DSfC - NHS Bristol, North Somerset and South Gloucestershire CCG - IV, RS & Comm
NHS Bristol, North Somerset and South Gloucestershire ICB · Sub ICB Location
Listed under NHS Bristol, North Somerset and South Gloucestershire Integrated Care Board.
Expired The latest version ended on 4 January 2024. The September 2026 register still lists the agreement, but its term has passed.
- Reference
- DARS-NIC-186885-Q1T3D
- Latest version
- v5.3
- Term of latest version
- 5 January 2021 to 4 January 2024
- Start date
- Before 1 April 2019
- Data controller
- Sole Data Controller
- Commercial purposes
- No
- Sublicensing
- No
- Files released to date
- 0
Why the data was released
Objective for processing
INVOICE VALIDATION
Invoice validation is part of a process by which providers of care or services get paid for the work they do.
Invoices are submitted to the Clinical Commissioning Group (CCG) so the CCG is are able to ensure that the activity claimed for each patient is their responsibility. This is done by processing and analysing Secondary User Services (SUS+) data, which is received into a secure Controlled Environment for Finance (CEfF). The SUS+ data is identifiable at the level of NHS number. The NHS number is only used to confirm the accuracy of backing-data sets (data from providers) and will not be used further.
The CCG are advised by the appointed CEfF whether payment for invoices can be made or not.
Invoice Validation will be conducted by NHS Bristol, North Somerset and South Gloucestershire CCG
RISK STRATIFICATION
Risk stratification is a tool for identifying and predicting which patients are at high risk (of health deterioration and using multiple services) or are likely to be at high risk and prioritising the management of their care in order to prevent worse outcomes.
To conduct risk stratification Secondary User Services (SUS+) data, identifiable at the level of NHS number is pseudonymised and linked with Primary Care data (from GPs) and an algorithm is applied to produce risk scores. Risk Stratification provides focus for future demands by enabling commissioners to prepare plans for both individual and groups of vulnerable patients. Commissioners can then prepare plans for patients who may require high levels of care. Risk Stratification, following re-identification, also enables General Practitioners (GPs) to better target intervention in Primary Care.
Risk Stratification will be conducted by NHS South Central and West Commissioning Support Unit.
COMMISSIONING
To use pseudonymised data to provide intelligence to support the commissioning of health services. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the CCG area.
The CCGs commission services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.
The following pseudonymised datasets are required to provide intelligence to support commissioning of health services:
- Secondary Uses Service (SUS+)
- Local Provider Flows
a. Acute
b. Ambulance
c. Community
d. Demand for Service
e. Diagnostic Service
f. Emergency Care
g. Experience, Quality and Outcomes
h. Mental Health
i. Other Not Elsewhere Classified
j. Population Data
k. Primary Care Services
l. Public Health Screening
- Mental Health Minimum Data Set (MHMDS)
- Mental Health Learning Disability Data Set (MHLDDS)
- Mental Health Services Data Set (MHSDS)
- Maternity Services Data Set (MSDS)
- Improving Access to Psychological Therapy (IAPT)
- Child and Young People Health Service (CYPHS)
- Community Services Data Set (CSDS)
- Diagnostic Imaging Data Set (DIDS)
- National Cancer Waiting Times Monitoring Data Set (CWT)
- Civil Registries Data (CRD) (Births)
- Civil Registries Data (CRD) (Deaths)
- National Diabetes Audit (NDA)
- Patient Reported Outcome Measures (PROMs)
- e-Referral Service (eRS)
- Personal Demographics Service (PDS)
- Summary Hospital-level Mortality Indicator (SHMI)
The pseudonymised data is required to for the following purposes:
1. Population health management:
a. Understanding the interdependency of care services
b. Targeting care more effectively
c. Using value as the redesign principle
2. Data Quality and Validation – allowing data quality checks on the submitted data
3. Thoroughly investigating the needs of the population, to ensure the right services are available for individuals when and where they need them
4. Understanding cohorts of residents who are at risk of becoming users of some of the more expensive services, to better understand and manage those needs
5. Monitoring population health and care interactions to understand where people may slip through the net, or where the provision of care may be being duplicated
6. Modelling activity across all data sets to understand how services interact with each other, and to understand how changes in one service may affect flows through another
7. Service redesign
8. Health Needs Assessment – identification of underlying disease prevalence within the local population
9. Patient stratification and predictive modelling - to highlight cohorts of patients at risk of requiring hospital admission and other avoidable factors such as risk of falls, computed using algorithms executed against linked de-identified data, and identification of future service delivery models
10. Demand Management - to improve the care service for patients by predicting the impact on certain care pathways and support the secondary care system in ensuring enough capacity to manage the demand.
11. Support measuring the health, mortality or care needs of the total local population
The pseudonymised data is required to ensure that analysis of health care provision can be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets.
Processing for commissioning will be conducted by the following data processors
NHS South Central and West Commissioning Support Unit (SCWCSU)
SCWCSU provide commissioning functions such as, but not limited to, data quality and validation checks, data linkages, the submission of routine statutory returns, performance benchmarking, geographical mapping and intelligence and CCG commissioned reporting for performance, activity and financial monitoring.
Outcomes Based Healthcare (OBH)
Outcomes Based Healthcare is a private limited company based at the King's fund contracted by NHS Bristol North Somerset and South Gloucestershire CCG to assist in developing local Outcomes Frameworks for diabetes and respiratory programmes. Clinical outcomes have been prioritised through workshops and engagement with commissioners, providers, clinicians and services users and two types of outcome measures have been selected;
• Clinical and Social Outcome Measures (CSOMs), where existing health and care data is used,
• Person-Centred Outcome Measures (PCOMs), where surveys/PROMs are used to collect this data directly from service users.
Having previously baselined (2016-2017) data the ongoing monitoring and development of CSOMs selected for the BNSSG Outcomes Frameworks, pseudonymised, patient-level health and care data is required to populate the BNSSG/OBH Outcomes Platform, where this information is processed, aggregated and visualised for monitoring, reporting and planning service delivery.
Optum Health Solutions (UK) Ltd
NHS Bristol, North Somerset and South Gloucestershire CCG is working with NHS England as a Wave 2 Population Health Management CCG. NHS England have contracted Optum Health Solutions (UK) Ltd to work with selected CCGs to undertake population health and actuarial analysis to build up a methodology for dissemination across the NHS in England.
Data held by Optum Health Solutions (UK) Ltd, will be destroyed within 6 months of completion of the project and permissions as a data processor will be removed from this agreement by amendment.
University of Bristol / University of the West of England
NHS Bristol, North Somerset and South Gloucestershire CCG has strong analytical relationships with local Universities. The CCG offers local universities opportunities for carefully controlled analysis projects for students on industrial placement years. Working in partnership with local universities the CCG has been very successful in securing funding for bespoke projects.
The University of Bristol has a global reputation for multi-morbidity research, medical statistics and health data science and the University of the West of England has a top UK Business School. Across each of these disciplines the CCG works to maximise achievable benefits to both the NHS and academia.
Project allocation will be undertaken on a project by project basis as determined by the CCG PHM Steering Group with due reference to the activities allowed under this agreement. Additionally these projects will only be in relation to the Commissioning purposes laid out in this agreement. Data sharing will be managed according to the over-riding principles of the CCG PHM Programme, namely;
i) that work be performed collaboratively,
ii) for the good of the BNSSG health and care system,
iii) under lead of a designated CCG problem owner, with role-based accesses awarded and controlled in partnership with our IT provider (SWCSU)
iv) on specific projects authorised by the BNSSG PHM Steering Group,
v) decided on through a project-by-project basis,
vi) with only the minimum required data being provided, and
vii) through an approved, secure channel.
Any funding provided to University of Bristol and University of the West of England for the processing carried out under this agreement is provided by the CCG and consequently there are no commercial aspects to this agreement.
COVID-19 Testing data
In order to support commissioning during the COVID-19 pandemic, the CCG also receive a flow of COVID-19 testing data directly from Public Health England which is then linked to the datasets received in this DSA. This will greatly enhance the quality of the data through;
• Modelling – through enhanced geospatial analysis, the CCG will be in a better position to predict incoming hospital demand
• Population Health Management - Inclusion of intelligence on COVID-19 in the population will help inform decision making about the health and care delivery of the population
• Dynamically map prevalence of prior and current infection of COVID-19 through location, NHS system-wide data linkage and data visualisation
Processing activities
PROCESSING CONDITIONS:
Data must only be used for the purposes stipulated within this Data Sharing Agreement. Any additional disclosure / publication will require further approval from NHS Digital.
Data Processors must only act upon specific instructions from the Data Controller.
Data can only be stored at the addresses listed under storage addresses.
All access to data is managed under Role-Based Access Controls. Users can only access data authorised by their role and the tasks that they are required to undertake.
Patient level data will not be linked other than as specifically detailed within this Data Sharing Agreement. Data released will only be shared with those parties listed and will only be used for the purposes laid out in the application/agreement.
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)
The DSCRO (part of NHS Digital) will apply National Opt-outs before any identifiable data leaves the DSCRO only for the purpose of Risk Stratification.
CCGs should work with general practices within their CCG to help them fulfil data controller responsibilities regarding flow of identifiable data into risk stratification tools.
The only identifier available in the data set is the NHS numbers. Any further identification of the patients will only be completed by the patient’s clinician on their own systems for the purpose of direct care with a legitimate relationship.
ONWARD SHARING:
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.
Aggregated reports only with small number suppression can be shared externally as set out within NHS Digital guidance applicable to each data set.
SEGREGATION:
Where the Data Processor and/or the Data Controller hold both identifiable and pseudonymised data, the data will be held separately so data cannot be linked.
Where the Data Processor and/or the Data Controller hold identifiable data with opt outs applied and identifiable data with opt outs not applied, the data will be held separately so data cannot be linked.
All access to data is auditable by NHS Digital.
Data for the purpose of Invoice Validation is kept within the CEfF, and only used by staff properly trained and authorised for the activity. Only CEfF staff are able to access data in the CEfF and only CEfF staff operate the invoice validation process within the CEfF. Data flows directly in to the CEfF from the DSCRO and from the providers – it does not flow through any other processors.
DATA MINIMISATION
Data Minimisation in relation to the data sets listed within this application are listed below. This also includes the purpose on which they would be applied -
For the purpose of Commissioning:
• Patients who are normally registered and/or resident within the NHS Bristol, North Somerset and South Gloucestershire CCG (including historical activity where the patient was previously registered or resident in another commissioner).
and/or
• Patients treated by a provider where NHS Bristol, North Somerset and South Gloucestershire CCG is the host/co-ordinating commissioner and/or has the primary responsibility for the provider services in the local health economy – this is only for commissioning and relates to both national and local flows.
and/or
• Activity identified by the provider and recorded as such within national systems (such as SUS+) as for the attention of NHS Bristol, North Somerset and South Gloucestershire CCG - this is only for commissioning and relates to both national and local flows.
For the purpose of Risk Stratification:
• Patients who are normally registered and/or resident within NHS Bristol, North Somerset and South Gloucestershire CCG (including historical activity where the patient was previously registered or resident in another commissioner)
For the purpose of Invoice Validation:
• CCG of residence and/or registration.
In addition to the dissemination of Cancer Waiting Times Data via the DSCRO, the CCG is able to access reports held within the CWT system in NHS Digital directly. Access within the CCG is limited to those with a need to process the data for the purposes described in this agreement.
A CCG user will be able to access the provider extracts from the portal for any provider where at least 1 patient for whom they are the registered CCG for that individuals GP practice appears in that setting
Although a CCG user may have access to pseudonymised patient information not related to that CCG, users should only process and analyse data for which they have a legitimate relationship (as described within Data Minimisation).
Microsoft Limited supply Cloud Services for Outcomes Based Healthcare and South Central and West Commissioning Support Unit and are therefore listed as a data processor. They supply support to the system, but do not access data. Therefore, any access to the data held under this agreement would be considered a breach of agreement. This includes granting of access to the database[s] containing the data.
Microsoft Limited and Amazon Web Services provide cloud services for Optum Health Solutions (UK) Limited and are therefore listed as processors. They supply support to the system, but do not access data. Therefore, any access to the data held under this agreement would be considered a breach of the agreement. This includes granting of access to the database[s] containing the data.
ANS Group Limited will be assisting in the set up and management of the South Central and West Commissioning Support Unit Microsoft Azure Cloud and are therefore listed as a data processor. They will not have any additional processing / storage addresses (as these will be the Microsoft Azure addresses). Using the data for any other purpose would be considered a breach of this agreement.
University Hospitals Bristol NHS Foundation Trust do not access data held under this agreement as they only supply the building. Therefore, any access to the data held under this agreement would be considered a breach of the agreement. This includes granting of access to the database[s] containing the data.
INVOICE VALIDATION - NHS Bristol, North Somerset and South Gloucestershire CCG
1. Identifiable SUS+ Data is obtained from the SUS+ Repository by the Data Services for Commissioners Regional Office (DSCRO).
2. The DSCRO pushes a one-way data flow of SUS+ data into the Controlled Environment for Finance (CEfF) located in the CCG.
3. The CEfF also receive backing data from the provider.
4. The CEfF conduct the following processing activities for invoice validation purposes:
a. Validating that the Clinical Commissioning Group are responsible for payment for the care of the individual by using SUS+ and/or provider backing flow data.
b. Once the provider backing information is received, it will be checked against national NHS and local commissioning policies, as well as being checked against system access and reports provided by NHS Digital to confirm the payments are:
i. In line with Payment by Results tariffs
ii. In relation to a patient registered with the CCG, GP or resident within the CCG area.
iii. The health care provided should be paid by the CCG in line with CCG guidance.
5. The CCG are notified by the CEfF that the invoice has been validated and can be paid. Any discrepancies or non-validated invoices are investigated and resolved.
RISK STRATIFICATION - South Central and West Commissioning Support Unit
1. Identifiable SUS+ data is obtained from the SUS Repository to the Data Services for Commissioners Regional Office (DSCRO).
2. Data quality management and standardisation of data is completed by the DSCRO and the data identifiable at the level of NHS number is transferred securely to South Central and West Commissioning Support Unit, who hold the SUS+ data within the secure Data Centre.
3. Identifiable GP Data is securely sent from the GP system to South Central and West Commissioning Support Unit.
4. SUS+ data is linked to GP data in the risk stratification tool by the data processor.
5. 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 only identifier available to GPs is the NHS numbers of their own patients. Any further identification of the patients will be completed by the GP on their own systems.
6. Once South Central and West Commissioning Support Unit has completed the processing, the CCG can access the online system via a secure connection to access the data pseudonymised at patient level
COMMISSIONING
The Data Services for Commissioners Regional Office (DSCRO) obtains the following data sets:
1. SUS+
2. Local Provider Flows (received directly from providers)
a. Acute
b. Ambulance
c. Community
d. Demand for Service
e. Diagnostic Service
f. Emergency Care
g. Experience, Quality and Outcomes
h. Mental Health
i. Other Not Elsewhere Classified
j. Population Data
k. Primary Care Services
l. Public Health Screening
3. Mental Health Minimum Data Set (MHMDS)
4. Mental Health Learning Disability Data Set (MHLDDS)
5. Mental Health Services Data Set (MHSDS)
6. Maternity Services Data Set (MSDS)
7. Improving Access to Psychological Therapy (IAPT)
8. Child and Young People Health Service (CYPHS)
9. Community Services Data Set (CSDS)
10. Diagnostic Imaging Data Set (DIDS)
11. National Cancer Waiting Times Monitoring Data Set (CWT)
12. Civil Registries Data (CRD) (Births)
13. Civil Registries Data (CRD) (Deaths)
14. National Diabetes Audit (NDA)
15. Patient Reported Outcome Measures (PROMs)
16. e-Referral Service (eRS)
17. Personal Demographics Service (PDS)
18. Summary Hospital-level Mortality Indicator (SHMI)
Data quality management and pseudonymisation is completed within the DSCRO and is then disseminated as follows:
Data Processor - NHS South Central and West Commissioning Support Unit
1. Pseudonymised SUS+, Local Provider data, Mental Health data (MHSDS, MHMDS, MHLDDS), Maternity data (MSDS), Improving Access to Psychological Therapies data (IAPT), Child and Young People’s Health data (CYPHS), Community Services Data Set (CSDS), Diagnostic Imaging data (DIDS), National Cancer Waiting Times Monitoring Data Set (CWT), Civil Registries Data (CRD) (Births and Deaths), National Diabetes Audit (NDA), Patient Reported Outcome Measures (PROMs) and e-Referral Service (eRS) Personal Demographics Service (PDS) and Summary Hospital-level Mortality Indicator (SHMI) data only is transferred from the DSCRO to South, Central and West Commissioning Support Unit.
2. South, Central and West Commissioning Support Unit receives GP data (see points i – vii below).
3. South, Central and West Commissioning Support Unit receive a flow of social care data (see points i – vii below).
4. South, Central and West Commissioning Support Unit also receive a flow of COVID-19 testing data (see points i – vii below)
5. South, Central and West Commissioning Support Unit for the add derived fields, link data sets and provide analysis.
6. Allowed linkage is only between data listed in point 1, point 2, point 3 and point 4. No further linkage is permitted.
7. South, Central and West Commissioning Support Unit provide analysis such as, but not limited to, data quality and validation checks, data linkages, the submission of routine statutory returns, performance benchmarking, geographical mapping and intelligence and CCG commissioned reporting for performance, activity and financial monitoring.
8. South, Central and West Commissioning Support Unit then pass the processed, pseudonymised and linked data to the CCG.
9. Aggregation of required data for CCG management use will be completed by South, Central and West Commissioning Support Unit as instructed by the CCG.
GP, Social Care and Testing Data
i. Identifiable GP data is submitted to South Central and West Commissioning Support Unit in a ring-fenced area and pseudonymised using a pseudonymisation tool, different to that used by the DSCRO.
ii. Social Care data is either:
a) pseudonymised within the provider, prior to submission, using a pseudonymisation tool, different to that used by the DSCRO. The provider requests a pseudonymisation key from the DSCRO. The key can only be used once. The key is specific to the Local Authority and to that specific date.
or
b) identifiable Social Care data land in a ring-fenced area and pseudonymised using a pseudonymisation tool, different to that used by the DSCRO.
iii. COVID-19 Testing data is either
a) pseudonymised within the provider, prior to submission, using a pseudonymisation tool, different to that used by the DSCRO. The provider requests a pseudonymisation key from the DSCRO. The key can only be used once. The key is specific to this project
or
b) identifiable COVID-19 Testing data lands in a ring-fenced area and pseudonymised using a pseudonymisation tool, different to that used by the DSCRO.
iv. There is a Data Processing Agreement in place between the providers (GP, Local Authority and Public Health England) and South Central and West Commissioning Support Unit. A specific named individual within South Central and West Commissioning Support Unit acts on behalf of the providers.
v. This individual has access to a black box. The pseudonymised data is passed through the black box process where the pseudonymisation is mapped to the pseudonymisation used by the DSCRO.
vi. Once mapped, the data is passed into South Central and West Commissioning Support, but before South Central and West Commissioning Support Unit will receive the data from the ring-fenced area, they require confirmation that the identifiable data has been deleted.
vii. The data is then passed into the non-ringfenced area with the pseudo algorithm specific to them.
Black Box Software
- The Black Box is a software process with very limited access, restricted to only those who administer it.
- It is a set of logic that is hidden from users. It generates a re-pseudonymised output from the data that users enter.
- The purpose of the Black Box is to map the data such that the resulting pseudonymisation is the same as that used at the DSCRO.
- The Black Box works by calling upon a mapping table from the DSCRO and re-pseudonymising by switching the pseudonym. No data is persisted in the Black Box.
- The Black Box is held within a private part of South Central and West Commissioning Support Unit secure network and physically located at the storage address within the DARS application/agreement with the same underlying security controls.)
Data Processor - Outcomes Based Health
1. Pseudonymised SUS+ (pseudonymised using an encryption key specific to this project), only is securely transferred from the DSCRO to South, Central and West Commissioning Support Unit.
2. South, Central and West Commissioning Support Unit add derived fields and securely transfer the data to the CCG.
3. The CCG passes the pseudonymised data to Outcomes Based Health
4. Outcomes Based Health then analyse the data to:
o Develop outcomes, baselining and monitoring of individual outcomes
o Provide detailed analysis relating to outcomes
5. Aggregation of required data for CCG management use will be completed by Outcomes Based Health or the CCG as instructed by the CCG.
Data Processor - Optum Health Solutions (UK) Ltd
1. Pseudonymised SUS, Local Provider Data, GP Primary Care data and Social Care data is securely transferred from NHS Bristol, North Somerset and South Gloucestershire CCG to Optum Health Solutions (UK) Ltd. The data is decoupled from the other national datasets and sent as individual data flows
2. Optum Health Solutions (UK) Ltd provide analysis to:
• Whole population segmentation to assess population health needs
• Prospective risk scoring for individuals to indicate the likelihood of future adverse events
• Predictive modelling to determine individuals at risk and an understanding of the drivers of risk
• Longitudinal analysis of intersegmental drift - identifying individuals who move between complexity classifications and the drivers of these transitions
• The production of individual-level theographs to identify gaps in care
3. Allowed linkage is between the datasets contained within point (1) above. GP and Social Care datasets are needed for the processing carried out by Optum to enhance the population health analytics beyond SUS and LPFs which contain only secondary cre activity
4. Optum Health Solutions (UK) Ltd then pass the processed, pseudonymised and linked data to the CCG.
5. Aggregated of required data for CCG management use will be completed by Optum Health Solutions (UK) Ltd or the CCG as instructed by the CCG.
6. Patient level data will not be shared outside of the CCG and will only be shared within the CCG on a need to know basis, as per the purposes stipulated within the Data Sharing Agreement. External aggregated reports only with small number suppression can be shared as set out within NHS Digital guidance applicable to each data set.
7. Optum Health Solutions (UK) Ltd will only be in receipt of data and only be permitted to act as Data Processors for the period specified in the NHSE contract with NHS Bristol, North Somerset and South Gloucestershire CCG.
Data held by Optum Health Solutions (UK) Ltd, will be destroyed within 6 months of completion of the project and permissions as a data processor will be removed from this agreement by amendment.
Data Processor – University of Bristol / University of the West of England
NHS Bristol, North Somerset and South Gloucestershire CCG will allocate projects to either the University of Bristol or University of the West of England.
Project allocation will be undertaken on a project by project basis as determined by the CCG PHM Steering Group. Data sharing will be managed according to the over-riding principles of the CCG PHM Programme, namely;
i) that work be performed collaboratively,
ii) for the good of the BNSSG health and care system,
iii) under lead of a designated CCG problem owner, with role-based accesses awarded and controlled in partnership with NHS Bristol, North Somerset and South Gloucestershire CCG’s IT provider (SWCSU)
iv) on specific projects authorised by the BNSSG PHM Steering Group,
v) decided on through a project-by-project basis,
vi) with only the minimum required data being provided, and
vii) through an approved, secure channel.
Data will be shared with each University as follows:
1. Pseudonymised subsets of SUS, Local Provider Data, GP Primary Care data, Social Care data and COVID-19 Testing data is securely transferred from NHS Bristol, North Somerset and South Gloucestershire CCG to the University*. The data is decoupled from the other national datasets and sent as individual data flows
2. The University* provides bespoke analysis for:
• Whole population segmentation to assess population health needs
• Prospective risk scoring for individuals to indicate the likelihood of future adverse events
• Predictive modelling to determine individuals at risk and an understanding of the drivers of risk
• Longitudinal analysis of intersegmental drift - identifying individuals who move between complexity classifications and the drivers of these transitions
• The production of individual-level theographs to identify gaps in care
3. Allowed linkage is between the datasets contained within point (1) above. GP and Social Care datasets are needed for the processing to enhance the population health analytics beyond SUS and LPFs which contain only secondary care activity. Linkage to COVID-19 Testing data will further enhance this.
4. The University* then pass the processed, pseudonymised and linked data to the CCG.
5. Aggregation of required data for CCG management use will be completed by the University* under direction of the CCG as instructed by the CCG, or the CCG.
6. Patient level data will not be shared outside of the CCG and will only be shared within the CCG on a need to know basis, as per the purposes stipulated within the Data Sharing Agreement. External aggregated reports only with small number suppression can be shared as set out within NHS Digital guidance applicable to each data set.
7. The University* will only be in receipt of data and only be permitted to act as Data Processors for the period specified in the contract with NHS Bristol, North Somerset and South Gloucestershire CCG
*References to ‘The University’ is either the University of Bristol or the University of the West of England only.
Expected output
INVOICE VALIDATION
1. The Controlled Environment for Finance (CEfF) will enable the CCG to challenge invoices and raise discrepancies and disputes.
2. Outputs from the CEfF will enable accurate production of budget reports, which will:
a. Assist in addressing poor quality data issues
b. Assist in business intelligence
3. Validation of invoices for non-contracted events where a service delivered to a patient by a provider that does not have a written contract with the patient’s responsible commissioner, but does have a written contract with another NHS commissioner/s.
4. Budget control of the CCG.
RISK STRATIFICATION
1. As part of the risk stratification processing activity detailed above, GPs have access to the risk stratification tool which highlights patients for whom the GP is responsible and have been classed as at risk. The only identifier available to GPs is the NHS numbers of their own patients. Any further identification of the patients will be completed by the GP on their own systems.
2. 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.
CCGs will be able to:
1. Target specific vulnerable patient groups and enable clinicians with the duty of care for the patient to offer appropriate interventions.
2. Reduce hospital readmissions and targeting clinical interventions to high risk patients.
3. Identify patients at risk of deterioration and providing effective care.
4. Reduce in the difference in the quality of care between those with the best and worst outcomes.
5. Re-design care to reduce admissions.
6. Set up capitated budgets – budgets based on care provided to the specific population.
7. Identify health determinants of risk of admission to hospital, or other adverse care outcomes.
8. Monitor vulnerable groups of patients including but not limited to frailty, COPD, Diabetes, elderly.
9. Health needs assessments – identifying numbers of patients with specific health conditions or combination of conditions.
10. Classify vulnerable groups based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost.
11. Production of Theographs – a visual timeline of a patients encounters with hospital providers.
12. Analyse based on specific diseases
In addition:
- The risk stratification tool will provide aggregate reporting of number and percentage of population found to be at risk.
- Record level output (pseudonymised) will be available for commissioners (of the CCG), pseudonymised at patient level. Onward sharing of this data is not permitted
COMMISSIONING
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.
g. Statutory returns.
h. Statutory returns - monthly activity return.
i. Statutory returns - quarterly activity return.
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.
9. Comparators of CCG performance with similar CCGs as set out by a specific range of care quality and performance measures detailed activity and cost reports
10. Data Quality and Validation measures allowing data quality checks on the submitted data
11. Contract Management and Modelling
12. Patient Stratification, such as:
a. Patients at highest risk of admission
b. Users of high cost activity
c. Frail and elderly
d. Patients that are currently in hospital
e. Patients with most referrals to secondary care
f. Patients with most emergency activity
g. Patients with most expensive prescriptions
h. Patients recently moving from one care setting to another
i. Discharged from hospital
ii. Discharged from community
13. Profiling population health and wider determinants to identify and target those most in need
a. Understanding population profile and demographics
b. Identify patient cohorts with specific needs or who may benefit from interventions
c. Identifying disease prevalence. health and care needs for population cohorts
d. Contributing to Joint Strategic Needs Assessment (JSNA)
e. Geographical mapping and analysis
14. Identifying and managing preventable and existing conditions
a. Identifying types of individuals and population cohorts at risk of non-elective re-admission
b. Risk stratification to identify populations suitable for case management
c. Risk profiling and predictive modelling
d. Risk stratification for planning services for population cohorts
e. Identification of disease incidence and diagnosis stratification
15. Reducing health inequalities
a. Identifying cohorts of patients who have worse health outcomes typically deprived, ethnic groups, homeless, travellers etc. to enable services to proactively target their needs
b. Socio-demographic analysis
16. Managing demand
a. Waiting times analysis
b. Service demand and supply modelling
c. Understanding cross-border and overseas visitor
d. Winter planning
e. Emergency preparedness, business continuity, recovery and contingency planning
17. Care co-ordination and planning
a. Planning packages of care
b. Service planning
c. Planning care co-ordination
18. Monitoring individual patient health, service utilisation, pathway compliance experience & outcomes across the heath and care system
a. Patient pathway analysis across health and care
b. Outcomes & experience analysis
c. Analysis to support anti-terror initiatives
d. Analysis to identify vulnerable patients with potential safeguarding issues
e. Understanding equity of care and unwarranted variation
f. Modelling patient flow
g. Tracking patient pathways
h. Monitoring to support New Models of Care
i. Identifying duplications in care
j. Identifying gaps in care, missed diagnoses and triple fail events
k. Analysing individual and aggregated timelines
19. Undertaking budget planning, management and reporting
a. Tracking financial performance against plans
b. Budget reporting
c. Tariff development
d. Developing and monitoring capitated budgets
e. Developing and monitoring individual-level budgets
f. Future budget planning and forecasting
g. Paying for care of overseas visitors and cross-border flow
20. Monitoring the value for money
a. Service-level costing & comparisons
b. Identification of cost pressures
a. Cost benefit analysis
b. Equity of spend across services and population cohorts
c. Finance impact assessment
21. Comparing population groups, peers, national and international best practice
d. Identification of variation in productivity, cost, outcomes, quality, experience, compared with peers, national and international & best practice
e. Benchmarking against other parts of the country
f. Identifying unwarranted variations
22. Comparing expected levels
g. Standardised comparisons for prevalence, activity, cost, quality, experience, outcomes for given populations
23. Comparing local targets & plan
h. Monitoring of local variation in productivity, cost, outcomes, quality and experience
i. Local performance dashboards by service provider, commissioner, geography, NMOC, STPs
24. Monitoring activity and cost compliance against contract and agreed plans
j. Contract monitoring
k. Contract reconciliation and challenge
l. Invoice validation
25. Monitoring provider quality, demand, experience and outcomes against contract and agreed plans
m. Performance dashboards
n. CQUIN reporting
o. Clinical audit
p. Patient experience surveys
q. Demand, supply, outcome & experience analysis
r. Monitoring cross-border flows and overseas visitor activity
26. Improving provider data quality
s. Coding audit
t. Data quality validation and review
u. Checking validity of patient identity and commissioner assignment
27. Validation for payment approval, ability to validate that claims are not being made after an individual has died, like Oxygen services.
28. Validation of programs implemented to improve patient pathway e.g. High users unable to validate if the process to help patients find the best support are working or did the patient die.
29. Clinical - understand reasons why patients are dying, what additional support services can be put in to support.
30. Understanding where patient are dying e.g. are patients dying at hospitals due to hospices closing due to Local authorities withdrawing support, or is there a problem at a particular trust.
31. Removal of patients from Risk Stratification reports.
32. Re births provide a one stop shop of information, Births are recorded in multiple sources covering hospital and home births, a chance to overlook activity.
33. Manage demand, by understanding the quantity of assessments required CCGs are able to improve the care service for patients by predicting the impact on certain care pathways and ensure the secondary care system has enough capacity to manage the demand.
34. Monitor the timing of key actions relating to referral letters. CCG’s are unable to see the contents of the referral letters.
35. Identify low priority procedures which could be directed to community-based alternatives and as such commission these services and deflect referrals for low priority procedures resulting in a reduction in hospital referrals.
36. Allow Commissioners to better protect or improve the public health of the total local patient population
37. Allow Commissioners to plan, evaluate and monitor health and social care policies, services, or interventions for the total local patient population
38. Allow Commissioners to compare their providers (trusts) mortality outcomes to the national baseline.
39. Investigate mortality outcomes for trusts
Outcomes Based Healthcare:
The main outputs are aggregated monthly values for each outcome outputs will comply with the NHS Digital guidance on suppression rules. The aggregated monthly outcomes data will be made available through OBH’s online tool (available to named individuals in the CCG and CCG commissioned providers only) via a secure login.
This enables the CCGs and to:
- visualise baselines for each outcome
- set improvement trajectories
- monitor outcomes on an on-going basis.
In addition, the CCGs will receive an information schedule describing the outcomes to be monitored, the technical description, and annual baseline data for each outcome.
All outputs will be delivered within the timescales of the contract between OBH and the CCG.
Optum Health Solutions UK Limited
The outputs, as part of the NHS England Wave 2 PHM national programme will identify patient cohorts and inequalities in outcome, spend and opportunity for further investigation, with a view to improving service delivery and patient health outcomes.
Wave 2 PHM will also begin to develop the CCG capability to undertake actuarial analysis of linked datasets from multiple care settings to develop further the understanding of the wider determinants of health across the population.
All outputs will be delivered within the timescales of the contract between Optum Health Solutions UK Limited and the CCG.
University of Bristol, University of the West of England
Given the relative specialisms of the universities, as outlined in Section 5a, BNSSG would expect clinical development projects for commissioning development to be concentrated with the University of Bristol.
Similarly the expected outputs from the University of the West of England are expected to relate more to the mathematical modelling of flow, demand and capacity.
Expected outputs include, but are not limited to;
1. Profiling population health and wider determinants to identify and target those most in need
a. Understanding population profile and demographics
b. Identify patient cohorts with specific needs or who may benefit from interventions
c. Identifying disease prevalence. health and care needs for population cohorts
d. Contributing to Joint Strategic Needs Assessment (JSNA)
e. Geographical mapping and analysis
2. Identifying and managing preventable and existing conditions
a. Identifying types of individuals and population cohorts at risk of non-elective re-admission
b. Identification of disease incidence and diagnosis stratification
3. Reducing health inequalities
a. Identifying cohorts of patients who have worse health outcomes typically deprived, ethnic groups, homeless, travellers etc. to enable services to proactively target their needs
b. Socio-demographic analysis
Outputs from the approved projects will be aggregated with small number suppression in line with NHS Digital analysis guidelines. These will be used to inform and develop clinical services across BNSSG and findings would expect to be published in research articles for peer reviewed academic journals and for presentation at the relevant workshops and academic conferences. Such publications could include case studies of analytics projects carried out using the data, or specific statistical analyses. This builds on existing practice within CCG Modelling and Analytics, which publishes work and presents at national conferences and which already has close working relationships with the University Centres for Healthcare Innovation and Improvement, the University of Bristol Population Health Sciences Institute and Elizabeth Blackwell Institute, as well as the NIHR South-West Applied Research Collaboration (ARC).
Availability of usable real-world data is well-established a major barrier to realising practical benefits from research projects in academic statistical modelling and operational research. This has been acknowledged in the work of the national Plethora project for example, which was set up in part to bridge the gap between academic knowledge/technique generation and practical application of those outputs by healthcare analysts at the NHS coalface. Dissemination of findings would – in addition to traditional academic publication and conference channels – also promote posting of relevant reusable open source code, summary results, and documentation to sites such as NHS Futures and via the NHS BNSSG Analytics GitHub repository, in order to support exposure to other healthcare systems.
All outputs will be delivered within the timescales of the contract between the universities and the CCG
COVID-19 Testing Data
Record-level testing data will dramatically improve the capability of the CCG’s local forecasting approaches, including ‘nowcasting’ methods and the SEIR model. The outputs of these models regularly feed the system’s major incident Bronze and Silver Commands. Thus improving the quality of these models allows them to provide better quality information to senior system leaders in the decision-making process.
Work includes population segmentation, cohort analysis and impact analysis, underpinned by disciplines such as impact assessments and evaluation. From this, decisions about the health and care delivery of the population can be made using an evidence base and insight to inform service transformation and monitor value through outcomes.
Aggregated small numbers suppressed data from this analysis will be shared externally to help inform an urgent public health study (COVID-19 Mapping and Mitigation in Schools) run from the University of Bristol
Expected measurable benefits
INVOICE VALIDATION
The invoice validation process supports the ongoing delivery of patient care across the NHS and the CCG region by:
1. Ensuring that activity is fully financially validated.
2. Ensuring that service providers are accurately paid for the patients treatment.
3. Enabling services to be planned, commissioned, managed, and subjected to financial control.
4. Enabling commissioners to confirm that they are paying appropriately for treatment of patients for whom they are responsible.
5. Fulfilling commissioners duties to fiscal probity and scrutiny.
6. Ensuring full financial accountability for relevant organisations.
7. Ensuring robust commissioning and performance management.
8. Ensuring commissioning objectives do not compromise patient confidentiality.
9. Ensuring the avoidance of misappropriation of public funds.
RISK STRATIFICATION
Risk stratification promotes improved case management in primary 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 and health outcomes through more effective commissioning of services.
COMMISSIONING
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.
c. 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).
4. Commissioning cycle support for grouping and re-costing previous activity.
5. Enables monitoring of:
a. CCG outcome indicators.
b. Financial and 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 – only on data initially provided by the service providers.
7. 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.
8. Improved quality of services through reduced emergency readmissions, especially avoidable emergency admissions. This is achieved through mapping of frequent users of emergency services and early intervention of appropriate care.
9. 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.
10. Potentially reduced premature mortality by more targeted intervention in primary care, which supports the commissioner to meets its requirement to reduce premature mortality in line with the CCG Outcome Framework.
11. Better understanding of the health of and the variations in health outcomes within the population to help understand local population characteristics.
12. Better understanding of contract requirements, contract execution, and required services for management of existing contracts, and to assist with identification and planning of future contracts
13. Insights into patient outcomes, and identification of the possible efficacy of outcomes-based contracting opportunities.
14. Reviewing current service provision
a. Cost-benefit analysis and service impact assessments to underpin service transformation across health economy
b. Service planning and re-design (development of NMoC and integrated care pathways, new partnerships, working with new providers etc.)
c. Impact analysis for different models or productivity measures, efficiency and experience
d. Service and pathway review
e. Service utilisation review
15. Ensuring compliance with evidence and guidance
a. Testing approaches with evidence and compliance with guidance.
16. Monitoring outcomes
a. Analysis of variation in outcomes across population group
17. Understanding how services impact across the health economy
a. Service evaluation
b. Programme reviews
c. Analysis of productivity, outcomes, experience, plan, targets and actuals
d. Assessing value for money and efficiency gains
e. Understanding impact of services on health inequalities
18. Understanding how services impact on the health of the population and patient cohorts
a. Measuring and assessing improvement in service provision, patient experience & outcomes and the cost to achieve this
b. Propensity matching and scoring
c. Triple aim analysis
19. Understanding future drivers for change across health economy
a. Forecasting health and care needs for population and population cohorts across STPs
b. Identifying changes in disease trends and prevalence
c. Efficiencies that can be gained from procuring services across wider footprints, from new innovations
d. Predictive modelling
20. Delivering services that meet changing needs of population
a. Analysis to support policy development
b. Ethical and equality impact assessments
c. Implementation of NMOC
d. What do next years contracts need to include?
e. Workforce planning
21. Maximising services and outcomes within financial envelopes across health economy
a. What-if analysis
b. Cost-benefit analysis
c. Health economics analysis
d. Scenario planning and modelling
e. Investment and disinvestment in services analysis
f. Opportunity analysis
22. Providing greater understanding of the underlying courses and look to commission improved supportive networks, this would be ongoing work which would be continually assessed.
23. Insight to understand the numerous factors that play a role in the outcome for both datasets. The linkage will allow the reporting both prior to, during and after the activity, to provide greater assurance on predictive outcomes and delivery of best practice.
24. Provision of indicators of health problems, and patterns of risk within the commissioning region.
25. Support of benchmarking for evaluating progress in future years.
26. Allow reporting to drive changes and improve the quality of commissioned services and health outcomes for people.
27. Assists commissioners to make better decisions to support patients
28. Allows comparisons of providers performance to assist improvement in services – increase the quality
29. Allow analysis of health care provision to be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets.
30. To evaluate the impact of new services and innovations (e.g. if commissioners implement a new service or type of procedure with a provider, they can evaluate whether it improves outcomes for patients compared to the previous one).
31. Monitoring of entire population, as a pose to only those that engage with services
32. Enable Commissioners to be able to see early indications of potential practice resilience issues in that an early warning marker can often be a trend of patients re-registering themselves at a neighbouring practice.
33. Monitor the quality and safety of the delivery of healthcare services.
34. Allow focused commissioning support based on factual data rather than assumed and projected sources
All Data Processors
Outcomes are often described as those things that matter to people, and are typically the end results of care across complete care pathways. Access to a population-level view of all people with relevant long-term conditions, in near real-time, is the essential starting point for accurate outcome measurement. It is also an essential enabler supporting quality process improvement within care pathways.
Outcomes measured using existing clinical and administrative data typically measure the reduction in illness, disease and complications, and their severity, in addition to system activity metrics.
Measuring outcomes aims to refocus providers (including health and social care providers) to work together to reduce the burden of disease. By setting longer-term targets and improvement trajectories for each outcome, providers can focus their efforts on improving these outcomes, for specific population groups, over a period of years.
Anticipated outputs include, but are not limited to;
1. Health needs assessments – identifying numbers of patients with specific health conditions or combination of conditions.
2. Classification and creation of reference groups of vulnerable groups based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost.
3. Production of Theographs – a visual timeline of a patients encounters with hospital providers.
4. Analysis based on specific diseases
5. 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.
6. Profiles of the health of and the variations in health outcomes within the population to help understand local population characteristics
7. Descriptions and illustrations of the impact of services on health inequalities, the health of the population and patient cohorts
COVID-19 Testing Data
- improving the management of COVID-19 infection and control in the community
- improving the health of the whole population by sharing information and expertise, and identifying and preparing for future public health challenges/COVID-19 challenges
- researching, collecting and analysing data to improve understanding of this public health challenge, and come up with answers to public health problems arising from COVID-19
- providing reliable information on covid19 and potentially changing the standard of care that the NHS offers which could improve outcomes for patients in the CCG area
Benefits reported so far
Data is used in support of ongoing transformation plans to deliver against savings plan. To date, around £28.5m of savings have been identified. Work supported by analyst use of data to initially develop savings plans and identify impacts.
Ongoing activity monitoring support and reporting:
Data used to monitor impact of major system changes, including the overnight closure of an A&E department within the BNSSG area. Activity data used to measure impact on system and patients and inform decision making around the process.
Development of bespoke reporting tools which are used in a range of settings, including an unwarranted practice variation tool which has been used to identify referral outliers and inform further work to understand activity.
Continued use of data in support of monitoring around delivery of constitutional standards, with standards achieved in a number of measures. Data used to help inform plans aimed at achieving targets in other areas requiring improvement, by understanding drivers behind performance and identifying opportunities for improvements.
Identify data and performance issues at provider organisations to initiate discussions at contract meetings which has led to: further analysis to identify root causes and mitigating actions; using contractual levers i.e. issuing contractual notices (Contract Performance Notices and Information Breach Notices) to facilitate improvement through joint investigations and remedial action plans and; identifying good practice and lessons learned to ensure consistency across BNSSG's 3 providers to support equity of provision.
Provide assurance to CCG Governing Body and Healthier Together STP (System Delivery Oversight Group): that contracts with providers are being managed effectively and; how the BNSSG population is being served; Provides evidence to STP system wide groups on areas of good and poor performance such as urgent care, planned care and cancer to share learning, identify improvements and develop joint plans. Support the work with providers to develop joint activity plans, performance trajectories and strategies.
NHS Bristol, North Somerset and South Gloucestershire CCG are an evidence-based organisation using data to underpin their decision making processes. Key achievements which have been informed by use of data include:
Funding mental health support in schools: NHS Bristol, North Somerset and South Gloucestershire CCG became the first city in the country to fund a mental health-focused training package for staff in every primary and secondary school, working closely with Bristol City Council. The training is designed to raise the profile of Child and Adolescent Mental Health Services (CAMHS), with the focus on early intervention to make a significant difference to young people’s lives.
Advancing the CCGs dementia care: NHS Bristol, North Somerset and South Gloucestershire CCG have established leading dementia wellbeing services, with around 2,000 patients benefiting from specialised support last year. A key feature is that people are never discharged from the service and can access support whenever they need it. NHS Bristol, North Somerset and South Gloucestershire CCG are making continued investments and the number of people the service supports has nearly doubled over the last 12 months.
Sustainability and Transformation Partnership: NHS Bristol, North Somerset and South Gloucestershire CCG developed a new plan to guide commissioning activity until 2021 as a partnership between Bristol, North Somerset and South Gloucestershire CCGs. After drafting the plan together, NHS Bristol, North Somerset and South Gloucestershire CCG involved the community and other clinical groups to gain their input. NHS Bristol, North Somerset and South Gloucestershire CCG had meetings with the three local authority health scrutiny committees and community volunteers. BNSSG's work together provided the set up to develop the best possible healthcare services for their population’s needs in the coming years.
Designing healthcare with young people: NHS Bristol, North Somerset and South Gloucestershire CCG held a major consultation to find out what local young people, their parents and professionals involved in their care, thought of BNSSG's community health services. NHS Bristol, North Somerset and South Gloucestershire CCG received over 1,200 ideas and have been using that feedback to shape children’s and young people’s health services.
Improving hospital discharge for older people: the CCGs Discharge to Assess (D2A) scheme speeds up hospital discharge times for older patients, helping them get home quicker. The D2A team support patients to be discharged and assess ongoing care at home, on the same day, by community teams of social workers, nurses, physiotherapists and occupational therapists. The scheme has helped 20 people who would otherwise be in hospital receive therapy in their own homes and enabled the CCG to save a total of 376 hospital bed days.
Appointing a new community healthcare services provider: In partnership with NHS England and North Somerset Council, NHS Bristol, North Somerset and South Gloucestershire CCG appointed North Somerset Community Partnership (NSCP) to provide community healthcare services. They provide all adult and some children’s community health services and specialist services, such as those for people with Parkinson’s disease, until April 2019.
Developing better out-of-hospital care: Helping people to live safely and independently at home as they age has been a high priority. NHS Bristol, North Somerset and South Gloucestershire CCG introduced several initiatives to help people get better outside of hospital, from helping them discharge as soon as they’re fit to leave, to outpatient appointments in the community, and working with Age UK to provide better support to people as they age.
Transforming community services for children: NHS Bristol, North Somerset and South Gloucestershire CCG re-procured children’s community health services for Bristol and South Gloucestershire. This involved a partnership of five commissioning organisations working together to develop a cost-effective service for the whole area that recognises specific local needs, delivering coordinated care to children, young people and families.
Tackling diabetes and promoting self-care: NHS Bristol, North Somerset and South Gloucestershire CCG joined the second wave of the national Diabetes Prevention Programme in April 2017, building on a pilot at Leap Valley GP practice in Emersons Green, Bristol. Together with Bristol and South Gloucestershire CCGs, the CCG has since been selected to pilot the digital stream, which aims to establish whether digital interventions are effective in supporting behaviour change in people with non-diabetic hyperglycemia (NDH) and overweight and or obese individuals.
Datasets on the latest version
Legal basis for provision: Health and Social Care Act 2012 - s261 - 'Other dissemination of information'; Health and Social Care Act 2012 – s261(7); National Health Service Act 2006 - s251 - 'Control of patient information'.
| Dataset | Type of data | Sensitivity | Frequency | Confidential data |
|---|---|---|---|---|
| Acute-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Ambulance-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Children and Young People Health | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Civil Registration - Births | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Civil Registrations of Death | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Community Services Data Set (CSDS) | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Community-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Demand for Service-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Diagnostic Imaging Data Set (DID) | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Diagnostic Services-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| e-Referral Service for Commissioning | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Emergency Care-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Experience, Quality and Outcomes-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Improving Access to Psychological Therapies (IAPT) v1.5 | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Maternity Services Data Set | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Mental Health and Learning Disabilities Data Set (MHLDDS) | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Mental Health Minimum Data Set (MHMDS) | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Mental Health Services Data Set (MHSDS) | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Mental Health-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| National Cancer Waiting Times Monitoring DataSet (NCWTMDS) | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| National Diabetes Audit | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Other Not Elsewhere Classified (NEC)-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Patient Reported Outcome Measures (PROMs) | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Personal Demographic Service | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Population Data-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Primary Care Services-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Public Health and Screening Services-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Summary Hospital-level Mortality Indicator (SHMI) | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| SUS for Commissioners | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| SUS for Commissioners | Identifiable | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
Files released
Files released counts only files released externally by DARS. Access granted in NHS England's own systems, such as its Secure Data Environment, is not included.
No files recorded as released under this agreement.
Version history
The register lists each renewal of this agreement as a separate row. This site has 5 versions — earlier versions existed before this site's records begin.
DARS-NIC-186885-Q1T3D-v5.3 5 January 2021 to 4 January 2024
- Title
- DSfC - NHS Bristol, North Somerset and South Gloucestershire CCG - IV, RS & Comm
- Commercial
- No
- Sublicensing
- No
- Datasets
- 30
- Files released
- 0
Datasets: Acute-Local Provider Flows; Ambulance-Local Provider Flows; Children and Young People Health; Civil Registration - Births; Civil Registrations of Death; Community Services Data Set (CSDS); Community-Local Provider Flows; Demand for Service-Local Provider Flows; Diagnostic Imaging Data Set (DID); Diagnostic Services-Local Provider Flows; e-Referral Service for Commissioning; Emergency Care-Local Provider Flows; Experience, Quality and Outcomes-Local Provider Flows; Improving Access to Psychological Therapies (IAPT) v1.5; Maternity Services Data Set; Mental Health and Learning Disabilities Data Set (MHLDDS); Mental Health Minimum Data Set (MHMDS); Mental Health Services Data Set (MHSDS); Mental Health-Local Provider Flows; National Cancer Waiting Times Monitoring DataSet (NCWTMDS); National Diabetes Audit; Other Not Elsewhere Classified (NEC)-Local Provider Flows; Patient Reported Outcome Measures (PROMs); Personal Demographic Service; Population Data-Local Provider Flows; Primary Care Services-Local Provider Flows; Public Health and Screening Services-Local Provider Flows; Summary Hospital-level Mortality Indicator (SHMI); SUS for Commissioners; SUS for Commissioners
What changed from DARS-NIC-186885-Q1T3D-v4.5
Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.
| Field | Was | Became |
|---|---|---|
| Start date | 2021-01-05 | |
| End date | 2024-01-04 | |
| Acute-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Ambulance-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Children and Young People Health: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Civil Registration - Births: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Civil Registrations of Death: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Community Services Data Set (CSDS): legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Community-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Demand for Service-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Diagnostic Imaging Data Set (DID): legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Diagnostic Services-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Emergency Care-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Experience, Quality and Outcomes-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Improving Access to Psychological Therapies Data Set_v1.5: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Maternity Services Data Set v1.5: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Mental Health Minimum Data Set (MHMDS): legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Mental Health Services Data Set (MHSDS): legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Mental Health and Learning Disabilities Data Set (MHLDDS): legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Mental Health-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| National Cancer Waiting Times Monitoring DataSet (NCWTMDS): legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| National Diabetes Audit: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Other Not Elsewhere Classified (NEC)-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Patient Reported Outcome Measures (PROMs): legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Population Data-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Primary Care Services-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Public Health and Screening Services-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| SUS for Commissioners: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information'; Health and Social Care Act 2012 – s261(7); National Health Service Act 2006 - s251 - 'Control of patient information'. | |
| e-Referral Service for Commissioning: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' |
Datasets: + Personal Demographic Service; + Summary Hospital-level Mortality Indicator (SHMI)
Objective for processing
[41 paragraphs unchanged] - Personal Demographics Service (PDS) - Summary Hospital-level Mortality Indicator (SHMI) [14 paragraphs unchanged] 11. Support measuring the health, mortality or care needs of the total local population [24 paragraphs unchanged] COVID-19 Testing data In order to support commissioning during the COVID-19 pandemic, the CCG also receive a flow of COVID-19 testing data directly from Public Health England which is then linked to the datasets received in this DSA. This will greatly enhance the quality of the data through; • Modelling – through enhanced geospatial analysis, the CCG will be in a better position to predict incoming hospital demand • Population Health Management - Inclusion of intelligence on COVID-19 in the population will help inform decision making about the health and care delivery of the population • Dynamically map prevalence of prior and current infection of COVID-19 through location, NHS system-wide data linkage and data visualisation
Processing activities
[85 paragraphs unchanged]
17. Personal Demographics Service (PDS)
18. Summary Hospital-level Mortality Indicator (SHMI)
[2 paragraphs unchanged]
1. Pseudonymised SUS+, Local Provider data, Mental Health data (MHSDS, MHMDS, MHLDDS),
[42 words unchanged]
Diabetes Audit (NDA), Patient Reported Outcome Measures (PROMs) and e-Referral Service (eRS)
Personal Demographics Service (PDS) and Summary Hospital-level Mortality Indicator (SHMI)
data only is
held until points 2 – 8 are completed.
transferred from the DSCRO to South, Central and West Commissioning Support Unit.
[1 paragraph unchanged]
3. South, Central and West Commissioning Support Unit
also
receive a flow of social care data (see points i – vii below).
4. South, Central and West Commissioning Support Unit
for the add derived fields, link
also receive a flow of COVID-19 testing
data
sets and provide analysis.
(see points i – vii below)
5. Allowed linkage is only between data listed in point 1, point 2 and point 3. No further linkage is permitted.
5. South, Central and West Commissioning Support Unit for the add derived fields, link data sets and provide analysis.
6. South, Central and West Commissioning Support Unit provide analysis such as, but not limited to, data quality and validation checks, data linkages, the submission of routine statutory returns, performance benchmarking, geographical mapping and intelligence and CCG commissioned reporting for performance, activity and financial monitoring.
6. Allowed linkage is only between data listed in point 1, point 2, point 3 and point 4. No further linkage is permitted.
7. South, Central and West Commissioning Support Unit then pass the processed, pseudonymised and linked data to the CCG.
7. South, Central and West Commissioning Support Unit provide analysis such as, but not limited to, data quality and validation checks, data linkages, the submission of routine statutory returns, performance benchmarking, geographical mapping and intelligence and CCG commissioned reporting for performance, activity and financial monitoring.
8.
Aggregation of required data for CCG management use will be completed by
South, Central and West Commissioning Support Unit
as instructed by
then pass the processed, pseudonymised and linked data to
the CCG.
GP & Social Care Data
9. Aggregation of required data for CCG management use will be completed by South, Central and West Commissioning Support Unit as instructed by the CCG.
i. Identifiable data is submitted to South Central and West Commissioning Support Unit.
GP, Social Care and Testing Data
i. Identifiable GP data is submitted to South Central and West Commissioning Support Unit in a ring-fenced area and pseudonymised using a pseudonymisation tool, different to that used by the DSCRO.
[4 paragraphs unchanged]
iii. Identifiable GP data land in a ring-fenced area and pseudonymised using a pseudonymisation tool, different to that used by the DSCRO.
iii. COVID-19 Testing data is either
iv. There is a Data Processing Agreement in place between the provider (GP or Local Authority) and South Central and West Commissioning Support Unit. A specific named individual within South Central and West Commissioning Support Unit acts on behalf of the GP and/or Local Authority).
a) pseudonymised within the provider, prior to submission, using a pseudonymisation tool, different to that used by the DSCRO. The provider requests a pseudonymisation key from the DSCRO. The key can only be used once. The key is specific to this project
or
b) identifiable COVID-19 Testing data lands in a ring-fenced area and pseudonymised using a pseudonymisation tool, different to that used by the DSCRO.
iv. There is a Data Processing Agreement in place between the providers (GP, Local Authority and Public Health England) and South Central and West Commissioning Support Unit. A specific named individual within South Central and West Commissioning Support Unit acts on behalf of the providers.
[42 paragraphs unchanged]
1. Pseudonymised subsets of SUS, Local Provider Data, GP Primary Care
data, Social Care
data and
Social Care
COVID-19 Testing
data is securely transferred from NHS Bristol, North Somerset and South Gloucestershire
[7 words unchanged]
decoupled from the other national datasets and sent as individual data flows
[6 paragraphs unchanged]
3. Allowed linkage is between the datasets contained within point (1) above.
[13 words unchanged]
population health analytics beyond SUS and LPFs which contain only secondary care
activity
activity. Linkage to COVID-19 Testing data will further enhance this.
[5 paragraphs unchanged]
Expected output
[144 paragraphs unchanged] 36. Allow Commissioners to better protect or improve the public health of the total local patient population 37. Allow Commissioners to plan, evaluate and monitor health and social care policies, services, or interventions for the total local patient population 38. Allow Commissioners to compare their providers (trusts) mortality outcomes to the national baseline. 39. Investigate mortality outcomes for trusts [31 paragraphs unchanged] COVID-19 Testing Data Record-level testing data will dramatically improve the capability of the CCG’s local forecasting approaches, including ‘nowcasting’ methods and the SEIR model. The outputs of these models regularly feed the system’s major incident Bronze and Silver Commands. Thus improving the quality of these models allows them to provide better quality information to senior system leaders in the decision-making process. Work includes population segmentation, cohort analysis and impact analysis, underpinned by disciplines such as impact assessments and evaluation. From this, decisions about the health and care delivery of the population can be made using an evidence base and insight to inform service transformation and monitor value through outcomes. Aggregated small numbers suppressed data from this analysis will be shared externally to help inform an urgent public health study (COVID-19 Mapping and Mitigation in Schools) run from the University of Bristol
Expected measurable benefits
[18 paragraphs unchanged]
All of the above lead to improved patient experience
and health outcomes
through more effective commissioning of services.
[74 paragraphs unchanged]
28. Help drive changes in healthcare
28. Allows comparisons of providers performance to assist improvement in services – increase the quality
29. Allows comparisons of providers performance to assist improvement in services – increase the quality
29. Allow analysis of health care provision to be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets.
30. Inform commissioners and improve services
30. To evaluate the impact of new services and innovations (e.g. if commissioners implement a new service or type of procedure with a provider, they can evaluate whether it improves outcomes for patients compared to the previous one).
31. Allow analysis of health care provision to be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets.
31. Monitoring of entire population, as a pose to only those that engage with services
32. Understanding the interdependency of care services
32. Enable Commissioners to be able to see early indications of potential practice resilience issues in that an early warning marker can often be a trend of patients re-registering themselves at a neighbouring practice.
33. Targeting care more effectively
33. Monitor the quality and safety of the delivery of healthcare services.
34. Using value as the redesign principle
34. Allow focused commissioning support based on factual data rather than assumed and projected sources
35. Thoroughly investigating the needs of the population, to ensure the right services are available for individuals when and where they need them
36. Monitoring population health and care interactions to understand where people may slip through the net, or where the provision of care may be being duplicated
37. Modelling activity across all data sets to understand how services interact with each other, and to understand how changes in one service may affect flows through another
38. Service redesign
39. Health Needs Assessment – identification of underlying disease prevalence within the local population
40. To evaluate the impact of new services and innovations (e.g. if commissioners implement a new service or type of procedure with a provider, they can evaluate whether it improves outcomes for patients compared to the previous one).
[12 paragraphs unchanged]
COVID-19 Testing Data
- improving the management of COVID-19 infection and control in the community
- improving the health of the whole population by sharing information and expertise, and identifying and preparing for future public health challenges/COVID-19 challenges
- researching, collecting and analysing data to improve understanding of this public health challenge, and come up with answers to public health problems arising from COVID-19
- providing reliable information on covid19 and potentially changing the standard of care that the NHS offers which could improve outcomes for patients in the CCG area
Unchanged: Benefits reported.
DARS-NIC-186885-Q1T3D-v4.5 1 September 2020 to 31 August 2023
- Title
- DSfC - NHS Bristol, North Somerset and South Gloucestershire CCG - IV, RS & Comm
- Commercial
- No
- Sublicensing
- No
- Datasets
- 28
- Files released
- 0
Datasets: Acute-Local Provider Flows; Ambulance-Local Provider Flows; Children and Young People Health; Civil Registration - Births; Civil Registrations of Death; Community Services Data Set (CSDS); Community-Local Provider Flows; Demand for Service-Local Provider Flows; Diagnostic Imaging Data Set (DID); Diagnostic Services-Local Provider Flows; e-Referral Service for Commissioning; Emergency Care-Local Provider Flows; Experience, Quality and Outcomes-Local Provider Flows; Improving Access to Psychological Therapies (IAPT) v1.5; Maternity Services Data Set; Mental Health and Learning Disabilities Data Set (MHLDDS); Mental Health Minimum Data Set (MHMDS); Mental Health Services Data Set (MHSDS); Mental Health-Local Provider Flows; National Cancer Waiting Times Monitoring DataSet (NCWTMDS); National Diabetes Audit; Other Not Elsewhere Classified (NEC)-Local Provider Flows; Patient Reported Outcome Measures (PROMs); Population Data-Local Provider Flows; Primary Care Services-Local Provider Flows; Public Health and Screening Services-Local Provider Flows; SUS for Commissioners; SUS for Commissioners
What changed from DARS-NIC-186885-Q1T3D-v3.5
Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.
| Field | Was | Became |
|---|---|---|
| Title | DSfC - NHS Bristol, North Somerset and South Gloucestershire CCG - IV, RS & Comm | |
| Start date | 2020-09-01 | |
| End date | 2023-08-31 |
Datasets: + e-Referral Service for Commissioning
Objective for processing
[40 paragraphs unchanged]
- e-Referral Service (eRS)
[12 paragraphs unchanged]
9. Patient stratification and predictive modelling - to highlight
cohorts of
patients at risk of requiring hospital admission and other avoidable factors such
[7 words unchanged]
executed against linked de-identified data, and identification of future service delivery models
10. Demand Management - to improve the care service for patients by predicting the impact on certain care pathways and support the secondary care system in ensuring enough capacity to manage the demand.
[1 paragraph unchanged]
Processing for commissioning will be conducted by South Central and West Commissioning Support Unit, NHS Bristol, North Somerset and South Gloucestershire CCG, Optum Health Solutions UK Limited and Outcomes Based Health (OBH)
Processing for commissioning will be conducted by the following data processors
Clinical Commissioning Groups (CCGs) were established as part of the Health and Social Care Act in 2012 and are responsible for the commissioning of health care services across England.
Clinical Commissioning Groups (CCGs) have a statutory responsibility for commissioning most NHS services and are responsible for approximately 2/3 of the total NHS budget. Increasingly they are also involved in commissioning primary care and some specialised services.
CCGs are groups of local GP practices whose governing bodies include GPs, others clinicians such as nurses and secondary care consultants, patient representatives, general managers and – in some cases – practice managers and local authority representatives.
CCGs have both statutory duties and statutory powers in relation to commissioning healthcare services including but not limited to:
o Community health services
o Maternity services
o Elective hospital care
o Rehabilitation services
o A&E,
o Ambulance services
o Out-of-hours services
o Older people’s healthcare services
o Healthcare services for children
o Healthcare services for people with mental health conditions
o Healthcare services for people with learning disabilities
o Continuing healthcare
o Abortion services
o Infertility services
o Wheelchair services
o Home oxygen services
o Treatment of infectious diseases
CCGs statutory duties and power are defined within the Health and Social Care Act 2012.
Data is required to provide intelligence to support the commissioning of health services and meet the CCGs duties and powers. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the CCG area.
The CCGs commission services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.
The data is required to ensure that analysis of health care provision can be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets.
The overarching objectives of the CCG and use of these data is to:
- Promote accountability and service improvements locally
- Ensure value for money is achieved
- Fulfil statutory functions
- Promote population health management by
a. Understanding the interdependency of care services
b. Targeting care more effectively
c. Using value as the redesign principle
d. Promoting interoperability across care pathways
e. Investigating the needs of the population
- Understanding cohorts of residents who are at risk and managing needs
- Stratify patients by highlighting those patients at risk of requiring hospital admission and other avoidable factors such as risk of falls.
- Identifying gaps in service and where individuals may slip through the net.
- Identifying duplications in service provision.
- Identifying of underlying disease prevalence with the local population through Health Needs Assessments.
The data will further be used for quality and validation purposes, to allow quality checks on the submitted data and to aid in the redesign of services throughout the local region.
DATA PROCESSORS
NHS Bristol, North Somerset and South Gloucestershire CCG
NHS Bristol, North Somerset and South Gloucestershire CCG host the Controlled Environment for Finance to enable the CCG to conduct Invoice Validation.
[1 paragraph unchanged]
NSCWCSU are the approved risk stratification provider for the CCG
[1 paragraph unchanged]
Outcomes Based
Health
Healthcare
(OBH)
Outcomes Based Healthcare is a private limited company based at the King's fund contracted by
NHS Bristol North Somerset and South Gloucestershire CCG
is
to assist in
developing local Outcomes Frameworks for diabetes and respiratory programmes. Clinical outcomes have
[10 words unchanged]
and services users and two types of outcome measures have been selected;
[2 paragraphs unchanged]
Having previously baselined (2016-2017) data the ongoing monitoring and development of CSOMs selected for the BNSSG Outcomes Frameworks, pseudonymised, patient-level health and care data is required to
to
populate the BNSSG/OBH Outcomes Platform, where this information is processed, aggregated and visualised for monitoring, reporting and planning service delivery.
[1 paragraph unchanged]
NHS Bristol, North Somerset and South Gloucestershire CCG is working with NHS
[30 words unchanged]
to build up a methodology for dissemination across the NHS in England.
The NHS Bristol, North Somerset and South Gloucestershire CCG involvement is for 20 weeks, anticipated to start in February 2020 for approximately 20 weeks.
[1 paragraph unchanged]
University of Bristol / University of the West of England
NHS Bristol, North Somerset and South Gloucestershire CCG has strong analytical relationships with local Universities. The CCG offers local universities opportunities for carefully controlled analysis projects for students on industrial placement years. Working in partnership with local universities the CCG has been very successful in securing funding for bespoke projects.
The University of Bristol has a global reputation for multi-morbidity research, medical statistics and health data science and the University of the West of England has a top UK Business School. Across each of these disciplines the CCG works to maximise achievable benefits to both the NHS and academia.
Project allocation will be undertaken on a project by project basis as determined by the CCG PHM Steering Group with due reference to the activities allowed under this agreement. Additionally these projects will only be in relation to the Commissioning purposes laid out in this agreement. Data sharing will be managed according to the over-riding principles of the CCG PHM Programme, namely;
i) that work be performed collaboratively,
ii) for the good of the BNSSG health and care system,
iii) under lead of a designated CCG problem owner, with role-based accesses awarded and controlled in partnership with our IT provider (SWCSU)
iv) on specific projects authorised by the BNSSG PHM Steering Group,
v) decided on through a project-by-project basis,
vi) with only the minimum required data being provided, and
vii) through an approved, secure channel.
Any funding provided to University of Bristol and University of the West of England for the processing carried out under this agreement is provided by the CCG and consequently there are no commercial aspects to this agreement.
Processing activities
[13 paragraphs unchanged]
The Data Controller and any Data Processor listed will only have access to records of patients of residence and registration within the CCG.
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 Bristol, North Somerset and South Gloucestershire CCG is a Data Controller who also processes data
[17 paragraphs unchanged]
Microsoft UK supply Cloud Services for Outcomes Based Healthcare and are therefore listed as a data processor. They supply support to the system, but do not access data. Therefore, any access to the data held under this agreement would be considered a breach of agreement. This includes granting of access to the database[s] containing the data.
In addition to the dissemination of Cancer Waiting Times Data via the DSCRO, the CCG is able to access reports held within the CWT system in NHS Digital directly. Access within the CCG is limited to those with a need to process the data for the purposes described in this agreement.
A CCG user will be able to access the provider extracts from the portal for any provider where at least 1 patient for whom they are the registered CCG for that individuals GP practice appears in that setting
Although a CCG user may have access to pseudonymised patient information not related to that CCG, users should only process and analyse data for which they have a legitimate relationship (as described within Data Minimisation).
Microsoft Limited supply Cloud Services for Outcomes Based Healthcare and South Central and West Commissioning Support Unit and are therefore listed as a data processor. They supply support to the system, but do not access data. Therefore, any access to the data held under this agreement would be considered a breach of agreement. This includes granting of access to the database[s] containing the data.
Microsoft Limited and Amazon Web Services provide cloud services for Optum Health Solutions (UK) Limited and are therefore listed as processors. They supply support to the system, but do not access data. Therefore, any access to the data held under this agreement would be considered a breach of the agreement. This includes granting of access to the database[s] containing the data.
ANS Group Limited will be assisting in the set up and management of the South Central and West Commissioning Support Unit Microsoft Azure Cloud and are therefore listed as a data processor. They will not have any additional processing / storage addresses (as these will be the Microsoft Azure addresses). Using the data for any other purpose would be considered a breach of this agreement.
[1 paragraph unchanged]
Black Box Software
- The Black Box is a software process with very limited access, restricted to only those who administer it.
- It is a set of logic that is hidden from users. It generates a re-pseudonymised output from the data that users enter.
- The purpose of the Black Box is to map the data such that the resulting pseudonymisation is the same as that used at the DSCRO.
- The Black Box works by calling upon a mapping table from the DSCRO and re-pseudonymising by switching the
pseudonym. No data is persisted in the Black Box.
The Black Box is held within a private part of South Central and West Commissioning Support Unit secure network and physically located at the storage address within the DARS application/agreement with the same underlying security controls.)
[47 paragraphs unchanged]
16. e-Referral Service (eRS)
[2 paragraphs unchanged]
1. Pseudonymised SUS+, Local Provider data, Mental Health data (MHSDS, MHMDS, MHLDDS),
[32 words unchanged]
Set (CWT), Civil Registries Data (CRD) (Births and Deaths), National Diabetes Audit
(NDA) and
(NDA),
Patient Reported Outcome Measures (PROMs)
and e-Referral Service (eRS) data
only is held until points 2 – 8 are completed.
[1 paragraph unchanged]
3. South, Central and West Commissioning Support Unit also receive a flow of social care data (see points i – vii
or points viii - xii
below).
[16 paragraphs unchanged]
Black Box Software
- The Black Box is a software process with very limited access, restricted to only those who administer it.
- It is a set of logic that is hidden from users. It generates a re-pseudonymised output from the data that users enter.
- The purpose of the Black Box is to map the data such that the resulting pseudonymisation is the same as that used at the DSCRO.
- The Black Box works by calling upon a mapping table from the DSCRO and re-pseudonymising by switching the pseudonym. No data is persisted in the Black Box.
- The Black Box is held within a private part of South Central and West Commissioning Support Unit secure network and physically located at the storage address within the DARS application/agreement with the same underlying security controls.)
[21 paragraphs unchanged]
8. The NHSE/Optum contractual period with NHS Bristol, North Somerset and South Gloucestershire CCG is anticipated to end in July 2020, at which point the data processor will be be removed from this agreement by amendment.
[1 paragraph unchanged]
Data Processor – University of Bristol / University of the West of England
NHS Bristol, North Somerset and South Gloucestershire CCG will allocate projects to either the University of Bristol or University of the West of England.
Project allocation will be undertaken on a project by project basis as determined by the CCG PHM Steering Group. Data sharing will be managed according to the over-riding principles of the CCG PHM Programme, namely;
i) that work be performed collaboratively,
ii) for the good of the BNSSG health and care system,
iii) under lead of a designated CCG problem owner, with role-based accesses awarded and controlled in partnership with NHS Bristol, North Somerset and South Gloucestershire CCG’s IT provider (SWCSU)
iv) on specific projects authorised by the BNSSG PHM Steering Group,
v) decided on through a project-by-project basis,
vi) with only the minimum required data being provided, and
vii) through an approved, secure channel.
Data will be shared with each University as follows:
1. Pseudonymised subsets of SUS, Local Provider Data, GP Primary Care data and Social Care data is securely transferred from NHS Bristol, North Somerset and South Gloucestershire CCG to the University*. The data is decoupled from the other national datasets and sent as individual data flows
2. The University* provides bespoke analysis for:
• Whole population segmentation to assess population health needs
• Prospective risk scoring for individuals to indicate the likelihood of future adverse events
• Predictive modelling to determine individuals at risk and an understanding of the drivers of risk
• Longitudinal analysis of intersegmental drift - identifying individuals who move between complexity classifications and the drivers of these transitions
• The production of individual-level theographs to identify gaps in care
3. Allowed linkage is between the datasets contained within point (1) above. GP and Social Care datasets are needed for the processing to enhance the population health analytics beyond SUS and LPFs which contain only secondary care activity
4. The University* then pass the processed, pseudonymised and linked data to the CCG.
5. Aggregation of required data for CCG management use will be completed by the University* under direction of the CCG as instructed by the CCG, or the CCG.
6. Patient level data will not be shared outside of the CCG and will only be shared within the CCG on a need to know basis, as per the purposes stipulated within the Data Sharing Agreement. External aggregated reports only with small number suppression can be shared as set out within NHS Digital guidance applicable to each data set.
7. The University* will only be in receipt of data and only be permitted to act as Data Processors for the period specified in the contract with NHS Bristol, North Somerset and South Gloucestershire CCG
*References to ‘The University’ is either the University of Bristol or the University of the West of England only.
Expected output
[141 paragraphs unchanged] 33. Manage demand, by understanding the quantity of assessments required CCGs are able to improve the care service for patients by predicting the impact on certain care pathways and ensure the secondary care system has enough capacity to manage the demand. 34. Monitor the timing of key actions relating to referral letters. CCG’s are unable to see the contents of the referral letters. 35. Identify low priority procedures which could be directed to community-based alternatives and as such commission these services and deflect referrals for low priority procedures resulting in a reduction in hospital referrals. [12 paragraphs unchanged] University of Bristol, University of the West of England Given the relative specialisms of the universities, as outlined in Section 5a, BNSSG would expect clinical development projects for commissioning development to be concentrated with the University of Bristol. Similarly the expected outputs from the University of the West of England are expected to relate more to the mathematical modelling of flow, demand and capacity. Expected outputs include, but are not limited to; 1. Profiling population health and wider determinants to identify and target those most in need a. Understanding population profile and demographics b. Identify patient cohorts with specific needs or who may benefit from interventions c. Identifying disease prevalence. health and care needs for population cohorts d. Contributing to Joint Strategic Needs Assessment (JSNA) e. Geographical mapping and analysis 2. Identifying and managing preventable and existing conditions a. Identifying types of individuals and population cohorts at risk of non-elective re-admission b. Identification of disease incidence and diagnosis stratification 3. Reducing health inequalities a. Identifying cohorts of patients who have worse health outcomes typically deprived, ethnic groups, homeless, travellers etc. to enable services to proactively target their needs b. Socio-demographic analysis Outputs from the approved projects will be aggregated with small number suppression in line with NHS Digital analysis guidelines. These will be used to inform and develop clinical services across BNSSG and findings would expect to be published in research articles for peer reviewed academic journals and for presentation at the relevant workshops and academic conferences. Such publications could include case studies of analytics projects carried out using the data, or specific statistical analyses. This builds on existing practice within CCG Modelling and Analytics, which publishes work and presents at national conferences and which already has close working relationships with the University Centres for Healthcare Innovation and Improvement, the University of Bristol Population Health Sciences Institute and Elizabeth Blackwell Institute, as well as the NIHR South-West Applied Research Collaboration (ARC). Availability of usable real-world data is well-established a major barrier to realising practical benefits from research projects in academic statistical modelling and operational research. This has been acknowledged in the work of the national Plethora project for example, which was set up in part to bridge the gap between academic knowledge/technique generation and practical application of those outputs by healthcare analysts at the NHS coalface. Dissemination of findings would – in addition to traditional academic publication and conference channels – also promote posting of relevant reusable open source code, summary results, and documentation to sites such as NHS Futures and via the NHS BNSSG Analytics GitHub repository, in order to support exposure to other healthcare systems. All outputs will be delivered within the timescales of the contract between the universities and the CCG
Expected measurable benefits
[91 paragraphs unchanged] 26. Allow reporting to drive changes and improve the quality of commissioned services and health outcomes for people. 27. Assists commissioners to make better decisions to support patients 28. Help drive changes in healthcare 29. Allows comparisons of providers performance to assist improvement in services – increase the quality 30. Inform commissioners and improve services 31. Allow analysis of health care provision to be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets. 32. Understanding the interdependency of care services 33. Targeting care more effectively 34. Using value as the redesign principle 35. Thoroughly investigating the needs of the population, to ensure the right services are available for individuals when and where they need them 36. Monitoring population health and care interactions to understand where people may slip through the net, or where the provision of care may be being duplicated 37. Modelling activity across all data sets to understand how services interact with each other, and to understand how changes in one service may affect flows through another 38. Service redesign 39. Health Needs Assessment – identification of underlying disease prevalence within the local population 40. To evaluate the impact of new services and innovations (e.g. if commissioners implement a new service or type of procedure with a provider, they can evaluate whether it improves outcomes for patients compared to the previous one). [12 paragraphs unchanged]
Benefits reported
[5 paragraphs unchanged]
Identify data and performance issues at provider organisations to initiate discussions at
[38 words unchanged]
plans and; identifying good practice and lessons learned to ensure consistency across
our
BNSSG's
3 providers to support equity of provision.
[1 paragraph unchanged]
NHS Bristol, North Somerset and South Gloucestershire CCG are an evidence-based organisation using data to underpin
our
their
decision making processes. Key achievements which have been informed by use of data include:
[2 paragraphs unchanged]
Sustainability and Transformation Partnership: NHS Bristol, North Somerset and South Gloucestershire CCG developed a new plan to guide
our
commissioning activity until 2021 as a partnership between Bristol, North Somerset and
[36 words unchanged]
meetings with the three local authority health scrutiny committees and community volunteers.
Our
BNSSG's
work together
provided the
set
us
up to develop the best possible healthcare services for
our
their
population’s needs in the coming years.
Designing healthcare with young people: NHS Bristol, North Somerset and South Gloucestershire
[10 words unchanged]
young people, their parents and professionals involved in their care, thought of
our
BNSSG's
community health services. NHS Bristol, North Somerset and South Gloucestershire CCG received
[5 words unchanged]
been using that feedback to shape children’s and young people’s health services.
[5 paragraphs unchanged]
Objective for processing
INVOICE VALIDATION
Invoice validation is part of a process by which providers of care or services get paid for the work they do.
Invoices are submitted to the Clinical Commissioning Group (CCG) so the CCG is are able to ensure that the activity claimed for each patient is their responsibility. This is done by processing and analysing Secondary User Services (SUS+) data, which is received into a secure Controlled Environment for Finance (CEfF). The SUS+ data is identifiable at the level of NHS number. The NHS number is only used to confirm the accuracy of backing-data sets (data from providers) and will not be used further.
The CCG are advised by the appointed CEfF whether payment for invoices can be made or not.
Invoice Validation will be conducted by NHS Bristol, North Somerset and South Gloucestershire CCG
RISK STRATIFICATION
Risk stratification is a tool for identifying and predicting which patients are at high risk (of health deterioration and using multiple services) or are likely to be at high risk and prioritising the management of their care in order to prevent worse outcomes.
To conduct risk stratification Secondary User Services (SUS+) data, identifiable at the level of NHS number is pseudonymised and linked with Primary Care data (from GPs) and an algorithm is applied to produce risk scores. Risk Stratification provides focus for future demands by enabling commissioners to prepare plans for both individual and groups of vulnerable patients. Commissioners can then prepare plans for patients who may require high levels of care. Risk Stratification, following re-identification, also enables General Practitioners (GPs) to better target intervention in Primary Care.
Risk Stratification will be conducted by NHS South Central and West Commissioning Support Unit.
COMMISSIONING
To use pseudonymised data to provide intelligence to support the commissioning of health services. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the CCG area.
The CCGs commission services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.
The following pseudonymised datasets are required to provide intelligence to support commissioning of health services:
- Secondary Uses Service (SUS+)
- Local Provider Flows
a. Acute
b. Ambulance
c. Community
d. Demand for Service
e. Diagnostic Service
f. Emergency Care
g. Experience, Quality and Outcomes
h. Mental Health
i. Other Not Elsewhere Classified
j. Population Data
k. Primary Care Services
l. Public Health Screening
- Mental Health Minimum Data Set (MHMDS)
- Mental Health Learning Disability Data Set (MHLDDS)
- Mental Health Services Data Set (MHSDS)
- Maternity Services Data Set (MSDS)
- Improving Access to Psychological Therapy (IAPT)
- Child and Young People Health Service (CYPHS)
- Community Services Data Set (CSDS)
- Diagnostic Imaging Data Set (DIDS)
- National Cancer Waiting Times Monitoring Data Set (CWT)
- Civil Registries Data (CRD) (Births)
- Civil Registries Data (CRD) (Deaths)
- National Diabetes Audit (NDA)
- Patient Reported Outcome Measures (PROMs)
- e-Referral Service (eRS)
The pseudonymised data is required to for the following purposes:
1. Population health management:
a. Understanding the interdependency of care services
b. Targeting care more effectively
c. Using value as the redesign principle
2. Data Quality and Validation – allowing data quality checks on the submitted data
3. Thoroughly investigating the needs of the population, to ensure the right services are available for individuals when and where they need them
4. Understanding cohorts of residents who are at risk of becoming users of some of the more expensive services, to better understand and manage those needs
5. Monitoring population health and care interactions to understand where people may slip through the net, or where the provision of care may be being duplicated
6. Modelling activity across all data sets to understand how services interact with each other, and to understand how changes in one service may affect flows through another
7. Service redesign
8. Health Needs Assessment – identification of underlying disease prevalence within the local population
9. Patient stratification and predictive modelling - to highlight cohorts of patients at risk of requiring hospital admission and other avoidable factors such as risk of falls, computed using algorithms executed against linked de-identified data, and identification of future service delivery models
10. Demand Management - to improve the care service for patients by predicting the impact on certain care pathways and support the secondary care system in ensuring enough capacity to manage the demand.
The pseudonymised data is required to ensure that analysis of health care provision can be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets.
Processing for commissioning will be conducted by the following data processors
NHS South Central and West Commissioning Support Unit (SCWCSU)
SCWCSU provide commissioning functions such as, but not limited to, data quality and validation checks, data linkages, the submission of routine statutory returns, performance benchmarking, geographical mapping and intelligence and CCG commissioned reporting for performance, activity and financial monitoring.
Outcomes Based Healthcare (OBH)
Outcomes Based Healthcare is a private limited company based at the King's fund contracted by NHS Bristol North Somerset and South Gloucestershire CCG to assist in developing local Outcomes Frameworks for diabetes and respiratory programmes. Clinical outcomes have been prioritised through workshops and engagement with commissioners, providers, clinicians and services users and two types of outcome measures have been selected;
• Clinical and Social Outcome Measures (CSOMs), where existing health and care data is used,
• Person-Centred Outcome Measures (PCOMs), where surveys/PROMs are used to collect this data directly from service users.
Having previously baselined (2016-2017) data the ongoing monitoring and development of CSOMs selected for the BNSSG Outcomes Frameworks, pseudonymised, patient-level health and care data is required to populate the BNSSG/OBH Outcomes Platform, where this information is processed, aggregated and visualised for monitoring, reporting and planning service delivery.
Optum Health Solutions (UK) Ltd
NHS Bristol, North Somerset and South Gloucestershire CCG is working with NHS England as a Wave 2 Population Health Management CCG. NHS England have contracted Optum Health Solutions (UK) Ltd to work with selected CCGs to undertake population health and actuarial analysis to build up a methodology for dissemination across the NHS in England.
Data held by Optum Health Solutions (UK) Ltd, will be destroyed within 6 months of completion of the project and permissions as a data processor will be removed from this agreement by amendment.
University of Bristol / University of the West of England
NHS Bristol, North Somerset and South Gloucestershire CCG has strong analytical relationships with local Universities. The CCG offers local universities opportunities for carefully controlled analysis projects for students on industrial placement years. Working in partnership with local universities the CCG has been very successful in securing funding for bespoke projects.
The University of Bristol has a global reputation for multi-morbidity research, medical statistics and health data science and the University of the West of England has a top UK Business School. Across each of these disciplines the CCG works to maximise achievable benefits to both the NHS and academia.
Project allocation will be undertaken on a project by project basis as determined by the CCG PHM Steering Group with due reference to the activities allowed under this agreement. Additionally these projects will only be in relation to the Commissioning purposes laid out in this agreement. Data sharing will be managed according to the over-riding principles of the CCG PHM Programme, namely;
i) that work be performed collaboratively,
ii) for the good of the BNSSG health and care system,
iii) under lead of a designated CCG problem owner, with role-based accesses awarded and controlled in partnership with our IT provider (SWCSU)
iv) on specific projects authorised by the BNSSG PHM Steering Group,
v) decided on through a project-by-project basis,
vi) with only the minimum required data being provided, and
vii) through an approved, secure channel.
Any funding provided to University of Bristol and University of the West of England for the processing carried out under this agreement is provided by the CCG and consequently there are no commercial aspects to this agreement.
Expected output
INVOICE VALIDATION
1. The Controlled Environment for Finance (CEfF) will enable the CCG to challenge invoices and raise discrepancies and disputes.
2. Outputs from the CEfF will enable accurate production of budget reports, which will:
a. Assist in addressing poor quality data issues
b. Assist in business intelligence
3. Validation of invoices for non-contracted events where a service delivered to a patient by a provider that does not have a written contract with the patient’s responsible commissioner, but does have a written contract with another NHS commissioner/s.
4. Budget control of the CCG.
RISK STRATIFICATION
1. As part of the risk stratification processing activity detailed above, GPs have access to the risk stratification tool which highlights patients for whom the GP is responsible and have been classed as at risk. The only identifier available to GPs is the NHS numbers of their own patients. Any further identification of the patients will be completed by the GP on their own systems.
2. 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.
CCGs will be able to:
1. Target specific vulnerable patient groups and enable clinicians with the duty of care for the patient to offer appropriate interventions.
2. Reduce hospital readmissions and targeting clinical interventions to high risk patients.
3. Identify patients at risk of deterioration and providing effective care.
4. Reduce in the difference in the quality of care between those with the best and worst outcomes.
5. Re-design care to reduce admissions.
6. Set up capitated budgets – budgets based on care provided to the specific population.
7. Identify health determinants of risk of admission to hospital, or other adverse care outcomes.
8. Monitor vulnerable groups of patients including but not limited to frailty, COPD, Diabetes, elderly.
9. Health needs assessments – identifying numbers of patients with specific health conditions or combination of conditions.
10. Classify vulnerable groups based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost.
11. Production of Theographs – a visual timeline of a patients encounters with hospital providers.
12. Analyse based on specific diseases
In addition:
- The risk stratification tool will provide aggregate reporting of number and percentage of population found to be at risk.
- Record level output (pseudonymised) will be available for commissioners (of the CCG), pseudonymised at patient level. Onward sharing of this data is not permitted
COMMISSIONING
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.
g. Statutory returns.
h. Statutory returns - monthly activity return.
i. Statutory returns - quarterly activity return.
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.
9. Comparators of CCG performance with similar CCGs as set out by a specific range of care quality and performance measures detailed activity and cost reports
10. Data Quality and Validation measures allowing data quality checks on the submitted data
11. Contract Management and Modelling
12. Patient Stratification, such as:
a. Patients at highest risk of admission
b. Users of high cost activity
c. Frail and elderly
d. Patients that are currently in hospital
e. Patients with most referrals to secondary care
f. Patients with most emergency activity
g. Patients with most expensive prescriptions
h. Patients recently moving from one care setting to another
i. Discharged from hospital
ii. Discharged from community
13. Profiling population health and wider determinants to identify and target those most in need
a. Understanding population profile and demographics
b. Identify patient cohorts with specific needs or who may benefit from interventions
c. Identifying disease prevalence. health and care needs for population cohorts
d. Contributing to Joint Strategic Needs Assessment (JSNA)
e. Geographical mapping and analysis
14. Identifying and managing preventable and existing conditions
a. Identifying types of individuals and population cohorts at risk of non-elective re-admission
b. Risk stratification to identify populations suitable for case management
c. Risk profiling and predictive modelling
d. Risk stratification for planning services for population cohorts
e. Identification of disease incidence and diagnosis stratification
15. Reducing health inequalities
a. Identifying cohorts of patients who have worse health outcomes typically deprived, ethnic groups, homeless, travellers etc. to enable services to proactively target their needs
b. Socio-demographic analysis
16. Managing demand
a. Waiting times analysis
b. Service demand and supply modelling
c. Understanding cross-border and overseas visitor
d. Winter planning
e. Emergency preparedness, business continuity, recovery and contingency planning
17. Care co-ordination and planning
a. Planning packages of care
b. Service planning
c. Planning care co-ordination
18. Monitoring individual patient health, service utilisation, pathway compliance experience & outcomes across the heath and care system
a. Patient pathway analysis across health and care
b. Outcomes & experience analysis
c. Analysis to support anti-terror initiatives
d. Analysis to identify vulnerable patients with potential safeguarding issues
e. Understanding equity of care and unwarranted variation
f. Modelling patient flow
g. Tracking patient pathways
h. Monitoring to support New Models of Care
i. Identifying duplications in care
j. Identifying gaps in care, missed diagnoses and triple fail events
k. Analysing individual and aggregated timelines
19. Undertaking budget planning, management and reporting
a. Tracking financial performance against plans
b. Budget reporting
c. Tariff development
d. Developing and monitoring capitated budgets
e. Developing and monitoring individual-level budgets
f. Future budget planning and forecasting
g. Paying for care of overseas visitors and cross-border flow
20. Monitoring the value for money
a. Service-level costing & comparisons
b. Identification of cost pressures
a. Cost benefit analysis
b. Equity of spend across services and population cohorts
c. Finance impact assessment
21. Comparing population groups, peers, national and international best practice
d. Identification of variation in productivity, cost, outcomes, quality, experience, compared with peers, national and international & best practice
e. Benchmarking against other parts of the country
f. Identifying unwarranted variations
22. Comparing expected levels
g. Standardised comparisons for prevalence, activity, cost, quality, experience, outcomes for given populations
23. Comparing local targets & plan
h. Monitoring of local variation in productivity, cost, outcomes, quality and experience
i. Local performance dashboards by service provider, commissioner, geography, NMOC, STPs
24. Monitoring activity and cost compliance against contract and agreed plans
j. Contract monitoring
k. Contract reconciliation and challenge
l. Invoice validation
25. Monitoring provider quality, demand, experience and outcomes against contract and agreed plans
m. Performance dashboards
n. CQUIN reporting
o. Clinical audit
p. Patient experience surveys
q. Demand, supply, outcome & experience analysis
r. Monitoring cross-border flows and overseas visitor activity
26. Improving provider data quality
s. Coding audit
t. Data quality validation and review
u. Checking validity of patient identity and commissioner assignment
27. Validation for payment approval, ability to validate that claims are not being made after an individual has died, like Oxygen services.
28. Validation of programs implemented to improve patient pathway e.g. High users unable to validate if the process to help patients find the best support are working or did the patient die.
29. Clinical - understand reasons why patients are dying, what additional support services can be put in to support.
30. Understanding where patient are dying e.g. are patients dying at hospitals due to hospices closing due to Local authorities withdrawing support, or is there a problem at a particular trust.
31. Removal of patients from Risk Stratification reports.
32. Re births provide a one stop shop of information, Births are recorded in multiple sources covering hospital and home births, a chance to overlook activity.
33. Manage demand, by understanding the quantity of assessments required CCGs are able to improve the care service for patients by predicting the impact on certain care pathways and ensure the secondary care system has enough capacity to manage the demand.
34. Monitor the timing of key actions relating to referral letters. CCG’s are unable to see the contents of the referral letters.
35. Identify low priority procedures which could be directed to community-based alternatives and as such commission these services and deflect referrals for low priority procedures resulting in a reduction in hospital referrals.
Outcomes Based Healthcare:
The main outputs are aggregated monthly values for each outcome outputs will comply with the NHS Digital guidance on suppression rules. The aggregated monthly outcomes data will be made available through OBH’s online tool (available to named individuals in the CCG and CCG commissioned providers only) via a secure login.
This enables the CCGs and to:
- visualise baselines for each outcome
- set improvement trajectories
- monitor outcomes on an on-going basis.
In addition, the CCGs will receive an information schedule describing the outcomes to be monitored, the technical description, and annual baseline data for each outcome.
All outputs will be delivered within the timescales of the contract between OBH and the CCG.
Optum Health Solutions UK Limited
The outputs, as part of the NHS England Wave 2 PHM national programme will identify patient cohorts and inequalities in outcome, spend and opportunity for further investigation, with a view to improving service delivery and patient health outcomes.
Wave 2 PHM will also begin to develop the CCG capability to undertake actuarial analysis of linked datasets from multiple care settings to develop further the understanding of the wider determinants of health across the population.
All outputs will be delivered within the timescales of the contract between Optum Health Solutions UK Limited and the CCG.
University of Bristol, University of the West of England
Given the relative specialisms of the universities, as outlined in Section 5a, BNSSG would expect clinical development projects for commissioning development to be concentrated with the University of Bristol.
Similarly the expected outputs from the University of the West of England are expected to relate more to the mathematical modelling of flow, demand and capacity.
Expected outputs include, but are not limited to;
1. Profiling population health and wider determinants to identify and target those most in need
a. Understanding population profile and demographics
b. Identify patient cohorts with specific needs or who may benefit from interventions
c. Identifying disease prevalence. health and care needs for population cohorts
d. Contributing to Joint Strategic Needs Assessment (JSNA)
e. Geographical mapping and analysis
2. Identifying and managing preventable and existing conditions
a. Identifying types of individuals and population cohorts at risk of non-elective re-admission
b. Identification of disease incidence and diagnosis stratification
3. Reducing health inequalities
a. Identifying cohorts of patients who have worse health outcomes typically deprived, ethnic groups, homeless, travellers etc. to enable services to proactively target their needs
b. Socio-demographic analysis
Outputs from the approved projects will be aggregated with small number suppression in line with NHS Digital analysis guidelines. These will be used to inform and develop clinical services across BNSSG and findings would expect to be published in research articles for peer reviewed academic journals and for presentation at the relevant workshops and academic conferences. Such publications could include case studies of analytics projects carried out using the data, or specific statistical analyses. This builds on existing practice within CCG Modelling and Analytics, which publishes work and presents at national conferences and which already has close working relationships with the University Centres for Healthcare Innovation and Improvement, the University of Bristol Population Health Sciences Institute and Elizabeth Blackwell Institute, as well as the NIHR South-West Applied Research Collaboration (ARC).
Availability of usable real-world data is well-established a major barrier to realising practical benefits from research projects in academic statistical modelling and operational research. This has been acknowledged in the work of the national Plethora project for example, which was set up in part to bridge the gap between academic knowledge/technique generation and practical application of those outputs by healthcare analysts at the NHS coalface. Dissemination of findings would – in addition to traditional academic publication and conference channels – also promote posting of relevant reusable open source code, summary results, and documentation to sites such as NHS Futures and via the NHS BNSSG Analytics GitHub repository, in order to support exposure to other healthcare systems.
All outputs will be delivered within the timescales of the contract between the universities and the CCG
Benefits reported
Data is used in support of ongoing transformation plans to deliver against savings plan. To date, around £28.5m of savings have been identified. Work supported by analyst use of data to initially develop savings plans and identify impacts.
Ongoing activity monitoring support and reporting:
Data used to monitor impact of major system changes, including the overnight closure of an A&E department within the BNSSG area. Activity data used to measure impact on system and patients and inform decision making around the process.
Development of bespoke reporting tools which are used in a range of settings, including an unwarranted practice variation tool which has been used to identify referral outliers and inform further work to understand activity.
Continued use of data in support of monitoring around delivery of constitutional standards, with standards achieved in a number of measures. Data used to help inform plans aimed at achieving targets in other areas requiring improvement, by understanding drivers behind performance and identifying opportunities for improvements.
Identify data and performance issues at provider organisations to initiate discussions at contract meetings which has led to: further analysis to identify root causes and mitigating actions; using contractual levers i.e. issuing contractual notices (Contract Performance Notices and Information Breach Notices) to facilitate improvement through joint investigations and remedial action plans and; identifying good practice and lessons learned to ensure consistency across BNSSG's 3 providers to support equity of provision.
Provide assurance to CCG Governing Body and Healthier Together STP (System Delivery Oversight Group): that contracts with providers are being managed effectively and; how the BNSSG population is being served; Provides evidence to STP system wide groups on areas of good and poor performance such as urgent care, planned care and cancer to share learning, identify improvements and develop joint plans. Support the work with providers to develop joint activity plans, performance trajectories and strategies.
NHS Bristol, North Somerset and South Gloucestershire CCG are an evidence-based organisation using data to underpin their decision making processes. Key achievements which have been informed by use of data include:
Funding mental health support in schools: NHS Bristol, North Somerset and South Gloucestershire CCG became the first city in the country to fund a mental health-focused training package for staff in every primary and secondary school, working closely with Bristol City Council. The training is designed to raise the profile of Child and Adolescent Mental Health Services (CAMHS), with the focus on early intervention to make a significant difference to young people’s lives.
Advancing the CCGs dementia care: NHS Bristol, North Somerset and South Gloucestershire CCG have established leading dementia wellbeing services, with around 2,000 patients benefiting from specialised support last year. A key feature is that people are never discharged from the service and can access support whenever they need it. NHS Bristol, North Somerset and South Gloucestershire CCG are making continued investments and the number of people the service supports has nearly doubled over the last 12 months.
Sustainability and Transformation Partnership: NHS Bristol, North Somerset and South Gloucestershire CCG developed a new plan to guide commissioning activity until 2021 as a partnership between Bristol, North Somerset and South Gloucestershire CCGs. After drafting the plan together, NHS Bristol, North Somerset and South Gloucestershire CCG involved the community and other clinical groups to gain their input. NHS Bristol, North Somerset and South Gloucestershire CCG had meetings with the three local authority health scrutiny committees and community volunteers. BNSSG's work together provided the set up to develop the best possible healthcare services for their population’s needs in the coming years.
Designing healthcare with young people: NHS Bristol, North Somerset and South Gloucestershire CCG held a major consultation to find out what local young people, their parents and professionals involved in their care, thought of BNSSG's community health services. NHS Bristol, North Somerset and South Gloucestershire CCG received over 1,200 ideas and have been using that feedback to shape children’s and young people’s health services.
Improving hospital discharge for older people: the CCGs Discharge to Assess (D2A) scheme speeds up hospital discharge times for older patients, helping them get home quicker. The D2A team support patients to be discharged and assess ongoing care at home, on the same day, by community teams of social workers, nurses, physiotherapists and occupational therapists. The scheme has helped 20 people who would otherwise be in hospital receive therapy in their own homes and enabled the CCG to save a total of 376 hospital bed days.
Appointing a new community healthcare services provider: In partnership with NHS England and North Somerset Council, NHS Bristol, North Somerset and South Gloucestershire CCG appointed North Somerset Community Partnership (NSCP) to provide community healthcare services. They provide all adult and some children’s community health services and specialist services, such as those for people with Parkinson’s disease, until April 2019.
Developing better out-of-hospital care: Helping people to live safely and independently at home as they age has been a high priority. NHS Bristol, North Somerset and South Gloucestershire CCG introduced several initiatives to help people get better outside of hospital, from helping them discharge as soon as they’re fit to leave, to outpatient appointments in the community, and working with Age UK to provide better support to people as they age.
Transforming community services for children: NHS Bristol, North Somerset and South Gloucestershire CCG re-procured children’s community health services for Bristol and South Gloucestershire. This involved a partnership of five commissioning organisations working together to develop a cost-effective service for the whole area that recognises specific local needs, delivering coordinated care to children, young people and families.
Tackling diabetes and promoting self-care: NHS Bristol, North Somerset and South Gloucestershire CCG joined the second wave of the national Diabetes Prevention Programme in April 2017, building on a pilot at Leap Valley GP practice in Emersons Green, Bristol. Together with Bristol and South Gloucestershire CCGs, the CCG has since been selected to pilot the digital stream, which aims to establish whether digital interventions are effective in supporting behaviour change in people with non-diabetic hyperglycemia (NDH) and overweight and or obese individuals.
DARS-NIC-186885-Q1T3D-v3.5 15 January 2020 to 14 January 2023
- Title
- DSfC - NHS Bristol, North Somerset and South Gloucestershire CCG
- Commercial
- No
- Sublicensing
- No
- Datasets
- 27
- Files released
- 0
Datasets: Acute-Local Provider Flows; Ambulance-Local Provider Flows; Children and Young People Health; Civil Registration - Births; Civil Registrations of Death; Community Services Data Set (CSDS); Community-Local Provider Flows; Demand for Service-Local Provider Flows; Diagnostic Imaging Data Set (DID); Diagnostic Services-Local Provider Flows; Emergency Care-Local Provider Flows; Experience, Quality and Outcomes-Local Provider Flows; Improving Access to Psychological Therapies (IAPT) v1.5; Maternity Services Data Set; Mental Health and Learning Disabilities Data Set (MHLDDS); Mental Health Minimum Data Set (MHMDS); Mental Health Services Data Set (MHSDS); Mental Health-Local Provider Flows; National Cancer Waiting Times Monitoring DataSet (NCWTMDS); National Diabetes Audit; Other Not Elsewhere Classified (NEC)-Local Provider Flows; Patient Reported Outcome Measures (PROMs); Population Data-Local Provider Flows; Primary Care Services-Local Provider Flows; Public Health and Screening Services-Local Provider Flows; SUS for Commissioners; SUS for Commissioners
What changed from DARS-NIC-186885-Q1T3D-v2.2
Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.
| Field | Was | Became |
|---|---|---|
| Title | DSfC - NHS Bristol, North Somerset and South Gloucestershire CCG | |
| Start date | 2020-01-15 | |
| End date | 2023-01-14 |
Objective for processing
[7 paragraphs unchanged]
To conduct risk stratification Secondary User Services (SUS+) data, identifiable at the level of NHS number is
pseudonymised and
linked with Primary Care data (from GPs) and an algorithm is applied
[28 words unchanged]
prepare plans for patients who may require high levels of care. Risk
Stratification
Stratification, following re-identification,
also enables General Practitioners (GPs) to better target intervention in Primary Care.
Risk Stratification will be conducted by NHS South Central and West Commissioning Support
Unit
Unit.
[6 paragraphs unchanged]
o
a.
Acute
o
b.
Ambulance
o
c.
Community
o
d.
Demand for Service
o
e.
Diagnostic Service
o
f.
Emergency Care
o
g.
Experience, Quality and Outcomes
o
h.
Mental Health
o
i.
Other Not Elsewhere Classified
o
j.
Population Data
o
k.
Primary Care Services
o
l.
Public Health Screening
[14 paragraphs unchanged]
1.
Population health management:
•
a.
Understanding the interdependency of care services
•
b.
Targeting care more effectively
•
c.
Using value as the redesign principle
2.
Data Quality and Validation – allowing data quality checks on the submitted data
3.
Thoroughly investigating the needs of the population, to ensure the right services are available for individuals when and where they need them
4.
Understanding cohorts of residents who are at risk of becoming users of some of the more expensive services, to better understand and manage those needs
5.
Monitoring population health and care interactions to understand where people may slip through the net, or where the provision of care may be being duplicated
6.
Modelling activity across all data sets to understand how services interact with each other, and to understand how changes in one service may affect flows through another
7.
Service redesign
8.
Health Needs Assessment – identification of underlying disease prevalence within the local population
9.
Patient stratification and predictive modelling - to highlight patients at risk of
[15 words unchanged]
executed against linked de-identified data, and identification of future service delivery models
[1 paragraph unchanged]
Processing for commissioning will be conducted by South Central and West Commissioning Support
Unit
Unit, NHS Bristol, North Somerset and South Gloucestershire CCG, Optum Health Solutions UK Limited
and Outcomes Based Health (OBH)
Clinical Commissioning Groups (CCGs) were established as part of the Health and Social Care Act in 2012 and are responsible for the commissioning of health care services across England.
Clinical Commissioning Groups (CCGs) have a statutory responsibility for commissioning most NHS services and are responsible for approximately 2/3 of the total NHS budget. Increasingly they are also involved in commissioning primary care and some specialised services.
CCGs are groups of local GP practices whose governing bodies include GPs, others clinicians such as nurses and secondary care consultants, patient representatives, general managers and – in some cases – practice managers and local authority representatives.
CCGs have both statutory duties and statutory powers in relation to commissioning healthcare services including but not limited to:
o Community health services
o Maternity services
o Elective hospital care
o Rehabilitation services
o A&E,
o Ambulance services
o Out-of-hours services
o Older people’s healthcare services
o Healthcare services for children
o Healthcare services for people with mental health conditions
o Healthcare services for people with learning disabilities
o Continuing healthcare
o Abortion services
o Infertility services
o Wheelchair services
o Home oxygen services
o Treatment of infectious diseases
CCGs statutory duties and power are defined within the Health and Social Care Act 2012.
Data is required to provide intelligence to support the commissioning of health services and meet the CCGs duties and powers. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the CCG area.
The CCGs commission services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.
The data is required to ensure that analysis of health care provision can be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets.
The overarching objectives of the CCG and use of these data is to:
- Promote accountability and service improvements locally
- Ensure value for money is achieved
- Fulfil statutory functions
- Promote population health management by
a. Understanding the interdependency of care services
b. Targeting care more effectively
c. Using value as the redesign principle
d. Promoting interoperability across care pathways
e. Investigating the needs of the population
- Understanding cohorts of residents who are at risk and managing needs
- Stratify patients by highlighting those patients at risk of requiring hospital admission and other avoidable factors such as risk of falls.
- Identifying gaps in service and where individuals may slip through the net.
- Identifying duplications in service provision.
- Identifying of underlying disease prevalence with the local population through Health Needs Assessments.
The data will further be used for quality and validation purposes, to allow quality checks on the submitted data and to aid in the redesign of services throughout the local region.
DATA PROCESSORS
NHS Bristol, North Somerset and South Gloucestershire CCG
NHS Bristol, North Somerset and South Gloucestershire CCG host the Controlled Environment for Finance to enable the CCG to conduct Invoice Validation.
NHS South Central and West Commissioning Support Unit (SCWCSU)
NSCWCSU are the approved risk stratification provider for the CCG
SCWCSU provide commissioning functions such as, but not limited to, data quality and validation checks, data linkages, the submission of routine statutory returns, performance benchmarking, geographical mapping and intelligence and CCG commissioned reporting for performance, activity and financial monitoring.
Outcomes Based Health (OBH)
NHS Bristol North Somerset and South Gloucestershire CCG is developing local Outcomes Frameworks for diabetes and respiratory programmes. Clinical outcomes have been prioritised through workshops and engagement with commissioners, providers, clinicians and services users and two types of outcome measures have been selected;
• Clinical and Social Outcome Measures (CSOMs), where existing health and care data is used,
• Person-Centred Outcome Measures (PCOMs), where surveys/PROMs are used to collect this data directly from service users.
Having previously baselined (2016-2017) data the ongoing monitoring and development of CSOMs selected for the BNSSG Outcomes Frameworks, pseudonymised, patient-level health and care data is required to to populate the BNSSG/OBH Outcomes Platform, where this information is processed, aggregated and visualised for monitoring, reporting and planning service delivery.
Optum Health Solutions (UK) Ltd
NHS Bristol, North Somerset and South Gloucestershire CCG is working with NHS England as a Wave 2 Population Health Management CCG. NHS England have contracted Optum Health Solutions (UK) Ltd to work with selected CCGs to undertake population health and actuarial analysis to build up a methodology for dissemination across the NHS in England. The NHS Bristol, North Somerset and South Gloucestershire CCG involvement is for 20 weeks, anticipated to start in February 2020 for approximately 20 weeks.
Data held by Optum Health Solutions (UK) Ltd, will be destroyed within 6 months of completion of the project and permissions as a data processor will be removed from this agreement by amendment.
Processing activities
[13 paragraphs unchanged]
The Data Controller and any Data Processor listed will only have access to records of patients of residence and registration within the CCG.
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 Bristol, North Somerset and South Gloucestershire CCG is a Data Controller who also processes data
[6 paragraphs unchanged]
Data Minimisation in relation to the data sets listed within
section 3
this application
are listed below. This also includes the purpose on which they would be applied -
[12 paragraphs unchanged]
Black Box Software
- The Black Box is a software process with very limited access, restricted to only those who administer it.
- It is a set of logic that is hidden from users. It generates a re-pseudonymised output from the data that users enter.
- The purpose of the Black Box is to map the data such that the resulting pseudonymisation is the same as that used at the DSCRO.
- The Black Box works by calling upon a mapping table from the DSCRO and re-pseudonymising by switching the
pseudonym. No data is persisted in the Black Box.
The Black Box is held within a private part of South Central and West Commissioning Support Unit secure network and physically located at the storage address within the DARS application/agreement with the same underlying security controls.)
[48 paragraphs unchanged]
Data Processor
1
-
South,
NHS South
Central and West Commissioning Support Unit
[1 paragraph unchanged]
2. South, Central and West Commissioning Support Unit receives GP
data. GP Data is received as follows:
data (see points i – vii below).
o Identifiable GP data is submitted to South Central and West Commissioning Support Unit.
3. South, Central and West Commissioning Support Unit also receive a flow of social care data (see points i – vii or points viii - xii below).
o The identifiable data lands in a ring-fenced area for GP data only.
4. South, Central and West Commissioning Support Unit for the add derived fields, link data sets and provide analysis.
o The GP data is pseudonymised using a pseudonymisation tool, different to that used by the DSCRO.
5. Allowed linkage is only between data listed in point 1, point 2 and point 3. No further linkage is permitted.
o There is a Data Processing Agreement in place between the GP and South Central and West Commissioning Support Unit. A specific named individual within South Central and West Commissioning Support Unit acts on behalf of the GP.
6. South, Central and West Commissioning Support Unit provide analysis such as, but not limited to, data quality and validation checks, data linkages, the submission of routine statutory returns, performance benchmarking, geographical mapping and intelligence and CCG commissioned reporting for performance, activity and financial monitoring.
o This individual has access to a black box. The pseudonymised data is passed through the black box process where the pseudonymisation is mapped to the pseudonymisation used by the DSCRO.
7. South, Central and West Commissioning Support Unit then pass the processed, pseudonymised and linked data to the CCG.
o Once mapped, the data is passed into South Central and West Commissioning Support, but before South Central and West Commissioning Support Unit will receive the data from the ring-fenced area, they require confirmation that the identifiable data has been deleted.
8. Aggregation of required data for CCG management use will be completed by South, Central and West Commissioning Support Unit as instructed by the CCG.
o South Central and West Commissioning Support Unit are then sent the pseudonymised GP data with the pseudo algorithm specific to them.
GP & Social Care Data
3. South, Central and West Commissioning Support Unit also receive a flow of social care data. Social Care data is received in one of the following 2 ways:
i. Identifiable data is submitted to South Central and West Commissioning Support Unit.
o Pseudonymised:
ii. Social Care data is either:
Social Care data is
a)
pseudonymised within the
provider
provider, prior to submission,
using a pseudonymisation tool, different to that used by the DSCRO. The
[16 words unchanged]
key is specific to the Local Authority and to that specific date.
The pseudonymised data lands in a ring-fenced area for social care data only.
or
There is a Data Processing Agreement in place between the Provider and South Central and West Commissioning Support Unit. A specific named individual within South Central and West Commissioning Support Unit acts on behalf of the Provider.
b) identifiable Social Care data land in a ring-fenced area and pseudonymised using a pseudonymisation tool, different to that used by the DSCRO.
This individual has access to a black box. The pseudonymised data is passed through the black box process where the pseudonymisation is mapped to the pseudonymisation used by the DSCRO.
iii. Identifiable GP data land in a ring-fenced area and pseudonymised using a pseudonymisation tool, different to that used by the DSCRO.
The data is then passed into the non-ringfenced area with the pseudo algorithm specific to them.
iv. There is a Data Processing Agreement in place between the provider (GP or Local Authority) and South Central and West Commissioning Support Unit. A specific named individual within South Central and West Commissioning Support Unit acts on behalf of the GP and/or Local Authority).
o Identifiable:
v. This individual has access to a black box. The pseudonymised data is passed through the black box process where the pseudonymisation is mapped to the pseudonymisation used by the DSCRO.
Identifiable social care data is submitted to South Central and West Commissioning Support Unit.
vi. Once mapped, the data is passed into South Central and West Commissioning Support, but before South Central and West Commissioning Support Unit will receive the data from the ring-fenced area, they require confirmation that the identifiable data has been deleted.
The identifiable data lands in a ring-fenced area for social care data only.
vii. The data is then passed into the non-ringfenced area with the pseudo algorithm specific to them.
The social care data is pseudonymised using a pseudonymisation tool, different to that used by the DSCRO.
Data Processor - Outcomes Based Health
There is a Data Processing Agreement in place between the Local Authority and South Central and West Commissioning Support Unit. A specific named individual within South Central and West Commissioning Support Unit acts on behalf of the provider.
This individual has access to a black box. The pseudonymised data is passed through the black box process where the pseudonymisation is mapped to the pseudonymisation used by the DSCRO.
Once mapped, the data is passed into South Central and West Commissioning Support, but before South Central and West Commissioning Support Unit will receive the data from the ring-fenced area, they require confirmation that the identifiable data has been deleted.
South Central and West Commissioning Support Unit are then sent the pseudonymised social care data with the pseudo algorithm specific to them.
4. Once the pseudonymised GP data and social care data is received, South, Central and West Commissioning Support Unit make a request to the DSCRO.
5. The DSCRO check the dates of the key generation (Point 2d and 3aii/3biv).
6. The DSCRO then send a mapping table to South, Central and West Commissioning Support Unit
7. South, Central and West Commissioning Support Unit then overwrite the organisation specific keys with the DSCRO key.
8. The mapping table is then deleted.
9. The DSCRO pass the pseudonymised SUS+, Local Provider data, Mental Health data (MHSDS, MHMDS, MHLDDS), Maternity data (MSDS), Improving Access to Psychological Therapies data (IAPT), Child and Young People’s Health data (CYPHS), Community Services Data Set (CSDS), Diagnostic Imaging data (DIDS), National Cancer Waiting Times Monitoring Data Set (CWT), Civil Registries Data (CRD) (Births and Deaths), National Diabetes Audit (NDA) and Patient Reported Outcome Measures (PROMs) securely to South, Central and West Commissioning Support Unit for the addition of derived fields, linkage of data sets and analysis.
10. Social care data is then linked to the data sets listed within point 9.
11. South, Central and West Commissioning Support Unit then pass the processed, pseudonymised and linked data to the CCG.
12. Aggregation of required data for CCG management use will be completed by South, Central and West Commissioning Support Unit as instructed by the CCG.
13. Patient level data will not be shared outside of the CCG and will only be shared within the CCG on a need to know basis, as per the purposes stipulated within the Data Sharing Agreement. External aggregated reports only with small number suppression can be shared as set out within NHS Digital guidance applicable to each data set.
Data Processor 2 - Outcomes Based Health
[7 paragraphs unchanged]
Data Processor - Optum Health Solutions (UK) Ltd
1. Pseudonymised SUS, Local Provider Data, GP Primary Care data and Social Care data is securely transferred from NHS Bristol, North Somerset and South Gloucestershire CCG to Optum Health Solutions (UK) Ltd. The data is decoupled from the other national datasets and sent as individual data flows
2. Optum Health Solutions (UK) Ltd provide analysis to:
• Whole population segmentation to assess population health needs
• Prospective risk scoring for individuals to indicate the likelihood of future adverse events
• Predictive modelling to determine individuals at risk and an understanding of the drivers of risk
• Longitudinal analysis of intersegmental drift - identifying individuals who move between complexity classifications and the drivers of these transitions
• The production of individual-level theographs to identify gaps in care
3. Allowed linkage is between the datasets contained within point (1) above. GP and Social Care datasets are needed for the processing carried out by Optum to enhance the population health analytics beyond SUS and LPFs which contain only secondary cre activity
4. Optum Health Solutions (UK) Ltd then pass the processed, pseudonymised and linked data to the CCG.
5. Aggregated of required data for CCG management use will be completed by Optum Health Solutions (UK) Ltd or the CCG as instructed by the CCG.
[1 paragraph unchanged]
7. Optum Health Solutions (UK) Ltd will only be in receipt of data and only be permitted to act as Data Processors for the period specified in the NHSE contract with NHS Bristol, North Somerset and South Gloucestershire CCG.
8. The NHSE/Optum contractual period with NHS Bristol, North Somerset and South Gloucestershire CCG is anticipated to end in July 2020, at which point the data processor will be be removed from this agreement by amendment.
Data held by Optum Health Solutions (UK) Ltd, will be destroyed within 6 months of completion of the project and permissions as a data processor will be removed from this agreement by amendment.
Expected output
[11 paragraphs unchanged]
3.
1.
Target specific vulnerable patient groups and enable clinicians with the duty of care for the patient to offer appropriate interventions.
4.
2.
Reduce hospital readmissions and targeting clinical interventions to high risk patients.
5.
3.
Identify patients at risk of deterioration and providing effective care.
6.
4.
Reduce in the difference in the quality of care between those with the best and worst outcomes.
7.
5.
Re-design care to reduce admissions.
8.
6.
Set up capitated budgets – budgets based on care provided to the specific population.
9.
7.
Identify health determinants of risk of admission to hospital, or other adverse care outcomes.
10.
8.
Monitor vulnerable groups of patients including but not limited to frailty, COPD, Diabetes, elderly.
11.
9.
Health needs assessments – identifying numbers of patients with specific health conditions or combination of conditions.
12.
10.
Classify vulnerable groups based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost.
13.
11.
Production of Theographs – a visual timeline of a patients encounters with hospital providers.
14.
12.
Analyse based on specific diseases
[70 paragraphs unchanged]
h. Monitoring to support
NMoC, ACOs, STPs
New Models of Care
[54 paragraphs unchanged]
All outputs will be delivered within the timescales of the contract between OBH and the
CCGs.
CCG.
Optum Health Solutions UK Limited
The outputs, as part of the NHS England Wave 2 PHM national programme will identify patient cohorts and inequalities in outcome, spend and opportunity for further investigation, with a view to improving service delivery and patient health outcomes.
Wave 2 PHM will also begin to develop the CCG capability to undertake actuarial analysis of linked datasets from multiple care settings to develop further the understanding of the wider determinants of health across the population.
All outputs will be delivered within the timescales of the contract between Optum Health Solutions UK Limited and the CCG.
Expected measurable benefits
[91 paragraphs unchanged]
Outcomes Based Healthcare:
All Data Processors
[3 paragraphs unchanged]
Anticipated outputs include, but are not limited to;
1. Health needs assessments – identifying numbers of patients with specific health conditions or combination of conditions.
2. Classification and creation of reference groups of vulnerable groups based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost.
3. Production of Theographs – a visual timeline of a patients encounters with hospital providers.
4. Analysis based on specific diseases
5. 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.
6. Profiles of the health of and the variations in health outcomes within the population to help understand local population characteristics
7. Descriptions and illustrations of the impact of services on health inequalities, the health of the population and patient cohorts
Benefits reported
Data
is
used in support of ongoing transformation plans to deliver against savings plan. To date, around £28.5m of savings
have been
identified. Work supported by analyst use of data to initially develop
and
savings plans and identify impacts.
Ongoing activity monitoring support and reporting.
Ongoing activity monitoring support and reporting:
[4 paragraphs unchanged]
Provide assurance to CCG Governing Body and
Healthy
Healthier
Together STP (System Delivery Oversight Group): that contracts with providers are being
[43 words unchanged]
work with providers to develop joint activity plans, performance trajectories and strategies.
[2 paragraphs unchanged]
Advancing the
CCCGs
CCGs
dementia care: NHS Bristol, North Somerset and South Gloucestershire CCG have established
[50 words unchanged]
people the service supports has nearly doubled over the last 12 months.
[6 paragraphs unchanged]
Tackling diabetes and promoting self-care: NHS Bristol, North Somerset and South Gloucestershire
[50 words unchanged]
digital interventions are effective in supporting behaviour change in people with non-diabetic
hyperglycaemia
hyperglycemia
(NDH) and overweight and or obese individuals.
Objective for processing
INVOICE VALIDATION
Invoice validation is part of a process by which providers of care or services get paid for the work they do.
Invoices are submitted to the Clinical Commissioning Group (CCG) so the CCG is are able to ensure that the activity claimed for each patient is their responsibility. This is done by processing and analysing Secondary User Services (SUS+) data, which is received into a secure Controlled Environment for Finance (CEfF). The SUS+ data is identifiable at the level of NHS number. The NHS number is only used to confirm the accuracy of backing-data sets (data from providers) and will not be used further.
The CCG are advised by the appointed CEfF whether payment for invoices can be made or not.
Invoice Validation will be conducted by NHS Bristol, North Somerset and South Gloucestershire CCG
RISK STRATIFICATION
Risk stratification is a tool for identifying and predicting which patients are at high risk (of health deterioration and using multiple services) or are likely to be at high risk and prioritising the management of their care in order to prevent worse outcomes.
To conduct risk stratification Secondary User Services (SUS+) data, identifiable at the level of NHS number is pseudonymised and linked with Primary Care data (from GPs) and an algorithm is applied to produce risk scores. Risk Stratification provides focus for future demands by enabling commissioners to prepare plans for both individual and groups of vulnerable patients. Commissioners can then prepare plans for patients who may require high levels of care. Risk Stratification, following re-identification, also enables General Practitioners (GPs) to better target intervention in Primary Care.
Risk Stratification will be conducted by NHS South Central and West Commissioning Support Unit.
COMMISSIONING
To use pseudonymised data to provide intelligence to support the commissioning of health services. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the CCG area.
The CCGs commission services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.
The following pseudonymised datasets are required to provide intelligence to support commissioning of health services:
- Secondary Uses Service (SUS+)
- Local Provider Flows
a. Acute
b. Ambulance
c. Community
d. Demand for Service
e. Diagnostic Service
f. Emergency Care
g. Experience, Quality and Outcomes
h. Mental Health
i. Other Not Elsewhere Classified
j. Population Data
k. Primary Care Services
l. Public Health Screening
- Mental Health Minimum Data Set (MHMDS)
- Mental Health Learning Disability Data Set (MHLDDS)
- Mental Health Services Data Set (MHSDS)
- Maternity Services Data Set (MSDS)
- Improving Access to Psychological Therapy (IAPT)
- Child and Young People Health Service (CYPHS)
- Community Services Data Set (CSDS)
- Diagnostic Imaging Data Set (DIDS)
- National Cancer Waiting Times Monitoring Data Set (CWT)
- Civil Registries Data (CRD) (Births)
- Civil Registries Data (CRD) (Deaths)
- National Diabetes Audit (NDA)
- Patient Reported Outcome Measures (PROMs)
The pseudonymised data is required to for the following purposes:
1. Population health management:
a. Understanding the interdependency of care services
b. Targeting care more effectively
c. Using value as the redesign principle
2. Data Quality and Validation – allowing data quality checks on the submitted data
3. Thoroughly investigating the needs of the population, to ensure the right services are available for individuals when and where they need them
4. Understanding cohorts of residents who are at risk of becoming users of some of the more expensive services, to better understand and manage those needs
5. Monitoring population health and care interactions to understand where people may slip through the net, or where the provision of care may be being duplicated
6. Modelling activity across all data sets to understand how services interact with each other, and to understand how changes in one service may affect flows through another
7. Service redesign
8. Health Needs Assessment – identification of underlying disease prevalence within the local population
9. Patient stratification and predictive modelling - to highlight patients at risk of requiring hospital admission and other avoidable factors such as risk of falls, computed using algorithms executed against linked de-identified data, and identification of future service delivery models
The pseudonymised data is required to ensure that analysis of health care provision can be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets.
Processing for commissioning will be conducted by South Central and West Commissioning Support Unit, NHS Bristol, North Somerset and South Gloucestershire CCG, Optum Health Solutions UK Limited and Outcomes Based Health (OBH)
Clinical Commissioning Groups (CCGs) were established as part of the Health and Social Care Act in 2012 and are responsible for the commissioning of health care services across England.
Clinical Commissioning Groups (CCGs) have a statutory responsibility for commissioning most NHS services and are responsible for approximately 2/3 of the total NHS budget. Increasingly they are also involved in commissioning primary care and some specialised services.
CCGs are groups of local GP practices whose governing bodies include GPs, others clinicians such as nurses and secondary care consultants, patient representatives, general managers and – in some cases – practice managers and local authority representatives.
CCGs have both statutory duties and statutory powers in relation to commissioning healthcare services including but not limited to:
o Community health services
o Maternity services
o Elective hospital care
o Rehabilitation services
o A&E,
o Ambulance services
o Out-of-hours services
o Older people’s healthcare services
o Healthcare services for children
o Healthcare services for people with mental health conditions
o Healthcare services for people with learning disabilities
o Continuing healthcare
o Abortion services
o Infertility services
o Wheelchair services
o Home oxygen services
o Treatment of infectious diseases
CCGs statutory duties and power are defined within the Health and Social Care Act 2012.
Data is required to provide intelligence to support the commissioning of health services and meet the CCGs duties and powers. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the CCG area.
The CCGs commission services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.
The data is required to ensure that analysis of health care provision can be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets.
The overarching objectives of the CCG and use of these data is to:
- Promote accountability and service improvements locally
- Ensure value for money is achieved
- Fulfil statutory functions
- Promote population health management by
a. Understanding the interdependency of care services
b. Targeting care more effectively
c. Using value as the redesign principle
d. Promoting interoperability across care pathways
e. Investigating the needs of the population
- Understanding cohorts of residents who are at risk and managing needs
- Stratify patients by highlighting those patients at risk of requiring hospital admission and other avoidable factors such as risk of falls.
- Identifying gaps in service and where individuals may slip through the net.
- Identifying duplications in service provision.
- Identifying of underlying disease prevalence with the local population through Health Needs Assessments.
The data will further be used for quality and validation purposes, to allow quality checks on the submitted data and to aid in the redesign of services throughout the local region.
DATA PROCESSORS
NHS Bristol, North Somerset and South Gloucestershire CCG
NHS Bristol, North Somerset and South Gloucestershire CCG host the Controlled Environment for Finance to enable the CCG to conduct Invoice Validation.
NHS South Central and West Commissioning Support Unit (SCWCSU)
NSCWCSU are the approved risk stratification provider for the CCG
SCWCSU provide commissioning functions such as, but not limited to, data quality and validation checks, data linkages, the submission of routine statutory returns, performance benchmarking, geographical mapping and intelligence and CCG commissioned reporting for performance, activity and financial monitoring.
Outcomes Based Health (OBH)
NHS Bristol North Somerset and South Gloucestershire CCG is developing local Outcomes Frameworks for diabetes and respiratory programmes. Clinical outcomes have been prioritised through workshops and engagement with commissioners, providers, clinicians and services users and two types of outcome measures have been selected;
• Clinical and Social Outcome Measures (CSOMs), where existing health and care data is used,
• Person-Centred Outcome Measures (PCOMs), where surveys/PROMs are used to collect this data directly from service users.
Having previously baselined (2016-2017) data the ongoing monitoring and development of CSOMs selected for the BNSSG Outcomes Frameworks, pseudonymised, patient-level health and care data is required to to populate the BNSSG/OBH Outcomes Platform, where this information is processed, aggregated and visualised for monitoring, reporting and planning service delivery.
Optum Health Solutions (UK) Ltd
NHS Bristol, North Somerset and South Gloucestershire CCG is working with NHS England as a Wave 2 Population Health Management CCG. NHS England have contracted Optum Health Solutions (UK) Ltd to work with selected CCGs to undertake population health and actuarial analysis to build up a methodology for dissemination across the NHS in England. The NHS Bristol, North Somerset and South Gloucestershire CCG involvement is for 20 weeks, anticipated to start in February 2020 for approximately 20 weeks.
Data held by Optum Health Solutions (UK) Ltd, will be destroyed within 6 months of completion of the project and permissions as a data processor will be removed from this agreement by amendment.
Expected output
INVOICE VALIDATION
1. The Controlled Environment for Finance (CEfF) will enable the CCG to challenge invoices and raise discrepancies and disputes.
2. Outputs from the CEfF will enable accurate production of budget reports, which will:
a. Assist in addressing poor quality data issues
b. Assist in business intelligence
3. Validation of invoices for non-contracted events where a service delivered to a patient by a provider that does not have a written contract with the patient’s responsible commissioner, but does have a written contract with another NHS commissioner/s.
4. Budget control of the CCG.
RISK STRATIFICATION
1. As part of the risk stratification processing activity detailed above, GPs have access to the risk stratification tool which highlights patients for whom the GP is responsible and have been classed as at risk. The only identifier available to GPs is the NHS numbers of their own patients. Any further identification of the patients will be completed by the GP on their own systems.
2. 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.
CCGs will be able to:
1. Target specific vulnerable patient groups and enable clinicians with the duty of care for the patient to offer appropriate interventions.
2. Reduce hospital readmissions and targeting clinical interventions to high risk patients.
3. Identify patients at risk of deterioration and providing effective care.
4. Reduce in the difference in the quality of care between those with the best and worst outcomes.
5. Re-design care to reduce admissions.
6. Set up capitated budgets – budgets based on care provided to the specific population.
7. Identify health determinants of risk of admission to hospital, or other adverse care outcomes.
8. Monitor vulnerable groups of patients including but not limited to frailty, COPD, Diabetes, elderly.
9. Health needs assessments – identifying numbers of patients with specific health conditions or combination of conditions.
10. Classify vulnerable groups based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost.
11. Production of Theographs – a visual timeline of a patients encounters with hospital providers.
12. Analyse based on specific diseases
In addition:
- The risk stratification tool will provide aggregate reporting of number and percentage of population found to be at risk.
- Record level output (pseudonymised) will be available for commissioners (of the CCG), pseudonymised at patient level. Onward sharing of this data is not permitted
COMMISSIONING
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.
g. Statutory returns.
h. Statutory returns - monthly activity return.
i. Statutory returns - quarterly activity return.
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.
9. Comparators of CCG performance with similar CCGs as set out by a specific range of care quality and performance measures detailed activity and cost reports
10. Data Quality and Validation measures allowing data quality checks on the submitted data
11. Contract Management and Modelling
12. Patient Stratification, such as:
a. Patients at highest risk of admission
b. Users of high cost activity
c. Frail and elderly
d. Patients that are currently in hospital
e. Patients with most referrals to secondary care
f. Patients with most emergency activity
g. Patients with most expensive prescriptions
h. Patients recently moving from one care setting to another
i. Discharged from hospital
ii. Discharged from community
13. Profiling population health and wider determinants to identify and target those most in need
a. Understanding population profile and demographics
b. Identify patient cohorts with specific needs or who may benefit from interventions
c. Identifying disease prevalence. health and care needs for population cohorts
d. Contributing to Joint Strategic Needs Assessment (JSNA)
e. Geographical mapping and analysis
14. Identifying and managing preventable and existing conditions
a. Identifying types of individuals and population cohorts at risk of non-elective re-admission
b. Risk stratification to identify populations suitable for case management
c. Risk profiling and predictive modelling
d. Risk stratification for planning services for population cohorts
e. Identification of disease incidence and diagnosis stratification
15. Reducing health inequalities
a. Identifying cohorts of patients who have worse health outcomes typically deprived, ethnic groups, homeless, travellers etc. to enable services to proactively target their needs
b. Socio-demographic analysis
16. Managing demand
a. Waiting times analysis
b. Service demand and supply modelling
c. Understanding cross-border and overseas visitor
d. Winter planning
e. Emergency preparedness, business continuity, recovery and contingency planning
17. Care co-ordination and planning
a. Planning packages of care
b. Service planning
c. Planning care co-ordination
18. Monitoring individual patient health, service utilisation, pathway compliance experience & outcomes across the heath and care system
a. Patient pathway analysis across health and care
b. Outcomes & experience analysis
c. Analysis to support anti-terror initiatives
d. Analysis to identify vulnerable patients with potential safeguarding issues
e. Understanding equity of care and unwarranted variation
f. Modelling patient flow
g. Tracking patient pathways
h. Monitoring to support New Models of Care
i. Identifying duplications in care
j. Identifying gaps in care, missed diagnoses and triple fail events
k. Analysing individual and aggregated timelines
19. Undertaking budget planning, management and reporting
a. Tracking financial performance against plans
b. Budget reporting
c. Tariff development
d. Developing and monitoring capitated budgets
e. Developing and monitoring individual-level budgets
f. Future budget planning and forecasting
g. Paying for care of overseas visitors and cross-border flow
20. Monitoring the value for money
a. Service-level costing & comparisons
b. Identification of cost pressures
a. Cost benefit analysis
b. Equity of spend across services and population cohorts
c. Finance impact assessment
21. Comparing population groups, peers, national and international best practice
d. Identification of variation in productivity, cost, outcomes, quality, experience, compared with peers, national and international & best practice
e. Benchmarking against other parts of the country
f. Identifying unwarranted variations
22. Comparing expected levels
g. Standardised comparisons for prevalence, activity, cost, quality, experience, outcomes for given populations
23. Comparing local targets & plan
h. Monitoring of local variation in productivity, cost, outcomes, quality and experience
i. Local performance dashboards by service provider, commissioner, geography, NMOC, STPs
24. Monitoring activity and cost compliance against contract and agreed plans
j. Contract monitoring
k. Contract reconciliation and challenge
l. Invoice validation
25. Monitoring provider quality, demand, experience and outcomes against contract and agreed plans
m. Performance dashboards
n. CQUIN reporting
o. Clinical audit
p. Patient experience surveys
q. Demand, supply, outcome & experience analysis
r. Monitoring cross-border flows and overseas visitor activity
26. Improving provider data quality
s. Coding audit
t. Data quality validation and review
u. Checking validity of patient identity and commissioner assignment
27. Validation for payment approval, ability to validate that claims are not being made after an individual has died, like Oxygen services.
28. Validation of programs implemented to improve patient pathway e.g. High users unable to validate if the process to help patients find the best support are working or did the patient die.
29. Clinical - understand reasons why patients are dying, what additional support services can be put in to support.
30. Understanding where patient are dying e.g. are patients dying at hospitals due to hospices closing due to Local authorities withdrawing support, or is there a problem at a particular trust.
31. Removal of patients from Risk Stratification reports.
32. Re births provide a one stop shop of information, Births are recorded in multiple sources covering hospital and home births, a chance to overlook activity.
Outcomes Based Healthcare:
The main outputs are aggregated monthly values for each outcome outputs will comply with the NHS Digital guidance on suppression rules. The aggregated monthly outcomes data will be made available through OBH’s online tool (available to named individuals in the CCG and CCG commissioned providers only) via a secure login.
This enables the CCGs and to:
- visualise baselines for each outcome
- set improvement trajectories
- monitor outcomes on an on-going basis.
In addition, the CCGs will receive an information schedule describing the outcomes to be monitored, the technical description, and annual baseline data for each outcome.
All outputs will be delivered within the timescales of the contract between OBH and the CCG.
Optum Health Solutions UK Limited
The outputs, as part of the NHS England Wave 2 PHM national programme will identify patient cohorts and inequalities in outcome, spend and opportunity for further investigation, with a view to improving service delivery and patient health outcomes.
Wave 2 PHM will also begin to develop the CCG capability to undertake actuarial analysis of linked datasets from multiple care settings to develop further the understanding of the wider determinants of health across the population.
All outputs will be delivered within the timescales of the contract between Optum Health Solutions UK Limited and the CCG.
Benefits reported
Data is used in support of ongoing transformation plans to deliver against savings plan. To date, around £28.5m of savings have been identified. Work supported by analyst use of data to initially develop savings plans and identify impacts.
Ongoing activity monitoring support and reporting:
Data used to monitor impact of major system changes, including the overnight closure of an A&E department within the BNSSG area. Activity data used to measure impact on system and patients and inform decision making around the process.
Development of bespoke reporting tools which are used in a range of settings, including an unwarranted practice variation tool which has been used to identify referral outliers and inform further work to understand activity.
Continued use of data in support of monitoring around delivery of constitutional standards, with standards achieved in a number of measures. Data used to help inform plans aimed at achieving targets in other areas requiring improvement, by understanding drivers behind performance and identifying opportunities for improvements.
Identify data and performance issues at provider organisations to initiate discussions at contract meetings which has led to: further analysis to identify root causes and mitigating actions; using contractual levers i.e. issuing contractual notices (Contract Performance Notices and Information Breach Notices) to facilitate improvement through joint investigations and remedial action plans and; identifying good practice and lessons learned to ensure consistency across our 3 providers to support equity of provision.
Provide assurance to CCG Governing Body and Healthier Together STP (System Delivery Oversight Group): that contracts with providers are being managed effectively and; how the BNSSG population is being served; Provides evidence to STP system wide groups on areas of good and poor performance such as urgent care, planned care and cancer to share learning, identify improvements and develop joint plans. Support the work with providers to develop joint activity plans, performance trajectories and strategies.
NHS Bristol, North Somerset and South Gloucestershire CCG are an evidence-based organisation using data to underpin our decision making processes. Key achievements which have been informed by use of data include:
Funding mental health support in schools: NHS Bristol, North Somerset and South Gloucestershire CCG became the first city in the country to fund a mental health-focused training package for staff in every primary and secondary school, working closely with Bristol City Council. The training is designed to raise the profile of Child and Adolescent Mental Health Services (CAMHS), with the focus on early intervention to make a significant difference to young people’s lives.
Advancing the CCGs dementia care: NHS Bristol, North Somerset and South Gloucestershire CCG have established leading dementia wellbeing services, with around 2,000 patients benefiting from specialised support last year. A key feature is that people are never discharged from the service and can access support whenever they need it. NHS Bristol, North Somerset and South Gloucestershire CCG are making continued investments and the number of people the service supports has nearly doubled over the last 12 months.
Sustainability and Transformation Partnership: NHS Bristol, North Somerset and South Gloucestershire CCG developed a new plan to guide our commissioning activity until 2021 as a partnership between Bristol, North Somerset and South Gloucestershire CCGs. After drafting the plan together, NHS Bristol, North Somerset and South Gloucestershire CCG involved the community and other clinical groups to gain their input. NHS Bristol, North Somerset and South Gloucestershire CCG had meetings with the three local authority health scrutiny committees and community volunteers. Our work together set us up to develop the best possible healthcare services for our population’s needs in the coming years.
Designing healthcare with young people: NHS Bristol, North Somerset and South Gloucestershire CCG held a major consultation to find out what local young people, their parents and professionals involved in their care, thought of our community health services. NHS Bristol, North Somerset and South Gloucestershire CCG received over 1,200 ideas and have been using that feedback to shape children’s and young people’s health services.
Improving hospital discharge for older people: the CCGs Discharge to Assess (D2A) scheme speeds up hospital discharge times for older patients, helping them get home quicker. The D2A team support patients to be discharged and assess ongoing care at home, on the same day, by community teams of social workers, nurses, physiotherapists and occupational therapists. The scheme has helped 20 people who would otherwise be in hospital receive therapy in their own homes and enabled the CCG to save a total of 376 hospital bed days.
Appointing a new community healthcare services provider: In partnership with NHS England and North Somerset Council, NHS Bristol, North Somerset and South Gloucestershire CCG appointed North Somerset Community Partnership (NSCP) to provide community healthcare services. They provide all adult and some children’s community health services and specialist services, such as those for people with Parkinson’s disease, until April 2019.
Developing better out-of-hospital care: Helping people to live safely and independently at home as they age has been a high priority. NHS Bristol, North Somerset and South Gloucestershire CCG introduced several initiatives to help people get better outside of hospital, from helping them discharge as soon as they’re fit to leave, to outpatient appointments in the community, and working with Age UK to provide better support to people as they age.
Transforming community services for children: NHS Bristol, North Somerset and South Gloucestershire CCG re-procured children’s community health services for Bristol and South Gloucestershire. This involved a partnership of five commissioning organisations working together to develop a cost-effective service for the whole area that recognises specific local needs, delivering coordinated care to children, young people and families.
Tackling diabetes and promoting self-care: NHS Bristol, North Somerset and South Gloucestershire CCG joined the second wave of the national Diabetes Prevention Programme in April 2017, building on a pilot at Leap Valley GP practice in Emersons Green, Bristol. Together with Bristol and South Gloucestershire CCGs, the CCG has since been selected to pilot the digital stream, which aims to establish whether digital interventions are effective in supporting behaviour change in people with non-diabetic hyperglycemia (NDH) and overweight and or obese individuals.
DARS-NIC-186885-Q1T3D-v2.2 15 November 2019 to 14 November 2022
- Title
- DSfC - NHS Bristol, North Somerset and South Gloucestershire CCG - Comm IV RS
- Commercial
- No
- Sublicensing
- No
- Datasets
- 27
- Files released
- 0
Datasets: Acute-Local Provider Flows; Ambulance-Local Provider Flows; Children and Young People Health; Civil Registration - Births; Civil Registrations of Death; Community Services Data Set (CSDS); Community-Local Provider Flows; Demand for Service-Local Provider Flows; Diagnostic Imaging Data Set (DID); Diagnostic Services-Local Provider Flows; Emergency Care-Local Provider Flows; Experience, Quality and Outcomes-Local Provider Flows; Improving Access to Psychological Therapies (IAPT) v1.5; Maternity Services Data Set; Mental Health and Learning Disabilities Data Set (MHLDDS); Mental Health Minimum Data Set (MHMDS); Mental Health Services Data Set (MHSDS); Mental Health-Local Provider Flows; National Cancer Waiting Times Monitoring DataSet (NCWTMDS); National Diabetes Audit; Other Not Elsewhere Classified (NEC)-Local Provider Flows; Patient Reported Outcome Measures (PROMs); Population Data-Local Provider Flows; Primary Care Services-Local Provider Flows; Public Health and Screening Services-Local Provider Flows; SUS for Commissioners; SUS for Commissioners
What changed from DARS-NIC-186885-Q1T3D-v1.3
Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.
| Field | Was | Became |
|---|---|---|
| Start date | 2019-11-15 | |
| End date | 2022-11-14 | |
| Acute-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Ambulance-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Children and Young People Health: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Civil Registration - Births: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Civil Registrations of Death: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Community Services Data Set (CSDS): common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Community-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Demand for Service-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Diagnostic Imaging Data Set (DID): common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Diagnostic Services-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Emergency Care-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Experience, Quality and Outcomes-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Improving Access to Psychological Therapies Data Set_v1.5: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Maternity Services Data Set v1.5: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Mental Health Minimum Data Set (MHMDS): common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Mental Health Services Data Set (MHSDS): common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Mental Health and Learning Disabilities Data Set (MHLDDS): common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Mental Health-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| National Cancer Waiting Times Monitoring DataSet (NCWTMDS): common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Other Not Elsewhere Classified (NEC)-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Population Data-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Primary Care Services-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Public Health and Screening Services-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| SUS for Commissioners: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
Datasets: + National Diabetes Audit; + Patient Reported Outcome Measures (PROMs)
Objective for processing
[2 paragraphs unchanged]
Invoices are submitted to the Clinical Commissioning Group (CCG) so
they
the CCG is
are able to ensure that the activity claimed for each patient is
[37 words unchanged]
NHS number is only used to confirm the accuracy of backing-data sets
(data from providers)
and will not be used further.
The CCG are advised by the
appointed
CEfF whether payment for invoices can be made or not.
[2 paragraphs unchanged]
Risk stratification is a tool for identifying and predicting which patients are at high risk
(of health deterioration and using multiple services)
or are likely to be at high risk and prioritising the management of their care in order to prevent worse outcomes.
To conduct risk stratification Secondary User Services (SUS+) data, identifiable at the
[23 words unchanged]
provides focus for future demands by enabling commissioners to prepare plans for
both individual and groups of vulnerable
patients. Commissioners can then prepare plans for patients who may require high
[5 words unchanged]
also enables General Practitioners (GPs) to better target intervention in Primary Care.
[2 paragraphs unchanged]
The NHS and local councils have come together in 44 areas covering all of England to develop proposals to improve health and care. They have formed new partnerships – known as sustainability and transformation partnerships – to plan jointly for the next few years.
To use pseudonymised data to provide intelligence to support the commissioning of health services. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the CCG area.
Sustainability and transformation partnerships build on collaborative work that began under the NHS Shared Planning Guidance for 2016/17 – 2020/21, to support implementation of the Five Year Forward View. They are supported by six national health and care bodies: NHS England; NHS Improvement; the Care Quality Commission (CQC); Health Education England (HEE); Public Health England (PHE) and the National Institute for Health and Care Excellence (NICE).
The CCGs commission services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.
The CCG is part of the Bristol, North Somerset and South Gloucestershire Sustainable Transformation Partnership. The STP is responsible for implementing large parts of the 5 year forward view from NHS England. The STP is implementing several initiatives:
- Putting the patient at the heart of the health system
- Working across organisational boundaries to deliver care and including social care, public Health, providers and GPs as well as CCGs
- Reviewing patient pathways to improve patient experience whilst reducing costs e.g. reduce the number of standard tests a patient may have and only have the ones they need
- Planning the demand and capacity across the healthcare system across 2 CCGs to ensure we have the right buildings, services and staff to cope with demand whilst reducing the impact on costs
- Working to prevent or capture conditions early as they are cheaper to treat
- Introduce initiatives to change behaviours e.g. move more care into the community
- Patient pathway planning for the above
To ensure the patient is at the heart of care, the STP is focussing on where services are required across the geographical region. This assists to ensure delivery of care in the right place for patients who may move and change services across the CCG.
The CCG will work proactively and collaboratively in the STP to redesign services across boundaries to integrate services.
The CCG will use pseudonymised data to provide intelligence to support the commissioning of health services. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the STP area.
The CCG commissions services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.
[24 paragraphs unchanged]
- Civil Registries Data (CRD)
(Births and Deaths)
(Births)
- Civil Registries Data (CRD) (Deaths)
- National Diabetes Audit (NDA)
- Patient Reported Outcome Measures (PROMs)
[5 paragraphs unchanged]
• Ensuring we do what we should
[7 paragraphs unchanged]
Patient stratification and predictive modelling - to
identify specific
highlight
patients at risk of requiring hospital admission and other avoidable factors such
[7 words unchanged]
executed against linked de-identified data, and identification of future service delivery models
[2 paragraphs unchanged]
Processing activities
PROCESSING CONDITIONS:
[3 paragraphs unchanged]
All access to data is managed under Role-Based Access Controls. Users can only access data authorised by their role and the tasks that they are required to undertake.
Patient level data will not be linked other than as specifically detailed within this Data Sharing Agreement. Data released will only be shared with those parties listed and will only be used for the purposes laid out in the application/agreement.
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)
The DSCRO (part of NHS Digital) will apply National Opt-outs before any identifiable data leaves the DSCRO only for the purpose of Risk Stratification.
CCGs should work with general practices within their CCG to help them fulfil data controller responsibilities regarding flow of identifiable data into risk stratification tools.
The only identifier available in the data set is the NHS numbers. Any further identification of the patients will only be completed by the patient’s clinician on their own systems for the purpose of direct care with a legitimate relationship.
ONWARD SHARING:
[1 paragraph unchanged]
All access to data is managed under Roles-Based Access Controls.
Aggregated reports only with small number suppression can be shared externally as set out within NHS Digital guidance applicable to each data set.
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.
SEGREGATION:
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)
The DSCRO (part of NHS Digital) will apply Type 2 objections before any identifiable data leaves the DSCRO only for the purpose of Risk Stratification.
CCGs should work with general practices within their CCG to help them fulfil data controller responsibilities regarding flow of identifiable data into risk stratification tools.
Segregation
[1 paragraph unchanged]
Where the Data Processor and/or the Data Controller hold identifiable data with opt outs applied and identifiable data with opt outs not applied, the data will be held separately so data cannot be linked.
[14 paragraphs unchanged]
Microsoft UK supply Cloud Services for Outcomes Based Healthcare and are therefore listed as a data processor. They supply support to the system, but do not access data. Therefore, any access to the data held under this agreement would be considered a breach of agreement. This includes granting of access to the database[s] containing the data.
[1 paragraph unchanged]
Identifiable data will only be disclosed:
INVOICE VALIDATION - NHS Bristol, North Somerset and South Gloucestershire CCG
1) where the requesting Data Controller’s Caldicott Guardian/Senior Approving Officer has approved the disclosure
2) where the DSCRO Information Risk Owner has approved the disclosure
3) to requestor/recipients specified by the Data Controller
4) to recipients that have a legitimate relationship with the individuals identified by the data, e.g. clinician
5) using mechanisms and routes that are secure and have an appropriate legal basis for holding identifiable data
6) where there is a legal basis and it is covered by a Data Sharing Agreement that justifies its use or the data subject has consented or where there is a separate legal basis for making the dataset identifiable enabling the re-identification to take place
7) whilst continuing to respect the data subject’s preferences for data sharing
In order for identifiable data to be disclosed, all seven requirements must be met.
Where identifiable data for the same dataset to the same organisation is released by NHS Digital (via a DSCRO), relevant controls must be in place locally by the recipient organisation to ensure that identifiable data is stored separately, under strict access control provisions, from its original anonymised in accordance with the ICOACoP form and used only for the specific purpose stipulated in this agreement. There must be no efforts made by the recipient organisation to link these datasets.
Local Identifiers:
If a Data Controller organisation (or the Data Processor working on their behalf):
a. only receives a DSCRO disseminated identifiable (NHS Number) flow, then it can receive clear local identifiers.
b. receives and pseudonymised flow, then clear local identifiers can be included and used only for the purpose outlined within the Data Sharing Agreement
c. receives both DSCRO disseminated identifiable and pseudonymised flows, the identifiable flow must have the local identifiers pseudonymised or removed.
Invoice Validation
NHS Bristol, North Somerset and South Gloucestershire CCG
[2 paragraphs unchanged]
3. The CEfF conduct the following processing activities for invoice validation purposes:
3. The CEfF also receive backing data from the provider.
a. Validating that the Clinical Commissioning Group is responsible for payment for the care of the individual by using SUS+ and/or provider backing flow data.
4. The CEfF conduct the following processing activities for invoice validation purposes:
b. Once the provider backing information is received, this will be checked against national NHS and local commissioning policies as well as being checked against system access and reports provided by NHS Digital to confirm the payments are:
a. Validating that the Clinical Commissioning Group are responsible for payment for the care of the individual by using SUS+ and/or provider backing flow data.
b. Once the provider backing information is received, it will be checked against national NHS and local commissioning policies, as well as being checked against system access and reports provided by NHS Digital to confirm the payments are:
[1 paragraph unchanged]
ii. In relation to a patient registered with the
CCG
CCG,
GP or resident within the CCG area.
[1 paragraph unchanged]
4.
5.
The CCG are notified by the CEfF that the invoice has been validated and can be paid. Any discrepancies or non-validated invoices are investigated and
resolved
resolved.
Risk Stratification
RISK STRATIFICATION - South Central and West Commissioning Support Unit
South Central and West Commissioning Support Unit
[1 paragraph unchanged]
2. Data quality management and standardisation of data is completed by the
[19 words unchanged]
Commissioning Support Unit, who hold the SUS+ data within the secure Data
Centre on N3.
Centre.
[29 paragraphs unchanged]
12. Civil Registries Data (CRD)
(Births)
13. Civil Registries Data (CRD) (Deaths)
14. National Diabetes Audit (NDA)
15. Patient Reported Outcome Measures (PROMs)
[2 paragraphs unchanged]
1. Pseudonymised SUS+, Local Provider data, Mental Health data (MHSDS, MHMDS, MHLDDS),
[21 words unchanged]
(CSDS), Diagnostic Imaging data (DIDS), National Cancer Waiting Times Monitoring Data Set
(CWT) and
(CWT),
Civil Registries Data (CRD)
(Births and Deaths), National Diabetes Audit (NDA) and Patient Reported Outcome Measures (PROMs)
only is held until points 2 – 8 are completed.
[28 paragraphs unchanged]
9. The DSCRO pass the
Pseudonymised
pseudonymised
SUS+, Local Provider data, Mental Health data (MHSDS, MHMDS, MHLDDS), Maternity data
[19 words unchanged]
(CSDS), Diagnostic Imaging data (DIDS), National Cancer Waiting Times Monitoring Data Set
(CWT) and
(CWT),
Civil Registries Data (CRD)
(Births and Deaths), National Diabetes Audit (NDA) and Patient Reported Outcome Measures (PROMs)
securely to South, Central and West Commissioning Support Unit for the addition of derived fields, linkage of data sets and
analysis
analysis.
[5 paragraphs unchanged]
1. Pseudonymised SUS+ (pseudonymised using an encryption
key’
key
specific to this project), only is securely transferred from the DSCRO to South, Central and West Commissioning Support Unit.
[7 paragraphs unchanged]
Expected output
[9 paragraphs unchanged]
2. Output from the risk stratification tool will provide aggregate reporting of number and percentage of population found to be at risk.
2. 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.
3. Record level output will be available for commissioners (of the CCG), pseudonymised at patient level.
CCGs will be able to:
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.
3. Target specific vulnerable patient groups and enable clinicians with the duty of care for the patient to offer appropriate interventions.
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:
4. Reduce hospital readmissions and targeting clinical interventions to high risk patients.
a. Stratify populations based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost
5. Identify patients at risk of deterioration and providing effective care.
b. Plan work for commissioning services and contracts
6. Reduce in the difference in the quality of care between those with the best and worst outcomes.
c. Set up capitated budgets
7. Re-design care to reduce admissions.
d. Identify health determinants of risk of admission to hospital, or other adverse care outcomes.
8. Set up capitated budgets – budgets based on care provided to the specific population.
9. Identify health determinants of risk of admission to hospital, or other adverse care outcomes.
10. Monitor vulnerable groups of patients including but not limited to frailty, COPD, Diabetes, elderly.
11. Health needs assessments – identifying numbers of patients with specific health conditions or combination of conditions.
12. Classify vulnerable groups based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost.
13. Production of Theographs – a visual timeline of a patients encounters with hospital providers.
14. Analyse based on specific diseases
In addition:
- The risk stratification tool will provide aggregate reporting of number and percentage of population found to be at risk.
- Record level output (pseudonymised) will be available for commissioners (of the CCG), pseudonymised at patient level. Onward sharing of this data is not permitted
[19 paragraphs unchanged]
8. GP Practice level dashboard
reports include high flyers.
reports.
[5 paragraphs unchanged]
b. Most expensive patients (top 15%)
b. Users of high cost activity
[83 paragraphs unchanged]
27. Validation for payment approval, ability to validate that claims are not being made after an individual has died, like Oxygen services.
28. Validation of programs implemented to improve patient pathway e.g. High users unable to validate if the process to help patients find the best support are working or did the patient die.
29. Clinical - understand reasons why patients are dying, what additional support services can be put in to support.
30. Understanding where patient are dying e.g. are patients dying at hospitals due to hospices closing due to Local authorities withdrawing support, or is there a problem at a particular trust.
31. Removal of patients from Risk Stratification reports.
32. Re births provide a one stop shop of information, Births are recorded in multiple sources covering hospital and home births, a chance to overlook activity.
[1 paragraph unchanged]
The main outputs are aggregated monthly values for each outcome
(with small number suppression, including any values under 5).
outputs will comply with the NHS Digital guidance on suppression rules.
The aggregated monthly outcomes data will be made available through OBH’s online
[5 words unchanged]
in the CCG and CCG commissioned providers only) via a secure login.
[6 paragraphs unchanged]
Expected measurable benefits
[17 paragraphs unchanged]
5. Better understanding of local population characteristics through analysis of their health and
healthcare outcomes
6. healthcare outcomes
[69 paragraphs unchanged]
22. Providing greater understanding of the underlying courses and look to commission improved supportive networks, this would be ongoing work which would be continually assessed.
23. Insight to understand the numerous factors that play a role in the outcome for both datasets. The linkage will allow the reporting both prior to, during and after the activity, to provide greater assurance on predictive outcomes and delivery of best practice.
24. Provision of indicators of health problems, and patterns of risk within the commissioning region.
25. Support of benchmarking for evaluating progress in future years.
[4 paragraphs unchanged]
Benefits reported
[1 paragraph unchanged]
Data used to monitor impact of major system changes, including the overnight closure of an
AE
A&E
department within the BNSSG area. Activity data used to measure impact on system and patients and inform decision making around the process.
[4 paragraphs unchanged]
As a
NHS Bristol, North Somerset and South Gloucestershire
CCG
we
are an evidence-based organisation using data to underpin our decision making processes. Key achievements which have been informed by use of data include:
Funding mental health support in schools:
we
NHS Bristol, North Somerset and South Gloucestershire CCG
became the first city in the country to fund a mental health-focused
[35 words unchanged]
on early intervention to make a significant difference to young people’s lives.
Advancing
our
the CCCGs
dementia care:
We
NHS Bristol, North Somerset and South Gloucestershire CCG
have established leading dementia wellbeing services, with around 2,000 patients benefiting from
[12 words unchanged]
discharged from the service and can access support whenever they need it.
We’re
NHS Bristol, North Somerset and South Gloucestershire CCG are
making continued investments and the number of people the service supports has nearly doubled over the last 12 months.
Sustainability and Transformation Partnership:
We
NHS Bristol, North Somerset and South Gloucestershire CCG
developed a new plan to guide our commissioning activity until 2021 as a partnership between Bristol, North Somerset and South Gloucestershire CCGs. After drafting the plan together,
we
NHS Bristol, North Somerset and South Gloucestershire CCG
involved the community and other clinical groups to gain their input.
We
NHS Bristol, North Somerset and South Gloucestershire CCG
had meetings with the three local authority health scrutiny committees and community
[10 words unchanged]
best possible healthcare services for our population’s needs in the coming years.
Designing healthcare with
our
young people:
We
NHS Bristol, North Somerset and South Gloucestershire CCG
held a major consultation to find out what local young people, their parents and professionals involved in their care, thought of our community health services.
We
NHS Bristol, North Somerset and South Gloucestershire CCG
received over 1,200 ideas and have been using that feedback to shape children’s and young people’s health services.
Improving hospital discharge for older people:
Our
the CCGs
Discharge to Assess (D2A) scheme speeds up hospital discharge times for older
[43 words unchanged]
otherwise be in hospital receive therapy in their own homes and enabled
us
the CCG
to save a total of 376 hospital bed days.
Appointing a new community healthcare services provider: In partnership with NHS England and North Somerset Council,
we
NHS Bristol, North Somerset and South Gloucestershire CCG
appointed North Somerset Community Partnership (NSCP) to provide community healthcare services. They
[11 words unchanged]
services, such as those for people with Parkinson’s disease, until April 2019.
Developing better out-of-hospital care: Helping people to live safely and independently at home as they age has been a high priority.
We’ve
NHS Bristol, North Somerset and South Gloucestershire CCG
introduced several initiatives to help people get better outside of hospital, from
[18 words unchanged]
with Age UK to provide better support to people as they age.
Transforming community services for children:
We
NHS Bristol, North Somerset and South Gloucestershire CCG
re-procured children’s community health services for Bristol and South Gloucestershire. This involved
[19 words unchanged]
specific local needs, delivering coordinated care to children, young people and families.
Tackling diabetes and promoting self-care:
We
NHS Bristol, North Somerset and South Gloucestershire CCG
joined the second wave of the national Diabetes Prevention Programme in April
[9 words unchanged]
practice in Emersons Green, Bristol. Together with Bristol and South Gloucestershire CCGs,
we’ve also
the CCG has
since been selected to pilot the digital stream, which aims to establish
[9 words unchanged]
in people with non-diabetic hyperglycaemia (NDH) and overweight and or obese individuals.
Objective for processing
INVOICE VALIDATION
Invoice validation is part of a process by which providers of care or services get paid for the work they do.
Invoices are submitted to the Clinical Commissioning Group (CCG) so the CCG is are able to ensure that the activity claimed for each patient is their responsibility. This is done by processing and analysing Secondary User Services (SUS+) data, which is received into a secure Controlled Environment for Finance (CEfF). The SUS+ data is identifiable at the level of NHS number. The NHS number is only used to confirm the accuracy of backing-data sets (data from providers) and will not be used further.
The CCG are advised by the appointed CEfF whether payment for invoices can be made or not.
Invoice Validation will be conducted by NHS Bristol, North Somerset and South Gloucestershire CCG
RISK STRATIFICATION
Risk stratification is a tool for identifying and predicting which patients are at high risk (of health deterioration and using multiple services) or are likely to be at high risk and prioritising the management of their care in order to prevent worse outcomes.
To conduct risk stratification Secondary User Services (SUS+) data, identifiable at the level of NHS number is linked with Primary Care data (from GPs) and an algorithm is applied to produce risk scores. Risk Stratification provides focus for future demands by enabling commissioners to prepare plans for both individual and groups of vulnerable patients. Commissioners can then prepare plans for patients who may require high levels of care. Risk Stratification also enables General Practitioners (GPs) to better target intervention in Primary Care.
Risk Stratification will be conducted by NHS South Central and West Commissioning Support Unit
COMMISSIONING
To use pseudonymised data to provide intelligence to support the commissioning of health services. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the CCG area.
The CCGs commission services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.
The following pseudonymised datasets are required to provide intelligence to support commissioning of health services:
- Secondary Uses Service (SUS+)
- Local Provider Flows
o Acute
o Ambulance
o Community
o Demand for Service
o Diagnostic Service
o Emergency Care
o Experience, Quality and Outcomes
o Mental Health
o Other Not Elsewhere Classified
o Population Data
o Primary Care Services
o Public Health Screening
- Mental Health Minimum Data Set (MHMDS)
- Mental Health Learning Disability Data Set (MHLDDS)
- Mental Health Services Data Set (MHSDS)
- Maternity Services Data Set (MSDS)
- Improving Access to Psychological Therapy (IAPT)
- Child and Young People Health Service (CYPHS)
- Community Services Data Set (CSDS)
- Diagnostic Imaging Data Set (DIDS)
- National Cancer Waiting Times Monitoring Data Set (CWT)
- Civil Registries Data (CRD) (Births)
- Civil Registries Data (CRD) (Deaths)
- National Diabetes Audit (NDA)
- Patient Reported Outcome Measures (PROMs)
The pseudonymised data is required to for the following purposes:
Population health management:
• Understanding the interdependency of care services
• Targeting care more effectively
• Using value as the redesign principle
Data Quality and Validation – allowing data quality checks on the submitted data
Thoroughly investigating the needs of the population, to ensure the right services are available for individuals when and where they need them
Understanding cohorts of residents who are at risk of becoming users of some of the more expensive services, to better understand and manage those needs
Monitoring population health and care interactions to understand where people may slip through the net, or where the provision of care may be being duplicated
Modelling activity across all data sets to understand how services interact with each other, and to understand how changes in one service may affect flows through another
Service redesign
Health Needs Assessment – identification of underlying disease prevalence within the local population
Patient stratification and predictive modelling - to highlight patients at risk of requiring hospital admission and other avoidable factors such as risk of falls, computed using algorithms executed against linked de-identified data, and identification of future service delivery models
The pseudonymised data is required to ensure that analysis of health care provision can be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets.
Processing for commissioning will be conducted by South Central and West Commissioning Support Unit and Outcomes Based Health (OBH)
Expected output
INVOICE VALIDATION
1. The Controlled Environment for Finance (CEfF) will enable the CCG to challenge invoices and raise discrepancies and disputes.
2. Outputs from the CEfF will enable accurate production of budget reports, which will:
a. Assist in addressing poor quality data issues
b. Assist in business intelligence
3. Validation of invoices for non-contracted events where a service delivered to a patient by a provider that does not have a written contract with the patient’s responsible commissioner, but does have a written contract with another NHS commissioner/s.
4. Budget control of the CCG.
RISK STRATIFICATION
1. As part of the risk stratification processing activity detailed above, GPs have access to the risk stratification tool which highlights patients for whom the GP is responsible and have been classed as at risk. The only identifier available to GPs is the NHS numbers of their own patients. Any further identification of the patients will be completed by the GP on their own systems.
2. 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.
CCGs will be able to:
3. Target specific vulnerable patient groups and enable clinicians with the duty of care for the patient to offer appropriate interventions.
4. Reduce hospital readmissions and targeting clinical interventions to high risk patients.
5. Identify patients at risk of deterioration and providing effective care.
6. Reduce in the difference in the quality of care between those with the best and worst outcomes.
7. Re-design care to reduce admissions.
8. Set up capitated budgets – budgets based on care provided to the specific population.
9. Identify health determinants of risk of admission to hospital, or other adverse care outcomes.
10. Monitor vulnerable groups of patients including but not limited to frailty, COPD, Diabetes, elderly.
11. Health needs assessments – identifying numbers of patients with specific health conditions or combination of conditions.
12. Classify vulnerable groups based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost.
13. Production of Theographs – a visual timeline of a patients encounters with hospital providers.
14. Analyse based on specific diseases
In addition:
- The risk stratification tool will provide aggregate reporting of number and percentage of population found to be at risk.
- Record level output (pseudonymised) will be available for commissioners (of the CCG), pseudonymised at patient level. Onward sharing of this data is not permitted
COMMISSIONING
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.
g. Statutory returns.
h. Statutory returns - monthly activity return.
i. Statutory returns - quarterly activity return.
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.
9. Comparators of CCG performance with similar CCGs as set out by a specific range of care quality and performance measures detailed activity and cost reports
10. Data Quality and Validation measures allowing data quality checks on the submitted data
11. Contract Management and Modelling
12. Patient Stratification, such as:
a. Patients at highest risk of admission
b. Users of high cost activity
c. Frail and elderly
d. Patients that are currently in hospital
e. Patients with most referrals to secondary care
f. Patients with most emergency activity
g. Patients with most expensive prescriptions
h. Patients recently moving from one care setting to another
i. Discharged from hospital
ii. Discharged from community
13. Profiling population health and wider determinants to identify and target those most in need
a. Understanding population profile and demographics
b. Identify patient cohorts with specific needs or who may benefit from interventions
c. Identifying disease prevalence. health and care needs for population cohorts
d. Contributing to Joint Strategic Needs Assessment (JSNA)
e. Geographical mapping and analysis
14. Identifying and managing preventable and existing conditions
a. Identifying types of individuals and population cohorts at risk of non-elective re-admission
b. Risk stratification to identify populations suitable for case management
c. Risk profiling and predictive modelling
d. Risk stratification for planning services for population cohorts
e. Identification of disease incidence and diagnosis stratification
15. Reducing health inequalities
a. Identifying cohorts of patients who have worse health outcomes typically deprived, ethnic groups, homeless, travellers etc. to enable services to proactively target their needs
b. Socio-demographic analysis
16. Managing demand
a. Waiting times analysis
b. Service demand and supply modelling
c. Understanding cross-border and overseas visitor
d. Winter planning
e. Emergency preparedness, business continuity, recovery and contingency planning
17. Care co-ordination and planning
a. Planning packages of care
b. Service planning
c. Planning care co-ordination
18. Monitoring individual patient health, service utilisation, pathway compliance experience & outcomes across the heath and care system
a. Patient pathway analysis across health and care
b. Outcomes & experience analysis
c. Analysis to support anti-terror initiatives
d. Analysis to identify vulnerable patients with potential safeguarding issues
e. Understanding equity of care and unwarranted variation
f. Modelling patient flow
g. Tracking patient pathways
h. Monitoring to support NMoC, ACOs, STPs
i. Identifying duplications in care
j. Identifying gaps in care, missed diagnoses and triple fail events
k. Analysing individual and aggregated timelines
19. Undertaking budget planning, management and reporting
a. Tracking financial performance against plans
b. Budget reporting
c. Tariff development
d. Developing and monitoring capitated budgets
e. Developing and monitoring individual-level budgets
f. Future budget planning and forecasting
g. Paying for care of overseas visitors and cross-border flow
20. Monitoring the value for money
a. Service-level costing & comparisons
b. Identification of cost pressures
a. Cost benefit analysis
b. Equity of spend across services and population cohorts
c. Finance impact assessment
21. Comparing population groups, peers, national and international best practice
d. Identification of variation in productivity, cost, outcomes, quality, experience, compared with peers, national and international & best practice
e. Benchmarking against other parts of the country
f. Identifying unwarranted variations
22. Comparing expected levels
g. Standardised comparisons for prevalence, activity, cost, quality, experience, outcomes for given populations
23. Comparing local targets & plan
h. Monitoring of local variation in productivity, cost, outcomes, quality and experience
i. Local performance dashboards by service provider, commissioner, geography, NMOC, STPs
24. Monitoring activity and cost compliance against contract and agreed plans
j. Contract monitoring
k. Contract reconciliation and challenge
l. Invoice validation
25. Monitoring provider quality, demand, experience and outcomes against contract and agreed plans
m. Performance dashboards
n. CQUIN reporting
o. Clinical audit
p. Patient experience surveys
q. Demand, supply, outcome & experience analysis
r. Monitoring cross-border flows and overseas visitor activity
26. Improving provider data quality
s. Coding audit
t. Data quality validation and review
u. Checking validity of patient identity and commissioner assignment
27. Validation for payment approval, ability to validate that claims are not being made after an individual has died, like Oxygen services.
28. Validation of programs implemented to improve patient pathway e.g. High users unable to validate if the process to help patients find the best support are working or did the patient die.
29. Clinical - understand reasons why patients are dying, what additional support services can be put in to support.
30. Understanding where patient are dying e.g. are patients dying at hospitals due to hospices closing due to Local authorities withdrawing support, or is there a problem at a particular trust.
31. Removal of patients from Risk Stratification reports.
32. Re births provide a one stop shop of information, Births are recorded in multiple sources covering hospital and home births, a chance to overlook activity.
Outcomes Based Healthcare:
The main outputs are aggregated monthly values for each outcome outputs will comply with the NHS Digital guidance on suppression rules. The aggregated monthly outcomes data will be made available through OBH’s online tool (available to named individuals in the CCG and CCG commissioned providers only) via a secure login.
This enables the CCGs and to:
- visualise baselines for each outcome
- set improvement trajectories
- monitor outcomes on an on-going basis.
In addition, the CCGs will receive an information schedule describing the outcomes to be monitored, the technical description, and annual baseline data for each outcome.
All outputs will be delivered within the timescales of the contract between OBH and the CCGs.
Benefits reported
Data used in support of ongoing transformation plans to deliver against savings plan. To date, around £28.5m of savings identified. Work supported by analyst use of data to initially develop and savings plans and identify impacts. Ongoing activity monitoring support and reporting.
Data used to monitor impact of major system changes, including the overnight closure of an A&E department within the BNSSG area. Activity data used to measure impact on system and patients and inform decision making around the process.
Development of bespoke reporting tools which are used in a range of settings, including an unwarranted practice variation tool which has been used to identify referral outliers and inform further work to understand activity.
Continued use of data in support of monitoring around delivery of constitutional standards, with standards achieved in a number of measures. Data used to help inform plans aimed at achieving targets in other areas requiring improvement, by understanding drivers behind performance and identifying opportunities for improvements.
Identify data and performance issues at provider organisations to initiate discussions at contract meetings which has led to: further analysis to identify root causes and mitigating actions; using contractual levers i.e. issuing contractual notices (Contract Performance Notices and Information Breach Notices) to facilitate improvement through joint investigations and remedial action plans and; identifying good practice and lessons learned to ensure consistency across our 3 providers to support equity of provision.
Provide assurance to CCG Governing Body and Healthy Together STP (System Delivery Oversight Group): that contracts with providers are being managed effectively and; how the BNSSG population is being served; Provides evidence to STP system wide groups on areas of good and poor performance such as urgent care, planned care and cancer to share learning, identify improvements and develop joint plans. Support the work with providers to develop joint activity plans, performance trajectories and strategies.
NHS Bristol, North Somerset and South Gloucestershire CCG are an evidence-based organisation using data to underpin our decision making processes. Key achievements which have been informed by use of data include:
Funding mental health support in schools: NHS Bristol, North Somerset and South Gloucestershire CCG became the first city in the country to fund a mental health-focused training package for staff in every primary and secondary school, working closely with Bristol City Council. The training is designed to raise the profile of Child and Adolescent Mental Health Services (CAMHS), with the focus on early intervention to make a significant difference to young people’s lives.
Advancing the CCCGs dementia care: NHS Bristol, North Somerset and South Gloucestershire CCG have established leading dementia wellbeing services, with around 2,000 patients benefiting from specialised support last year. A key feature is that people are never discharged from the service and can access support whenever they need it. NHS Bristol, North Somerset and South Gloucestershire CCG are making continued investments and the number of people the service supports has nearly doubled over the last 12 months.
Sustainability and Transformation Partnership: NHS Bristol, North Somerset and South Gloucestershire CCG developed a new plan to guide our commissioning activity until 2021 as a partnership between Bristol, North Somerset and South Gloucestershire CCGs. After drafting the plan together, NHS Bristol, North Somerset and South Gloucestershire CCG involved the community and other clinical groups to gain their input. NHS Bristol, North Somerset and South Gloucestershire CCG had meetings with the three local authority health scrutiny committees and community volunteers. Our work together set us up to develop the best possible healthcare services for our population’s needs in the coming years.
Designing healthcare with young people: NHS Bristol, North Somerset and South Gloucestershire CCG held a major consultation to find out what local young people, their parents and professionals involved in their care, thought of our community health services. NHS Bristol, North Somerset and South Gloucestershire CCG received over 1,200 ideas and have been using that feedback to shape children’s and young people’s health services.
Improving hospital discharge for older people: the CCGs Discharge to Assess (D2A) scheme speeds up hospital discharge times for older patients, helping them get home quicker. The D2A team support patients to be discharged and assess ongoing care at home, on the same day, by community teams of social workers, nurses, physiotherapists and occupational therapists. The scheme has helped 20 people who would otherwise be in hospital receive therapy in their own homes and enabled the CCG to save a total of 376 hospital bed days.
Appointing a new community healthcare services provider: In partnership with NHS England and North Somerset Council, NHS Bristol, North Somerset and South Gloucestershire CCG appointed North Somerset Community Partnership (NSCP) to provide community healthcare services. They provide all adult and some children’s community health services and specialist services, such as those for people with Parkinson’s disease, until April 2019.
Developing better out-of-hospital care: Helping people to live safely and independently at home as they age has been a high priority. NHS Bristol, North Somerset and South Gloucestershire CCG introduced several initiatives to help people get better outside of hospital, from helping them discharge as soon as they’re fit to leave, to outpatient appointments in the community, and working with Age UK to provide better support to people as they age.
Transforming community services for children: NHS Bristol, North Somerset and South Gloucestershire CCG re-procured children’s community health services for Bristol and South Gloucestershire. This involved a partnership of five commissioning organisations working together to develop a cost-effective service for the whole area that recognises specific local needs, delivering coordinated care to children, young people and families.
Tackling diabetes and promoting self-care: NHS Bristol, North Somerset and South Gloucestershire CCG joined the second wave of the national Diabetes Prevention Programme in April 2017, building on a pilot at Leap Valley GP practice in Emersons Green, Bristol. Together with Bristol and South Gloucestershire CCGs, the CCG has since been selected to pilot the digital stream, which aims to establish whether digital interventions are effective in supporting behaviour change in people with non-diabetic hyperglycaemia (NDH) and overweight and or obese individuals.
DARS-NIC-186885-Q1T3D-v1.3 1 April 2019 to 31 March 2022
- Title
- DSfC - NHS Bristol, North Somerset and South Gloucestershire CCG - Comm IV RS
- Commercial
- No
- Sublicensing
- No
- Datasets
- 25
- Files released
- 0
Datasets: Acute-Local Provider Flows; Ambulance-Local Provider Flows; Children and Young People Health; Civil Registration - Births; Civil Registrations of Death; Community Services Data Set (CSDS); Community-Local Provider Flows; Demand for Service-Local Provider Flows; Diagnostic Imaging Data Set (DID); Diagnostic Services-Local Provider Flows; Emergency Care-Local Provider Flows; Experience, Quality and Outcomes-Local Provider Flows; Improving Access to Psychological Therapies (IAPT) v1.5; Maternity Services Data Set; Mental Health and Learning Disabilities Data Set (MHLDDS); Mental Health Minimum Data Set (MHMDS); Mental Health Services Data Set (MHSDS); Mental Health-Local Provider Flows; National Cancer Waiting Times Monitoring DataSet (NCWTMDS); Other Not Elsewhere Classified (NEC)-Local Provider Flows; Population Data-Local Provider Flows; Primary Care Services-Local Provider Flows; Public Health and Screening Services-Local Provider Flows; SUS for Commissioners; SUS for Commissioners
Objective for processing
Invoice Validation
Invoice validation is part of a process by which providers of care or services get paid for the work they do.
Invoices are submitted to the Clinical Commissioning Group (CCG) so they are able to ensure that the activity claimed for each patient is their responsibility. This is done by processing and analysing Secondary User Services (SUS+) data, which is received into a secure Controlled Environment for Finance (CEfF). The SUS+ data is identifiable at the level of NHS number. The NHS number is only used to confirm the accuracy of backing-data sets and will not be used further.
The CCG are advised by the CEfF whether payment for invoices can be made or not.
Invoice Validation will be conducted by NHS Bristol, North Somerset and South Gloucestershire CCG
Risk Stratification
Risk stratification is a tool for identifying and predicting which patients are at high risk or are likely to be at high risk and prioritising the management of their care in order to prevent worse outcomes.
To conduct risk stratification Secondary User Services (SUS+) data, identifiable at the level of NHS number is linked with Primary Care data (from GPs) and an algorithm is applied to produce risk scores. Risk Stratification provides focus for future demands by enabling commissioners to prepare plans for patients. Commissioners can then prepare plans for patients who may require high levels of care. Risk Stratification also enables General Practitioners (GPs) to better target intervention in Primary Care.
Risk Stratification will be conducted by NHS South Central and West Commissioning Support Unit
Commissioning
The NHS and local councils have come together in 44 areas covering all of England to develop proposals to improve health and care. They have formed new partnerships – known as sustainability and transformation partnerships – to plan jointly for the next few years.
Sustainability and transformation partnerships build on collaborative work that began under the NHS Shared Planning Guidance for 2016/17 – 2020/21, to support implementation of the Five Year Forward View. They are supported by six national health and care bodies: NHS England; NHS Improvement; the Care Quality Commission (CQC); Health Education England (HEE); Public Health England (PHE) and the National Institute for Health and Care Excellence (NICE).
The CCG is part of the Bristol, North Somerset and South Gloucestershire Sustainable Transformation Partnership. The STP is responsible for implementing large parts of the 5 year forward view from NHS England. The STP is implementing several initiatives:
- Putting the patient at the heart of the health system
- Working across organisational boundaries to deliver care and including social care, public Health, providers and GPs as well as CCGs
- Reviewing patient pathways to improve patient experience whilst reducing costs e.g. reduce the number of standard tests a patient may have and only have the ones they need
- Planning the demand and capacity across the healthcare system across 2 CCGs to ensure we have the right buildings, services and staff to cope with demand whilst reducing the impact on costs
- Working to prevent or capture conditions early as they are cheaper to treat
- Introduce initiatives to change behaviours e.g. move more care into the community
- Patient pathway planning for the above
To ensure the patient is at the heart of care, the STP is focussing on where services are required across the geographical region. This assists to ensure delivery of care in the right place for patients who may move and change services across the CCG.
The CCG will work proactively and collaboratively in the STP to redesign services across boundaries to integrate services.
The CCG will use pseudonymised data to provide intelligence to support the commissioning of health services. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the STP area.
The CCG commissions services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.
The following pseudonymised datasets are required to provide intelligence to support commissioning of health services:
- Secondary Uses Service (SUS+)
- Local Provider Flows
o Acute
o Ambulance
o Community
o Demand for Service
o Diagnostic Service
o Emergency Care
o Experience, Quality and Outcomes
o Mental Health
o Other Not Elsewhere Classified
o Population Data
o Primary Care Services
o Public Health Screening
- Mental Health Minimum Data Set (MHMDS)
- Mental Health Learning Disability Data Set (MHLDDS)
- Mental Health Services Data Set (MHSDS)
- Maternity Services Data Set (MSDS)
- Improving Access to Psychological Therapy (IAPT)
- Child and Young People Health Service (CYPHS)
- Community Services Data Set (CSDS)
- Diagnostic Imaging Data Set (DIDS)
- National Cancer Waiting Times Monitoring Data Set (CWT)
- Civil Registries Data (CRD) (Births and Deaths)
The pseudonymised data is required to for the following purposes:
Population health management:
• Understanding the interdependency of care services
• Targeting care more effectively
• Using value as the redesign principle
• Ensuring we do what we should
Data Quality and Validation – allowing data quality checks on the submitted data
Thoroughly investigating the needs of the population, to ensure the right services are available for individuals when and where they need them
Understanding cohorts of residents who are at risk of becoming users of some of the more expensive services, to better understand and manage those needs
Monitoring population health and care interactions to understand where people may slip through the net, or where the provision of care may be being duplicated
Modelling activity across all data sets to understand how services interact with each other, and to understand how changes in one service may affect flows through another
Service redesign
Health Needs Assessment – identification of underlying disease prevalence within the local population
Patient stratification and predictive modelling - to identify specific patients at risk of requiring hospital admission and other avoidable factors such as risk of falls, computed using algorithms executed against linked de-identified data, and identification of future service delivery models
The pseudonymised data is required to ensure that analysis of health care provision can be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets.
Processing for commissioning will be conducted by South Central and West Commissioning Support Unit and Outcomes Based Health (OBH)
Expected output
Invoice Validation
1. The Controlled Environment for Finance (CEfF) will enable the CCG to challenge invoices and raise discrepancies and disputes.
2. Outputs from the CEfF will enable accurate production of budget reports, which will:
a. Assist in addressing poor quality data issues
b. Assist in business intelligence
3. Validation of invoices for non-contracted events where a service delivered to a patient by a provider that does not have a written contract with the patient’s responsible commissioner, but does have a written contract with another NHS commissioner/s.
4. Budget control of the CCG.
Risk Stratification
1. As part of the risk stratification processing activity detailed above, GPs have access to the risk stratification tool which highlights patients for whom the GP is responsible and have been classed as at risk. The only identifier available to GPs is the NHS numbers of their own patients. Any further identification of the patients will be completed by the GP on their own systems.
2. Output from the risk stratification tool will provide aggregate reporting of number and percentage of population found to be at risk.
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:
a. Stratify populations based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost
b. Plan work for commissioning services and contracts
c. Set up capitated budgets
d. Identify health determinants of risk of admission to hospital, or other adverse care outcomes.
Commissioning
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.
g. Statutory returns.
h. Statutory returns - monthly activity return.
i. Statutory returns - quarterly activity return.
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.
9. Comparators of CCG performance with similar CCGs as set out by a specific range of care quality and performance measures detailed activity and cost reports
10. Data Quality and Validation measures allowing data quality checks on the submitted data
11. Contract Management and Modelling
12. Patient Stratification, such as:
a. Patients at highest risk of admission
b. Most expensive patients (top 15%)
c. Frail and elderly
d. Patients that are currently in hospital
e. Patients with most referrals to secondary care
f. Patients with most emergency activity
g. Patients with most expensive prescriptions
h. Patients recently moving from one care setting to another
i. Discharged from hospital
ii. Discharged from community
13. Profiling population health and wider determinants to identify and target those most in need
a. Understanding population profile and demographics
b. Identify patient cohorts with specific needs or who may benefit from interventions
c. Identifying disease prevalence. health and care needs for population cohorts
d. Contributing to Joint Strategic Needs Assessment (JSNA)
e. Geographical mapping and analysis
14. Identifying and managing preventable and existing conditions
a. Identifying types of individuals and population cohorts at risk of non-elective re-admission
b. Risk stratification to identify populations suitable for case management
c. Risk profiling and predictive modelling
d. Risk stratification for planning services for population cohorts
e. Identification of disease incidence and diagnosis stratification
15. Reducing health inequalities
a. Identifying cohorts of patients who have worse health outcomes typically deprived, ethnic groups, homeless, travellers etc. to enable services to proactively target their needs
b. Socio-demographic analysis
16. Managing demand
a. Waiting times analysis
b. Service demand and supply modelling
c. Understanding cross-border and overseas visitor
d. Winter planning
e. Emergency preparedness, business continuity, recovery and contingency planning
17. Care co-ordination and planning
a. Planning packages of care
b. Service planning
c. Planning care co-ordination
18. Monitoring individual patient health, service utilisation, pathway compliance experience & outcomes across the heath and care system
a. Patient pathway analysis across health and care
b. Outcomes & experience analysis
c. Analysis to support anti-terror initiatives
d. Analysis to identify vulnerable patients with potential safeguarding issues
e. Understanding equity of care and unwarranted variation
f. Modelling patient flow
g. Tracking patient pathways
h. Monitoring to support NMoC, ACOs, STPs
i. Identifying duplications in care
j. Identifying gaps in care, missed diagnoses and triple fail events
k. Analysing individual and aggregated timelines
19. Undertaking budget planning, management and reporting
a. Tracking financial performance against plans
b. Budget reporting
c. Tariff development
d. Developing and monitoring capitated budgets
e. Developing and monitoring individual-level budgets
f. Future budget planning and forecasting
g. Paying for care of overseas visitors and cross-border flow
20. Monitoring the value for money
a. Service-level costing & comparisons
b. Identification of cost pressures
a. Cost benefit analysis
b. Equity of spend across services and population cohorts
c. Finance impact assessment
21. Comparing population groups, peers, national and international best practice
d. Identification of variation in productivity, cost, outcomes, quality, experience, compared with peers, national and international & best practice
e. Benchmarking against other parts of the country
f. Identifying unwarranted variations
22. Comparing expected levels
g. Standardised comparisons for prevalence, activity, cost, quality, experience, outcomes for given populations
23. Comparing local targets & plan
h. Monitoring of local variation in productivity, cost, outcomes, quality and experience
i. Local performance dashboards by service provider, commissioner, geography, NMOC, STPs
24. Monitoring activity and cost compliance against contract and agreed plans
j. Contract monitoring
k. Contract reconciliation and challenge
l. Invoice validation
25. Monitoring provider quality, demand, experience and outcomes against contract and agreed plans
m. Performance dashboards
n. CQUIN reporting
o. Clinical audit
p. Patient experience surveys
q. Demand, supply, outcome & experience analysis
r. Monitoring cross-border flows and overseas visitor activity
26. Improving provider data quality
s. Coding audit
t. Data quality validation and review
u. Checking validity of patient identity and commissioner assignment
Outcomes Based Healthcare:
The main outputs are aggregated monthly values for each outcome (with small number suppression, including any values under 5). The aggregated monthly outcomes data will be made available through OBH’s online tool (available to named individuals in the CCG and CCG commissioned providers only) via a secure login.
This enables the CCGs and to:
- visualise baselines for each outcome
- set improvement trajectories
- monitor outcomes on an on-going basis.
In addition, the CCGs will receive an information schedule describing the outcomes to be monitored, the technical description, and annual baseline data for each outcome.
All outputs will be delivered within the timescales of the contract between OBH and the CCGs.
Benefits reported
Data used in support of ongoing transformation plans to deliver against savings plan. To date, around £28.5m of savings identified. Work supported by analyst use of data to initially develop and savings plans and identify impacts. Ongoing activity monitoring support and reporting.
Data used to monitor impact of major system changes, including the overnight closure of an AE department within the BNSSG area. Activity data used to measure impact on system and patients and inform decision making around the process.
Development of bespoke reporting tools which are used in a range of settings, including an unwarranted practice variation tool which has been used to identify referral outliers and inform further work to understand activity.
Continued use of data in support of monitoring around delivery of constitutional standards, with standards achieved in a number of measures. Data used to help inform plans aimed at achieving targets in other areas requiring improvement, by understanding drivers behind performance and identifying opportunities for improvements.
Identify data and performance issues at provider organisations to initiate discussions at contract meetings which has led to: further analysis to identify root causes and mitigating actions; using contractual levers i.e. issuing contractual notices (Contract Performance Notices and Information Breach Notices) to facilitate improvement through joint investigations and remedial action plans and; identifying good practice and lessons learned to ensure consistency across our 3 providers to support equity of provision.
Provide assurance to CCG Governing Body and Healthy Together STP (System Delivery Oversight Group): that contracts with providers are being managed effectively and; how the BNSSG population is being served; Provides evidence to STP system wide groups on areas of good and poor performance such as urgent care, planned care and cancer to share learning, identify improvements and develop joint plans. Support the work with providers to develop joint activity plans, performance trajectories and strategies.
As a CCG we are an evidence-based organisation using data to underpin our decision making processes. Key achievements which have been informed by use of data include:
Funding mental health support in schools: we became the first city in the country to fund a mental health-focused training package for staff in every primary and secondary school, working closely with Bristol City Council. The training is designed to raise the profile of Child and Adolescent Mental Health Services (CAMHS), with the focus on early intervention to make a significant difference to young people’s lives.
Advancing our dementia care: We have established leading dementia wellbeing services, with around 2,000 patients benefiting from specialised support last year. A key feature is that people are never discharged from the service and can access support whenever they need it. We’re making continued investments and the number of people the service supports has nearly doubled over the last 12 months.
Sustainability and Transformation Partnership: We developed a new plan to guide our commissioning activity until 2021 as a partnership between Bristol, North Somerset and South Gloucestershire CCGs. After drafting the plan together, we involved the community and other clinical groups to gain their input. We had meetings with the three local authority health scrutiny committees and community volunteers. Our work together set us up to develop the best possible healthcare services for our population’s needs in the coming years.
Designing healthcare with our young people: We held a major consultation to find out what local young people, their parents and professionals involved in their care, thought of our community health services. We received over 1,200 ideas and have been using that feedback to shape children’s and young people’s health services.
Improving hospital discharge for older people: Our Discharge to Assess (D2A) scheme speeds up hospital discharge times for older patients, helping them get home quicker. The D2A team support patients to be discharged and assess ongoing care at home, on the same day, by community teams of social workers, nurses, physiotherapists and occupational therapists. The scheme has helped 20 people who would otherwise be in hospital receive therapy in their own homes and enabled us to save a total of 376 hospital bed days.
Appointing a new community healthcare services provider: In partnership with NHS England and North Somerset Council, we appointed North Somerset Community Partnership (NSCP) to provide community healthcare services. They provide all adult and some children’s community health services and specialist services, such as those for people with Parkinson’s disease, until April 2019.
Developing better out-of-hospital care: Helping people to live safely and independently at home as they age has been a high priority. We’ve introduced several initiatives to help people get better outside of hospital, from helping them discharge as soon as they’re fit to leave, to outpatient appointments in the community, and working with Age UK to provide better support to people as they age.
Transforming community services for children: We re-procured children’s community health services for Bristol and South Gloucestershire. This involved a partnership of five commissioning organisations working together to develop a cost-effective service for the whole area that recognises specific local needs, delivering coordinated care to children, young people and families.
Tackling diabetes and promoting self-care: We joined the second wave of the national Diabetes Prevention Programme in April 2017, building on a pilot at Leap Valley GP practice in Emersons Green, Bristol. Together with Bristol and South Gloucestershire CCGs, we’ve also since been selected to pilot the digital stream, which aims to establish whether digital interventions are effective in supporting behaviour change in people with non-diabetic hyperglycaemia (NDH) and overweight and or obese individuals.
Register history
When this agreement appeared in, or was edited in, each monthly edition of the register. Built by comparing every edition this site holds, the earliest of which is July 2021.
-
July 2021 —
already listed in the earliest edition this site holds, so it may be older. 5 versions: DARS-NIC-186885-Q1T3D-v1.3, DARS-NIC-186885-Q1T3D-v2.2, DARS-NIC-186885-Q1T3D-v3.5, DARS-NIC-186885-Q1T3D-v4.5, DARS-NIC-186885-Q1T3D-v5.3
-
October 2022
Succeeded Applicant organisation: NHS Bristol, North Somerset and South Gloucestershire CCG succeeded by NHS Bristol, North Somerset and South Gloucestershire ICB from 1 July 2022, according to NHS ODS. Not counted as a change.Succeeded Data controllers: NHS Bristol, North Somerset and South Gloucestershire CCG succeeded by NHS Bristol, North Somerset and South Gloucestershire ICB from 1 July 2022, according to NHS ODS. Not counted as a change.
-
December 2022
Register-wide edit DARS-NIC-186885-Q1T3D-v1.3, DARS-NIC-186885-Q1T3D-v2.2, DARS-NIC-186885-Q1T3D-v3.5, DARS-NIC-186885-Q1T3D-v4.5 — Datasets: legal basis: “
s261(1) and” taken out. Made to 639 agreements in this edition, so it is reported once, on the changes page, and not counted as an amendment of this agreement.
Cite this page
NHS England (2026) Data Uses Register, September 2026 edition, agreement DARS-NIC-186885-Q1T3D, “DSfC - NHS Bristol, North Somerset and South Gloucestershire CCG - IV, RS & Comm”. Read via NHS Data Access Explorer (unofficial), https://healthdatauses.uk/agreements/dars-nic-186885-q1t3d/ (accessed [date]).
This address stays the same, but the page is rebuilt with each monthly edition, so the citation names the edition it shows. Every edition's data is kept in the facts store.
Source: datausesregister_september2026.xlsx, September 2026 edition of the NHS England Data Uses Register. Search that workbook for DARS-NIC-186885-Q1T3D to see the original rows.