DSfC - Northern Eastern and Western Devon CCG IV, RS

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 they are able to ensure that the activity claimed for each patient is their responsibility. This is done by processing and analysing Secondary User Services (SUS+) data, which is received into a secure Controlled Environment for Finance (CEfF). The SUS+ data is identifiable at the level of NHS number. The NHS number is only used to confirm the accuracy of backing-data sets and will not be used further.

Invoice Validation with be conducted by NHS Northern Eastern and Western Devon CCG

or NHS South Devon and Torbay CCG.

The CCG are advised by NHS Northern Eastern and Western Devon CCG or NHS South Devon and Torbay CCG whether payment for invoices can be made or not.

Risk Stratification

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 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 Northern Eastern and Western Devon CCG

or NHS South Devon and Torbay CCG.

NHS Northern Eastern and Western Devon CCG is data controller for data relating to NHS Northern Eastern and Western Devon CCG (patients of residence and registration). They will also process data for their own CCG.

NHS South Devon and Torbay CCG is data controller for data relating to NHS South Devon and Torbay CCG (patients of residence and registration). They will also process data for their own CCG.

NHS Northern Eastern and Western Devon CCG (as data controller) instruct NHS South Devon and Torbay CCG (as data processor) to conduct risk stratification and invoice validation on their behalf. A data processing agreement is in place.

NHS South Devon and Torbay CCG (as data controller) instruct NHS Northern Eastern and Western Devon CCG (as data processor) to conduct risk stratification and invoice validation on their behalf. A data processing agreement is in place.

NHS Northern Eastern and Western Devon CCG are data controller for NHS Northern Eastern and Western Devon CCG data and data processor for NHS South Devon and Torbay CCG data.

NHS South Devon and Torbay CCG are data controller for NHS South Devon and Torbay CCG data and data processor for NHS Northern Eastern and Western Devon CCG data.

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

Data Processors must only act upon specific instructions from the Data Controller.

Data can only be stored at the addresses listed under storage addresses.

Patient level data will not be shared outside of the CCG unless it is for the purpose of Direct Care, where it may be shared only with those health professionals who have a legitimate relationship with the patient and a legitimate reason to access the data.

All access to data is managed under Roles-Based Access Controls

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)

The DSCRO (part of NHS Digital) will apply Type 2 objections 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.

Segregation

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

All access to data is auditable by NHS Digital.

Data for the purpose of Invoice Validation is kept within the CEfF, and only used by staff properly trained and authorised for the activity. Only CEfF staff are able to access data in the CEfF and only CEfF staff operate the invoice validation process within the CEfF. Data flows directly in to the CEfF from the DSCRO and from the providers – it does not flow through any other processors.

Data Minimisation

Data Minimisation in relation to the data sets listed within section 3 are listed below. This also includes the purpose on which they would be applied -

Data Minimisation in relation to the data sets listed within section 3 are listed below. This also includes the purpose on which they would be applied -

For the purpose of Risk Stratification:

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

For the purpose of Invoice Validation:

• CCG of residence and/or registration.

Invoice Validation

1. Identifiable SUS+ Data is obtained from the SUS+ Repository by the Data Services for Commissioners regional Office (DSCRO).

2. The DSCRO pushes a one-way data flow of SUS+ data into the Controlled Environment for Finance (CEfF) located in NHS Northern Eastern and Western Devon CCG.

3. NHS Northern Eastern and Western Devon CCG send the data securely to NHS South Devon and Torbay CCG.

Both CCGs then follow the follow the following process:

4. The CEfF conduct the following processing activities for invoice validation purposes:

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

b. Once the backing information is received, this will be checked against national NHS and local commissioning policies as well as being checked against system access and reports provided by NHS Digital to confirm the payments are:

i. In line with Payment by Results tariffs

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

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

Staff from either NHS Northern Eastern and Western Devon CCG or NHS South Devon and Torbay CCG perform invoice validation on provider backing data for either CCG.

5. The CCG are notified by the relevant CEfF that the invoice has been validated and can be paid. Any discrepancies or nonvalidated invoices are investigated and resolved.

Invoice Validation work is only undertaken once. There is no duplication of the work. The CCG will only receive data related to that CCG.

Risk Stratification

1. Identifiable SUS+ data is obtained from the SUS Repository to the Data Services for Commissioners Regional Office (DSCRO).

2. Data quality management and standardisation of data is completed by the DSCRO and the data identifiable at the level of NHS number is transferred securely to the NHS Northern Eastern and Western Devon CCG, who hold the SUS+ data within the secure Data Centre on N3.

3. NHS Northern Eastern and Western Devon CCG send the data securely to NHS South Devon and Torbay CCG.

Both CCGs then follow the follow the following process:

4. Identifiable GP Data is securely sent from the GP system to the CCG.

5. SUS+ data is linked to GP data in the risk stratification tool by the data processor.

6. 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.

7. Once the CCG has completed the processing, access is available through the online system via a secure N3 connection to access the data pseudonymised at patient level.

Risk Stratification work is only undertaken once. There is no duplication of the work. The CCG will only receive data related to that 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.

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. Output from the risk stratification tool will provide aggregate reporting of number and percentage of population found to be at risk.

3. Record level output will be available for commissioners (of the CCG), pseudonymised at patient level.

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.

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:

o Stratify populations based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost

o Plan work for commissioning services and contracts

o Set up capitated budgets

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

Invoice Validation

1. Financial validation of activity

2. CCG Budget control

3. Commissioning and performance management

4. Meeting commissioning objectives without compromising patient confidentiality

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

Risk Stratification

Risk stratification promotes improved case management in primary care and will lead to the following benefits being realised:

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

2. Improved quality of services through reduced emergency readmissions, especially avoidable emergency admissions. This is achieved through mapping of frequent users of emergency services thus allowing early intervention.

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

4. Supports the commissioner to meets its requirement to reduce premature mortality in line with the CCG Outcome Framework by allowing for more targeted intervention in primary care.

5. Better understanding of local population characteristics through analysis of their health and healthcare outcomes

All of the above lead to improved patient experience through more effective commissioning of services.

Not stated in the register.