DSfC - NHS St Helens CCG; RS & IV

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) and will not be used further.

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

Invoice Validation will be conducted by 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 Arden and GEM CSU, Midlands and Lancashire CSU and Graphnet Health Limited.

Graphnet Health Ltd

The processing is not excessive or parallel as the platform through which the risk stratification is deployed is different to the way the other existing Risk Stratification solutions is deployed and created due to:-

• The Graphnet risk stratification solution works with near real time updates from primary care providing scores which are based on more up to date data set.

• It provides better decision making capability for GP’s, allowing them to access a wider set of information alongside the stratified data set (e.g. accessing social care, community and mental health pages within the shared cared record)

• The GP’s can access the shared care record risk stratification information from within the EMIS clinical solution allowing GP’s to access risk stratification information seamlessly.

When the solution is live, the CCG will look to consolidate the use of different solutions.

PROCESSING CONDITIONS:

Data must only be used for the purposes stipulated within this Data Sharing Agreement. Any additional disclosure / publication will require further approval from NHS Digital.

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

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

All access to data is managed under Role-Based Access Controls. Users can only access data authorised by their role and the tasks that they are required to undertake.

Patient level data will not be linked other than as specifically detailed within this Data Sharing Agreement. Data released will only be shared with those parties listed and will only be used for the purposes laid out in the application/agreement.

NHS Digital reminds all organisations party to this agreement of the need to comply with the Data Sharing Framework Contract requirements, including those regarding the use (and purposes of that use) by “Personnel” (as defined within the Data Sharing Framework Contract ie: employees, agents and contractors of the Data Recipient who may have access to that data)

The DSCRO (part of NHS Digital) will apply National Opt-outs before any identifiable data leaves the DSCRO only for the purpose of Risk Stratification.

CCGs should work with general practices within their CCG to help them fulfil data controller responsibilities regarding flow of identifiable data into risk stratification tools.

The only identifier available in the data set is the NHS numbers. Any further identification of the patients will only be completed by the patient’s clinician on their own systems for the purpose of direct care with a legitimate relationship.

ONWARD SHARING:

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

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

SEGREGATION:

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

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.

Lima Networks Ltd supply IT infrastructure for NHS Midlands and Lancashire CSU 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 supply Microsoft Azure Cloud Services for NHS Midlands and Lancashire Commissioning Support Unit, NHS Arden and Greater Eastern Midlands Commissioning Support Unit, Liaison Financial Services Ltd and Graphnet Health 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.

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.

St Helen's and Knowsley NHS Foundation Trust (who hosts St Helens and Knowsley Health Informatics [also known as STHK Health Informatics Service]) supply IT infrastructure and staff resource for NHS St Helen's CCG and are therefore listed as a data processor.

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

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 the NHS St. Helens CCG (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.

INVOICE VALIDATION - Liaison Financial Services Ltd

1.Identifiable SUS+ Data is obtained from the SUS+ Repository to 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) 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/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

Data Processor 1 – NHS Arden and Greater Eastern Midlands Commissioning Support Unit

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 NHS Arden and Greater Eastern Midlands Commissioning Support Unit, who hold the SUS+ data.

3. Identifiable GP Data is securely sent from the GP system to NHS Arden and Greater Eastern Midlands Commissioning Support Unit.

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

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

6. Once NHS Arden and Greater Eastern Midlands Commissioning Support Unit has completed the processing, the CCG can access the online system via a secure connection to access the data pseudonymised at patient level.

7. NHS Arden and Greater Eastern Midlands Commissioning Support Unit also pass identifiable risk stratification outputs to NHS Midlands and Lancashire Commissioning Support Unit (who are also a risk stratification supplier).

Data Processor 2 – NHS Midlands and Lancashire Commissioning Support Unit

1. Identifiable risk stratification outputs are transferred securely to NHS Midlands and Lancashire Commissioning Support Unit (from NHS Arden and Greater Eastern Midlands Commissioning Support Unit) who apply the data to the BI tool to produce reports.

2. Once NHS Midlands and Lancashire Commissioning Support Unit has completed the processing, the CCG can access the online system via a secure N3 connection to access the data pseudonymised at patient level and aggregated reports.

3. As part of the risk stratification processing activity, GPs have access to the NHS Midlands and Lancashire Commissioning Support Unit 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.

Data Processor 3 - Graphnet Health Ltd

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 Graphnet Health Limited, who securely hold the SUS+ data.

3. Identifiable GP Data is sourced from the CareCentric Shared Care Record system held by Graphnet Health Limited.

4. SUS+ data is linked to GP data in the risk stratification algorithm within the CareCentric system by the data processor.

5. GPs will have access to the risk stratification scores within the CareCentric system. Clinicians will open their clinical system and launch CareCentric from within it, to access risk stratification reports.

6. The application allows Clinicians (in this instance GPs) to access risk stratification scores for patients alongside further information from the Shared Care Record, providing up to date information on events within primary care, secondary care, community care, mental health and social care. This supports better and more effective clinical decision making and saves time for clinicians as they do not have to search through different systems to gather information on a patients care.

7. Once Graphnet Health Limited has completed the processing, the CCG can access the online system via a secure connection to access the data pseudonymised at patient level.

INVOICE VALIDATION – 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.

RISK STRATIFICATION - Graphnet Healthcare Ltd

Graphnet Healthcare are working in partnership with Johns Hopkins ACG System to integrate

the established Adjusted clinical Groups algorithms within the CareCentric platform. There are

numerous risk models available to utilise but some of the most common ones used are:

-  Patients at risk of emergency hospitalisation

 Probability of an extended stay in hospital

 Probability of a patient being high cost

 Probability of a patient having high pharmacy costs.

The ACG system allows a user to stratify the population by the scale of morbidity, age, gender,

pharmacy, resource utilisation and multimorbidity with a particular emphasis on co-morbidity.

The Johns Hopkins ACG risk stratification tool is used by Graphnet Healthcare Ltd to provide the risk stratification algorithm and is software only. No data is permitted to be shared with Johns Hopkins Healthcare or any other associated organisation.

INVOICE VALIDATION – 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 through more effective commissioning of services.

RISK STRATIFICATION - Graphnet Healthcare Ltd

• The primary data source used to feed the algorithms is updated much more regularly than the current system is. The data is fed from the CareCentric shared care record utilises near real time data flows in some cases.

• Rather than risk stratification being available in a separate standalone system, risk stratification scores will be available to view within the CareCentric application. This is a big bonus for clinicians who can open their clinical system and launch CareCentric from within it, accessing risk stratification reports without extra user logins and websites / applications.

• This application allows a clinician to access risk stratification scores for patients alongside further information from the shared care record, providing up to date information on events within primary care, secondary care, community care, mental health and social care. This supports better and more effective clinical decision making and again saves time for clinicians as they do not have to search through different systems to gather information on a patients care.

Not stated in the register.