DSfC - NHS Bedfordshire CCG - RS

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 Prescribing Services Limited

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.

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. The data to be released from NHS Digital will not be national data.

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.

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 the application are listed below. This also includes the purpose on which they would be applied -

For the purpose of Risk Stratification:

• Patients who are normally registered and/or resident within NHS Bedfordshire CCG (including historical activity where the patient was previously registered or resident in another commissioner).

The Bunker Secure Hosting Ltd 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.

Risk Stratification

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

Prescribing Services Ltd, who hold the SUS+ data within the secure Data Centre on N3.

3. Identifiable GP Data is securely sent from the GP system to Prescribing Services Ltd.

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 Prescribing Services Ltd has completed the processing, the CCG can access the online system via a secure connection to access the data pseudonymised at patient level.

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:

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

o Plan work for commissioning services and contracts

o Set up capitated budgets

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

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 through more effective commissioning of services.

Yielded Benefits is not a requirement for new applications.