CPN time spent
band 6 = 16 hours 4 hours - 12 hrs prior and after change. These costs may
Health Costs on post diagnostic
band 5 = 24 hours 16 hrs - 8 hrs not releasable but highlight how much
support
band 3 = 26 hours 8.5 hrs - 15.5 hrs resource has been released for other
£53,907 £26,021 £27,886 work.
Summary of Social care £51,772 £87,245 -£65,473 These are real costs
Recurrent Costs Health care £53,907 £26,021 £27,886 This is the value of hours released
Issue around impact on hospital and care home admissions
27. Applying it in practice
Step Three
Identify what impacts have non financial
consequences
28. Depending on what
we use reduced
time for all sorts of
Individuals Reduction in
Reduce potential impacts
better admissions to
CPN time supported care homes and
providing in the acute hospitals
post Increased number
community -ve
diagnostic of people
support accessing assistive
technology
Increase Increased number Benefits of
Increase
AZ Increased of people with referring Increased
in number
number of anticipatory care for number of
support of people
people plans diagnosis referrals to
worker diagnosed
accessing improved OACMHTs
time AZ and more for
support Increased number visible to diagnosis
of people receiving GPs
appropriate post
Reduce diagnostic Experience
time from information improved
referral to satisfaction with
individual service
receiving Increased number providers
post of people where
diagnostic Talking Points is
support being used
Increased Increased
Better links referrals of waiting
Increased referrals to local people with lists for
to locality link communities dementia to lunch
offices lunch clubs clubs
29. Non Financial Consequences
Potential non-financial measures
Direction 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
30. Applying it in practice
Step Four
Identify your non-recurrent costs
31. Non-recurrent Costs
Costs associated with staff time spent
on project
AfC Band
Hours spent (or Midpoint
on project equivalent) Costing (£)1 Other Comments
Includes advertising costs, interview
Recruitment costs for new post £1,500
costs etc
band 7, band
Awareness raising with exisitng staff
2 hours each 6 x2, band 5, £172
around additional post and how will work
band 3
9 Hours of Health Project Management
Non-recurrent Project manager time 18 hours band 7 £402 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
Consultant
Psychiatrist 2 hours £106
Salary
TOTAL
Summary of non recurrent costs - Health care £801 £801
Summary of non recurrent costs - Social Care £201 £1,500 £1,701
32. Hourly rate
adjusted for Enter
Staff Role Pay Scale Weekly Hourly employer Hours Total
or Pay Banding midpoint* rate (£) rate (£) costs (24%) worked** cost (£)
AfC 1 14,008 269 7.16 8.88 0.00
AfC 2 14,987 287 7.66 9.50 0.00
AfC 3 17,118 328 8.75 10.86 0.00
AfC 4 19,933 382 10.19 12.64 0.00
AfC 5 24,059 461 12.30 15.26 0.00
AfC 6 29,464 565 15.07 18.69 0.00
AfC 7 35,184 675 17.99 22.31 0.00
AfC 8a 42,850 822 21.92 27.18 0.00
AfC 8b 50,351 966 25.75 31.93 0.00
AfC 8c 59,799 1,147 30.58 37.92 0.00
AfC 8d 71,642 1,374 36.64 45.43 0.00
AfC 9 86,721 1,663 44.35 55.00 0.00
SMgr A 50,873 976 26.02 32.26 0.00
SMgr B 58,377 1,120 29.86 37.02 0.00
SMgr C 66,989 1,285 34.26 42.48 0.00
SMgr D 75,735 1,453 38.73 48.03 0.00
SMgr E 86,908 1,667 44.45 55.12 0.00
SMgr F 99,729 1,913 51.01 63.25 0.00
SMgr G 114,441 2,195 58.53 72.58 0.00
SMgr H 131,324 2,519 67.16 83.28 0.00
SMgr I 150,696 2,890 77.07 95.57 0.00
FHO 1 23,928 459 12.24 15.17 0.00
FHO 2 29,763 571 15.22 18.88 0.00
Specialist Reg 38,374 736 19.63 24.34 0.00
House Officer 23,928 459 12.24 15.17 0.00
Senior HO 33,416 641 17.09 21.19 0.00
Consultant 83,829 1,608 42.87 53.16 0.00
Speciality Doctor 52,546 1,008 26.87 33.32 0.00
Associate Specialist 51,667 991 26.42 32.77 0.00
Clinical Medical Officer 38,857 745 19.87 24.64 0.00
Sen Clin Med Officer 55,994 1,074 28.64 35.51 0.00
Total (£) 0.00
34. Health Social Care
Non-recurrent costs £801 £1,701
Recurrent -£27,886 (productive £65,473 (actual costs)
costs/savings savings)
Non financial • 80% of individuals receiving post diagnostic support
reporting satisfied or highly satisfied (baseline of 40%)
consequences
• 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 Impact on use of care home beds and acute hospital
evaluate beds longer term
35. More detailed analysis should sit
behind the summary e.g
No of individuals currently with named contact worker providing support
Number of Individuals Accessing Post Diagnostic Support
70
60
New model of
post diagnostic
support
50 implemented
40
New Alzheimer
30 Scotland post
diagnostic support
worker started
20
10
0
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
36. Issues
• 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
37. 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
Get them to then line up in room in order of how much willing to pay –but once have most and least get them to space out as if room is the spectrum so you can see visually whether they cluster around a similar amount. Ask the most and least just to say why they put that much. Aim of this is just to get them to see that they put different financial values on the benefits – suspect they will cluster around a certain amount but there will also be outliers. Will come back to this at later stage when talk about how CCA treats non-financial benefits and why it doesn’t look to put a financial value on it – as leaves it open for each individual to put that value on.
Pick up any other one-off costs that were shouted out in previous exercise here.
Assuming inflation is zero so don’t have to get into Net Present Value issues and discounting as this is just an overview. Need to check with Paul if going to pick this up in costing bit
In terms of second question – refer back to initial exercise and highlight that it is worth different amounts to different people. Talk about traditional approach to economic analysis would be to put a financial value against the hot water on demand and being warm. However financial value can be very finger in air and also people can put a value on to make business case stack up. Cost consequence says lets not do this – lets just state the non-financial benefits and leave decision makers to put their own value on them. Is a more transparant way of doing things.
So this is what you would consider when doing a CCA for a change initiative. Traditionally we don’t think about the non-recurrent costs of making the change – but these can be significant and need to be thought about. Also in terms of transferring learning – it is useful for other areas to see how much time it took to make the change.
Give them a couple of mins to discuss and then get them to shout out the addition information they need – which include Cost of installing the central heating and any other non-recurrent costs Current amount spent on heating bills Predicted amount once central heating installed
So in terms of working out your outcome and process measures – we’ve promoted the concept of driver diagrams. Nothing fancy here – just saying work out what your aim is – and then which bits of the system you will need to work on to deliver that aim. The advantage of them is that they help to show that it is rarely just one thing you have to work on to deliver an aim.
First step is to identify where the non-financial consequences are Then you want to think about how you might measure them And then you need to think about proportionality – how much work is involved in measuring them and decide whether the benefits of measuring outweigh the costs.
Give them a couple of mins to discuss and then get them to shout out the addition information they need – which include Cost of installing the central heating and any other non-recurrent costs Current amount spent on heating bills Predicted amount once central heating installed