DSfC NHS Coventry and Warwickshire 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 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 Arden and Greater East Midlands Commissioning Support Unit and Liaison Financial Services Ltd.

Liaison Financial Services Ltd conduct an independent ad-hoc review on retrospective payments made. Investing resource, skills and experience into deeper reconciliation, this identifies overcharges already paid and recovers savings for the CCG that would otherwise be lost.

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 Prescribing Services Ltd

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.

This Agreement permits the use of 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 Sustainability Transformation Partnership (STP) area, which includes the following:

- Coventry and Warwickshire NHS Partnership Trust

- Coventry City Council

- George Eliot Hospital NHS Trust

- South Warwickshire NHS Foundation Trust

- University Hospitals Coventry and Warwickshire NHS Trust

- Warwickshire County Council

- NHS Coventry and Warwickshire CCG

Only the CCG will have access to patient level data, the other organisations will only have access to aggregated data in line with NHS Digital small suppression rules.

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.

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 Coventry and Warwickshire CCG, NHS Arden and GEM Commissioning Support Unit, South Warwickshire GP and South Warwickshire NHS Foundation Trust

The CCG wish to include pseudonymised primary care data in the population health management and patient stratification analyses to enable more comprehensive and patient/pathway focused analyses.

Patient data historically sits in silos within various NHS services. Linking datasets including GP data enables commissioners to better understand the effective delivery of health and social care services for the populations they manage and not just for those directly receiving treatment. It supports commissioners to allocate resources as well as providing greater insight into the provision of services and into the health of the population.

Linking primary care and secondary care data supports with understanding a patient’s full journey across their pathway and across the community which can provide opportunities for understanding health needs pre and post treatment across numerous health services, for example, analysis has shown that those able to manage their health conditions (GP data) are less likely to attend Accident and Emergency and less likely to be admitted in an emergency (secondary care data). It can also support with coordinating discharge planning and integration of services as those receiving social care can be a key driver of demand for health and care.

Processing for commissioning, including the pseudo at source processing necessary for patient stratification and population health management will be conducted by NHS Arden and GEM Commissioning Support Unit.

The CCG of the STP programme have planned a number of initiatives and work-streams for local service providers to work together and develop new service models for the future delivery of high quality, efficient and effective services across Coventry and Warwickshire, for example the Out-of-Hospital Programme.

The STP and the CCG wish to engage the services of additional data processors to better utilise the potential provided through the linking of primary care data and secondary care data (previously approved) particularly for additional support with their population health management and patient stratification programme.

• South Warwickshire GP Federation Ltd (SWGP)

and

• South Warwickshire Foundation NHS Trust (SWFT)

and

• Optum Health Solutions UK Limited

These data processors will each bring their own specific expertise in analysing the pseudonymised datasets SWGP will apply their primary care expertise from experience, knowledge and insight about GP data and SWFT will apply their secondary care expertise from their associated experience, knowledge and insight regarding the hospital and community data. There will be a small team of analysts providing this support within each organisation, so access to data will be restricted, especially with the Provider Trust (SWFT).

NHS Coventry and Warwickshire CCG is working with NHS England as a Wave 2 and 3 Population Health Management CCG. NHS England have contracted Optum Health Solutions (UK) Ltd to work with selected CCGs to undertake population health and actuarial analysis to build up a methodology for dissemination across the NHS in England.

Data held by Optum Health Solutions (UK) Ltd, will be destroyed within 6 months of completion of the project and permissions as a data processor will be removed from this agreement by amendment.

The pseudonymised outputs of the analysis will be used by the CCG to support their whole commissioning agenda, for example to support the CCG with work around data quality and service re-design in both primary and secondary care. Pseudonymised outputs will also be used to feed into the interdisciplinary teams of clinical staff that will work across Coventry and Warwickshire. Only the GP Practice where the patient is registered will be able to re-identify patients and only when they need to do so for direct care purposes. GP Practices will make referrals to services as required.

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 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:

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

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

A&E High Attendance usage

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

Polypharmacy re-IDs

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

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

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

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

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

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

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

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

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

SEGREGATION:

Where the Data Processor and/or the Data Controller hold both identifiable and pseudonymised data, the data will be held separately so data cannot be linked.

Where the Data Processor and/or the Data Controller hold identifiable data with opt outs applied and identifiable data with opt outs not applied, the data will be held separately so data cannot be linked.

All access to data is auditable by NHS Digital.

Data 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 Coventry and Warwickshire CCG region (including historical activity where the patient was previously registered or resident in another commissioner).

and/or

• Patients treated by a provider where NHS Coventry and Warwickshire 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 Coventry and Warwickshire 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 the NHS Coventry and Warwickshire CCG region (including historical activity where the patient was previously registered or resident in another commissioner

For the purpose of Invoice Validation:

• Patients who are resident and/or registered within the CCG region.

This includes data that was previously under a different organisation name but has now merged into this CCG

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).

Microsoft Limited supply Cloud Services for South Warwickshire GP Limited, NHS Arden and GEM CSU and Liaison Financial Services Ltd 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.

Microsoft Limited and Amazon Web Services supply Cloud Services for Optum Health Solutions UK Limited and are therefore listed as a data processor. They supply support to the system, but do not access data. Therefore, any access to the data held under this agreement would be considered a breach of the agreement. This includes granting of access to the database[s] containing the data.

Coventry and Warwickshire Partnership NHS Trust 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.

NHS Midlands and Lancashire Commissioning Support Unit and Greater Manchester Shared Services (hosted by Salford Royal NHS Foundation Trust) supply IT infrastructure for Arden and GEM Commissioning Support Unit and are therefore listed as data processors. 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.

Ilkeston Community Hospital (Part of Derbyshire Community Health Services NHS Foundation Trust), Wrightington, Wigan and Leigh NHS Foundation Trust and The Bunker 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.

INVOICE VALIDATION

Arden and GEM CSU

1. Identifiable SUS+ and PDS Data is obtained by the Data Services for Commissioners Regional Office (DSCRO).

2. The DSCRO pushes a one-way data flow of SUS+ and PDS data into the Controlled Environment for Finance (CEfF) in the Arden and GEM CSU.

3. The CEfF also receive backing data from the provider.

4. Arden and GEM CSU carry out the following processing activities within the CEfF for invoice validation purposes:

a. Validating that the Clinical Commissioning Group are responsible for payment for the care of the individual by using SUS+ and PDS and/or provider backing flow data.

b. Once the provider 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.

5. 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 Arden and GEM CSU 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.

Liaison Financial Services Ltd

1. Identifiable SUS+ and PDS Data is obtained by the Data Services for Commissioners Regional Office (DSCRO).

2. The DSCRO pushes a one-way data flow of SUS+ and PDS data into the Controlled Environment for Finance (CEfF) in the Liaison Financial Services Ltd.

3. The CEfF also receive backing data from the provider.

4. Liaison Financial Services Ltd carry out the following processing activities within the CEfF for invoice validation purposes:

a. Validating that the Clinical Commissioning Group are responsible for payment for the care of the individual by using SUS+ and PDS and/or provider backing flow data.

b. Once the provider 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.

5. 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 Liaison Financial Services Ltd 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

Prescribing Services Ltd

1. Identifiable SUS+ and Mental Health Services Dataset (MHSDS) data is transferred to the Data Services for Commissioners Regional Office (DSCRO).

2. Data quality management and standardisation of data is completed by the DSCRO and the data identifiable at the level of NHS number is transferred securely to Prescribing Services Ltd, who securely hold the SUS+ and MHSDS data.

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

4. SUS+ and MHSDS data is linked to GP data in the risk stratification tool by the data processor.

5. As part of the risk stratification processing activity, GPs have access to the risk stratification tool within the data processor, which highlights patients with whom the GP has a legitimate relationship and have been classed as at risk. The only identifier available to GPs is the NHS numbers of their own patients. Any further identification of the patients will be completed by the GP on their own systems.

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

COMMISSIONING

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

1. SUS+

2. Local Provider Flows (received directly from providers)

a. Acute

b. Ambulance

c. Community

d. Demand for Service

e. Diagnostic Service

f. Emergency Care

g. Experience, Quality and Outcomes

h. Mental Health

i. Other Not Elsewhere Classified

j. Population Data

k. Primary Care Services

l. Public Health Screening

3. Mental Health Minimum Data Set (MHMDS)

4. Mental Health Learning Disability Data Set (MHLDDS)

5. Mental Health Services Data Set (MHSDS)

6. Maternity Services Data Set (MSDS)

7. Improving Access to Psychological Therapy (IAPT)

8. Child and Young People Health Service (CYPHS)

9. Community Services Data Set (CSDS)

10. Diagnostic Imaging Data Set (DIDS)

11. National Cancer Waiting Times Monitoring Data Set (CWT)

12. Civil Registries Data (CRD) (Births)

13. Civil Registries Data (CRD) (Deaths)

14. National Diabetes Audit (NDA)

15. Patient Reported Outcome Measures (PROMs)

16. e-Referral Service (eRS)

17. Personal Demographics Service (PDS)

18. Summary Hospital-level Mortality Indicator (SHMI)

19. Medicines Dispensed in Primary Care (NHSBSA Data)

20. Adult Social Care Data

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

Data Processor 1 – NHS Arden and GEM Commissioning Support Unit

1. Pseudonymised SUS+, Local Provider data, Mental Health data (MHSDS, MHMDS, MHLDDS), Maternity data (MSDS), Improving Access to Psychological Therapies data (IAPT), Child and Young People’s Health data (CYPHS), Community Services Data Set (CSDS). Diagnostic Imaging data (DIDS), National Cancer Waiting Times Monitoring Data Set (CWT), Civil Registries Data (CRD) (Births and Deaths), Patient Reported Outcome Measures (PROMs), National Diabetes Audit (NDA) , 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 Arden and GEM Commissioning Support Unit..

2. NHS Arden and Greater East Midlands Commissioning Support Unit receive GP data (as points i-x)

3. Data listed within point 1 is then linked to the pseudonymised GP data and analysis is provided 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

4. NHS Arden and Greater East Midlands 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 NHS Arden and Greater East Midlands Commissioning Support Unit or the CCG as instructed by the CCG.

6. Patient level data will not be shared outside of the CCG, other than with their member GP Practices for each Practices own patients only 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 outside of this as set out within NHS Digital guidance applicable to each data set.

7. GP Practices may only re-identify data when they need to do so for direct care purposes.

GP data

i. Identifiable GP data is submitted to NHS Arden and Greater East Midlands Commissioning Support Unit.

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

iii. A specific named individual within NHS Arden and Greater East Midlands Commissioning Support Unit acts on behalf of the GP practice. This person has access to a closed black box system (which includes a pseudonymisation process).

iv. The individual requests a pseudonymisation key from the DSCRO to use with the black box system. There will be a separate key specific to the pseudonymisation request and the key will only be used for that specific project. The key is specific to the pseudonymisation request. The access controls around the individual’s role does not give them access to the data once it has been passed on to the NHS Arden and Greater East Midlands Commissioning Support Unit.

v. The GP data is then pseudonymised using the black box and DSCRO issued key. The identifiable GP data is then deleted from the ring-fenced area.

vi. The data is then transferred into a separate part of NHS Arden and Greater East Midlands Commissioning Support Unit.

vii. NHS Arden and Greater East Midlands Commissioning Support Unit make a request to NHS Digital (DSCRO).

viii. The DSCRO send a mapping table to NHS Arden and Greater East Midlands Commissioning Support Unit.

ix. NHS Arden and Greater East Midlands Commissioning Support Unit overwrite the organisations specific pseudonymisation keys with the DSCRO provided keys.

x. The mapping table is then deleted.

Data Processor 2 – South Warwickshire GP Ltd

1. South Warwickshire GP Ltd will receive the linked pseudonymised primary care and secondary care data from Step 4, under Data Processor 1 processing activities from either NHS Arden and GEM CSU or from the CCG.

2. South Warwickshire GP Ltd will analyse the data with a focus on primary care and provide reports to the CCG and to the GP Practices as instructed by the CCG. South Warwickshire GP Ltd provide analytics to support population health management to help those providing patient care. The reports provide insight into a patient’s care and can highlight that a patient’s care needs to be reassessed to see if further intervention is required

3. Patient level data will not be shared outside of the CCG, other than with their member GP Practices for each Practices own patients only 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 outside of this as set out within NHS Digital guidance applicable to each data set.

4. GP Practices may only re-identify data when they need to do so for direct care purposes.

5. South Warwickshire GP Ltd will not link this data to any other data that they hold or have access to.

Data Processor 3 – South Warwickshire NHS Foundation Trust

1. South Warwickshire NHS Foundation Trust will receive the linked pseudonymised primary care and secondary care data from Step 4, under Data Processor 1 processing activities from either NHS Arden and GEM CSU or from the CCG.

2. South Warwickshire NHS Foundation Trust will analyse the data to give greater insight into population health and patient stratification and provide reports to the CCG and to the GP Practices as instructed by the CCG. The reports will provide insight that will raise suggestions about the direct care of the patient.

3. Patient level data will not be shared outside of the CCG, other than with their member GP Practices for each Practices own patients only 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 outside of this as set out within NHS Digital guidance applicable to each data set.

4. GP Practices may only re-identify data when they need to do so for direct care purposes.

5. South Warwickshire NHS Foundation Trust will not link this data to any other data that they hold or have access to.

Data Processor 4 – Optum Health Solutions (UK) Limited

1. Optum Health Solutions (UK) Limited will receive the linked pseudonymised primary care and secondary care data from Step 4, under Data Processor 1 processing activities from either NHS Arden and GEM CSU or from the CCG.

2. Optum Health Solutions (UK) Limited will analyse the data to give greater insight into population health and patient stratification and provide reports to the CCG and to the GP Practices as instructed by the CCG. The reports will provide insight that will raise suggestions about the direct care of the patient.

3. Patient level data will not be shared outside of the CCG, other than with their member GP Practices for each Practices own patients only 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 outside of this as set out within NHS Digital guidance applicable to each data set.

4. GP Practices may only re-identify data when they need to do so for direct care purposes.

5. Optum Health Solutions (UK) Limited will not link this data to any other data that they hold or have access to.

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.

Liaison Financial Services Ltd

1. Validation of Continuing Healthcare related invoices and payments

2. Independent Identification of potential overpayments made by the CCG through invoice validation

3. Liaising with providers with a view to recouping these monies

4. Review is completed for the retrospective period from date of contract with Liaison Financial Services back to 01/04/2013.

5. Reviews take 3-9 months depending on number of claims to investigate and resolve

6. Liaison Financial Services would repeat the exercise 2-3 years later

7. CCGs could request reviews to be done more frequently

8. SUS+ would only be requested each time a review was completed, and could be requested at different times as independent reviews

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

South Warwickshire GP Ltd:

Using their knowledge of primary care data, South Warwickshire GP Ltd will be able to provide further analysis of the data, specifically around patient stratification. This will allow more detailed analysis of patients who may be at risk and provide prevention strategies. These reports will be made available to GP Practises for their own patients where they may only re-identify for direct care purposes

South Warwickshire GP Federation Ltd will be able to support practices by identifying these patients (through the pseudonymised route) for practices to re-identify as necessary for direct care and target suitable interventions and care plans and reducing the burden and workload on GP practices. The Federation will in turn have greater familiarity with the tool and its findings and share this knowledge and expertise with their practice population. They will be supporting the Practices with additional knowledge and expertise on getting the most out of data, tools and reporting but also supporting the CCG with expertise and knowledge of primary care data and GP systems and services.

South Warwickshire NHS Foundation Trust:

Using their knowledge of secondary care data, South Warwickshire NHS Foundation Trust give greater insight into population health and patient stratification and provide reports to GP Practises for their own patients where they may only re-identify for direct care purposes.

While the system is usually aware of the top 5% most complex patients, it is the next 15% of the population that the stratification analysis can identify which will provide vital information to multi-disciplinary teams that support GP Practices and the health system as a whole. The teams can then review these patients as directed by the GP Practices which they support to inform future care plans and interventions such as lifestyle management to assist in preventing hospitalisation. SWFT, as data processor on behalf of the CCGs, can fully support this process and work with the GP Practices to prioritise this patient cohort.

Following the COVID-19 pandemic, it will be more important than ever for the CCGs, Practices, SWFT and GP Federation to work collaboratively across the system to use Patient Stratification and Population Health Management techniques to better understand what that population needs during and post COVID-19. The analytical outputs will support in under-pinning the restoration of services and pathways and to help prioritise the needs of the population.

Optum Health Solutions UK Limited

The outputs, as part of the NHS England Wave 3 PHM national programme will identify patient cohorts and inequalities in outcome, spend and opportunity for further investigation, with a view to improving service delivery and patient health outcomes.

Wave 3 PHM will also begin to develop the CCG capability to undertake actuarial analysis of linked datasets from multiple care settings to develop further the understanding of the wider determinants of health across the population.

All outputs will be delivered within the timescales of the contract between Optum Health Solutions UK Limited and the CCG.

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.

Liaison Financial Services Ltd

1. Financial validation of activity

2. CCG Budget control

3. Assurances over the robustness of internal control mechanisms relating to the payment of invoices and/or suggested improvements

4. Identification and recovery of monies which would otherwise be lost

5. Meeting commissioning objectives without compromising patient confidentiality

6. The avoidance of misappropriation of public funds to ensure the ongoing delivery of patient care

7. Benefit delivered 3-9 months from receiving data, depending on number of claims to investigate and resolve

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 and health outcomes 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.

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

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

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

21. Allow analysis of health care provision to be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets.

22. To evaluate the impact of new services and innovations (e.g. if commissioners implement a new service or type of procedure with a provider, they can evaluate whether it improves outcomes for patients compared to the previous one).

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

24. Enable Commissioners to be able to see early indications of potential practice resilience issues in that an early warning marker can often be a trend of patients re-registering themselves at a neighbouring practice.

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

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

27. Understand admissions linked to overprescribing.

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

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

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

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

The CCG want to utilise these 2 additional data processors because of their expertise in primary and secondary care data and the added resource they will provide. Therefore, the level of benefit overall will be much higher.

South Warwickshire GP Ltd

1. Higher level of patient stratification allowing direct care intervention

2. Knowledge sharing and best practices procedures for GP practises

3. Higher utilisation of the data and its tools allowing GP practices to easily identify areas of concern

South Warwickshire NHS Foundation Trust:

1. Greater insight into population and patient stratification using secondary care data

2. Higher level of patient stratification allowing direct care intervention

3. Allow further identification of possible factors relating to patients soon to be at risk, not previously identified

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.

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.