DSfC - NHS South Worcestershire CCG IV, RS, Comm

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 pseudonymised.

The CCG are advised by the appointed CEfF whether payment for invoices can be made or not.

Invoice Validation will be conducted by Midlands and Lancashire CSU.

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 Midlands and Lancashire 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

- Acute

- Ambulance

- Community

- Demand for Service

- Diagnostic Service

- Emergency Care

- Experience, Quality and Outcomes

- Mental Health

- Other Not Elsewhere Classified

- Population Data

- Primary Care Services

- 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)

- 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 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 Midlands and Lancashire Commissioning Support Unit.

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.

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 Commissioning:

• Patients who are normally registered and/or resident within the NHS South Worcestershire

CCG (including historical activity where the patient was previously registered or resident in

another commissioner).

and/or

• Patients treated by a provider where NHS South Worcestershire 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 South Worcestershire 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 South Worcestershire

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.

LIMA Networks Ltd and Blackpool Victoria Hospital supply 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.

Invoice Validation

1. Identifiable SUS+ Data is obtained from the SUS+ Repository to the Data Services for

Commissioners Regional Office (DSCRO).

2. Data quality management and pseudonymisation is completed within the DSCRO and the

data is then sent to the Controlled Environment for Finance (CEfF) in Midlands and

Lancashire Commissioning Support Unit.

3. NHS Midlands and Lancashire Commissioning Support Unit carry out the following

processing activities within the CEfF for invoice validation purposes:

a. Validating that the Clinical Commissioning Group is responsible for payment for the care of

the individual by using SUS+ and/or backing flow data.

b. Once the 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:

i. In line with Payment by Results tariffs

ii. are in relation to a patient registered with a CCG GP or resident within the CCG area.

iii. The health care provided should be paid by the CCG in line with CCG guidance.

4. The CCG are notified that the invoice has been validated and can be paid. Any

discrepancies or non-validated invoices are investigated and resolved between NHS

Midlands and Lancashire Commissioning Support Unit CEfF team and the provider

meaning that no identifiable data needs to be sent to the CCG. The CCG only receives

notification to pay and management reporting detailing the total quantum of invoices

received pending, processed etc.

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 Midlands and

Lancashire Commissioning Support Unit, who securely hold the SUS+ data.

3. Identifiable GP Data is securely sent from the GP system to Midlands and Lancashire CSU.

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 Midlands and Lancashire CSU has completed the processing, the CCG can access the

online system via a secure connection to access the data pseudonymised at patient level /

aggregate with small number suppression / aggregate without small number suppression /

anonymous reports.

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. Diagnostic Imaging Data Set (DIDS)

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

Data Processor 1 – Midlands and Lancashire 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) and Diagnostic Imaging data (DIDS)

only is securely transferred from the DSCRO to Midlands and Lancashire Commissioning

Support Unit.

2. Midlands and Lancashire Commissioning Support Unit add derived fields, link data and

provide 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

3. Allowed linkage is between the data sets contained within point 1.

4. Midlands and Lancashire Commissioning Support Unit then pass the processed,

pseudonymised and linked data to the CCG.

5. Aggregation of required data for CCG management use will be completed by Midlands

and Lancashire Commissioning Support Unit 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.

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 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:

o Patients at highest risk of admission

o Most expensive patients (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 patients 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.

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 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. 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.

Not stated in the register.