DSfC - NHS Surrey Downs CCG - RS

Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.

Datasets: − Acute-Local Provider Flows; − Ambulance-Local Provider Flows; − Children and Young People Health; − Community Services Data Set (CSDS); − Community-Local Provider Flows; − Demand for Service-Local Provider Flows; − Diagnostic Imaging Data Set (DID); − Diagnostic Services-Local Provider Flows; − Emergency Care-Local Provider Flows; − Experience, Quality and Outcomes-Local Provider Flows; − Improving Access to Psychological Therapies Data Set_v1.5; − Maternity Services Data Set v1.5; − Mental Health Minimum Data Set (MHMDS); − Mental Health Services Data Set (MHSDS); − Mental Health and Learning Disabilities Data Set (MHLDDS); − Mental Health-Local Provider Flows; − National Cancer Waiting Times Monitoring DataSet (NCWTMDS); − Other Not Elsewhere Classified (NEC)-Local Provider Flows; − Population Data-Local Provider Flows; − Primary Care Services-Local Provider Flows; − Public Health and Screening Services-Local Provider Flows

Objective for processing

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. Risk stratification is a tool for identifying and predicting which patients are at high risk 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. 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 a forecast of future demand by identifying high risk 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. The legal basis for this to occur is under Section 251 of NHS Act 2006 (CAG 7-04(a)). [1 paragraph unchanged] 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) The pseudonymised data is required to for the following purposes:  Population health management: • Understanding the interdependency of care services • Targeting care more effectively • Using value as the redesign principle  Data Quality and Validation – allowing data quality checks on the submitted data  Thoroughly investigating the needs of the population, to ensure the right services are available for individuals when and where they need them  Understanding cohorts of residents who are at risk of becoming users of some of the more expensive services, to better understand and manage those needs  Monitoring population health and care interactions to understand where people may slip through the net, or where the provision of care may be being duplicated  Modelling activity across all data sets to understand how services interact with each other, and to understand how changes in one service may affect flows through another  Service redesign  Health Needs Assessment – identification of underlying disease prevalence within the local population  Patient stratification and predictive modelling - to identify specific patients at risk of requiring hospital admission and other avoidable factors such as risk of falls, computed using algorithms executed against linked de-identified data, and identification of future service delivery models The pseudonymised data is required to ensure that analysis of health care provision can be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets. Processing for commissioning will be conducted by North East London Commissioning Support Unit.

Processing activities

Processing activities: 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 must only be used as stipulated within this Data Sharing Agreement. [2 paragraphs unchanged] The Data Controller and any Data Processor will only have access to records of patients of residence and registration within the CCG. All access to data is managed under Role-Based Access Controls. Users can only access data authorised by their role. 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. The data to be released from NHS Digital will not be national data. 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. (RS) The only identifier available in the data set is the NHS numbers. Any further identification of the patients will only be completed by the patient’s clinician on their own systems for the purpose of direct care with a legitimate relationship. Onward Sharing [1 paragraph unchanged] All access to data is managed under Roles-Based Access Controls Aggregated reports only with small number suppression can be shared externally as set out within NHS Digital guidance applicable to each data set. 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. No patient level data will be linked other than as specifically detailed within this agreement. Data will only be shared with those parties listed and will only be used for the purposes laid out in the application/agreement. The data to be released from NHS Digital will not be national data, but only that data relating to the specific locality and that data required by the applicant. 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) [3 paragraphs unchanged] 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 Risk Stratification: • Patients who are normally registered and/or resident within NHS Surrey Downs CCG (including historical activity where the patient was previously registered or resident in another commissioner [2 paragraphs unchanged] 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 Docobo Ltd, Ltd., who securely hold the SUS+ data within the secure Data Centre on N3. data. [3 paragraphs unchanged] 6. Once Docobo Ltd 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) Data quality management and pseudonymisation is completed within the DSCRO and is then disseminated as follows: Data Processor 1 – North East London 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) and National Cancer Waiting Times Monitoring Data Set (CWT) only is securely transferred from the DSCRO to North East London Commissioning Support Unit. 2. North East London Commissioning Support Unit add derived fields, link data and provide analysis to: a. See patient journeys for pathways or service design, re-design and de-commissioning. b. Check recorded activity against contracts or invoices and facilitate discussions with providers. c. Undertake population health management d. Undertake data quality and validation checks e. Thoroughly investigate the needs of the population f. Understand cohorts of residents who are at risk g. Conduct Health Needs Assessments 3. Allowed linkage is between the data sets contained within point 1. 4. North East London 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 North East London Commissioning Support Unit or the CCG as instructed by the CCG. 6. Patient level data will not be shared outside of the CCG and will only be shared within the CCG on a need to know basis, as per the purposes stipulated within the Data Sharing Agreement. External aggregated reports only with small number suppression can be shared as set out within NHS Digital guidance applicable to each data set.

Expected output

[2 paragraphs unchanged] 2. Output from the risk stratification tool will provide aggregate reporting of number and percentage of population found to be at risk. 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. 3. Record level output will be available for commissioners (of the CCG), pseudonymised at patient level. CCGs will be able to: 4. 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. 3. Target specific vulnerable patient groups and enable clinicians with the duty of care for the patient to offer appropriate interventions. 5. The CCG will be able to target specific patient groups and enable clinicians with the duty of care for the patient to offer appropriate interventions. The CCG will also be able to: 4. Reduce hospital readmissions and targeting clinical interventions to high risk patients. o Stratify populations based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost 5. Identify patients at risk of deterioration and providing effective care. o Plan work for commissioning services and contracts 6. Reduce in the difference in the quality of care between those with the best and worst outcomes. o Set up capitated budgets 7. Re-design care to reduce admissions. o Identify health determinants of risk of admission to hospital, or other adverse care outcomes. 8. Set up capitated budgets – budgets based on care provided to the specific population. Commissioning 9. Identify health determinants of risk of admission to hospital, or other adverse care outcomes. 1. Commissioner reporting: 10. Monitor vulnerable groups of patients including but not limited to frailty, COPD, Diabetes, elderly. a. Summary by provider view - plan & actuals year to date (YTD). 11. Health needs assessments – identifying numbers of patients with specific health conditions or combination of conditions. b. Summary by Patient Outcome Data (POD) view - plan & actuals YTD. 12. Classify vulnerable groups based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost. c. Summary by provider view - activity & finance variance by POD. 13. Production of Theographs – a visual timeline of a patients encounters with hospital providers. d. Planned care by provider view - activity & finance plan & actuals YTD. 14. Analyse based on specific diseases e. Planned care by POD view - activity plan & actuals YTD. In addition: f. Provider reporting. - The risk stratification tool will provide aggregate reporting of number and percentage of population found to be at risk. g. Statutory returns. - Record level output (pseudonymised) will be available for commissioners (of the CCG), pseudonymised at patient level. Onward sharing of this data is not permitted. h. Statutory returns - monthly activity return. i. Statutory returns - quarterly activity return. j. Delayed discharges. k. Quality & performance referral to treatment reporting. 2. Readmissions analysis. 3. Production of aggregate reports for CCG Business Intelligence. 4. Production of project / programme level dashboards. 5. Monitoring of acute / community / mental health quality matrix. 6. Clinical coding reviews / audits. 7. Budget reporting down to individual GP Practice level. 8. GP Practice level dashboard reports include high flyers. 9. Comparators of CCG performance with similar CCGs as set out by a specific range of care quality and performance measures detailed activity and cost reports 10. Data Quality and Validation measures allowing data quality checks on the submitted data 11. Contract Management and Modelling 12. Patient Stratification, such as: o Patients at highest risk of admission o Most expensive patients (top 15%) o Frail and elderly o Patients that are currently in hospital o Patients with most referrals to secondary care o Patients with most emergency activity o Patients with most expensive prescriptions o Patients recently moving from one care setting to another i. Discharged from hospital ii. Discharged from community

Expected measurable benefits

[8 paragraphs unchanged] 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.

Benefits reported

Stated in the previous version and removed here.

Risk Stratification

Risk stratification has promoted improved case management in primary care and has led to the realisation of the following benefits:

1. Improved planning from the better understanding patient flows through the healthcare system, having allowed commissioners to design appropriate pathways to improve patient flow and having allowed commissioners to identify priorities and identify plans to address these.

2. Improvement in the quality of services through reduced emergency readmissions, especially avoidable emergency admissions. This has been achieved through mapping of frequent users of emergency services and thus allowing early intervention.

3. Improvements in access to services by identifying which services are in demand but have poor access, and the identification of areas where improvement has been required.

4. Has supported 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 have led to improvements in patient experience through more effective commissioning of services.

Commissioning

1. Supporting Quality Innovation Productivity and Prevention (QIPP) to review demand management, integrated care and pathways.

a. Analysis to support full business cases.

b. Develop business models.

c. Monitor In year projects.

2. Supporting Joint Strategic Needs Assessment (JSNA) for specific disease types.

3. Health economic modelling using:

a. Analysis on provider performance against 18 weeks wait targets.

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

c. Analysis of outcome measures for differential treatments, accounting for the full patient pathway.

d. Analysis to understand emergency care and linking A&E and Emergency Urgent Care Flows (EUCC).

4. Commissioning cycle support for grouping and re-costing previous activity.

5. Enables monitoring of:

a. CCG outcome indicators.

b. Financial and Non-financial validation of activity.

c. Successful delivery of integrated care within the CCG.

d. Checking frequent or multiple attendances to improve early intervention and avoid admissions.

e. Case management.

f. Care service planning.

g. Commissioning and performance management.

h. List size verification by GP practices.

i. Understanding the care of patients in nursing homes.

6. Feedback to NHS service providers on data quality at an aggregate and individual record level – only on data initially provided by the service providers.

7. Improved planning by better understanding patient flows through the healthcare system, thus allowing commissioners to design appropriate pathways to improve patient flow and allowing commissioners to identify priorities and identify plans to address these.

8. Improved quality of services through reduced emergency readmissions, especially avoidable emergency admissions. This is achieved through mapping of frequent users of emergency services and early intervention of appropriate care.

9. Improved access to services by identifying which services may be in demand but have poor access, and from this identify areas where improvement is required.

10. Potentially reduced premature mortality by more targeted intervention in primary care, which supports the commissioner to meets its requirement to reduce premature mortality in line with the CCG Outcome Framework.

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

12. Better understanding of contract requirements, contract execution, and required services for management of existing contracts, and to assist with identification and planning of future contracts

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