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Using PBMA (Programme Budgeting and Marginal Analysis)

PBMA is a tool that can be used to help prioritise investment or disinvestment in health programmes. It involves drawing up a programme budget, which shows spend and outputs by programme area, and then looking at what changes can be made to budgets at the margin to deliver healthcare more efficiently. PBMA involves starting with services as they are, and usually involves making stepwise changes in investment, rather than wholesale redesign of services. The principles of PBMA are adaptable and the process has been done in different ways.
i. Features of PBMA


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Outputs Based Starts with reality Pragmatic Resource Neutral Data Hungry Participative
Key questions for PBMA

1) What resources are available? 2) On which services are NHS resources spent (hospital, community, GP prescribing, non-NHS partner agencies)? 3) Which services are candidates for more resources, and what is the added cost and added benefit of each? (Wish list) 4) Can any services be provided as effectively with fewer resources, or minimally effective services curtailed, and if they were discontinued, what savings would arise and what benefits would be foregone? (Hit list or 5) Is it possible to invest in some items on the wish list by disinvesting in some from the hit list? (Implementation list or shift list)

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Example of a PBMA Process for Mental Health Service Redesign

1. Define programme area i.e. mental health what is included and excluded Determine the aim and scope of the PBMA process. 2. Develop Programme Budget showing current expenditure and activity i.e. Draw up a list of budgets and what they buy us, i.e. 500,000 takes care of x people with moderate depression, or y people with serious psychosis. This will give an idea of cost of different services. 3. Look at total burden of disease Look at estimates of burden of disease and total number of people known to services. Are there any client groups that are not currently catered for by services? 4. Convene group to draw up (dis) investment options Group should have input from Directors, from decision makers, and from members of the public. 5. Determine decision making criteria i.e. think about weights given to different aspects of programme. This is the step of the process that really involves value judgements, and having a vision for the service, the data can only tell you so much for this. 6. Evaluate options (marginal analysis) Look at productivity of service to understand marginal benefits of commissioned activity. Could use: [Cost of service] / [number of client contacts * typical severity of illness] Severity of illness could maybe be measured using HoNOS clusters? If data highlights services that are less productive, i.e. are seeing a similar type of severity, but at a higher cost per patient, then maybe these services can be looked at in more detail as being candidates for disinvestment. Groups need to come up with a finite number of options that fit in with budget envelope. Look at candidates for disinvestment, or providing services in a more efficient way. Decide which options provide the most efficient, or equitable service.

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Think about feasibility of changes, for instance changes may be easier if they involve staff moving from one task to another, rather than large scale recruitment or redundancies. 7. Recommend changes Make the decision public and affect the change. 8. Evaluation In the longer term, we should evaluate what effect the changes have had on services. But in the short term, the decision-making process should be evaluated to check it has been transparent, fair and consistent. One framework for this is the accountability for reasonableness framework, outlined in box 1 below.
Box 1. Conditions of Accountability for Reasonableness framework
Condition Publicity Relevance Description Limit-setting decisions and their rationales must be publicly accessible. These rationales must rest on evidence, reasons, and principles that fair-minded parties (managers, clinicians, patients, and consumers in general) can agree are relevant to deciding how to meet the diverse needs of a covered population under necessary resource constraints. There is a mechanism for challenge and dispute resolution regarding limit-setting decisions, including the opportunity for revising decisions in light of further evidence or arguments. There is either voluntary or public regulation of the process to ensure that the first three conditions are met.

Appeals Enforcement

From Mitton and Donaldson Cost Effectiveness and Resource Allocation 2004 2:3 doi:10.1186/1478-7547-2-3

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Examples of PBMA

There are lots of examples of PBMA being used, with varying rates of success. The main problem for many PBMA projects has been indentifying disinvestment areas to balance out new investments. The YHPHO (Yorkshire & Humber Public Health Observatory) website has three examples of PBMA being used in English regions, including for mental health in Norfolk; http://www.yhpho.org.uk/default.aspx?RID=8478

Brendan Collins | Health Economist East London and the City Alliance - Health Intelligence Unit
brendan.collins@nhs.net

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