DSfC - NHS Greater Manchester Integrated Care Board - Commissioning / Invoice Validation / Risk Stratification and Research

The Health and Social Care Act 2022 created 42 Integrated Care Boards (ICB). These are legal entities which have replaced CCGs. The ICB has taken on the NHS commissioning functions of CCGs as well as some of NHS England’s commissioning functions. It is accountable for NHS spend and performance within the system. Within each ICB geographical area, there will also be an Integrated Care Partnership (ICP), a joint committee which brings together the ICB and their partner local authorities, and other locally determined representatives (for example from health, social care, public health; and potentially others, such as social care or housing providers) to set local priorities and develop an integrated health and social care strategy.

ICP constituent members (other than the ICB) do not carry out data controllership activities and do not make decisions on sub-licensing.

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 Integrated Care Board (ICB) so the ICB is able to ensure that the patient is their responsibility and the activity claimed is correct. This is done by processing and analysing Invoice Validation Datasets, which are received into a secure Controlled Environment for Finance (CEfF). The identifiers included are in line with the CAG approval. The identifiers are only used to link and confirm the accuracy of backing-data sets (data from providers).

The ICB are advised by the appointed CEfF 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 (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.

In order to conduct, Risk Stratification Datasets, identifiable at the level of NHS number are 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 cohorts of patients who may require high levels of care. Risk Stratification also enables General Practitioners (GPs) to better target intervention in Primary Care.

COMMISSIONING

To use pseudonymised Commissioning Datasets 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 ICB area.

The ICBs 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 pseudonymised data is required for the following purposes:

 Population health management

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

 Thoroughly investigating the needs of the population, to inform the commissioning or appropriate services for that population’s health needs

 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 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 – ensuring enough capacity to manage the demand by predicting the impact on certain care pathways.

 Support measuring the health and 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.

DIRECT CARE

In the development of cohorts of pseudonymised patients considered to be at risk, the data controllers may need the facility to provide identifiable results back to direct health or care professionals for the purpose of direct care. Additionally clinicians, made aware of a number of cases that they believe would need intervention may request re-identification for that direct care purpose. These instances of re-identification will generally be carried out as programmes of work or, separately, on an individual/small group basis as a result of coincidental findings. The ICB does not have a statutory function to provide direct care and as such, does not see the identifiable data.

NHS England provides a re-identification service for this process. All re-id requests will be processed and authorised by NHS England on a case by case basis, including requests under a sub-licence. 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. It is anticipated that this re-id ability in the future will allow risk stratification to be conducted under a single flow of pseudonymised data.

The following is a typical example of an instance where an ICB might want to use the re-identification process:

A&E High Attendance usage

The ICB can filter data to show for example the number of A&E attendances in a given period for each patient. The ICB 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.

RESEARCH

This use is permitted where the research relates to commissioning activities for the health and care benefit of the ICS (and other ICS footprints under the appropriate governance arrangements).

Each ICB in law is required in the exercise of its functions, to facilitate otherwise promote

(a) research on matters relevant to the health service, and

(b) the use in the health service of evidence obtained from research.

The data controller may only use the data for research for one or more of the following purposes, which align with the advantages of evidence-based commissioning:

• lead to innovation in service design and delivery,

• enhance the quality of health and care provision,

• reduce clinical variation between locations and providers,

• improve equity of access to services,

• improve patient and population outcomes.

Research can only be undertaken by the data controller(s),or a sub-licensee(s) who is permitted by the data controller(s) to undertake research, which must:

• be for the benefit of health or social care within the ICS footprint area; and

• assist health and social care commissioning objectives, and allow the ICB to extend benefits to other ICS footprints under Board review governance arrangements; and

• support one or more of the purposes listed above; and

• a sub-licence cannot be granted where the research only requires data supplied by NHS England. A sub-licence is needed where additional, non-NHS England supplied, data sets are required from the controller for the research to be undertaken

INVOICE VALIDATION

1. Accurate budget reports.

2. Enable a system of communication that will enable the ICB to challenge invoices and raise discrepancies and disputes.

3. Reports on the accuracy of invoices.

4. 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.

5. Budget control of the ICB.

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.

The ICB will be provided with the pseudonymised outputs of the risk stratification tool for which they are able to:

1. Identify patient groups at risk of deterioration and providing effective care.

2. Set up capitated budgets – budgets based on care provided to the specific population.

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

4. Monitor vulnerable groups of patients including but not limited to frailty, COPD, Diabetes, elderly.

5. Health needs assessments – identifying numbers of patients with specific health conditions or combination of conditions.

6. Classify vulnerable groups based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost.

7. Production of Theographs – a visual timeline of a patients encounters with hospital providers.

8. Analyse based on specific diseases.

9. Aggregate reporting of number and percentage of population found to be at risk.

COMMISSIONING

1. Commissioner reporting on providers, finances, readmission analysis etc…

2. Production of aggregate reports for ICB Business Intelligence.

3. Production of project / programme level dashboards.

4. Monitoring of acute / community / mental health quality matrix.

5. Clinical coding reviews / audits.

6. Budget reporting down to individual GP Practice level.

7. GP Practice level dashboard reports.

8. Comparators of ICB performance with similar ICBs as set out by a specific range of care quality and performance measures detailed activity and cost reports.

9. Data Quality and Validation measures allowing data quality checks on the submitted data.

10. Contract Management and Modelling.

11. Patient Stratification dashboards to highlight cohorts of patients with similar conditions at risk.

12. Manage demand, by understanding the quantity of assessments required ICBs 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.

13. 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.

14. Compare providers (trusts) mortality outcomes to the national baseline.

15. Identify medication prescribing trends and their effectiveness.

16. Linking prescribing habits to entry points into the health and social care system.

17. Identify, quantify and understand cohorts of patient’s high numbers of different medications (polypharmacy).

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

DIRECT CARE

1. Reports and dashboards that highlight cohorts of patients that can be targeted for clinical intervention by direct health and care professionals.

2. Lists of at risk patients made available to direct health and care professionals that require direct care intervention.

3. Reports and dashboards to show the outcome of clinical intervention including patient outcomes and modelled transactional cost savings.

RESEARCH

The research outputs from project commissioned in line with the purposes set out in section 5a,may include the following:

1. Predictive modelling tools based on research project outcomes,

2. Research studies proving insight into disparities in outcomes based on demographic factors,

3. Development of tools or algorithms that assist the ICB in resource allocation decision making,

4. Research outcomes focused on specific interventions or treatment by the ICB,

5. Research output that provides the ICB with cost-effectiveness assessments of specific health needs of the ICS population which can include analyses of disease.

6. Prevalence, health inequalities and social determinants of health guiding the strategic priorities for commissioning

No further benefits recorded on 11/09/2025

COMMISSIONING

Health data are used to collate and produce board reports on specific programmes and pathways of care, to monitor the quality of care delivered, assess delivery of targets, and monitor the impact of transformation schemes and improvement programmes based on agreed key performance indicators. These reports are utilised by programme transformation groups to take action where needed to support or improve services, and to drive decision making on development of new models of care.

INVOICE VALIDATION

Outputs from the processing of this data enables the ICB to validate invoices from providers and raise queries and formal disputes where appropriate (for example, around pricing or patient registration). This in turn supports both robust financial control and budgetary reporting at the ICB. Regular and ad hoc reporting of this data further enables the ICB to monitor provider performance against a number of key contractual metrics and targets (for instance, Elective Recovery performance) and support operational colleagues in making management decisions to enable improved provider and system-wide performance.

RISK STRATIFICATION

The ICB is using a medication-based risk stratification tool to identify patient who are likely to be put at risk of harm from their medication. The system is use for monitoring of the Medicines Optimisation Scheme. It is also used in relation to Quality Outcomes Framework (QOF)/Care Quality Commission (CQC) and specific therapeutic areas, for example, Diabetes.

RESEARCH

To be completed once used

The Health and Social Care Act 2022 has created 42 Integrated Care Boards (ICB). These are legal entities which have replaced CCGs. The ICB has taken on the NHS commissioning functions of CCGs as well as some of NHS England’s commissioning functions. It is accountable for NHS spend and performance within the system. Within each ICB geographical area, there will also be an Integrated Care Partnership (ICP), a joint committee which brings together the ICB and their partner local authorities, and other locally determined representatives (for example from health, social care, public health; and potentially others, such as social care or housing providers) to set local priorities and develop an integrated health and social care strategy.

ICP constituent members (other than the ICB) do not carry out data controllership activities and do not make decisions on sub-licensing.

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 Integrated Care Board (ICB) so the ICB is able to ensure that the patient is their responsibility and the activity claimed is correct. This is done by processing and analysing Invoice Validation Datasets, which are received into a secure Controlled Environment for Finance (CEfF). The identifiers included are in line with the CAG approval. The identifiers are only used to link and confirm the accuracy of backing-data sets (data from providers).

The ICB are advised by the appointed CEfF 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 (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.

In order to conduct, Risk Stratification Datasets, identifiable at the level of NHS number are 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 cohorts of patients who may require high levels of care. Risk Stratification also enables General Practitioners (GPs) to better target intervention in Primary Care.

COMMISSIONING

To use pseudonymised Commissioning Datasets 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 ICB area.

The ICBs 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 pseudonymised data is required to for the following purposes:

 Population health management

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

 Thoroughly investigating the needs of the population, to inform the commissioning or appropriate services for that population’s health needs

 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 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 – ensuring enough capacity to manage the demand by predicting the impact on certain care pathways.

 Support measuring the health and 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.

DIRECT CARE

In the development of cohorts of pseudonymised patients considered to be at risk, the data controllers may need the facility to provide identifiable results back to direct health or care professionals for the purpose of direct care. Additionally clinicians, made aware of a number of cases that they believe would need intervention may request re-identification for that direct care purpose. These instances of re-identification will generally be carried out as programmes of work or, separately, on an individual/small group basis as a result of coincidental findings. The ICB does not have a statutory function to provide direct care and as such, does not see the identifiable data.

NHS England provides a re-identification service for this process. All re-id requests will be processed and authorised by NHS England on a case by case basis, including requests under a sub-licence. 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. It is anticipated that this re-id ability in the future will allow risk stratification to be conducted under a single flow of pseudonymised data.

The following is a typical example of an instance where an ICB might want to use the re-identification process:

A&E High Attendance usage

The ICB can filter data to show for example the number of A&E attendances in a given period for each patient. The ICB 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.

RESEARCH

The research relates to commissioning activities for the health and care benefit of the ICS and allows the ICB to extend benefits to other ICS footprints under the appropriate governance arrangements.

Each integrated care board must, in the exercise of its functions, facilitate or otherwise promote

(a) research on matters relevant to the health service, and

(b) the use in the health service of evidence obtained from research.

Evidence from research may only be utilised by the data controller for one or more of the following purposes, which align with the advantages of evidence-based commissioning:

• lead to innovation in service design and delivery,

• enhance the quality of health and care provision,

• reduce clinical variation between locations and providers,

• improve equity of access to services,

• improve patient and population outcomes.

Research can only be undertaken by the data controller(s) or their sub-licensee(s). A sub-licence may only be issued for research which must:

· be for the benefit of health or social care within the ICS footprint area; and

· assist health and social care commissioning objectives, and allow the ICB to extend benefits to other ICS footprints under Board review governance arrangements; and

• support one or more of the purposes listed above

Where sub licencing occurs, the ICB is not the data controller as it does not determine the purposes and means for the data processing activities required.

INVOICE VALIDATION

1. Accurate budget reports.

2. Enable a system of communication that will enable the ICB to challenge invoices and raise discrepancies and disputes.

3. Reports on the accuracy of invoices.

4. 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.

5. Budget control of the ICB.

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.

The ICB will be provided with the pseudonymised outputs of the risk stratification tool for which they are able to:

1. Identify patient groups at risk of deterioration and providing effective care.

2. Set up capitated budgets – budgets based on care provided to the specific population.

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

4. Monitor vulnerable groups of patients including but not limited to frailty, COPD, Diabetes, elderly.

5. Health needs assessments – identifying numbers of patients with specific health conditions or combination of conditions.

6. Classify vulnerable groups based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost.

7. Production of Theographs – a visual timeline of a patients encounters with hospital providers.

8. Analyse based on specific diseases.

9. Aggregate reporting of number and percentage of population found to be at risk.

COMMISSIONING

1. Commissioner reporting on providers, finances, readmission analysis etc…

2. Production of aggregate reports for ICB Business Intelligence.

3. Production of project / programme level dashboards.

4. Monitoring of acute / community / mental health quality matrix.

5. Clinical coding reviews / audits.

6. Budget reporting down to individual GP Practice level.

7. GP Practice level dashboard reports.

8. Comparators of ICB performance with similar ICBs as set out by a specific range of care quality and performance measures detailed activity and cost reports.

9. Data Quality and Validation measures allowing data quality checks on the submitted data.

10. Contract Management and Modelling.

11. Patient Stratification dashboards to highlight cohorts of patients with similar conditions at risk.

12. Manage demand, by understanding the quantity of assessments required ICBs 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.

13. 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.

14. Compare providers (trusts) mortality outcomes to the national baseline.

15. Identify medication prescribing trends and their effectiveness.

16. Linking prescribing habits to entry points into the health and social care system.

17. Identify, quantify and understand cohorts of patient’s high numbers of different medications (polypharmacy).

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

DIRECT CARE

1. Reports and dashboards that highlight cohorts of patients that can be targeted for clinical intervention by direct health and care professionals.

2. Lists of at risk patients made available to direct health and care professionals that require direct care intervention.

3. Reports and dashboards to show the outcome of clinical intervention including patient outcomes and modelled transactional cost savings.

RESEARCH

The research outputs from project commissioned in line with the purposes set out in section 5a, may include the following:

• Predictive modelling tools based on research project outcomes,

• Research studies proving insight into disparities in outcomes based on demographic factors,

• Development of tools or algorithms that assist the ICB in resource allocation decision making,

• Research outcomes focused on specific interventions or treatment by the ICB,

• Research output that provides the ICB with cost-effectiveness assessments of specific health needs of the ICS population which can include analyses of disease

• prevalence, health inequalities and social determinants of health guiding the strategic priorities for commissioning

COMMISSIONING

Health data are used to collate and produce board reports on specific programmes and pathways of care, to monitor the quality of care delivered, assess delivery of targets, and monitor the impact of transformation schemes and improvement programmes based on agreed key performance indicators. These reports are utilised by programme transformation groups to take action where needed to support or improve services, and to drive decision making on development of new models of care.

INVOICE VALIDATION

Outputs from the processing of this data enables the ICB to validate invoices from providers and raise queries and formal disputes where appropriate (for example, around pricing or patient registration). This in turn supports both robust financial control and budgetary reporting at the ICB. Regular and ad hoc reporting of this data further enables the ICB to monitor provider performance against a number of key contractual metrics and targets (for instance, Elective Recovery performance) and support operational colleagues in making management decisions to enable improved provider and system-wide performance.

RISK STRATIFICATION

The ICB is using a medication-based risk stratification tool to identify patient who are likely to be put at risk of harm from their medication. The system is use for monitoring of the Medicines Optimisation Scheme. It is also used in relation to Quality Outcomes Framework (QOF)/Care Quality Commission (CQC) and specific therapeutic areas, for example, Diabetes.

RESEARCH

To be completed once used

The Health and Social Care Act 2022 has created 42 Integrated Care Boards (ICB). These are legal entities which have replaced CCGs. The ICB has taken on the NHS commissioning functions of CCGs as well as some of NHS England’s commissioning functions. It is accountable for NHS spend and performance within the system. Within each ICB geographical area, there will also be an Integrated Care Partnership (ICP), a joint committee which brings together the ICB and their partner local authorities, and other locally determined representatives (for example from health, social care, public health; and potentially others, such as social care or housing providers) to set local priorities and develop an integrated health and social care strategy.

ICP constituent members (other than the ICB) do not carry out data controllership activities and do not make decisions on sub-licensing.

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 Integrated Care Board (ICB) so the ICB is able to ensure that the patient is their responsibility and the activity claimed is correct. This is done by processing and analysing Invoice Validation Datasets, which are received into a secure Controlled Environment for Finance (CEfF). The identifiers included are in line with the CAG approval. The identifiers are only used to link and confirm the accuracy of backing-data sets (data from providers).

The ICB are advised by the appointed CEfF 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 (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.

In order to conduct, Risk Stratification Datasets, identifiable at the level of NHS number are 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 cohorts of patients who may require high levels of care. Risk Stratification also enables General Practitioners (GPs) to better target intervention in Primary Care.

COMMISSIONING

To use pseudonymised Commissioning Datasets 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 ICB area.

The ICBs 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 pseudonymised data is required to for the following purposes:

 Population health management

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

 Thoroughly investigating the needs of the population, to inform the commissioning or appropriate services for that population’s health needs

 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 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 – ensuring enough capacity to manage the demand by predicting the impact on certain care pathways.

 Support measuring the health and 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.

DIRECT CARE

In the development of cohorts of pseudonymised patients considered to be at risk, the data controllers may need the facility to provide identifiable results back to direct health or care professionals for the purpose of direct care. Additionally clinicians, made aware of a number of cases that they believe would need intervention may request re-identification for that direct care purpose. These instances of re-identification will generally be carried out as programmes of work or, separately, on an individual/small group basis as a result of coincidental findings. The ICB does not have a statutory function to provide direct care and as such, does not see the identifiable data.

NHS England provides a re-identification service for this process. All re-id requests will be processed and authorised by NHS England on a case by case basis, including requests under a sub-licence. 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. It is anticipated that this re-id ability in the future will allow risk stratification to be conducted under a single flow of pseudonymised data.

The following is a typical example of an instance where an ICB might want to use the re-identification process:

A&E High Attendance usage

The ICB can filter data to show for example the number of A&E attendances in a given period for each patient. The ICB 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.

RESEARCH

The research relates to commissioning activities for the health and care benefit of the ICS and allows the ICB to extend benefits to other ICS footprints under the appropriate governance arrangements.

Each integrated care board must, in the exercise of its functions, facilitate or otherwise promote

(a) research on matters relevant to the health service, and

(b) the use in the health service of evidence obtained from research.

Evidence from research may only be utilised by the data controller for one or more of the following purposes, which align with the advantages of evidence-based commissioning:

• lead to innovation in service design and delivery,

• enhance the quality of health and care provision,

• reduce clinical variation between locations and providers,

• improve equity of access to services,

• improve patient and population outcomes.

Research can only be undertaken by the data controller(s) or their sub-licensee(s). A sub-licence may only be issued for research which must:

· be for the benefit of health or social care within the ICS footprint area; and

· assist health and social care commissioning objectives, and allow the ICB to extend benefits to other ICS footprints under Board review governance arrangements; and

• support one or more of the purposes listed above

Where sub licencing occurs, the ICB is not the data controller as it does not determine the purposes and means for the data processing activities required.

INVOICE VALIDATION

1. Accurate budget reports.

2. Enable a system of communication that will enable the ICB to challenge invoices and raise discrepancies and disputes.

3. Reports on the accuracy of invoices.

4. 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.

5. Budget control of the ICB.

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.

The ICB will be provided with the pseudonymised outputs of the risk stratification tool for which they are able to:

1. Identify patient groups at risk of deterioration and providing effective care.

2. Set up capitated budgets – budgets based on care provided to the specific population.

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

4. Monitor vulnerable groups of patients including but not limited to frailty, COPD, Diabetes, elderly.

5. Health needs assessments – identifying numbers of patients with specific health conditions or combination of conditions.

6. Classify vulnerable groups based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost.

7. Production of Theographs – a visual timeline of a patients encounters with hospital providers.

8. Analyse based on specific diseases.

9. Aggregate reporting of number and percentage of population found to be at risk.

COMMISSIONING

1. Commissioner reporting on providers, finances, readmission analysis etc…

2. Production of aggregate reports for ICB Business Intelligence.

3. Production of project / programme level dashboards.

4. Monitoring of acute / community / mental health quality matrix.

5. Clinical coding reviews / audits.

6. Budget reporting down to individual GP Practice level.

7. GP Practice level dashboard reports.

8. Comparators of ICB performance with similar ICBs as set out by a specific range of care quality and performance measures detailed activity and cost reports.

9. Data Quality and Validation measures allowing data quality checks on the submitted data.

10. Contract Management and Modelling.

11. Patient Stratification dashboards to highlight cohorts of patients with similar conditions at risk.

12. Manage demand, by understanding the quantity of assessments required ICBs 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.

13. 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.

14. Compare providers (trusts) mortality outcomes to the national baseline.

15. Identify medication prescribing trends and their effectiveness.

16. Linking prescribing habits to entry points into the health and social care system.

17. Identify, quantify and understand cohorts of patient’s high numbers of different medications (polypharmacy).

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

DIRECT CARE

1. Reports and dashboards that highlight cohorts of patients that can be targeted for clinical intervention by direct health and care professionals.

2. Lists of at risk patients made available to direct health and care professionals that require direct care intervention.

3. Reports and dashboards to show the outcome of clinical intervention including patient outcomes and modelled transactional cost savings.

RESEARCH

The research outputs from project commissioned in line with the purposes set out in section 5a, may include the following:

• Predictive modelling tools based on research project outcomes,

• Research studies proving insight into disparities in outcomes based on demographic factors,

• Development of tools or algorithms that assist the ICB in resource allocation decision making,

• Research outcomes focused on specific interventions or treatment by the ICB,

• Research output that provides the ICB with cost-effectiveness assessments of specific health needs of the ICS population which can include analyses of disease

• prevalence, health inequalities and social determinants of health guiding the strategic priorities for commissioning

COMMISSIONING

Health data are used to collate and produce board reports on specific programmes and pathways of care, to monitor the quality of care delivered, assess delivery of targets, and monitor the impact of transformation schemes and improvement programmes based on agreed key performance indicators. These reports are utilised by programme transformation groups to take action where needed to support or improve services, and to drive decision making on development of new models of care.

INVOICE VALIDATION

Outputs from the processing of this data enables the ICB to validate invoices from providers and raise queries and formal disputes where appropriate (for example, around pricing or patient registration). This in turn supports both robust financial control and budgetary reporting at the ICB. Regular and ad hoc reporting of this data further enables the ICB to monitor provider performance against a number of key contractual metrics and targets (for instance, Elective Recovery performance) and support operational colleagues in making management decisions to enable improved provider and system-wide performance.

RISK STRATIFICATION

The ICB is using a medication-based risk stratification tool to identify patient who are likely to be put at risk of harm from their medication. The system is use for monitoring of the Medicines Optimisation Scheme. It is also used in relation to Quality Outcomes Framework (QOF)/Care Quality Commission (CQC) and specific therapeutic areas, for example, Diabetes.

RESEARCH

To be completed once used

The Health and Social Care Act 2022 has created 42 Integrated Care Boards (ICB). These are legal entities which have replaced CCGs. The ICB has taken on the NHS commissioning functions of CCGs as well as some of NHS England’s commissioning functions. It is accountable for NHS spend and performance within the system. Within each ICB geographical area, there will also be an Integrated Care Partnership (ICP), a joint committee which brings together the ICB and their partner local authorities, and other locally determined representatives (for example from health, social care, public health; and potentially others, such as social care or housing providers) to set local priorities and develop an integrated health and social care strategy.

ICP constituent members (other than the ICB) do not carry out data controllership activities and do not make decisions on sub-licensing.

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 Integrated Care Board (ICB) so the ICB is able to ensure that the patient is their responsibility and the activity claimed is correct. This is done by processing and analysing Invoice Validation Datasets, which are received into a secure Controlled Environment for Finance (CEfF). The identifiers included are in line with the CAG approval. The identifiers are only used to link and confirm the accuracy of backing-data sets (data from providers).

The ICB are advised by the appointed CEfF 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 (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.

In order to conduct, Risk Stratification Datasets, identifiable at the level of NHS number are 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 cohorts of patients who may require high levels of care. Risk Stratification also enables General Practitioners (GPs) to better target intervention in Primary Care.

COMMISSIONING

To use pseudonymised Commissioning Datasets 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 ICB area.

The ICBs 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 pseudonymised data is required to for the following purposes:

 Population health management

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

 Thoroughly investigating the needs of the population, to inform the commissioning or appropriate services for that population’s health needs

 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 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 – ensuring enough capacity to manage the demand by predicting the impact on certain care pathways.

 Support measuring the health and 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.

DIRECT CARE

In the development of cohorts of pseudonymised patients considered to be at risk, the data controllers may need the facility to provide identifiable results back to direct health or care professionals for the purpose of direct care. Additionally clinicians, made aware of a number of cases that they believe would need intervention may request re-identification for that direct care purpose. These instances of re-identification will generally be carried out as programmes of work or, separately, on an individual/small group basis as a result of coincidental findings. The ICB does not have a statutory function to provide direct care and as such, does not see the identifiable data.

NHS England provides a re-identification service for this process. All re-id requests will be processed and authorised by NHS England on a case by case basis, including requests under a sub-licence. 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. It is anticipated that this re-id ability in the future will allow risk stratification to be conducted under a single flow of pseudonymised data.

The following is a typical example of an instance where an ICB might want to use the re-identification process:

A&E High Attendance usage

The ICB can filter data to show for example the number of A&E attendances in a given period for each patient. The ICB 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.

RESEARCH

The research relates to commissioning activities for the health and care benefit of the ICS and allows the ICB to extend benefits to other ICS footprints under the appropriate governance arrangements.

Each integrated care board must, in the exercise of its functions, facilitate or otherwise promote

(a) research on matters relevant to the health service, and

(b) the use in the health service of evidence obtained from research.

Evidence from research may only be utilised by the data controller for one or more of the following purposes, which align with the advantages of evidence-based commissioning:

• lead to innovation in service design and delivery,

• enhance the quality of health and care provision,

• reduce clinical variation between locations and providers,

• improve equity of access to services,

• improve patient and population outcomes.

Research can only be undertaken by the data controller(s) or their sub-licensee(s). A sub-licence may only be issued for research which must:

· be for the benefit of health or social care within the ICS footprint area; and

· assist health and social care commissioning objectives, and allow the ICB to extend benefits to other ICS footprints under Board review governance arrangements; and

• support one or more of the purposes listed above

Where sub licencing occurs, the ICB is not the data controller as it does not determine the purposes and means for the data processing activities required.

INVOICE VALIDATION

1. Accurate budget reports.

2. Enable a system of communication that will enable the ICB to challenge invoices and raise discrepancies and disputes.

3. Reports on the accuracy of invoices.

4. 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.

5. Budget control of the ICB.

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.

The ICB will be provided with the pseudonymised outputs of the risk stratification tool for which they are able to:

1. Identify patient groups at risk of deterioration and providing effective care.

2. Set up capitated budgets – budgets based on care provided to the specific population.

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

4. Monitor vulnerable groups of patients including but not limited to frailty, COPD, Diabetes, elderly.

5. Health needs assessments – identifying numbers of patients with specific health conditions or combination of conditions.

6. Classify vulnerable groups based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost.

7. Production of Theographs – a visual timeline of a patients encounters with hospital providers.

8. Analyse based on specific diseases.

9. Aggregate reporting of number and percentage of population found to be at risk.

COMMISSIONING

1. Commissioner reporting on providers, finances, readmission analysis etc…

2. Production of aggregate reports for ICB Business Intelligence.

3. Production of project / programme level dashboards.

4. Monitoring of acute / community / mental health quality matrix.

5. Clinical coding reviews / audits.

6. Budget reporting down to individual GP Practice level.

7. GP Practice level dashboard reports.

8. Comparators of ICB performance with similar ICBs as set out by a specific range of care quality and performance measures detailed activity and cost reports.

9. Data Quality and Validation measures allowing data quality checks on the submitted data.

10. Contract Management and Modelling.

11. Patient Stratification dashboards to highlight cohorts of patients with similar conditions at risk.

12. Manage demand, by understanding the quantity of assessments required ICBs 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.

13. 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.

14. Compare providers (trusts) mortality outcomes to the national baseline.

15. Identify medication prescribing trends and their effectiveness.

16. Linking prescribing habits to entry points into the health and social care system.

17. Identify, quantify and understand cohorts of patient’s high numbers of different medications (polypharmacy).

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

DIRECT CARE

1. Reports and dashboards that highlight cohorts of patients that can be targeted for clinical intervention by direct health and care professionals.

2. Lists of at risk patients made available to direct health and care professionals that require direct care intervention.

3. Reports and dashboards to show the outcome of clinical intervention including patient outcomes and modelled transactional cost savings.

RESEARCH

The research outputs from project commissioned in line with the purposes set out in section 5a, may include the following:

• Predictive modelling tools based on research project outcomes,

• Research studies proving insight into disparities in outcomes based on demographic factors,

• Development of tools or algorithms that assist the ICB in resource allocation decision making,

• Research outcomes focused on specific interventions or treatment by the ICB,

• Research output that provides the ICB with cost-effectiveness assessments of specific health needs of the ICS population which can include analyses of disease

• prevalence, health inequalities and social determinants of health guiding the strategic priorities for commissioning

COMMISSIONING

Health data are used to collate and produce board reports on specific programmes and pathways of care, to monitor the quality of care delivered, assess delivery of targets, and monitor the impact of transformation schemes and improvement programmes based on agreed key performance indicators. These reports are utilised by programme transformation groups to take action where needed to support or improve services, and to drive decision making on development of new models of care.

INVOICE VALIDATION

Outputs from the processing of this data enables the ICB to validate invoices from providers and raise queries and formal disputes where appropriate (for example, around pricing or patient registration). This in turn supports both robust financial control and budgetary reporting at the ICB. Regular and ad hoc reporting of this data further enables the ICB to monitor provider performance against a number of key contractual metrics and targets (for instance, Elective Recovery performance) and support operational colleagues in making management decisions to enable improved provider and system-wide performance.

RISK STRATIFICATION

The ICB is using a medication-based risk stratification tool to identify patient who are likely to be put at risk of harm from their medication. The system is use for monitoring of the Medicines Optimisation Scheme. It is also used in relation to Quality Outcomes Framework (QOF)/Care Quality Commission (CQC) and specific therapeutic areas, for example, Diabetes.

RESEARCH

To be completed once used

On 1 February 2023, NHS Digital merged with NHS England. NHS England has assumed responsibility for all activities previously undertaken by NHS Digital. The merger was completed by a statute change. Any reference made to NHS Digital within this Data Sharing Agreement is in reference to the merged organisation known as NHS England.

The Health and Social Care Act 2022 has created 42 Integrated Care Boards (ICB). These are new legal entities which have replaced CCGs. The ICB will take on the NHS commissioning functions of CCGs as well as some of NHS England’s commissioning functions. It will also be accountable for NHS spend and performance within the system. Within each ICB geographical area, there will also be an Integrated Care Partnership (ICP), a joint committee which brings together the ICB and their partner local authorities, and other locally determined representatives (for example from health, social care, public health; and potentially others, such as social care or housing providers) to set local priorities and develop an integrated health and social care strategy.

ICP constituent members (other than the ICB) do not carry out data controllership activities and do not make decisions on sub-licensing.

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 Integrated Care Board (ICB) so the ICB is able to ensure that the patient is their responsibility and the activity claimed is correct. This is done by processing and analysing Invoice Validation Datasets, which are received into a secure Controlled Environment for Finance (CEfF). The identifiers included are in line with the CAG approval. The identifiers are only used to link and confirm the accuracy of backing-data sets (data from providers).

The ICB are advised by the appointed CEfF 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 (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.

In order to conduct, Risk Stratification Datasets, identifiable at the level of NHS number are 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 cohorts of patients who may require high levels of care. Risk Stratification also enables General Practitioners (GPs) to better target intervention in Primary Care.

COMMISSIONING

To use pseudonymised Commissioning Datasets 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 ICB area.

The ICBs 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 pseudonymised data is required to for the following purposes:

 Population health management

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

 Thoroughly investigating the needs of the population, to inform the commissioning or appropriate services for that population’s health needs

 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 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 – ensuring enough capacity to manage the demand by predicting the impact on certain care pathways.

 Support measuring the health and 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.

DIRECT CARE

In the development of cohorts of pseudonymised patients considered to be at risk, the data controllers may need the facility to provide identifiable results back to direct health or care professionals for the purpose of direct care. Additionally clinicians, made aware of a number of cases that they believe would need intervention may request re-identification for that direct care purpose. These instances of re-identification will generally be carried out as programmes of work or, separately, on an individual/small group basis as a result of coincidental findings. The ICB does not have a statutory function to provide direct care and as such, does not see the identifiable data.

NHS Digital provides a re-identification service for this process. All re-id requests will be processed and authorised by NHS Digital on a case by case basis, including requests under a sub-licence. 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. It is anticipated that this re-id ability in the future will allow risk stratification to be conducted under a single flow of pseudonymised data.

The following is a typical example of an instance where an ICB might want to use the re-identification process:

A&E High Attendance usage

The ICB can filter data to show for example the number of A&E attendances in a given period for each patient. The ICB 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.

INVOICE VALIDATION

1. Accurate budget reports.

2. Enable a system of communication that will enable the ICB to challenge invoices and raise discrepancies and disputes.

3. Reports on the accuracy of invoices.

4. 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.

5. Budget control of the ICB.

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.

The ICB will be provided with the pseudonymised outputs of the risk stratification tool for which they are able to:

1. Identify patient groups at risk of deterioration and providing effective care.

2. Set up capitated budgets – budgets based on care provided to the specific population.

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

4. Monitor vulnerable groups of patients including but not limited to frailty, COPD, Diabetes, elderly.

5. Health needs assessments – identifying numbers of patients with specific health conditions or combination of conditions.

6. Classify vulnerable groups based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost.

7. Production of Theographs – a visual timeline of a patients encounters with hospital providers.

8. Analyse based on specific diseases.

9. Aggregate reporting of number and percentage of population found to be at risk.

COMMISSIONING

1. Commissioner reporting on providers, finances, readmission analysis etc…

2. Production of aggregate reports for ICB Business Intelligence.

3. Production of project / programme level dashboards.

4. Monitoring of acute / community / mental health quality matrix.

5. Clinical coding reviews / audits.

6. Budget reporting down to individual GP Practice level.

7. GP Practice level dashboard reports.

8. Comparators of ICB performance with similar ICBs as set out by a specific range of care quality and performance measures detailed activity and cost reports.

9. Data Quality and Validation measures allowing data quality checks on the submitted data.

10. Contract Management and Modelling.

11. Patient Stratification dashboards to highlight cohorts of patients with similar conditions at risk.

12. Manage demand, by understanding the quantity of assessments required ICBs 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.

13. 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.

14. Compare providers (trusts) mortality outcomes to the national baseline.

15. Identify medication prescribing trends and their effectiveness.

16. Linking prescribing habits to entry points into the health and social care system.

17. Identify, quantify and understand cohorts of patient’s high numbers of different medications (polypharmacy).

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

DIRECT CARE

1. Reports and dashboards that highlight cohorts of patients that can be targeted for clinical intervention by direct health and care professionals.

2. Lists of at risk patients made available to direct health and care professionals that require direct care intervention.

3. Reports and dashboards to show the outcome of clinical intervention including patient outcomes and modelled transactional cost savings.

COMMISSIONING

Health data are used to collate and produce board reports on specific programmes and pathways of care, to monitor the quality of care delivered, assess delivery of targets, and monitor the impact of transformation schemes and improvement programmes based on agreed key performance indicators. These reports are utilised by programme transformation groups to take action where needed to support or improve services, and to drive decision making on development of new models of care.

INVOICE VALIDATION

Outputs from the processing of this data enables the ICB to validate invoices from providers and raise queries and formal disputes where appropriate (for example, around pricing or patient registration). This in turn supports both robust financial control and budgetary reporting at the ICB. Regular and ad hoc reporting of this data further enables the ICB to monitor provider performance against a number of key contractual metrics and targets (for instance, Elective Recovery performance) and support operational colleagues in making management decisions to enable improved provider and system-wide performance.

RISK STRATIFICATION

The ICB is using a medication-based risk stratification tool to identify patient who are likely to be put at risk of harm from their medication. The system is use for monitoring of the Medicines Optimisation Scheme. It is also used in relation to Quality Outcomes Framework (QOF)/Care Quality Commission (CQC) and specific therapeutic areas, for example, Diabetes.

On 1 February 2023, NHS Digital merged with NHS England. NHS England has assumed responsibility for all activities previously undertaken by NHS Digital. The merger was completed by a statute change. Any reference made to NHS Digital within this Data Sharing Agreement is in reference to the merged organisation known as NHS England.

The Health and Social Care Act 2022 has created 42 Integrated Care Boards (ICB). These are new legal entities which have replaced CCGs. The ICB will take on the NHS commissioning functions of CCGs as well as some of NHS England’s commissioning functions. It will also be accountable for NHS spend and performance within the system. Within each ICB geographical area, there will also be an Integrated Care Partnership (ICP), a joint committee which brings together the ICB and their partner local authorities, and other locally determined representatives (for example from health, social care, public health; and potentially others, such as social care or housing providers) to set local priorities and develop an integrated health and social care strategy.

ICP constituent members (other than the ICB) do not carry out data controllership activities and do not make decisions on sub-licensing.

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 Integrated Care Board (ICB) so the ICB is able to ensure that the patient is their responsibility and the activity claimed is correct. This is done by processing and analysing Invoice Validation Datasets, which are received into a secure Controlled Environment for Finance (CEfF). The identifiers included are in line with the CAG approval. The identifiers are only used to link and confirm the accuracy of backing-data sets (data from providers).

The ICB are advised by the appointed CEfF 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 (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.

In order to conduct, Risk Stratification Datasets, identifiable at the level of NHS number are 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 cohorts of patients who may require high levels of care. Risk Stratification also enables General Practitioners (GPs) to better target intervention in Primary Care.

COMMISSIONING

To use pseudonymised Commissioning Datasets 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 ICB area.

The ICBs 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 pseudonymised data is required to for the following purposes:

 Population health management

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

 Thoroughly investigating the needs of the population, to inform the commissioning or appropriate services for that population’s health needs

 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 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 – ensuring enough capacity to manage the demand by predicting the impact on certain care pathways.

 Support measuring the health and 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.

DIRECT CARE

In the development of cohorts of pseudonymised patients considered to be at risk, the data controllers may need the facility to provide identifiable results back to direct health or care professionals for the purpose of direct care. Additionally clinicians, made aware of a number of cases that they believe would need intervention may request re-identification for that direct care purpose. These instances of re-identification will generally be carried out as programmes of work or, separately, on an individual/small group basis as a result of coincidental findings. The ICB does not have a statutory function to provide direct care and as such, does not see the identifiable data.

NHS Digital provides a re-identification service for this process. All re-id requests will be processed and authorised by NHS Digital on a case by case basis, including requests under a sub-licence. 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. It is anticipated that this re-id ability in the future will allow risk stratification to be conducted under a single flow of pseudonymised data.

The following is a typical example of an instance where an ICB might want to use the re-identification process:

A&E High Attendance usage

The ICB can filter data to show for example the number of A&E attendances in a given period for each patient. The ICB 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.

INVOICE VALIDATION

1. Accurate budget reports.

2. Enable a system of communication that will enable the ICB to challenge invoices and raise discrepancies and disputes.

3. Reports on the accuracy of invoices.

4. 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.

5. Budget control of the ICB.

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.

The ICB will be provided with the pseudonymised outputs of the risk stratification tool for which they are able to:

1. Identify patient groups at risk of deterioration and providing effective care.

2. Set up capitated budgets – budgets based on care provided to the specific population.

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

4. Monitor vulnerable groups of patients including but not limited to frailty, COPD, Diabetes, elderly.

5. Health needs assessments – identifying numbers of patients with specific health conditions or combination of conditions.

6. Classify vulnerable groups based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost.

7. Production of Theographs – a visual timeline of a patients encounters with hospital providers.

8. Analyse based on specific diseases.

9. Aggregate reporting of number and percentage of population found to be at risk.

COMMISSIONING

1. Commissioner reporting on providers, finances, readmission analysis etc…

2. Production of aggregate reports for ICB Business Intelligence.

3. Production of project / programme level dashboards.

4. Monitoring of acute / community / mental health quality matrix.

5. Clinical coding reviews / audits.

6. Budget reporting down to individual GP Practice level.

7. GP Practice level dashboard reports.

8. Comparators of ICB performance with similar ICBs as set out by a specific range of care quality and performance measures detailed activity and cost reports.

9. Data Quality and Validation measures allowing data quality checks on the submitted data.

10. Contract Management and Modelling.

11. Patient Stratification dashboards to highlight cohorts of patients with similar conditions at risk.

12. Manage demand, by understanding the quantity of assessments required ICBs 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.

13. 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.

14. Compare providers (trusts) mortality outcomes to the national baseline.

15. Identify medication prescribing trends and their effectiveness.

16. Linking prescribing habits to entry points into the health and social care system.

17. Identify, quantify and understand cohorts of patient’s high numbers of different medications (polypharmacy).

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

DIRECT CARE

1. Reports and dashboards that highlight cohorts of patients that can be targeted for clinical intervention by direct health and care professionals.

2. Lists of at risk patients made available to direct health and care professionals that require direct care intervention.

3. Reports and dashboards to show the outcome of clinical intervention including patient outcomes and modelled transactional cost savings.

Yielded Benefits is not a requirement for new applications.