DSfC - NHS Wigan Borough CCG; RS, Comm

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 NHS Arden and GEM Commissioning Support Unit and Wigan Borough CCG

The CCG is using two different risk stratification algorithms. They complement each other and this enables the CCG to have comprehensive analysis available to best support them in their commissioning obligations

Arden and GEM Commissioning Support Unit.

The risk stratification is done using the Kings Fund Combined Predictive model and the data are made available to the CCG as an extract which can be analysed using local tools. GP Practices are provided with identifiable level data for their registered patients only directly from Arden and GEM CSU.

Wigan Borough CCG:

The risk stratification is done using the CCG’s bespoke risk stratification algorithm and the outputs are made available to the CCG analysts in pseudonymised form. GP Practices are provided with identifiable level data for their registered patients only directly from the CCG.

COMMISSIONING

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

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

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

- Secondary Uses Service (SUS+)

- Mental Health Services Data Set (MHSDS)

- Community Services Data Set (CSDS)

The pseudonymised data is required to for the following purposes:

 Population health management:

• Understanding the interdependency of care services

• Targeting care more effectively

• Using value as the redesign principle

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

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

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

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

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

 Service redesign

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

 Patient stratification and predictive modelling - to highlight 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 NHS Arden and GEM Commissioning Support Unit

Pseudonymisation at Source to link additional secondary care data, primary care data and social care data

The CCG has arranged for additional pseudonymised datasets to be linked to SUS, MHSDS and CSDS received from the DSCRO, as follows:

• Social care data from Wigan Council

• Primary care data from GP Practices

This will provide a much richer dataset and will better enable the CCG to fulfil its commissioning responsibilities.

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.

(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:

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 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 Wigan Borough 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 Wigan Borough 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 Wigan Borough 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 Wigan Borough CCG region (including historical activity where the patient was previously registered or resident in another commissioner

NHS Midlands and Lancashire Commissioning Support Unit and Greater Manchester Shared Services (hosted by NHS Oldham CCG) 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.

Agilisys supply IT infrastructure for NHS Wigan Borough CCG 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.

Ilkeston Community Hospital, Wrightington, Wigan and Leigh NHS Foundation Trust, Blackburn and Darwen Borough Council and Bolton Council 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.

Risk Stratification - Wigan Borough CCG

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 CCG, who securely hold the SUS+ data.

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

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

Risk Stratification - Arden and GEM 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 GEM Commissioning Support Unit, who securely hold the SUS+ data.

3. Identifiable GP Data is securely sent from the GP system to NHS Arden and GEM 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 GEM 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

Commissioning

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

1. SUS+

2. Mental Health Services Data Set (MHSDS)

3. Community Services Data Set (CSDS)

The data is pseudonymised within the DSCRO using the Open Pseudonymiser tool.

The encryption key for this is located within the DSCRO and maintained separately

1. Pseudonymised SUS+, Mental Health Services Data (MHSDS) and Community Services Data Set (CSDS) only is securely transferred from the DSCRO to Arden and Greater East Midlands Commissioning Support Unit.

2. NHS Arden and Greater East Midlands Commissioning Support Unit add derived fields then send directly to the CCG.

3. The CCG receives the data into a secure segregated environment for pseudonymised data

4. GP data is pseudonymised at source by the GP Practices using the open pseudonymisation tool. No patient identifiable data will leave any practice by whom it is held. The CCG also does not have access to the pseudonymisation tool. The ‘encryption key’ which is specific to the project, is provided by the DSCRO. The GP Practice then send the pseudonymised data to the CCG.

5. Wigan Council pseudonymise social care data, using the open pseudonymisation tool. The ‘encryption key’ which is specific to the project, is provided by the DSCRO. The Council then send the pseudonymised data to the CCG.

6. The CCG will undertake linkage of the data.

7. Allowed linkage is between the data sets contained within point 1, 4 and 5 above.

8. The CCG analyse the data 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

h. Produce high level reports

9. Aggregation of required data for CCG management use will be completed by the CCG.

10. 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.

The CCG does not have access to the Open Pseudonymiser tool. No re-identification is permitted under this agreement

Processing agreements are in place between the CCG and the GPs. The agreement between practices and the CCG for this type of arrangement is there for the GPs to allow the CCG to receive the pseudonymised GP data, link it to the other datasets and do further analysis. For this processing, all organisations are using Open Pseudonymiser, with the encryption key managed by the DSCRO. The DSCRO coordinates the encryption key with persons that will pseudonymise the primary care and social care data within the GP practices

Aggregate reports with small number suppression applicable to the commissioning datasets, will be available to a range of partner organisations. The data will be used to understand patent journeys for pathway and service re-design. Access to commissioning intelligence is governed by respective organisation employee code of practice, data protection policies and information governance protocols.

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 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

All outputs from the pseudonymisation at source processing are always shared in an aggregate format, which will group on age bands and where appropriate supress any output where there is less than 5 patients linked to a practice or LSOA, depending on how the BI Team are processing the data. Care is taken to ensure that no identifiers are included within the outputs which could be used to re-identify (for example Spell ID or Hospital ID). The pseudonymisation tool used is a one-way Pseudonymiser and there is no ability to reverse the pseudonymisation.

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

6. healthcare outcomes

All of the above lead to improved 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.

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.

Not stated in the register.