DSfC - NHS North East London CCG - Comm, RS & IV

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.

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 able to ensure that the activity claimed for each patient is their responsibility. This is done by processing and analysing Secondary User Services (SUS+) data, which is received into a secure Controlled Environment for Finance (CEfF). The SUS+ data is identifiable and is only used to confirm the accuracy of backing-data sets (data from providers) and determining if the CCG is the responsible commissioner for the patient.

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

Invoice Validation will be conducted by NHS North East London Commissioning Support Unit / North of England Commissioning Support Unit and the CCG

RISK STRATIFICATION

Risk stratification is a tool for identifying and predicting which patients are at high risk (of health deterioration and using multiple services) or are likely to be at high risk and prioritising the management of their care in order to prevent worse outcomes.

To conduct risk stratification, Secondary User Services (SUS+), 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 scores/classes are determined by GP/CCG prior to any processing activity. Risk Stratification provides focus for future demands by enabling commissioners to prepare plans for both individual and groups of vulnerable patients.  Commissioners can then prepare plans for patients who may require high levels of care. Risk Stratification also enables General Practitioners (GPs) to better target intervention in Primary Care.

Risk Stratification will be conducted by NHS North East London Commissioning Support Unit / North of England Commissioning Support Unit and the CCG

COMMISSIONING

To use pseudonymised data to provide intelligence to support the commissioning of health services. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the CCG area.

The CCGs commission services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.

The following pseudonymised datasets are required to provide intelligence to support commissioning of health services:

• Secondary Uses Service (SUS+)

• Local Provider Flows

o Acute

o Ambulance

o Community

o Demand for Service

o Diagnostic Service

o Emergency Care

o Experience, Quality and Outcomes

o Mental Health

o Other Not Elsewhere Classified

o Population Data

o Primary Care Services

o Public Health Screening

• Mental Health Minimum Data Set (MHMDS)

• Mental Health Learning Disability Data Set (MHLDDS)

• Mental Health Services Data Set (MHSDS)

• Maternity Services Data Set (MSDS)

• Improving Access to Psychological Therapy (IAPT)

• Child and Young People Health Service (CYPHS)

• Community Services Data Set (CSDS)

• Diagnostic Imaging Data Set (DIDS)

• National Cancer Waiting Times Monitoring Data Set (CWT)

• Civil Registries Data (CRD) (Births)

• Civil Registries Data (CRD) (Deaths)

• National Diabetes Audit (NDA)

• Patient Reported Outcome Measures (PROMs)

• e-Referral Service (eRS)

• 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.

 Provide intelligence about the safety and effectiveness of medicines.

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

Processing for commissioning will be conducted by NHS North East London Commissioning Support Unit / North of England Commissioning Support Unit, Queen Mary University of London and Optum Health Solutions UK Limited.

Queen Mary University of London (QMUL) host a clinical effectiveness group. The group evaluates clinical outcomes and recommend best practice with regard to long term conditions and other health priorities within the area.

The data analysed by QMUL was supplied as 'cuts' of the larger SUS+ extract. The cuts are minimised to the receiving CCG's geographical coverage. Any access to other data is not permitted. This data is minimised by locations as described in this point, as well as by time period, the University may only use the latest available as well as the previous 3 years of data.

NHS 111

In order to accurately evaluate and improve the NHS 111 Patient Relationship Manager (PRM) System the CCG requires the ability to link NHS 111 PRM Call processing to eventual outcomes in the wider Urgent and Emergency Care System. The SUS data will allow for linkage to Emergency Department’s (ED) and Urgent Care Centre’s (UCC, including Short Stay Admissions, in the DSCRO. That is, it is important to relate the attendance, and the outcomes from this attendance, in the wider Urgent and Emergency Care System; with the 111 call which initiated the Patient Journey. The accuracy and relevance of the processes in 111 can only be evaluated if the CCG understands how the Patient had their clinical issue ultimately resolved. It could be that callers to 111, who are associated with a specific Symptom Group and who received a particular disposition for Primary- or Self-Care; nevertheless end up in ED. In that case, the CCG will evaluate the effectiveness of the associated 111 processes.

When a caller rings NHS 111, the disposition from that call is a recommendation from the 111 System as to what the caller should do next, to resolve their clinical issue.

Most often, the disposition is in the form of a recommendation to attend a Service in person. The disposition, when given by a Call Handler, is derived by the NHS Pathways algorithm. One way to evaluate the accuracy of this algorithm with respect to a caller population, is to link the dispositions to the final outcomes of callers. This is achieved by linking the records of the different data sets by NEL Commissioning Support Unit, by using the data linkage algorithm described above. A high degree of correspondence between the type of final Service attended; and the type of service given in the disposition, would indicate that for these callers the NHS Pathways algorithm is highly accurate.

The PRM have introduced facilities in the System where repeat callers; and callers with a Care Plan, get connected to a clinician instead of a Call Handler. By analysing whether the final outcomes differ significantly for callers who spoke to a Call Handler; as compared to callers who spoke to a clinician; we can evaluate the impact on repeat callers and caller with a Care Plan, by the introduction of the PRM System.

Processing for this aspect will be conducted by North East London Commissioning Support Unit / North of England Commissioning Support Unit and Chelsea and Westminster Hospital NHS Foundation Trust (Hosting Health Research (NIHR) Collaboration for Leadership in Applied Research Collaboration (ARC))

Optum's analyses of data aims to understand the needs of the population through whole population segmentation. This focuses on the entirety of the Primary Care Networks or Place/Integrated Care Partnership population and differentiates it into segments using a complexity measure and age. Further analyses are presented that stratify individuals in segments according to the presence or risk of poor outcomes. Places/Integrated Care Partnerships and Primary Care Networks have full autonomy to delve into any of the segments to identify cohorts for proactive intervention. Groups of patients of c.100-200 will be identified and pseudonymised NHS numbers passed from Optum to North and East London Commissioning Support Unit support team for reports to be created within North and East London Commissioning Support Unit tooling for GPs with Role Based Access Controls and a legitimate caring relationship with the patients to identify individuals for intervention. Only those who already have a right to access this data e.g. for direct care purposes will be able to view this data.

INVOICE VALIDATION

1. The Controlled Environment for Finance (CEfF) will enable the CCG to challenge invoices and raise discrepancies and disputes.

2. Outputs from the CEfF will enable accurate production of budget reports, which will:

a. Assist in addressing poor quality data issues

b. Assist in business intelligence

3. Validation of invoices for non-contracted events where a service delivered to a patient by a provider that does not have a written contract with the patient’s responsible commissioner, but does have a written contract with another NHS commissioner/s.

4. Budget control of the CCG.

RISK STRATIFICATION

1. As part of the risk stratification processing activity detailed above, GPs have access to the risk stratification tool which highlights patients for whom the GP is responsible and have been classed as at risk. The only identifier available to GPs is the NHS numbers of their own patients. Any further identification of the patients will be completed by the GP on their own systems.

2. GP Practices will be able to view the risk scores for individual patients with the ability to display the underlying SUS+ data for the individual patients when it is required for direct care purposes by someone who has a legitimate relationship with the patient.

CCGs will be able to:

3. Target specific vulnerable patient groups and enable clinicians with the duty of care for the patient to offer appropriate interventions.

4. Reduce hospital readmissions and targeting clinical interventions to high risk patients.

5. Identify patients at risk of deterioration and providing effective care.

6. Reduce in the difference in the quality of care between those with the best and worst outcomes.

7. Re-design care to reduce admissions.

8. Set up capitated budgets – budgets based on care provided to the specific population.

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

10. Monitor vulnerable groups of patients including but not limited to frailty, COPD, Diabetes, elderly.

11. Health needs assessments – identifying numbers of patients with specific health conditions or combination of conditions.

12. Classify vulnerable groups based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost.

13. Production of Theographs – a visual timeline of a patients encounters with hospital providers.

14. Analyse based on specific diseases

In addition:

• The risk stratification tool will provide aggregate reporting of number and percentage of population found to be at risk.

• Record level output (pseudonymised) will be available for commissioners (of the CCG), pseudonymised at patient level. Onward sharing of this data is not permitted.

COMMISSIONING

1. Commissioner reporting:

a. Summary by provider view - plan & actuals year to date (YTD).

b. Summary by Patient Outcome Data (POD) view - plan & actuals YTD.

c. Summary by provider view - activity & finance variance by POD.

d. Planned care by provider view - activity & finance plan & actuals YTD.

e. Planned care by POD view - activity plan & actuals YTD.

f. Provider reporting.

g. Statutory returns.

h. Statutory returns - monthly activity return.

i. Statutory returns - quarterly activity return.

j. Delayed discharges.

k. Quality & performance referral to treatment reporting.

2. Readmissions analysis.

3. Production of aggregate reports for CCG Business Intelligence.

4. Production of project / programme level dashboards.

5. Monitoring of acute / community / mental health quality matrix.

6. Clinical coding reviews / audits.

7. Budget reporting down to individual GP Practice level.

8. GP Practice level dashboard reports.

9. Comparators of CCG performance with similar CCGs as set out by a specific range of care quality and performance measures detailed activity and cost reports

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

11. Contract Management and Modelling

12. Patient Stratification, such as:

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

NHS 111

- 111 Service; based on the Population’s prevalence of Repeat Callers and Callers with Care Plans (YTD).

- From analysis/review: Establishing the effectiveness of the NHS Pathways-derived

-Dispositions; and the extent to which this impact on a Population (YTD).

- From analysis/review: Establishing the cost and Service impacts of introducing the NHS 111 PRM System in a new region (YTD).

- From analysis/review: Establishing the extent to which Costs and benefits from introducing the NHS 111 PRM System differs across the boroughs of Greater London. What factors or variables in a population contribute to such differences (YTD).

- From analysis/review: Establishing what aspects of the NHS 111 PRM System have proven effective across a majority of populations; and what features of the System would require improvement (YTD).

- From analysis/review: Determining how the NHS 111 PR System can by improved, based on the impact on the caller population (YTD)

The CCGs (prior to merging to North East London CCG in 2021) have recently published their annual report for 2020/21 -

NHS Barking and Dagenham CCG - https://northeastlondonccg.nhs.uk/wp-content/uploads/2021/09/BD-CCG_Annual_Report_2020-21_FINAL.pdf

NHS City and Hackney CCG - https://northeastlondonccg.nhs.uk/wp-content/uploads/2021/09/City-Hackney-CCG_Annual_Report_2020-21_FINAL.pdf

NHS Havering CCG - https://northeastlondonccg.nhs.uk/wp-content/uploads/2021/09/Havering-CCG_Annual_Report_2020-21_FINAL.pdf

NHS Newham CCG - https://northeastlondonccg.nhs.uk/wp-content/uploads/2021/09/Newham-CCG_Annual_Report_2020-21_FINAL.pdf

NHS Redbridge CCG - https://northeastlondonccg.nhs.uk/wp-content/uploads/2021/09/Redbridge-CCG_Annual_Report_2020-21_FINAL.pdf

NHS Tower Hamlets CCG - https://northeastlondonccg.nhs.uk/wp-content/uploads/2021/09/Tower-Hamlets-CCG_Annual_Report_2020-21_FINAL.pdf

NHS Waltham Forest CCG - https://northeastlondonccg.nhs.uk/wp-content/uploads/2021/09/Waltham-Forest-CCG_Annual_Report_2020-21_FINAL.pdf

An overall summary can be found at https://northeastlondonccg.nhs.uk/wp-content/uploads/2021/09/NEL-CCG-Annual-report-summary-2021-.pdf

(can be found on page two of the report above)

• Barking and Dagenham made significant improvements to diabetes care and treatment, cutting the number of undiagnosed cases by over a thousand, producing patient information videos on foot care by our GPs in community languages, and reviewing patients in local parks during the Covid-19 lockdown.

• Redbridge’s award-winning atrial fibrillation work for people with heart conditions saw a sustained increase in the number of patients receiving high-quality care for their condition, and it was recognised as the most improved borough in London last year with real patient impact by preventing strokes. This model was developed with partners in Barking, Havering and Redbridge University Hospitals NHS Trust and was adopted across the three local CCGs. This is just one example of the way we work in partnership to benefit our patients and communities.

• In Havering, our borough with the highest population of older people, partners across health, the local authority, voluntary and community sectors have pioneered work to make the borough dementia friendly. In addition, CCG and North East London NHS Foundation Trust colleagues, with partners, have led work to plan and deliver a new health and wellbeing hub on the site of the former St George’s Hospital in Hornchurch.

• City and Hackney developed an innovative user-friendly digital platform for people with severe mental illness, allowing them to access health information on their digital devices. It also offers patients space to create a personalised recovery plan, supported by a range of apps; personalised logs and health tracking; access to personal health budgets; and the opportunity to share information and interact with professionals involved in their recovery.

• The Waltham Forest Integrated Discharge Hub was launched 18 months ago to support the safe and timely discharge of local residents from Whipps Cross Hospital and other hospitals outside of the borough. A team of skilled therapists, social workers and social care assistants provide support for residents to enable them to return home safely and remain at home while they recover and improve their independence. This has reduced people’s stay in hospital by up to five days.

• In response to the impact on children and young people’s mental health and a surge in referrals during 2020/21, Newham CCG was a leading partner in developing the Newham Multi-Agency Collaborative. The collaborative aims to reduce the mental health impact on young people waiting for a child and adolescent mental health service (CAMHS) intervention. It works by coordinating a pathway to timely therapeutic support, through interventions provided across a broad spectrum of partners, including the CAMHS service, school health teams and other voluntary and community sector organisations that support young people.

• Tower Hamlets has a long and successful track record of partnership working. Through the Tower Hamlets Together partnership, the ‘Born Well, Growing Well Asthma and Wheeze Project’ has successfully reduced the number of children and young people admitted to the Royal London Hospital with asthma and breathing problems. This work has been recognised nationally through a win at the 2021 HSJ Value Awards for best paediatric care initiative of the year.

This report highlights the achievements made during the year, of which some would only have been achieved by using the data from NHS Digital.

Further information about other achievements and future priorities can be found within the reports.

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 able to ensure that the activity claimed for each patient is their responsibility. This is done by processing and analysing Secondary User Services (SUS+) data, which is received into a secure Controlled Environment for Finance (CEfF). The SUS+ data is identifiable and is only used to confirm the accuracy of backing-data sets (data from providers) and determining if the CCG is the responsible commissioner for the patient.

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

Invoice Validation will be conducted by NHS North East London Commissioning Support Unit / North of England Commissioning Support Unit and the CCG

RISK STRATIFICATION

Risk stratification is a tool for identifying and predicting which patients are at high risk (of health deterioration and using multiple services) or are likely to be at high risk and prioritising the management of their care in order to prevent worse outcomes.

To conduct risk stratification, Secondary User Services (SUS+), identifiable at the level of NHS number is linked with Primary Care data (from GPs) and an algorithm is applied to produce risk scores. Risk Stratification provides focus for future demands by enabling commissioners to prepare plans for both individual and groups of vulnerable patients.  Commissioners can then prepare plans for patients who may require high levels of care. Risk Stratification also enables General Practitioners (GPs) to better target intervention in Primary Care.

Risk Stratification will be conducted by NHS North East London Commissioning Support Unit / North of England Commissioning Support Unit and the CCG

COMMISSIONING

To use pseudonymised data to provide intelligence to support the commissioning of health services. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the CCG area.

The CCGs commission services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.

The following pseudonymised datasets are required to provide intelligence to support commissioning of health services:

• Secondary Uses Service (SUS+)

• Local Provider Flows

o Acute

o Ambulance

o Community

o Demand for Service

o Diagnostic Service

o Emergency Care

o Experience, Quality and Outcomes

o Mental Health

o Other Not Elsewhere Classified

o Population Data

o Primary Care Services

o Public Health Screening

• Mental Health Minimum Data Set (MHMDS)

• Mental Health Learning Disability Data Set (MHLDDS)

• Mental Health Services Data Set (MHSDS)

• Maternity Services Data Set (MSDS)

• Improving Access to Psychological Therapy (IAPT)

• Child and Young People Health Service (CYPHS)

• Community Services Data Set (CSDS)

• Diagnostic Imaging Data Set (DIDS)

• National Cancer Waiting Times Monitoring Data Set (CWT)

• Civil Registries Data (CRD) (Births)

• Civil Registries Data (CRD) (Deaths)

• National Diabetes Audit (NDA)

• Patient Reported Outcome Measures (PROMs)

• e-Referral Service (eRS)

• 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.

 Provide intelligence about the safety and effectiveness of medicines.

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

Processing for commissioning will be conducted by NHS North East London Commissioning Support Unit / North of England Commissioning Support Unit and Queen Mary University of London

Queen Mary University of London (QMUL) host a clinical effectiveness group. The group evaluates clinical outcomes and recommend best practice with regard to long term conditions and other health priorities within the area.

The data analysed by QMUL was supplied as 'cuts' of the larger SUS+ extract. The cuts are minimised to the receiving CCG's geographical coverage. Any access to other data is not permitted. This data is minimised by locations as described in this point, as well as by time period, the University may only use the latest available as well as the previous 3 years of data.

NHS 111

In order to accurately evaluate and improve the NHS 111 Patient Relationship Manager (PRM) System the CCG requires the ability to link NHS 111 PRM Call processing to eventual outcomes in the wider Urgent and Emergency Care System. The SUS data will allow for linkage to Emergency Department’s (ED) and Urgent Care Centre’s (UCC, including Short Stay Admissions, in the DSCRO. That is, it is important to relate the attendance, and the outcomes from this attendance, in the wider Urgent and Emergency Care System; with the 111 call which initiated the Patient Journey. The accuracy and relevance of the processes in 111 can only be evaluated if the CCG understands how the Patient had their complaint ultimately resolved. It could be that callers to 111, who are associated with a specific Symptom Group and who received a particular disposition for Primary- or Self-Care; nevertheless end up in ED. In that case, the CCG will evaluate the effectiveness of the associated 111 processes.

When a caller rings NHS 111, the disposition from that call is a recommendation from the 111 System as to what the caller should do next, to resolve their clinical complaint.

Most often, the disposition is in the form of a recommendation to attend a Service in person. The disposition, when given by a Call Handler, is derived by the NHS Pathways algorithm. One way to evaluate the accuracy of this algorithm with respect to a caller population, is to link the dispositions to the final outcomes of callers. This is achieved by linking the records of the different data sets by NEL Commissioning Support Unit, by using the data linkage algorithm described above. A high degree of correspondence between the type of final Service attended; and the type of service given in the disposition, would indicate that for these callers the NHS Pathways algorithm is highly accurate.

The PRM have introduced facilities in the System where repeat callers; and callers with a Care Plan, get connected to a clinician instead of a Call Handler. By analysing whether the final outcomes differ significantly for callers who spoke to a Call Handler; as compared to callers who spoke to a clinician; we can evaluate the impact on repeat callers and caller with a Care Plan, by the introduction of the PRM System.

Processing for this aspect will be conducted by North East London Commissioning Support Unit / North of England Commissioning Support Unit and Chelsea and Westminster Hospital NHS Foundation Trust (Hosting Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC))

INVOICE VALIDATION

1. The Controlled Environment for Finance (CEfF) will enable the CCG to challenge invoices and raise discrepancies and disputes.

2. Outputs from the CEfF will enable accurate production of budget reports, which will:

a. Assist in addressing poor quality data issues

b. Assist in business intelligence

3. Validation of invoices for non-contracted events where a service delivered to a patient by a provider that does not have a written contract with the patient’s responsible commissioner, but does have a written contract with another NHS commissioner/s.

4. Budget control of the CCG.

RISK STRATIFICATION

1. As part of the risk stratification processing activity detailed above, GPs have access to the risk stratification tool which highlights patients for whom the GP is responsible and have been classed as at risk. The only identifier available to GPs is the NHS numbers of their own patients. Any further identification of the patients will be completed by the GP on their own systems.

2. GP Practices will be able to view the risk scores for individual patients with the ability to display the underlying SUS+ data for the individual patients when it is required for direct care purposes by someone who has a legitimate relationship with the patient.

CCGs will be able to:

3. Target specific vulnerable patient groups and enable clinicians with the duty of care for the patient to offer appropriate interventions.

4. Reduce hospital readmissions and targeting clinical interventions to high risk patients.

5. Identify patients at risk of deterioration and providing effective care.

6. Reduce in the difference in the quality of care between those with the best and worst outcomes.

7. Re-design care to reduce admissions.

8. Set up capitated budgets – budgets based on care provided to the specific population.

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

10. Monitor vulnerable groups of patients including but not limited to frailty, COPD, Diabetes, elderly.

11. Health needs assessments – identifying numbers of patients with specific health conditions or combination of conditions.

12. Classify vulnerable groups based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost.

13. Production of Theographs – a visual timeline of a patients encounters with hospital providers.

14. Analyse based on specific diseases

In addition:

• The risk stratification tool will provide aggregate reporting of number and percentage of population found to be at risk.

• Record level output (pseudonymised) will be available for commissioners (of the CCG), pseudonymised at patient level. Onward sharing of this data is not permitted.

COMMISSIONING

1. Commissioner reporting:

a. Summary by provider view - plan & actuals year to date (YTD).

b. Summary by Patient Outcome Data (POD) view - plan & actuals YTD.

c. Summary by provider view - activity & finance variance by POD.

d. Planned care by provider view - activity & finance plan & actuals YTD.

e. Planned care by POD view - activity plan & actuals YTD.

f. Provider reporting.

g. Statutory returns.

h. Statutory returns - monthly activity return.

i. Statutory returns - quarterly activity return.

j. Delayed discharges.

k. Quality & performance referral to treatment reporting.

2. Readmissions analysis.

3. Production of aggregate reports for CCG Business Intelligence.

4. Production of project / programme level dashboards.

5. Monitoring of acute / community / mental health quality matrix.

6. Clinical coding reviews / audits.

7. Budget reporting down to individual GP Practice level.

8. GP Practice level dashboard reports.

9. Comparators of CCG performance with similar CCGs as set out by a specific range of care quality and performance measures detailed activity and cost reports

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

11. Contract Management and Modelling

12. Patient Stratification, such as:

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

NHS 111

- 111 Service; based on the Population’s prevalence of Repeat Callers and Callers with Care Plans (YTD).

- From analysis/review: Establishing the effectiveness of the NHS Pathways-derived

-Dispositions; and the extent to which this impact on a Population (YTD).

- From analysis/review: Establishing the cost and Service impacts of introducing the NHS 111 PRM System in a new region (YTD).

- From analysis/review: Establishing the extent to which Costs and benefits from introducing the NHS 111 PRM System differs across the boroughs of Greater London. What factors or variables in a population contribute to such differences (YTD).

- From analysis/review: Establishing what aspects of the NHS 111 PRM System have proven effective across a majority of populations; and what features of the System would require improvement (YTD).

- From analysis/review: Determining how the NHS 111 PR System can by improved, based on the impact on the caller population (YTD)

The CCG 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.

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 CCG 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 CCG will use intelligence to add insight to strategic commissioning and service integration across the CCG Area. This work will continue year on year to match the delivery/funding of targets services for the population within the CCG Area.

Benefits to date are in line with what the CCG expected to achieve at the point in time as described in the previous application. The continued access to this data will enable the CCG to further understand and improve service performance and delivery, including patient pathway design, re-design and patient experience.

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 able to ensure that the activity claimed for each patient is their responsibility. This is done by processing and analysing Secondary User Services (SUS+) data, which is received into a secure Controlled Environment for Finance (CEfF). The SUS+ data is identifiable at the level of NHS number. The NHS number is only used to confirm the accuracy of backing-data sets (data from providers)

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

Invoice Validation will be conducted by NHS North East London Commissioning Support Unit and the CCG

RISK STRATIFICATION

Risk stratification is a tool for identifying and predicting which patients are at high risk (of health deterioration and using multiple services) or are likely to be at high risk and prioritising the management of their care in order to prevent worse outcomes.

To conduct risk stratification, Secondary User Services (SUS+), identifiable at the level of NHS number is linked with Primary Care data (from GPs) and an algorithm is applied to produce risk scores. Risk Stratification provides focus for future demands by enabling commissioners to prepare plans for both individual and groups of vulnerable patients.  Commissioners can then prepare plans for patients who may require high levels of care. Risk Stratification also enables General Practitioners (GPs) to better target intervention in Primary Care.

Risk Stratification will be conducted by NHS North East London Commissioning Support Unit and the CCG

COMMISSIONING

To use pseudonymised data to provide intelligence to support the commissioning of health services. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the CCG area.

The CCGs commission services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.

The following pseudonymised datasets are required to provide intelligence to support commissioning of health services:

• Secondary Uses Service (SUS+)

• Local Provider Flows

o Acute

o Ambulance

o Community

o Demand for Service

o Diagnostic Service

o Emergency Care

o Experience, Quality and Outcomes

o Mental Health

o Other Not Elsewhere Classified

o Population Data

o Primary Care Services

o Public Health Screening

• Mental Health Minimum Data Set (MHMDS)

• Mental Health Learning Disability Data Set (MHLDDS)

• Mental Health Services Data Set (MHSDS)

• Maternity Services Data Set (MSDS)

• Improving Access to Psychological Therapy (IAPT)

• Child and Young People Health Service (CYPHS)

• Community Services Data Set (CSDS)

• Diagnostic Imaging Data Set (DIDS)

• National Cancer Waiting Times Monitoring Data Set (CWT)

• Civil Registries Data (CRD) (Births)

• Civil Registries Data (CRD) (Deaths)

• National Diabetes Audit (NDA)

• Patient Reported Outcome Measures (PROMs)

• e-Referral Service (eRS)

• Personal Demographics Service (PDS)

• Summary Hospital-level Mortality Indicator (SHMI)

• Medicines Dispensed in Primary Care (NHSBSA Data)

The pseudonymised data is required to for the following purposes:

 Population health management:

• Understanding the interdependency of care services

• Targeting care more effectively

• Using value as the redesign principle

 Data Quality and Validation – allowing data quality checks on the submitted data

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

 Understanding cohorts of residents who are at risk of becoming users of some of the more expensive services, to better understand and manage those needs

 Monitoring population health and care interactions to understand where people may slip through the net, or where the provision of care may be being duplicated

 Modelling activity across all data sets to understand how services interact with each other, and to understand how changes in one service may affect flows through another

 Service redesign

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

 Patient stratification and predictive modelling - to highlight 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.

 Provide intelligence about the safety and effectiveness of medicines.

Processing for commissioning will be conducted by NHS North East London Commissioning Support Unit and Queen Mary University of London

Queen Mary University of London (QMUL) host a clinical effectiveness group. The group evaluates clinical outcomes and recommend best practice with regard to long term conditions and other health priorities within the area.

The data analysed by QMUL was supplied as 'cuts' of the larger SUS+ extract. The cuts are minimised to the receiving CCG's geographical coverage. Any access to other data is not permitted. This data is minimised by locations as described in this point, as well as by time period, the University may only use the latest available as well as the previous 3 years of data.

NHS 111

In order to accurately evaluate and improve the NHS 111 Patient Relationship Manager (PRM) System the CCG requires the ability to link NHS 111 PRM Call processing to eventual outcomes in the wider Urgent and Emergency Care System. The SUS data will allow for linkage to Emergency Department’s (ED) and Urgent Care Centre’s (UCC, including Short Stay Admissions, in the DSCRO. That is, it is important to relate the attendance, and the outcomes from this attendance, in the wider Urgent and Emergency Care System; with the 111 call which initiated the Patient Journey. The accuracy and relevance of the processes in 111 can only be evaluated if the CCG understands how the Patient had their complaint ultimately resolved. It could be that callers to 111, who are associated with a specific Symptom Group and who received a particular disposition for Primary- or Self-Care; nevertheless end up in ED. In that case, the CCG will evaluate the effectiveness of the associated 111 processes.

When a caller rings NHS 111, the disposition from that call is a recommendation from the 111 System as to what the caller should do next, to resolve their clinical complaint.

Most often, the disposition is in the form of a recommendation to attend a Service in person. The disposition, when given by a Call Handler, is derived by the NHS Pathways algorithm. One way to evaluate the accuracy of this algorithm with respect to a caller population, is to link the dispositions to the final outcomes of callers. This is achieved by linking the records of the different data sets by NEL Commissioning Support Unit, by using the data linkage algorithm described above. A high degree of correspondence between the type of final Service attended; and the type of service given in the disposition, would indicate that for these callers the NHS Pathways algorithm is highly accurate.

The PRM have introduced facilities in the System where repeat callers; and callers with a Care Plan, get connected to a clinician instead of a Call Handler. By analysing whether the final outcomes differ significantly for callers who spoke to a Call Handler; as compared to callers who spoke to a clinician; we can evaluate the impact on repeat callers and caller with a Care Plan, by the introduction of the PRM System.

Processing for this aspect will be conducted by North East London Commissioning Support Unit and Chelsea and Westminster Hospital NHS Foundation Trust (Hosting Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC))

INVOICE VALIDATION

1. The Controlled Environment for Finance (CEfF) will enable the CCG to challenge invoices and raise discrepancies and disputes.

2. Outputs from the CEfF will enable accurate production of budget reports, which will:

a. Assist in addressing poor quality data issues

b. Assist in business intelligence

3. Validation of invoices for non-contracted events where a service delivered to a patient by a provider that does not have a written contract with the patient’s responsible commissioner, but does have a written contract with another NHS commissioner/s.

4. Budget control of the CCG.

RISK STRATIFICATION

1. As part of the risk stratification processing activity detailed above, GPs have access to the risk stratification tool which highlights patients for whom the GP is responsible and have been classed as at risk. The only identifier available to GPs is the NHS numbers of their own patients. Any further identification of the patients will be completed by the GP on their own systems.

2. GP Practices will be able to view the risk scores for individual patients with the ability to display the underlying SUS+ data for the individual patients when it is required for direct care purposes by someone who has a legitimate relationship with the patient.

CCGs will be able to:

3. Target specific vulnerable patient groups and enable clinicians with the duty of care for the patient to offer appropriate interventions.

4. Reduce hospital readmissions and targeting clinical interventions to high risk patients.

5. Identify patients at risk of deterioration and providing effective care.

6. Reduce in the difference in the quality of care between those with the best and worst outcomes.

7. Re-design care to reduce admissions.

8. Set up capitated budgets – budgets based on care provided to the specific population.

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

10. Monitor vulnerable groups of patients including but not limited to frailty, COPD, Diabetes, elderly.

11. Health needs assessments – identifying numbers of patients with specific health conditions or combination of conditions.

12. Classify vulnerable groups based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost.

13. Production of Theographs – a visual timeline of a patients encounters with hospital providers.

14. Analyse based on specific diseases

In addition:

• The risk stratification tool will provide aggregate reporting of number and percentage of population found to be at risk.

• Record level output (pseudonymised) will be available for commissioners (of the CCG), pseudonymised at patient level. Onward sharing of this data is not permitted.

COMMISSIONING

1. Commissioner reporting:

a. Summary by provider view - plan & actuals year to date (YTD).

b. Summary by Patient Outcome Data (POD) view - plan & actuals YTD.

c. Summary by provider view - activity & finance variance by POD.

d. Planned care by provider view - activity & finance plan & actuals YTD.

e. Planned care by POD view - activity plan & actuals YTD.

f. Provider reporting.

g. Statutory returns.

h. Statutory returns - monthly activity return.

i. Statutory returns - quarterly activity return.

j. Delayed discharges.

k. Quality & performance referral to treatment reporting.

2. Readmissions analysis.

3. Production of aggregate reports for CCG Business Intelligence.

4. Production of project / programme level dashboards.

5. Monitoring of acute / community / mental health quality matrix.

6. Clinical coding reviews / audits.

7. Budget reporting down to individual GP Practice level.

8. GP Practice level dashboard reports.

9. Comparators of CCG performance with similar CCGs as set out by a specific range of care quality and performance measures detailed activity and cost reports

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

11. Contract Management and Modelling

12. Patient Stratification, such as:

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)

NHS 111

- 111 Service; based on the Population’s prevalence of Repeat Callers and Callers with Care Plans (YTD).

- From analysis/review: Establishing the effectiveness of the NHS Pathways-derived

-Dispositions; and the extent to which this impact on a Population (YTD).

- From analysis/review: Establishing the cost and Service impacts of introducing the NHS 111 PRM System in a new region (YTD).

- From analysis/review: Establishing the extent to which Costs and benefits from introducing the NHS 111 PRM System differs across the boroughs of Greater London. What factors or variables in a population contribute to such differences (YTD).

- From analysis/review: Establishing what aspects of the NHS 111 PRM System have proven effective across a majority of populations; and what features of the System would require improvement (YTD).

- From analysis/review: Determining how the NHS 111 PR System can by improved, based on the impact on the caller population (YTD)

Yielded Benefits is not a requirement for new applications.