Financial benchmarking service

The Financial Benchmarking System (FBS) developed by NA Wilson Associates (NAW) provides comparative costed inpatient HES data against which NHS organisations can compare their financial performance.

NAW works intensively with NHS organisations for relatively short periods of time (generally a few months, although this can extend to 1 year or more). During this period, the FBS is one of the tools and services to which NHS organisations are granted access. NAW staff work side-by-side with NHS organisation staff to use the evidence within the FBS to plan and implement changes in services and financial processes.

The data requested is necessary for the purposes of the legitimate interests pursued by the controller or by a third party, for access to HES data in the basis of Article 6(1)(f). NAW apply the three-part test:

• Purpose – The FBS is aimed at supporting NHS organisations achieve efficiency and effectiveness int eh services that they deliver to patients. As such the FBS benefits the public in general and patients in particular.

• Necessity – The FBS is one of many tools that NHS organisations may use to achieve the aims above. Past customers have found it to be a useful tool with many customers repeatedly approaching it for support. HES processing is the core of the FBS and NAW could not provide the FBS without processing HES data.

• Balancing test – Because the HES data for the FBS is pseudonymised, not linked with any other data, and access is restricted to a single individual in the organisation, the risk of identifying individuals from the HES data are low. NAW employees are required to abide by strict data processing requirements, which limits the likelihood of inappropriate onward sharing of data to other parties. The products from the FBS are shared only with the organisation to whom the data relates (never publicly published) and small number suppression is applied For these reasons, it is extremely unlikely that patients right would be breached, patients would be disadvantaged in any way, or that they would lose control of their personal data.

Processing HES for the FBS is necessary for the purpose of the provision of health or social care or treatment or the management of health or social care systems and services (Article 9 (2)(h) of the GDPR). The FBS is aimed at supporting NHS organisations achieve efficiency and effectiveness in the services that they deliver to patients, for the benefit of the public and patients.

NAW believe there is no moral or ethical impact of processing to support the FBS. There is very low risk of harm to the public, as described above (i.e. because the HES data for the FBS is pseudonymised, not linked with any other data, and access is restricted to a single individual within the organisation, the risk of identifying individuals from the HES data are low. NAW employees are required to abide by strict data processing requirements, which limits the likelihood of inappropriate onward sharing of data to other parties. The products from the FBS are shared only with the organisation to whom the data relates (never publicly published) and small number suppression is applied For these reasons, it is extremely unlikely that patients right would be breached, patients would be disadvantaged in any way, or that they would lose control of their personal data).

NAW have been using the FBS, or versions of this product, with NHS organisations since the company began in 2003. The FBS is not unique – many companies (both NHS and private) provide products similar to the FBS, including NHS England’s RightCare programme and NHS Improvement’s Model Hospital. The added benefit that NAW brings is the use of the FBS output in combination with intensive work by NAW personnel side-by-side with NHS organisation staff to use the evidence within the FBS to plan and implement changes in services and financial processes.

NAW will provide a service to NHS organisations only, more specifically to NHS hospital trusts, commissioning

organisations (e.g. CCGs, STPs/ICSs, NHS England) or national programmes (NHS England, NHS Improvement, GIRFT [(Getting it Right First Time)]). Current customers are restricted to NHS Trusts and commissioners, and to GIRFT . Output from the FBS is provided to the customer organisation only to support change internal to their programme. FBS output is not for public publication.

The data subjects are NHS patients treated in hospitals in the United Kingdom whose diagnoses and treatments are recorded in the HES datasets. The cohort for processing is always based on an organisation (e.g. CCG or NHS Trust). Values for this organisation are benchmarked against national or peer group average.

NAW will use HES data for three main purposes:

• To support NHS organisations during financial turn-around

• To support NHS organisations plan and implement service change for the benefit of patients

• To assure NHS organisations within a healthcare economy that financial transactions are fair, transparent and compliant with national guidance

The Financial Benchmarking System (FBS) developed by NAW provides comparative costed inpatient HES data against which NHS organisations can compare their financial performance. It is used as part of a comprehensive service delivered to NHS organisations within a health economy. This comprehensive service comprises the following steps:

(1) Working with the organisations to understand their specific concerns and needs;

(2) Using the FBS and other analytical tools to help organisations gain a detailed understanding of the financial state of their health economy;

(3) Reporting findings and recommendations;

(4) Working with organisations to plan and implement improve services and financial processes, or to arbitrate financial settlements.

NAW agrees a project initiation document (PID) with all clients. This PID describes the outputs (including the FBS) that NAW will provide, and actions that clients expect to undertake as a result of these outputs.

As an example of how NAW use the data from FBS with customers, a CCG may approach NAW to understand why their budget is over-performing but their contracted activity is not over-performing. A comparison of local data with the FBS data may illustrate that a local Acute Trust has begun recording 'co-morbidity' ICD10 codes thoroughly. The inclusion of 'co-morbidity' ICD10 codes can switch the assigned HRG from a 'without complications' to a 'with complications' HRG without patients necessarily having received an enhanced service. 'With complications' HRGs usually attract a higher national tariff. Using this evidence, NAW would work with the CCG to negotiate a financial adjustment with their local Acute Trust for the current year, and to plan changes to services to mitigate the impact of the financial impact for future years.

For the FBS, specifically to provide national comparator values, there is a requirement for inpatient activity for all patients who receive services in an English healthcare provider or whose care is paid for by an English commissioner.

There is a requirement for critical care and inpatient activity to ensure that the national tariff has accurately calculated the national tariff.

Pseudonymised patient ID is required for two purposes: (1) to track the pathway of patients as their service is delivered within a hospital or between hospitals; and (2) to allow the linkage of critical care records to the inpatient record for the calculation of the national tariff.

NAW require at least three-years of data for two main reasons: (1) the national tariff is based on reference costs from at least 3-years previous, and current activity with previous activity in both HES and reference costs to ensure accuracy of the analysis; and (2) trends in service change are important to track to both forecast the impact of proposed future service change and to track changes resulting form in implemented service change.

No other dataset can support the application of national tariff that is a central component of the FBS, and the calculation of national tariff could not be achieved without pseudonymised HES data. Similarly, the FBS and NAW work with NHS organisations to support patients would be significantly reduced without the geographical coverage which has been requested.

NAW works intensively with NHS organisations for relatively short periods of time (generally a few months, although this can extend to 1 year or more). During this period, the FBS is one of the tools and services to which NHS organisations are granted access. NAW staff work side-by-side with NHS organisation staff to use the evidence within the FBS to plan and implement changes in services and financial processes.

NAW customers are national. Some of the customers who have used the FBS over the past five years

include those below:

• Shropshire and Telford & Wrekin STP

• Sussex and East Surrey STP

• North Central London STP

• NHS England Year of Care programme

• NHS South Norfolk CCG

• NHS West Suffolk CCG

• NHS Cambridgeshire and Peterborough CCG

• NHS West Norfolk CCG

NAW will provide a service to NHS organisations only, more specifically NHS hospital trusts, commissioning

organisations (e.g. CCGs, STPs/ICSs, NHS England) or national programmes (e.g. NHS Improvement and NHS England).

NAW is the sole data controller and data processor. using a remote access facility to access the data in the UK FAST storage location. The sole data storage location organisation is UK FAST, data does not leave the UK FAST storage facility until aggregation and small number suppression has been applied.

All organisations party to this agreement must comply with the Data Sharing Framework Contract requirements, including those regarding the use (and purposes of that use) by “Personnel” (as defined within the Data Sharing Framework Contract ie: employees, agents and contractors of the Data Recipient who may have access to that data ).

No flows of data to NHS Digital are part of this application.

This application is for a flow of pseudonymised admission-level HES inpatients and critical care healthcare data from NHS Digital to NAW. Healthcare data is considered a special category under GDPR. The flow of data will be direct onto the dedicated server in NAW’s storage facility managed by UK FAST.

Analysed HES data from the FBS will not leave the UK FAST storage facility until aggregation and small number suppression has been applied.

Processing is restricted to a single user working at NAW’s processing location using an encrypted remote access facility to access data in the NAW’s storage location UK FAST. UKFast.net limited is whole based in the UK, with no overseas or offshore locations or access. HES data is never linked with any other data not mentioned in this agreement.

The bulk of the processing is as follows. HES admitted patient care (HES APC) data for inclusion in the FBS will be processed in the following way:

• FCE records will be grouped to spells using the Local Payment Grouper software (www.hscic.gov.uk/article/3938/HRG4-201415-Payment-Grouper);

• National Tariff Payment System rules will be applied (note: this will include linking the Inpatient HES dataset to the Critical Care HES dataset to ensure the correct calculation of excess bed day tariffs);

• National and indicative local tariffs will be applied to spells, including all national tariff adjustments;

• Aggregate average activity and cost ('expected') values for benchmarking comparisons will be calculated at HRG, ICD10 and OPCS4.7 level.

The FBS holds the processed data. Additional analysis carried out at this location may include the selection of peer group comparators.

Only aggregate level data with small number suppression leaves the UK FAST storage facility. Further visualisation to produce graphs and tables for inclusion in reports may take place at other NAW offices.

Inpatient HES records may be linked to other Inpatient HES records in the same dataset to track patient pathways for care. Inpatient HES records may be linked to Critical Care HES dataset to ensure the correct calculation of national tariff. The HES datasets will not be linked to any other dataset.

There is no requirement and there will be no attempt to identify individuals.

Data processing will be conducted by a single individual, a partner and SIRO of NAW, who will adhere to NAW’s information policy. NAW’s information policy has been developed and is managed by NAW’s Data protection Officer.

Access is via an encrypted remote access link from NAW’s processing location to NAW’s storage location.

Data will be stored at UKFast.net limited based in the UK, who are named as NAW’s data storage location in this agreement. NAW have purchased a dedicated server at this location to store the HES data. UK FAST personnel can access this server for IT management purposes. However no UK FAST employees will access data for the purposes set out above - that will only be done by NAW substantive employees.

NA Wilson Associates does not allow access to the FBS where NHS organisations wish to use the data for commercial purposes.

Only aggregate level 'expected' values are released either to clients or to other NAW offices. These releases are outputs that are all aggregated with small number suppressed in line with the HES analysis guide.

The reports produced by NAW that include data from the FBS contain tables and text where 'actual' values supplied by local NHS organisations (or calculated from the FBS) are compared with 'expected' values from FBS. 'Expected' values are average aggregate values, either the national average or the average calculated from similar organisations (e.g. similar Acute Trusts to the local Acute Trust, or similar CCGs to the local CCG).

Values from the FBS in tables or graphs in reports are the only HES data released to clients. Reports containing values from FBS are only provided to the NHS organisations who commission the work - no data is published publicly. NAW offer outputs from the FBS services to all NHS organisations.

NAW customers may extract graphs and tables from NAW reports for presentation to other organisations within their health economy for the purpose of improving services where the pathway for that service crosses organisational borders. For example:

• Specialised services might be shared between a network of NHS Trust organisation

• A diabetes or MSK service pathway will include primary care, community care and acute care providers

• A service may be set up between a group of GP Practices of a group of CCG commissioners within an STP (or ACS).

The communication approach generally includes the provision of a report (which may include spreadsheets or tables displaying aggregate values (with small number suppression)), presentation of this report to a senior management team, development of plans for service change (using evidence presented in the report) and implementation of service change. Occasionally, NAW will provide further output from the FBS to support monitoring the implementation of service change.

For this service that NAW provide, NHS customers approach NAW. Thus, NAW provide outputs from the FBS to NHS organisations only when they are requested. In this respect, the benchmarking product doesn’t differ significantly from many other user-access controlled national benchmarking tools available on the internet which calculate values using HES data (i.e. Model Hospital). Where the NAW offer differs from other benchmarking tools is that NAW work closely to tailor the output from the FBS to meet the specific needs of clients and NAW help their clients interpret results and use the results as evidence to support service change or financial validation. Thus, generally, NAW clients only gain access to outputs from the FBS for relatively short periods (i.e. months) for specific purposes.

All outputs will be aggregated outputs with small number suppresion applied in line with the HES analysis guide.

Benefits to NAW’s NHS clients as a result of outputs from the FBS service include:

• Improved transparency in financial and commissioning services between organisations in a healthcare economy;

• Ability of NHS organisations to commission or provide contracted services within their yearly budget (including financial turn-around);

• Assurance to organisations that they are compliant with national guidelines and accepted 'normal' codes of practice in clinical coding, commissioning and financial processing;

• Support to plan and implement financial, contractual or healthcare service changes. These changes improve the quality of care for patients and cost efficiency of services for NHS organisations.

NAW can supply many examples of past work that demonstrate financial savings to organisations, arbitration or advice that has improved transparency between organisations, and support for service changes for the benefit of patients. For example, the FBS service was part of a service delivered to a CCG and acute trust to understand their delivery of local rehabilitation services. The evidence indicated that the service was being delivered was expensive for both the acute trust and the CCG. As a result, the organisations worked to change their discharge planning process to deliver more rehabilitation in patients homes.

Because of NAW financial and commissioning expertise, NAW provide services to a number of national programmes and organisations (e.g. current programmes - the Specialist Orthopaedic Alliance, and the Get It Right First Time programme). NA Wilson Associates were one of the only external organisations invited to review the PbR payment system by the Audit Commission.

It is this type of service - helping primarily commissioning organisations to understand the services that they are purchasing with a view to working with local providers to improve the services that are delivered to patients - for which NAW will continue to use the FBS.

Benefits to NAW’s NHS clients as a result of outputs from the FBS service include:

• Improved transparency in financial and commissioning services between organisations in a healthcare economy;

• Ability of NHS organisations to commission or provide contracted services within their yearly budget (including financial turn-around);

• Assurance to organisations that they are compliant with national guidelines and accepted 'normal' codes of practice in clinical coding, commissioning and financial processing;

• Support to plan and implement financial, contractual or healthcare service changes. These changes improve the quality of care for patients and cost efficiency of services for NHS organisations.

NAW can evidence many examples of past work that demonstrate financial savings to organisations, arbitration or advice that has improved transparency between organisations, and support for service changes for the benefit of patients. For example, the FBS service was part of a service delivered to a CCG and acute trust to understand the delivery of local rehabilitation services. The evidence indicated that the service was being delivered was expensive for both the acute trust and the CCG. As a result, the organisations worked to change their discharge planning process to deliver more rehabilitation in patient’s homes.

The detail above illustrates that NAW’s FBS provides benefit to the tax-payer by supporting the delivery of cost-efficient healthcare services. NAW work with customers also helps provide more effective healthcare services for the benefit of patients.

For one recent customer, NAW used the FBS to help a CCG understand why their budget is over-performing but their contracted activity is not over-performing. A comparison of local data with the FBS data illustrated that a local Acute Trust has begun recording 'co-morbidity' ICD10 codes thoroughly. The inclusion of 'co-morbidity' ICD10 codes can switch the assigned HRG from a 'without complications' to a 'with complications' HRG without patients necessarily having received an enhanced service. 'With complications' HRGs usually attract a higher national tariff. Using this evidence, NAW worked with the CCG to negotiate a financial adjustment with their local Acute Trust for the current year, and to plan changes to services to mitigate the impact of the financial impact for future years. For this specific example, the CCG was able to negotiate a reduction of their invoice with the local Acute Trust of greater than £1 million. Changes to services were forecast to lead to savings in future years of significantly more that this value.

Because of NAW financial and commissioning expertise, NAW provide services to a number of national programmes and organisations (e.g. current programmes - the Specialist Orthopaedic Alliance, and the Get It Right First Time programme). NA Wilson Associates were one of the only external organisations invited to review the national payment system by the Audit Commission.

It is this type of service - helping primarily commissioning organisations to understand the services that they are purchasing with a view to working with local providers to improve the services that are delivered to patients - for which NAW will continue to use the FBS.

As a result of using HES 2016/17 inpatient data, NAW have been able to provide on-going commissioning support to Norfolk CCGs. NAW continues to work with all the CCGs in Norfolk, to monitor budget performance, negotiate clinical and financial service improvements with acute hospital providers, and work with GP practices to plan and implement service improvements.

NAW used the FBS to support work on children's services with the Norfolk County Council. Specifically helping the Council understand the children's services being delivered by local Acute Hospitals and undertake gap analysis to understand:

(1) what services were being duplicated by hospitals and the council; and

(2) what services were falling in the gap between hospital-delivered and council-delivered services.

NAW worked with the NHS England East of England regional team to review cancer services and provided information on where services were being delivered, the patient flows across the region and into specific hospitals, the spread of services both the place of delivery of complex care and the place of delivery of radiotherapy and chemotherapy.

NAW worked in the North Central London region to undertake a clinical audit of the Emergency pathway and reviewed A&E services, the admission of patients to observation wards, and the onward flow of patients to acute & general wards and eventually to specialty wards. The aim was to understand what services were delivered in each of these departments to understand what was most efficient. For example, should complex diagnostics be delivered in A&E, in an observation ward, or in the acute & general ward?