DSfC - Oxfordshire County Council, NHS Buckinghamshire, NHS Oxfordshire and NHS Berkshire West CCGs - Comm

One of the key changes under the new Health and Social Care bill is the creation of 42 Integrated Care Systems (ICS) constituted of new legal entities which replace CCGs. As this agreement is coming into existence shortly prior to the expected date of this change, it is understood that it is likely there will need to be a new, closely related agreement put in place well before the end date stated here.

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 Data Controller areas.

The Data Controllers 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.

The Local Authority, through the Director of Public Health, has legal duties defined by section 2(6)(zb) of the Local Government and Housing Act 1989, inserted by Schedule 5 of the Health and Social Care Act 2012.

This includes system-wide leadership in health improvement, health protection and healthcare public health, the duty to influence and facilitate system-wide change and to secure the improving health of their population. There is a requirement to contribute to and influence the work of NHS commissioners, helping to lead a whole system approach to public health across the public sector and advocate for an emphasis on reducing health inequalities and improving access in underserved groups in the work of commissioners, providers and other key stakeholders.

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 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.

 Provide intelligence about the safety and effectiveness of medicines.

 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

Atos Healthcare will be providing the South, Central and West (SCW) Commissioning Support Unit with staff resource and subject matter expertise to assist us in the delivery of products and services. Named individuals will have access to pseudonymised patient level data via SCW CSU servers and secure SCW CSU logins. No data will leave SCW CSU, therefore no processing and storage addresses are listed.

DIRECT CARE

Where necessary, the Data Controllers will allow re-identification of certain records (as described in section 5b) for the purposes of Direct Care.

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

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:

In the development of cohorts of pseudonymised patients considered to be at risk, the data controllers may need the facility to provide identifiable results back to direct health or care professionals for the purpose of direct care. Additionally clinicians, made aware of a number of cases that they believe would need intervention may request re-identification for that direct care purpose. These instances of re-identification will generally be carried out as programmes of work or, rarely, on an individual/small group basis.

NHS Digital provides a re-identification service for this process. All re-id requests will be processed and authorised by NHS Digital 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.

The following are examples of instances where the CCG has used the re-identification process:

· GPs have requested a list of patients registered with them who have depression, obesity, are on a waiting list, and aged 20-64. This is in order to assist them with direct patient care interventions for these patients to improve the outcomes using the existing services. The patient will benefit from an additional and more personalised support package and enhanced access to support. Any lessons learnt will also enable them to make changes to strengthen the patient pathway to others with the same conditions.

· GPs have requested a list of patients registered with them who are adolescents between the age of 15 – 24 who are asthmatic and have a mental health diagnosis. This is in order to assist them with direct patient care interventions for these patients to improve the outcomes using the existing services. The patient will benefit from an additional and more personalised support package and enhanced access to support. Any lessons learnt will also enable them to make changes to strengthen the patient pathway to others with the same conditions.

The recipient of the data following the reidentification request will be a person with the direct care responsibilities

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

1. The CCG identifies a patient cohort 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 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. These checks are carried out either by DSCRO staff using pre-approved information (timing’s, requester’s identity etc) or via an automated system.

4. For automated systems, steps 1 - 3 wouldn’t apply in most cases as it would be the direct care professional who identifies the cohort and as long as they are an approved re-id user and have gone through security checks initially, they will be able to re-id without further checks.

5. 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.

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

Aggregated reports only with small number suppression can be shared externally as set out within NHS Digital guidance applicable to each data set.

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)

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 section 3 are listed below. This also includes the purpose on which they would be applied -

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

and/or

• Patients treated by a provider where the CCGs are 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 the CCG's - this is only for commissioning and relates to both national and local flows.

and/or

• Patients treated by a provider where the CCGs have joint responsibility for the provider services in the local health economy – this is only for Ambulance Trust data

Microsoft Limited supply provide Cloud Services for 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 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.

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).

Commissioning

The Data Services for Commissioners Regional Office (DSCRO) obtains the following data sets:

1. SUS

2. Local Provider Flows (received directly from providers)

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

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 (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 DSCRO and is then disseminated as follows:

Data Processor 1 - 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), National Cancer Waiting Times (CWT), Civil Registration Data (CRD) (births and deaths), National Diabetes Audit (NDA), Patient Reported Outcome Measures (PROMs), Diagnostic Imaging data (DIDS), 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 to South Central and West Commissioning Support Unit (CSU)

2. The CSU also receives a flow of GP & Social Care data (points i - ix)

3. The CSU add derived fields by using existing data and provide analysis to:

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

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

o Undertake population health management

o Thoroughly investigate the needs of the population

o Understand cohorts of residents who are at risk

o Conduct Health Needs Assessments

4. Linkage is permitted between datasets in points 1 and 2.

5. The CSU then pass the processed, pseudonymised and linked data to the Data Controllers.

6. Aggregation of required data for management use will be completed by the CSU as instructed by the Data Controllers.

7. Patient level data will not be shared outside of the Data Controllers and will only be shared within on a need to know basis, as per the purposes stipulated within the Data Sharing Agreement.

GP & Social Care

South, Central and West Commissioning Support Unit have individual data processing agreements in place with GPs, Local Authorities and the CCGs, to pseudonymise data. Acting on their behalf, South, Central and West Commissioning Support Unit pseudonymises the data as follows:

i. Identifiable GP and Social Care data is submitted to South, Central and West Commissioning Support Unit.

ii. The data lands in a ring-fenced area.

iii. South, Central and West Commissioning Support Unit has access to a pseudonymisation tool. South, Central and West Commissioning Support Unit requests an organisation specific pseudonymisation key from the DSCRO. The key can only be used once. The key is specific to the individual request and the organisation it is being requested for.

iv. The data is then pseudonymised using the organisation specific pseudonymisation tool and DSCRO issued key. The identifiable data is then deleted from the ring-fenced area.

v. To enable linkage to data listed in point 1, South, Central and West Commissioning Support Unit make a request to the DSCRO.

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

vii. A black box uses the mapping table to overwrite the organisation specific pseudonym with the DSCRO pseudonym to enable linkage to NHS Digital released products (under this agreement).

viii. The mapping table if then deleted.

ix. In addition, for social care data only: Social Care organisations have access to the pseudonymisation tool and can request an organisation specific pseudonymisation key from the DSCRO. The key can only be used once and is specific to that date. The organisation then submits the pseudonymised social care data to South, Central and West Commissioning Support Unit. The data then follows from point v.

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

Data Processor- South, Central and West Commissioning Support Unit

1. Production of project / programme level dashboards.

2. Data Quality and Validation measures allowing data quality checks on the submitted data

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. 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

20. Help drive changes in healthcare

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

22. Inform commissioners and improve services

23. 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.

24. Understanding the interdependency of care services

25. Targeting care more effectively

26. Thoroughly investigating the needs of the population, to ensure the right services are available for individuals when and where they need them

27. 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

28. 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

29. Service redesign

30. Health Needs Assessment – identification of underlying disease prevalence within the local population

31. 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).

NHS Berkshire West CCG, NHS Oxfordshire CCG & NHS Buckinghamshire CCG, have published annual reports with the benefits of this data contained within links provided below;

https://www.berkshirewestccg.nhs.uk/media/5265/bw-ccg-annual-report-accounts-2020-21.pdf

https://www.buckinghamshireccg.nhs.uk/wp-content/uploads/2021/07/09a.-BCCG-NHS-Auditors-Annual-Report-Final.pdf

https://www.oxfordshireccg.nhs.uk/get-involved/Annual%20Reports/OCCG%20Annual%20Report%20and%20Account%2020_21%20combined%20with%20signatures%2018_06_21%20final.pdf

Examples:

Cancer waiting times

In recognition of the COVID-19 pandemic, cancer systems have been under significant pressure to deliver treatment for all patients. This has included systems across the BOB ICS. The OUH, along with other hospitals across BOB, has been working with the Thames Valley Cancer Alliance (TVCA) in the development of a recovery plan for cancer services with the aims of:

• Reducing unmet need and tackling health inequalities, working with GPs and the public locally to restore the number of people coming forward and appropriately being referred with suspected cancer to at least pre-pandemic levels

• Managing the immediate growth in people requiring cancer diagnosis and/or treatment returning to the service

• Thereby reducing the number of patients waiting for diagnostics and/or treatment longer than 62 days on an urgent pathway, or over 31 days on a treatment pathway, to pre-pandemic levels, with an immediate plan for those waiting longer than 104 days 22

Having access to the National Cancer Waiting Times dataset has allowed the CCG to monitor it's progress of these aims

C the Signs

C the Signs is a digital tool that uses artificial intelligence mapped with the latest evidence to identify patients at risk of cancer. Covering the entire spectrum of cancer and cross-referencing multiple diagnostic pathways, C the Signs can identify which cancer or cancers a patient is at risk of and the most appropriate next step. Data supplied under this application has helped the CCG to develop this algorithm. It can be used as a safety netting tool in primary care.

In October 2020 Oxfordshire OCCG started a pilot to trial C the Signs in the county; 57 practices have signed up. Data is being collated and an evaluation will be completed later in the year.

Cancer Care Review (CCR) Implementation Support Scheme

The CCR Implementation Support Scheme is part of the Thames Valley Cancer Alliance’s five-year delivery plan to improve outcomes for people with cancer by 2020 and it aligns with the national cancer strategy ‘Achieving World-Class Cancer Outcomes (A Strategy for England 2015-2020)’. The scheme is looking for all GP practices to adopt the standardised CCR template and undertake a second cancer care review with each patient (the first cancer care review is part of the primary care Quality Outcomes Framework). Across the BOB ICS, the Buckinghamshire and Oxfordshire schemes went live in December 2020. An engagement event was held with speakers from primary and secondary care, and the voluntary sector. More than 80 primary care clinicians joined the event. In Berkshire West, year one of the scheme closed in October 2020 with 457 reviews carried out by primary care. The launch of Year 2 of the scheme was delayed to April 2021 to support primary care to set up COVID-19 vaccination services. Use of data supplied by NHS Digital allows the CCG to assess the outcomes of the scheme.

Re-ID for direct care

GPs have requested a list of patients registered with them who are Obese, recently diagnosed with Depression aged 40-64 and have Metabolic Syndrome. This is in order to assist them with direct patient care interventions for these patients to improve the outcomes using the existing services and to tackle rising risk of long-term conditions.

The patient will benefit from an additional and more personalised support package and enhanced access to support.