DSfC - NHS Camden CCG; RS.

Risk Stratification

This is an application to use SUS data identifiable at the level of pseudonymised/encrypted NHS number for the purpose of Risk Stratification. Camden CCG Risk Stratification provides a forecast of future demand by identifying high risk groups as part of its population health management. This enables commissioners to initiate proactive management plans for cohorts / categories of clinical treatment that are potentially high service users.

The new risk stratification tool will be delivered through NEL Commissioning Support Unit in-house developed information system, NELIE. This well-established risk stratification tool has been effectively used by NEL CSU in other CCGs across London and the South East.

Uses and benefits of the NEL CSU Risk Stratification Tool include:

•The report allows you to choose to view patients with a specific Long Term Condition or demographic using GP practice data.

•The report can be drilled down to allow GPs to view the patient’s activity across the last 12 months

•The tool allows GPs to view their patients at risk of a hospital admission in the next 12 months. The risk stratification can be calculated from CPM, Q-admissions or PARR

•Supporting GP practices to use the tool and reporting output to identify patients with emerging need rather than patients with an already established high need.

•Identify patients at risk of future A&E attendances, unplanned admissions and at increased risk of being placed into a nursing or residential home

•Identify the most important conditions, including but not limited to, long term conditions effecting frail and elderly.

•Understanding the variation of risk of future unplanned attendances, hospital admissions and placements in residential or nursing care homes across the local population.

•Allow case finders to identify patients for review for case management intervention and multi-disciplinary team case conference.

Risk Stratification

1. Identifiable SUS data is obtained from the SUS Repository by North East London Data Services for Commissioners Regional Office (DSCRO).

2. Data quality management, standardisation and pseudonymisation of the data is completed by North East London DSCRO and the pseudonymised record level data is transferred securely to North East London CSU, who hold the SUS data within the secure Data Centre on N3.

3. GP Data identifiable at the level of NHS number is securely sent from the GP system to North East London CSU.

4. The look-up table held within the DSCRO pseudonymises the GP data using the same pseudo ID as SUS. The same Pseudo Id applies across all the datasets listed within the application.

5. The pseudonymised GP and SUS data is loaded into the risk stratification tool where the data is linked.

6. As part of the risk stratification processing activity, GPs have access to the risk stratification tool within the data processor, which highlights patients with whom the GP has a legitimate relationship and have been classed as at risk. The GPs access the pseudonymised NHS number of their own patients however do have the ability to access the NHS Number of those patients, following explicit action that initiates a re-identification from the pseudonymised NHS Number, for the purpose of direct care. Any further identification of the patients will be completed by the GP on their own systems, using the revealed NHS Numbers.

7. North East London CSU who hosts the risk stratification system that holds SUS data is limited to those administrative staff with authorised user accounts used for identification and authentication.

8. Once North East London CSU has completed the processing, the CCG can access the online system via a secure N3 connection to access the data pseudonymised at patient level.

Data must only be used as stipulated within the Data Sharing Agreement.

Data Processors must only act upon instruction from the Data Controller.

Data can only be stored at the addresses listed under the storage addresses.

Patient level data will not be shared outside of the CCG unless it is for the purpose of Direct Care, where it may be shared only with those health professionals who have a legitimate relationship with the patient and a legitimate reason to access the data.

All access to data is managed under Roles-Based Access Controls.

No patient level data will be linked other than as specifically detailed within this agreement. Data will only be shared with those parties listed and will only be used for the purposes laid out in the application/agreement. The data to be released from NHS Digital will not be national data, but only that data relating to the specific locality and that data required by the applicant.

NHS Digital reminds all organisations party to this agreement of the need to 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).

1) Commissioner reporting:

(a) Summary by provider view - plan & actuals year to date (YTD).

(b) Summary by Patient Outcome Data (POD) view - plan & actuals YTD.

(c) Summary by provider view - activity & finance variance by POD.

(d) Planned care by provider view - activity & finance plan & actuals YTD.

(e) Planned care by POD view - activity plan & actuals YTD.

(f) Provider reporting.

(j) Delayed discharges.

(k) Quality & performance referral to treatment reporting.

2) Readmissions analysis.

3) Production of aggregate reports for CCG Business Intelligence.

4) Production of project / programme level dashboards.

5) Monitoring of acute / community / mental health quality matrix.

6) Clinical coding reviews / audits.

7) Budget reporting down to individual GP Practice level.

8) GP Practice level dashboard reports include high flyers.

Risk Stratification

1) As part of the risk stratification processing activity detailed above, no access is available to re-identify any individual patient information.

2) Output from the risk stratification tool will provide aggregate reporting of number and percentage of population found to be at risk with no identifiers

3) Record level output will be available for commissioners (of the CCG), pseudonymised at patient level.

4) GP Practices will be able to view the risk scores for individual patients with the ability to display the underlying SUS+ data for the individual patients when it is required for direct care purposes by someone who has a legitimate relationship with the patient.

5) The CCG will be able to target specific patient groups and enable clinicians with the duty of care for the patient to offer appropriate interventions. The CCG will also be able to:

o Stratify populations based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost

o Plan work for commissioning services and contracts

o Set up capitated budgets

o Identify health determinants of risk of admission to hospital, or other adverse care outcomes.

1) Supporting Quality Innovation Productivity and Prevention (QIPP) to review demand management, Integrated care and pathways.

(a) Analysis to support full business cases.

(b) Develop business models.

(b) Monitor In year projects.

2) Supporting Joint Strategic Needs Assessment (JSNA) for specific disease types.

3) Health economic modelling using:

(a) Analysis on provider performance against 18 weeks wait targets.

(b) Learning from and predicting likely patient pathways for certain conditions, in order to influence early interventions and other treatments for patients.

(c) Analysis of outcome measures for differential treatments, accounting for the full patient pathway.

(d) Analysis to understand emergency care and linking A&E and Emergency Urgent Care Flows (EUCC) flows.

4) Commissioning cycle support for grouping and re-costing previous activity.

5) Enables monitoring of:

(a) CCG outcome indicators.

(b) Non-financial validation of activity.

(c) Successful delivery of integrated care within the CCG.

(d) Checking frequent or multiple attendances to improve early intervention and avoid admissions.

(e) Case management.

(f) Care service planning.

(g) Commissioning and performance management.

(h) List size verification by GP practices.

(i) Understanding the care of patients in nursing homes.

6) Feedback to NHS service providers on data quality at an aggregate and individual record level.

Risk Stratification

Risk stratification promotes improved case management in health care and will lead to the following benefits being realised:

1. Improved planning by better understanding patient flows through the healthcare system, thus allowing commissioners to design appropriate pathways to improve patient flow and allowing commissioners to identify priorities and identify plans to address these.

2. Improved quality of services through reduced emergency readmissions, especially avoidable emergency admissions. This is achieved through mapping of frequent users of emergency services thus allowing early intervention.

3. Improved access to services by identifying which services may be in demand but have poor access, and from this identify areas where improvement is required.

4. Supports the commissioner to meets its requirement to reduce premature mortality in line with the CCG Outcome Framework by allowing for more targeted intervention in primary care.

5. Better understanding of local population characteristics through analysis of their health and healthcare outcomes.

All of the above lead to improved patient experience through more effective commissioning of services.

Not stated in the register.