DSfC - NHS Devon CCG, NHS Kernow CCG & Cornwall Council - Commissioning

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.

NHS Devon & NHS Kernow CCGs work together on a collaborative basis. This request is for each CCG to receive data for the entire region covered by both the CCGs. Receiving data for the entire region will allow the CCGs to support each other in delivering their commissioning agendas, as well as supporting the newly established primary care networks across the region. The CCGs will receive datasets on a collaborative basis across their region, to be used for either collaborative reporting across the region, or at individual CCG level as required. This assists to ensure delivery of care in the right place for patients who may move and change services across CCGs. The CCGs will work proactively and collaboratively to redesign services across boundaries to integrate services. Collaborative sharing is required for CCGs to understand these requirements.

In addition, both CCGs work collaboratively with Cornwall Council in order to deliver the joint aims to support primary care networks and deliver population health management. Cornwall Council need to have visibility of the data without suppression applied in order to collaboratively redesign services to improve population outcomes.

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 Local Authority commissions social care and some other health services and requires access to the same data as the CCG in order to work more collaboratively.

As set out in the NHS Long Term Plan, the NHS will increasingly focus on population health and local partnerships with local authority-funded services, through Integrated Care Systems. Therefore Population Health Management (PHM) is the critical building block for integrated care systems and enables Primary Care Networks (PCNs) to deliver with their local partners true Personalised Care. Together, the three Ps (PHM, PCNs, Personalised Care) form a core offer for local people which ensures care is tailored to their personal needs and delivered as close to home as possible. PHM enables systems and local teams to understand and look for the best solutions to people’s needs – not just medically but also socially – including the wider determinants of people’s health. Many people need support with issues such as housing, employment, or social isolation – all of which can affect their physical and mental health – these solutions are often already available through, or better designed with, local people, the local council or a voluntary organisation. Better partnership working using PHM to join up the right person with the right care solution helps the CCGs and Local Authority to improve outcomes, reduce duplication and use the region's resources more effectively. To meet the challenge set by NHS England of achieving goals in meeting PHM and improving health inequalities, data needs to be shared between the CCGs and Local Authority to allow detailed insights that will allow change.

The intention is for this to be the start of an Integrated Care System (ICS) level sharing application. The Devon local authorities however were omitted from this application due to them to having sufficient information governance at this time.

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)

- e-Referral Service (eRS)

- Personal Demographics Service (PDS)

- Summary Hospital-level Mortality Indicator (SHMI)

- Medicines Dispensed in Primary Care (NHSBSA Data)

- Adult Social Care Data

Processing of the Medicines Dispensed in Primary Care (NHSBSA Data) dataset is only permitted to provide intelligence about the safety and effectiveness of medicines, as specified by the NHS Business Services Authority (NHSBSA) Medicines Data Directions 2019.

The pseudonymised data is required to for the following purposes:

 Population health management:

• Understanding the interdependency of care services

• Targeting care more effectively

 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 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

 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.

 Support measuring the health, mortality or care needs of the total local population

 Allow analysis of patient pathways across healthcare and social care.

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 NHS South Central and West Commissioning Support Unit, NHS North of England Commissioning Support Unit and Optum Health Solutions (UK) Ltd

In exceptional circumstances, where it is necessary to enable the direct care of that individual, individuals can be identified however this will only be restricted to direct healthcare professionals or local authority direct care staff and only for the strict purposes of direct care. All requests to re-identify will be processed and authorised on a case by case basis by the DSCRO.

Legal basis for processing:

Data is being processed under Article 6(1(e ) (processing is necessary for the performance of a task in the public interest or in the exercise of official authority vested in the controller)

And

Article 9(2)(h) ((processing is necessary for the purposes of preventive or occupational medicine, for the assessment of the working capacity of the employee, medical diagnosis, the provision of health or social care or treatment or the management of health or social care systems and services on the basis of Union or Member State law or pursuant to contract with a health professional and subject to the conditions and safeguards referred to in paragraph 3).

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)

ONWARD SHARING:

There is no requirement for the analytical teams to re-identify patients, but in the development of cohorts of patients considered to be at risk, the data controllers may need the facility to provide identifiable results back to direct healthcare professionals or local authority direct care staff only for the purpose of direct care. All re-id requests will be processed and authorised by the DSCRO on a case by case basis. National data opt outs are not applied in these cases as they are for the purposes of direct care which follows the legal basis of implied consent.

An example of a request for the re-id of patients for direct care may be;

A&E High Attendance usage

The CCG can filter data to show for example the number of A&E attendances in a given period for each patient. The CCG can then flag to the relevant GP of the patient any patients that require intervention. An outcome of this is earlier intervention in the patient(s) care thus potentially reducing future costs and minimising future risk.

Polypharmacy re-IDs

CCG's can request re-ID of a list of patients to be sent to the relevant GP with a high number of medications (ingredient count) and review the medication for these patients. This can help address the risk of polypharmacy which is recognised as an adverse risk factor for patient safety. A by-product of such reviews may be to reduce costs of medication.

The Re-identification process for direct care is as follows:

1. The CCG identifies a patient cohort (typically small numbers) to be re-identified for the purpose of direct care.

2. The CCG sends a re-id request to the DSCRO. This may be done through the CCG or CSU’s Business Intelligence (BI) Tool, or through a manual form.

3. The DSCRO (either through an automated system or manual checking in line with the request) assesses as to whether the request passes the specified re-identification process checks. Checks include if the requester is authorised to access identifiable data, if the number of patients in the cohort is appropriate, and that the request does not seem inappropriate or outside of expected parameters, including for example around timings and the requestor’s relationship with patients in the data

4. If successful/approved, the DSCRO re-identifies the relevant data item(s) for the appropriate patients and returns the identifiable fields to Health or care professional(s) with a legitimate relationship to the patient. The CCG does not see the identifiable record.

5. DSCROs retain an audit trail of all re-id requests

6. National Data opt outs are not applied for the purpose of direct care

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 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 Commissioning:

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

and/or

• Patients treated by a provider where Devon and Kernow 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 Devon and Kernow CCG - this is only for commissioning and relates to both national and local flows.

Microsoft Limited provide Cloud Services for South Central and West Commissioning Support Unit, North of England Commissioning Support Unit and Optum Health Solutions Limited 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 the agreement. This includes granting of access to the database[s] containing the data.

Amazon Web Services provide Cloud Services for Optum Health Solutions Limited 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 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

DELT Shared Services Ltd provide IT infrastructure 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 the agreement. This includes granting of access to the database[s] containing the data.

Stem Group, Royal Cornwall Hospitals Acute Trust, Pulsant, IT Professional Services Ltd and 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.

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. The Local Authority will not require access to this.

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).

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)

19. Medicines Dispensed in Primary Care (NHSBSA Data)

20. Adult Social Care Data

Data quality management and pseudonymisation is completed within the DSCROs and is then disseminated as follows:

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), e-Referral Service (eRS), Personal Demographics Service (PDS), Summary Hospital-level Mortality Indicator (SHMI), Medicines Dispensed in Primary Care (NHSBSA Data) and Adult Social Care data only is held until points 2-8 are completed.

2. NHS South, Central and West Commissioning Support Unit receives GP data. GP Data is received as follows:

o Identifiable GP data is submitted to NHS South, Central and West Commissioning Support Unit.

o The identifiable data lands in a ring-fenced area for GP data only.

o The GP data is pseudonymised using a pseudonymisation tool, different to that used by the DSCRO.

o There is a Data Processing Agreement in place between the GP and NHS South, Central and West Commissioning Support Unit. A specific named individual within NHS South, Central and West Commissioning Support Unit acts on behalf of the GP.

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.

o Once mapped, the data is passed into NHS South, Central and West Commissioning Support, but before NHS 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.

o NHS South, Central and West Commissioning Support Unit are then sent the pseudonymised GP data with the pseudo algorithm specific to them.

3. NHS 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:

o Pseudonymised:

- Social Care data is pseudonymised within the provider 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.

- The pseudonymised data lands in a ring-fenced area for social care data only.

- There is a Data Processing Agreement in place between the Provider and NHS South, Central and West Commissioning Support Unit. A specific named individual within NHS 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.

- The data is then passed into the non-ringfenced area with the pseudo algorithm specific to them.

o Identifiable:

- Identifiable social care data is submitted to NHS South, Central and West Commissioning Support Unit.

- The identifiable data lands in a ring-fenced area for social care data only.

- The social care data is pseudonymised using a pseudonymisation tool, different to that used by the DSCRO.

- There is a Data Processing Agreement in place between the Local Authority and NHS South, Central and West Commissioning Support Unit. A specific named individual within NHS 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 NHS South, Central and West Commissioning Support, but before NHS 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.

- NHS 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, NHS South, Central and West Commissioning Support Unit make a request to the DSCRO.

5. The DSCRO check the dates of the key generation.

6. The DSCRO then send a mapping table to NHS South, Central and West Commissioning Support Unit

7. NHS 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), Patient Reported Outcome Measures (PROMs), e-Referral Service (eRS), Personal Demographics Service (PDS), Summary Hospital-level Mortality Indicator (SHMI), Medicines Dispensed in Primary Care (NHSBSA Data) and Adult Social Care data only securely to NHS South, Central and West Commissioning Support Unit for the addition of derived fields, linkage of data sets and analysis.

10. Social Care Data and GP Data is then linked to the data sets listed within point 9. NHS South, Central and West Commissioning Support Unit then analyse the data to do the following:

a. See patient journeys for pathways or service design, re-design and de-commissioning

b. Check recorded activity against contracts or invoices and facilitate discussions with providers

c. Undertake population health management

d. Undertake data quality and validation checks

e. Thoroughly investigate the needs of the population

f. Understand cohorts of residents who are at risk

g. Conduct Health Needs Assessments

11. NHS South, Central and West Commissioning Support Unit then pass the processed, pseudonymised data to the CCGs for the further addition of derived fields, linkage of data sets and analysis to:

a. See patient journeys for pathways or service design, re-design and de-commissioning

b. Check recorded activity against contracts or invoices and facilitate discussions with providers

c. Undertake population health management

d. Undertake data quality and validation checks

e. Thoroughly investigate the needs of the population

f. Understand cohorts of residents who are at risk

g. Conduct Health Needs Assessments

12. The CCG's will then pass the processed pseudonymised data to the local authority. This is a more cost effective approach than the DSCRO flowing the data directly to the local authority.

13. Patient level data will not be shared outside of the Controllers and Processors and will only be shared within the Controllers and Processors 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.

Devon CCG

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), e-Referral Service (eRS), Personal Demographics Service (PDS), Summary Hospital-level Mortality Indicator (SHMI), Medicines Dispensed in Primary Care (NHSBSA Data) and Adult Social Care data only is securely transferred from the DSCRO (via North of England Commissioning Support Unit) to Devon CCG.

2. Devon CCG then analyse the data to do the following:

a. See patient journeys for pathways or service design, re-design and de-commissioning

b. Check recorded activity against contracts or invoices and facilitate discussions with providers

c. Undertake population health management

d. Undertake data quality and validation checks

e. Thoroughly investigate the needs of the population

f. Understand cohorts of residents who are at risk

g. Conduct Health Needs Assessments

3. Patient level data will not be shared outside of the Controllers and Processors and will only be shared within the Controllers and Processors 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.

Optum Health Solutions (UK) Limited

1. Pseudonymised SUS, Mental Health data (MHSDS), Community Services Data Set (CSDS) and GP data only is securely transferred from the South Central and West Commissioning Support Unit to Optum Health Solutions (UK) Limited.

2. Optum Health Solutions (UK) Limited process data for Wave 3 of the population Health Management programme

3. Patient level data will not be shared outside of the Controllers and Processors and will only be shared within the Controllers and Processors 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.

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:

o Patients at highest risk of admission

o High cost activity uses (top 15%)

o Frail and elderly

o Patients that are currently in hospital

o Patients with most referrals to secondary care

o Patients with most emergency activity

o Patients with most expensive prescriptions

o Patients recently moving from one care setting to another

i. Discharged from hospital

ii. Discharged from community

13. Validation for payment approval, ability to validate that claims are not being made after an individual has died, like Oxygen services.

14. 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.

15. Clinical - understand reasons why patients are dying, what additional support services can be put in to support.

16. 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.

17. Removal of patients from Risk Stratification reports.

18. 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.

19. 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.

20. Monitor the timing of key actions relating to referral letters. CCG’s are unable to see the contents of the referral letters.

21. 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.

22. Allow Commissioners to better protect or improve the public health of the total local patient population

23. Allow Commissioners to plan, evaluate and monitor health and social care policies, services, or interventions for the total local patient population

24. Allow Commissioners to compare their providers (trusts) mortality outcomes to the national baseline.

25. Investigate mortality outcomes for trusts.

26. Identify medication prescribing trends and their effectiveness.

27. Linking prescribing habits to entry points into the health and social care system.

28. Identify, quantify and understand cohorts of patient’s high numbers of different medications (polypharmacy).

29. Monitoring, at a population level, particular cohorts of service users and designing analytical models which support more effective interventions in health and adult social care

30. Monitoring service and integrated care outcomes across a pathway or care setting involving adult social care

Linking data on people living with long term conditions and mobility issues, who have high numbers of GP and A&E appointments and are living in households with assisted bin collections. Insights of this nature would enable health and care to find groups of people living with frailty who were in need of more proactive personalised care to keep them living well at home by arranging visits, home adaptations and introducing social prescribers to connect people into support groups in the community to reduce social isolation.

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. Providing greater understanding of the underlying courses and look to commission improved supportive networks, this would be ongoing work which would be continually assessed.

15. 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.

16. Provision of indicators of health problems, and patterns of risk within the commissioning region.

17. Support of benchmarking for evaluating progress in future years.

18. Joined up working with Councils to population health with one version of the truth and a centre of excellence over multiple CCG's and Councils.

18. Allow reporting to drive changes and improve the quality of commissioned services and health outcomes for people.

19. Assists commissioners to make better decisions to support patients and drive changes in health care

20. Allows comparisons of providers performance to assist improvement in services – increase the quality

21. 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.

22. 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).

23. Monitoring of entire population, as a pose to only those that engage with services

24. 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.

25. Monitor the quality and safety of the delivery of healthcare services.

26. Allow focused commissioning support based on factual data rather than assumed and projected sources.

27. Understand admissions linked to overprescribing.

28. Add value to the population health management workstream by adding prescribing data into linked dataset for segmentation and stratification.

29. Developing, through evaluation of person-level data, more effective prevention strategies and interventions across a pathway or care setting involving adult social care

30. Designing and implementing new payment models across health and adult social care

31. Understanding current and future population needs and resource utilisation for local strategic planning and commissioning purposes including for health, social care and public health needs.

Improved outcomes, reduced cost and reduction of health inequalities as set out by the NHS Long Term Plan.

The Data Controllers has realised the measurable benefits for the data collection and the provided data has enabled services to be delivered to match the population requirements whilst planning for future needs.

Listed below is a number of further yielded benefits for commissioning;

1. Monitoring In year projects

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

3. Successful delivery of integrated care within the CCG/LA area.

4. Better understanding of the health of and the variations in health outcomes within the population to help understand local population characteristics.

5. Insights into patient outcomes, and identification of the possible efficacy of outcomes-based contracting opportunities.

The Data Controllers will look to build on the yielded benefits of commissioning services that meet the needs of their local population, and that are effective in their delivery. The Data Controllers will use intelligence to add insight to strategic commissioning and service integration across the CCG/LA Area. This work will continue year on year to match the delivery/funding of targets services for the population within the CCG/LA Area.

The continued access to this data will enable the Data Controllers to further understand and improve service performance and delivery, including patient pathway design, re-design and patient experience.