DSfC - NHS Bassetlaw CCG; RS, IV & Comm.
NHS Nottingham and Nottinghamshire ICB · Sub ICB Location
Listed under NHS Nottingham and Nottinghamshire Integrated Care Board.
Expired The latest version ended on 24 November 2024. The September 2026 register still lists the agreement, but its term has passed.
- Reference
- DARS-NIC-90700-V8P0C
- Latest version
- v6.2
- Term of latest version
- 3 May 2022 to 24 November 2024
- Start date
- Before 30 March 2019
- Data controller
- Sole Data Controller
- Commercial purposes
- No
- Sublicensing
- No
- Files released to date
- 0
Why the data was released
Objective for processing
Invoice Validation
Invoice validation is part of a process by which providers of care or services get paid for the work they do.
Invoices are submitted to the Clinical Commissioning Group (CCG) so the CCG is are able to ensure that the activity claimed for each patient is their responsibility. This is done by processing and analysing Secondary User Services (SUS+) data, which is received into a secure Controlled Environment for Finance (CEfF). The SUS+ data is identifiable at the level of NHS number. The NHS number is only used to confirm the accuracy of backing-data sets (data from providers) and will not be used further.
Invoice Validation will be conducted by NHS Rotherham CCG.
Bassetlaw CCG are advised by NHS Rotherham CCG whether payment for invoices can be made or not.
Risk Stratification
Risk stratification is a tool for identifying and predicting which patients are at high risk (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 Nottingham and Nottinghamshire CCG / Nottinghamshire Health Informatics Service (via the GP Repository for Clinical Care - GPRCC) & Prescribing Services Ltd.
Commissioning
To use pseudonymised data to provide intelligence to support the commissioning of health services. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the CCG area.
The CCGs commission services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.
The following pseudonymised datasets are required to provide intelligence to support commissioning of health services:
- Secondary Uses Service (SUS+)
- Local Provider Flows
o Acute
o Ambulance
o Community
o Demand for Service
o Diagnostic Service
o Emergency Care
o Experience, Quality and Outcomes
o Mental Health
o Other Not Elsewhere Classified
o Population Data
o Primary Care Services
o Public Health Screening
- Mental Health Minimum Data Set (MHMDS)
- Mental Health Learning Disability Data Set (MHLDDS)
- Mental Health Services Data Set (MHSDS)
- Maternity Services Data Set (MSDS)
- Improving Access to Psychological Therapy (IAPT)
- Child and Young People Health Service (CYPHS)
- Community Services Data Set (CSDS)
- Diagnostic Imaging Data Set (DIDS)
- National Cancer Waiting Times Monitoring Data Set (CWT)
- Civil Registries Data – Births and Deaths (CRD)
- National Diabetes Audit (NDA)
- Patient Reported Outcome Measures (PROMs)
- e-Referral Service (eRS)
- Personal Demographics Service (PDS)
- Summary Hospital-level Mortality Indicator (SHMI)
- Medicines Dispensed in Primary Care (NHSBSA Data)
- Adult Social Care Data
Processing of the Medicines Dispensed in Primary Care (NHSBSA Data) dataset is only permitted to provide intelligence about the safety and effectiveness of medicines, as specified by the NHS Business Services Authority (NHSBSA) Medicines Data Directions 2019.
The pseudonymised data is required to for the following purposes:
§ Population health management:
· Understanding the interdependency of care services
· Targeting care more effectively
§ 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 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 - to improve the care service for patients by predicting the impact on certain care pathways and support the secondary care system in ensuring enough capacity to manage the demand.
§ Support measuring the health, mortality or 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.
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 Bassetlaw CCG, North of England Commissioning Support Unit, Attain Health Management & NHS Doncaster CCG.
Processing activities
Data must only be used for the purposes stipulated within this Data Sharing Agreement. Any additional disclosure / publication will require further approval from NHS Digital.
Data Processors must only act upon specific instructions from the Data Controller.
Data can only be stored at the addresses listed under storage addresses.
All access to data is managed under Role-Based Access Controls. Users can only access data authorised by their role and the tasks that they are required to undertake.
Patient level data will not be linked other than as specifically detailed within this Data Sharing Agreement. Data released will only be shared with those parties listed and will only be used for the purposes laid out in the application/agreement.
NHS Digital reminds all organisations party to this agreement of the need to comply with the Data Sharing Framework Contract requirements, including those regarding the use (and purposes of that use) by “Personnel” (as defined within the Data Sharing Framework Contract ie: employees, agents and contractors of the Data Recipient who may have access to that data)
The DSCRO (part of NHS Digital) will apply National Opt-outs before any identifiable data leaves the DSCRO only for the purpose of Risk Stratification.
CCGs should work with general practices within their CCG to help them fulfil data controller responsibilities regarding flow of identifiable data into risk stratification tools.
The 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:
There is no requirement for the analytical teams to re-identify patients, but in the development of cohorts of patients considered to be at risk, the data controllers may need the facility to provide identifiable results back to direct healthcare professionals or local authority direct care staff only for the purpose of direct care. All re-id requests will be processed and authorised by the DSCRO on a case by case basis. 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.
An example of a request for the re-id of patients for direct care may be;
A&E High Attendance usage
The CCG can filter data to show for example the number of A&E attendances in a given period for each patient. The CCG 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.
Polypharmacy re-IDs
CCG's can request re-ID of a list of patients to be sent to the relevant GP with a high number of medications (ingredient count) and review the medication for these patients. This can help address the risk of polypharmacy which is recognised as an adverse risk factor for patient safety. A by-product of such reviews may be to reduce costs of medication.
The Re-identification process for direct care is as follows:
1. The CCG identifies a patient cohort (typically small numbers) to be re-identified for the purpose of direct care.
2. The CCG sends a re-id request to the DSCRO. This may be done through the CCG or CSU’s Business Intelligence (BI) Tool, or through a manual form.
3. The DSCRO (either through an automated system or manual checking in line with the request) assesses as to whether the request passes the specified re-identification process checks. Checks include if the requester is authorised to access identifiable data, if the number of patients in the cohort is appropriate, and that the request does not seem inappropriate or outside of expected parameters, including for example around timings and the requestor’s relationship with patients in the data
4. If successful/approved, the DSCRO re-identifies the relevant data item(s) for the appropriate patients and returns the identifiable fields to Health or care professional(s) with a legitimate relationship to the patient. The CCG does not see the identifiable record.
5. DSCROs retain an audit trail of all re-id requests
6. National Data opt outs are not applied for the purpose of direct care
Aggregated reports only with small number suppression can be shared externally as set out within NHS Digital guidance applicable to each data set.
SEGREGATION:
Where the Data Processor and/or the Data Controller hold both identifiable and pseudonymised data, the data will be held separately so data cannot be linked.
Where the Data Processor and/or the Data Controller hold identifiable data with opt outs applied and identifiable data with opt outs not applied, the data will be held separately so data cannot be linked.
All access to data is auditable by NHS Digital.
Data for the purpose of Invoice Validation is kept within the CEfF, and only used by staff properly trained and authorised for the activity. Only CEfF staff are able to access data in the CEfF and only CEfF staff operate the invoice validation process within the CEfF. Data flows directly in to the CEfF from the DSCRO and from the providers – it does not flow through any other processors.
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 NHS Bassetlaw 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 Bassetlaw 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 Bassetlaw 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 Bassetlaw CCG region (including historical activity where the patient was previously registered or resident in another commissioner
For the purpose of Invoice Validation:
• Patients who are resident and/or registered within the CCG region.
Invoice Validation
Data Processor - NHS Rotherham CCG
1. Identifiable SUS+ Data is obtained from the SUS+ Repository by the Data Services for Commissioners Regional Office (DSCRO).
2. The DSCRO pushes a one-way data flow of SUS+ data into the Controlled Environment for Finance (CEfF) located in NHS Rotherham CCG.
3. The CEfF also receive backing data from the provider.
4. The CEfF conduct the following processing activities for invoice validation purposes:
a. Validating that the Clinical Commissioning Group is responsible for payment for the care of the individual by using SUS+ and/or backing flow data.
b. Once the provider backing information is received, it will be checked against national NHS and local commissioning policies, as well as being checked against system access and reports provided by NHS Digital to confirm the payments are:
i. In line with Payment by Results tariffs
ii. In relation to a patient registered with the CCG, GP or resident within the CCG area.
iii. The health care provided should be paid by the CCG in line with CCG guidance.
5. The CCG are notified by the CEfF that the invoice has been validated and can be paid. Any discrepancies or non-validated invoices are investigated and resolved
Risk Stratification
Data Processor - NHS Nottingham and Nottinghamshire CCG / Nottinghamshire Health Informatics Service
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 NHIS, who securely hold the SUS+ data.
3. Identifiable GP Data is securely sent from the GP system to NHIS.
4. SUS+ data is linked to GP data in the risk stratification tool by the data processor.
5. NHS Nottingham and Nottinghamshire CCG host an electronic information portal with secure role-based access control. GPs have access to the data (exclusively through the portal) for patients with whom the GP has a legitimate direct care relationship. The portal shows the individual risk of admission scores, highlighting those patients classed as at risk. The only identifier available to GPs in the Risk Stratification data is the NHS number, and this is only shown for their own patients. Any further identification of the patients will be completed by the GP using their own systems.
6. Once NHIS has completed the processing, the CCG can access the online system via a secure connection to access the data pseudonymised at patient level.
Data Processor - Prescribing Services Ltd
1. Identifiable SUS+ data is obtained from the SUS Repository to the Data Services for Commissioners Regional Office (DSCRO).
2. Data quality management and standardisation of data is completed by the DSCRO and the data identifiable at the level of NHS number is transferred securely to Prescribing Services Ltd, who securely hold the SUS+ data.
3. Identifiable GP Data is securely sent from the GP system to Prescribing Services Ltd.
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 Prescribing Services Ltd has completed the processing, the CCG can access the online system via a secure connection to access the data pseudonymised at patient level.
Commissioning
The Data Services for Commissioners Regional Office (DSCRO) obtains the following data sets:
1. SUS+
2. Local Provider Flows (received directly from providers)
a. Acute
b. Ambulance
c. Community
d. Demand for Service
e. Diagnostic Service
f. Emergency Care
g. Experience, Quality and Outcomes
h. Mental Health
i. Other Not Elsewhere Classified
j. Population Data
k. Primary Care Services
l. Public Health Screening
3. Mental Health Minimum Data Set (MHMDS)
4. Mental Health Learning Disability Data Set (MHLDDS)
5. Mental Health Services Data Set (MHSDS)
6. Maternity Services Data Set (MSDS)
7. Improving Access to Psychological Therapy (IAPT)
8. Child and Young People Health Service (CYPHS)
9. Community Services Data Set (CSDS)
10. Diagnostic Imaging Data Set (DIDS)
11. National Cancer Waiting Times Monitoring Data Set (CWT)
12. Civil Registries Data (CRD) (Births)
13. Civil Registries Data (CRD) (Deaths)
14. National Diabetes Audit (NDA)
15. Patient Reported Outcome Measures (PROMs)
16. e-Referral Service (eRS)
17. Personal Demographics Service (PDS)
18. Summary Hospital-level Mortality Indicator (SHMI)
19. Medicines Dispensed in Primary Care (NHSBSA Data)
20. Adult Social Care Data
Data quality management and pseudonymisation is completed within the DSCRO and is then disseminated as follows:
Data Processors - North of England Commissioning Support Unit (NECSU), NHS Bassetlaw CCG & NHS Doncaster CCG.
1. Pseudonymised SUS+, Local Provider data, Mental Health data (MHSDS, MHMDS, MHLDDS), Maternity data (MSDS), Improving Access to Psychological Therapies data (IAPT), Child and Young People’s Health data (CYPHS), Community Services Data Set (CSDS), Diagnostic Imaging data (DIDS), National Cancer Waiting Times Monitoring Data Set (CWT), Civil Registries Data (CRD) (Births and Deaths), National Diabetes Audit (NDA), Patient Reported Outcome Measures (PROMs), e-Referral Service (eRS), Personal Demographics Service (PDS), Summary Hospital-level Mortality Indicator (SHMI), Medicines Dispensed in Primary Care (NHSBSA Data) and Adult Social Care data only is securely transferred from the DSCRO to North of England Commissioning Support Unit.
2. North of England Commissioning Support Unit add derived fields by using existing data, link data and provide analysis.
3. Allowed linkage is between the data sets contained within point 1 only.
4. North of England Commissioning Support Unit then pass the processed, pseudonymised and linked data to the CCGs (Bassetlaw & Doncaster).
5. Data is analysed 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. Understand cohorts of residents who are at risk
6. Bassetlaw CCG & Doncaster CCG then analyse the data to see patient journeys for pathways or service design, re-design and de-commissioning.
7. Aggregation of required data for CCG management use will be completed by North of England Commissioning Support Unit, or the CCG’s as instructed by the CCG.
8. 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.
9. The CCG securely transfer Pseudonymised data back to the provider to:
a. confirm how patients are reported in SUS, and how the commissioner can reliably group these patients into categories for points of delivery;
b. allow for granular data validation whereby a commissioner may query the SUS record, and need to pass it back to the provider for checking; and
c. to allow the provider to undertake further analysis of a cohort of their patients as requested and specified by the commissioner.
10. The data transferred to the provider is only that which relates directly to the data previously uploaded by that particular provider .
Data Processor 3 - Attain Health Management Services Ltd
1. Pseudonymised SUS+ and Local Provider data only is securely transferred from the DSCRO to North of England Commissioning Support Unit.
2. North of England Commissioning Support Unit add derived fields, link data and provide analysis.
3. North of England Commissioning Support Unit also receive Identifiable Social care data from providers.
4. This data is kept secure and separate from any other data and is pseudonymised once it has entered the CSU. Any identifiable data is then destroyed.
5. North of England Commissioning Support Unit then link and process the pseudonymised data and pass the processed, pseudonymised and linked data to Attain.
6. Attain add derived fields, link data and provide analysis to:
a. See patient journeys for pathways or service design, re-design and de-commissioning. More specifically: Attain provide consultancy support to the South Yorkshire and Bassetlaw Sustainable Transformation Partnership (SYB). A hospital services review has been carried out to look at certain pathways across the SYB footprint (e.g. Hyper Acute Stroke).
7. Allowed linkage is between the data sets contained within point 1.
8. Attain then pass the processed, pseudonymised and linked data to the CCG.
9. Aggregation of required data for CCG management use will be completed by Attain or the CCG as instructed 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.
Expected output
Invoice Validation
1. The Controlled Environment for Finance (CEfF) will enable the CCG to challenge invoices and raise discrepancies and disputes.
2. Outputs from the CEfF will enable accurate production of budget reports, which will:
a. Assist in addressing poor quality data issues
b. Assist in business intelligence
3. 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.
4. Budget control of the CCG.
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
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:
• Patients at highest risk of admission
• Most expensive patients (top 15%)
• Frail and elderly
• Patients that are currently in hospital
• Patients with most referrals to secondary care
• Patients with most emergency activity
• Patients with most expensive prescriptions
• Patients recently moving from one care setting to another
i. Discharged from hospital
ii. Discharged from community
13. Validation for payment approval, ability to validate that claims are not being made after an individual has died, like Oxygen services.
14. Validation of programs implemented to improve patient pathway e.g. High users unable to validate if the process to help patients find the best support are working or did the patient die.
15. Clinical - understand reasons why patients are dying, what additional support services can be put in to support.
16. Understanding where patients are dying e.g. are patients dying at hospitals due to hospices closing due to Local authorities withdrawing support or is there a problem at a particular trust.
17. Removal of patients from Risk Stratification reports.
18. Re births provide a one stop shop of information, Births are recorded in multiple sources covering hospital and home births, a chance to overlook activity.
19. Manage demand, by understanding the quantity of assessments required CCGs 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.
20. Monitor the timing of key actions relating to referral letters. CCG’s are unable to see the contents of the referral letters.
21. 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.
22. Allow Commissioners to better protect or improve the public health of the total local patient population
23. Allow Commissioners to plan, evaluate and monitor health and social care policies, services, or interventions for the total local patient population
24. Allow Commissioners to compare their providers (trusts) mortality outcomes to the national baseline.
25. Investigate mortality outcomes for trusts.
26. Identify medication prescribing trends and their effectiveness.
27. Linking prescribing habits to entry points into the health and social care system
28. Identify, quantify and understand cohorts of patient’s high numbers of different medications (polypharmacy)
29. Monitoring, at a population level, particular cohorts of service users and designing analytical models which support more effective interventions in health and adult social care
30. Monitoring service and integrated care outcomes across a pathway or care setting involving adult social care
Expected measurable benefits
Invoice Validation
The invoice validation process supports the ongoing delivery of patient care across the NHS and the CCG region by:
1. Ensuring that activity is fully financially validated.
2. Ensuring that service providers are accurately paid for the patients treatment.
3. Enabling services to be planned, commissioned, managed, and subjected to financial control.
4. Enabling commissioners to confirm that they are paying appropriately for treatment of patients for whom they are responsible.
5. Fulfilling commissioners duties to fiscal probity and scrutiny.
6. Ensuring full financial accountability for relevant organisations.
7. Ensuring robust commissioning and performance management.
8. Ensuring commissioning objectives do not compromise patient confidentiality.
9. Ensuring the avoidance of misappropriation of public funds.
Risk Stratification
Risk stratification promotes improved case management in primary care and will lead to the following benefits being realised:
1. Improved planning by better understanding patient flows through the healthcare system, thus allowing commissioners to design appropriate pathways to improve patient flow and allowing commissioners to identify priorities and identify plans to address these.
2. Improved quality of services through reduced emergency readmissions, especially avoidable emergency admissions. This is achieved through mapping of frequent users of emergency services thus allowing early intervention.
3. Improved access to services by identifying which services may be in demand but have poor access, and from this identify areas where improvement is required.
4. Supports the commissioner to meets its requirement to reduce premature mortality in line with the CCG Outcome Framework by allowing for more targeted intervention in primary care.
5. Better understanding of local population characteristics through analysis of their health and healthcare outcomes
All of the above lead to improved patient experience through more effective commissioning of services.
GPRCC (NHS Nottingham and Nottinghamshire CCG / NHIS)
Risk stratification promotes improved case management in primary care and will lead to the following benefits
being realised:
1. Improved planning by better understanding patient flows through the healthcare system, thus allowing
commissioners to design appropriate pathways to improve patient flow and allowing commissioners to identify
priorities and identify plans to address these.
2. Improved quality of services through reduced emergency readmissions, especially avoidable emergency
admissions. This is achieved through mapping of frequent users of emergency services thus allowing early
intervention.
3. Improved access to services by identifying which services may be in demand but have poor access, and from this
identify areas where improvement is required.
4. Supports the commissioner to meets its requirement to reduce premature mortality in line with the CCG
Outcome Framework by allowing for more targeted intervention in primary care.
5. Better understanding of local population characteristics through analysis of their health and healthcare
outcomes All of the above lead to improved patient experience through more effective commissioning of services.
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.
18. Allow reporting to drive changes and improve the quality of commissioned services and health outcomes for people.
19. Assists commissioners to make better decisions to support patients and drive changes in health care
20. Allows comparisons of providers performance to assist improvement in services – increase the quality
21. Allow analysis of health care provision to 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.
22. To evaluate the impact of new services and innovations (e.g. if commissioners implement a new service or type of procedure with a provider, they can evaluate whether it improves outcomes for patients compared to the previous one).
23. Monitoring of entire population, as opposed to only those that engage with services
24. Enable Commissioners to be able to see early indications of potential practice resilience issues in that an early warning marker can often be a trend of patients re-registering themselves at a neighbouring practice.
25. Monitor the quality and safety of the delivery of healthcare services.
26. Allow focused commissioning support based on factual data rather than assumed and projected sources
27. Understand admissions linked to overprescribing.
28. Add value to the population health management workstream by adding prescribing data into linked dataset for segmentation and stratification.
29. Developing, through evaluation of person-level data, more effective prevention strategies and interventions across a pathway or care setting involving adult social care
30. Designing and implementing new payment models across health and adult social care
31. Understanding current and future population needs and resource utilisation for local strategic planning and commissioning purposes including for health, social care and public health needs.
Benefits reported so far
Invoice Validation
Improved data quality;
Financial assurance and financial savings
Risk Stratification
Identification of patients at higher risk of hospital admission/readmission to prioritise the work of GP Practices
Community Care Teams;
Better understanding of patients' needs in order to plan and commission preventative services to support people living longer independently at home
The CCG has worked collaboratively with our local GPs and have implemented a number of care pathways including oxygen and blood pressure monitoring at home aiming to prevent hospital admissions, Long Covid Clinics supporting patient recovery and rehabilitation, Emergency Department in-reach including additional
mental health support within A&E, discharge to assess, working with Bassetlaw Community Voluntary Service in relation to social prescribing within the Emergency Department/discharge support for patients, Digital Inclusion, Mental Health Directory of Services), increased Mental Health Service provision including Crisis Sanctuaries, Bereavement services, Community Ophthalmology.
Datasets on the latest version
Legal basis for provision: Health and Social Care Act 2012 - s261 - 'Other dissemination of information'; Health and Social Care Act 2012 – s261(7); National Health Service Act 2006 - s251 - 'Control of patient information'.
| Dataset | Type of data | Sensitivity | Frequency | Confidential data |
|---|---|---|---|---|
| Acute-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Adult Social Care | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Ambulance-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Children and Young People Health | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Civil Registration - Births | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Civil Registrations of Death | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Community Services Data Set (CSDS) | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Community-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Demand for Service-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Diagnostic Imaging Data Set (DID) | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Diagnostic Services-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| e-Referral Service for Commissioning | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Emergency Care-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Experience, Quality and Outcomes-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Improving Access to Psychological Therapies (IAPT) v1.5 | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Maternity Services Data Set | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Medicines dispensed in Primary Care (NHSBSA data) | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Mental Health and Learning Disabilities Data Set (MHLDDS) | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Mental Health Minimum Data Set (MHMDS) | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Mental Health Services Data Set (MHSDS) | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Mental Health-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| National Cancer Waiting Times Monitoring DataSet (NCWTMDS) | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| National Diabetes Audit | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Other Not Elsewhere Classified (NEC)-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Patient Reported Outcome Measures (PROMs) | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Personal Demographic Service | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Population Data-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Primary Care Services-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Public Health and Screening Services-Local Provider Flows | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| Summary Hospital-level Mortality Indicator (SHMI) | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| SUS for Commissioners | Anonymised - ICO Code Compliant | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
| SUS for Commissioners | Identifiable | Sensitive | Frequent Adhoc Flow | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
Files released
Files released counts only files released externally by DARS. Access granted in NHS England's own systems, such as its Secure Data Environment, is not included.
No files recorded as released under this agreement.
Version history
The register lists each renewal of this agreement as a separate row. This site has 5 versions — earlier versions existed before this site's records begin.
DARS-NIC-90700-V8P0C-v6.2 3 May 2022 to 24 November 2024
- Title
- DSfC - NHS Bassetlaw CCG; RS, IV & Comm.
- Commercial
- No
- Sublicensing
- No
- Datasets
- 32
- Files released
- 0
Datasets: Acute-Local Provider Flows; Adult Social Care; Ambulance-Local Provider Flows; Children and Young People Health; Civil Registration - Births; Civil Registrations of Death; Community Services Data Set (CSDS); Community-Local Provider Flows; Demand for Service-Local Provider Flows; Diagnostic Imaging Data Set (DID); Diagnostic Services-Local Provider Flows; e-Referral Service for Commissioning; Emergency Care-Local Provider Flows; Experience, Quality and Outcomes-Local Provider Flows; Improving Access to Psychological Therapies (IAPT) v1.5; Maternity Services Data Set; Medicines dispensed in Primary Care (NHSBSA data); Mental Health and Learning Disabilities Data Set (MHLDDS); Mental Health Minimum Data Set (MHMDS); Mental Health Services Data Set (MHSDS); Mental Health-Local Provider Flows; National Cancer Waiting Times Monitoring DataSet (NCWTMDS); National Diabetes Audit; Other Not Elsewhere Classified (NEC)-Local Provider Flows; Patient Reported Outcome Measures (PROMs); Personal Demographic Service; Population Data-Local Provider Flows; Primary Care Services-Local Provider Flows; Public Health and Screening Services-Local Provider Flows; Summary Hospital-level Mortality Indicator (SHMI); SUS for Commissioners; SUS for Commissioners
What changed from DARS-NIC-90700-V8P0C-v5.2
Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.
| Field | Was | Became |
|---|---|---|
| Start date | 2022-05-03 | |
| End date | 2024-11-24 | |
| Acute-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Ambulance-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Children and Young People Health: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Civil Registration - Births: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Civil Registrations of Death: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Community Services Data Set (CSDS): legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Community-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Demand for Service-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Diagnostic Imaging Data Set (DID): legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Diagnostic Services-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Emergency Care-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Experience, Quality and Outcomes-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Improving Access to Psychological Therapies Data Set_v1.5: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Maternity Services Data Set v1.5: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Mental Health Minimum Data Set (MHMDS): legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Mental Health Services Data Set (MHSDS): legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Mental Health and Learning Disabilities Data Set (MHLDDS): legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Mental Health-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| National Cancer Waiting Times Monitoring DataSet (NCWTMDS): legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| National Diabetes Audit: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Other Not Elsewhere Classified (NEC)-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Patient Reported Outcome Measures (PROMs): legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Population Data-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Primary Care Services-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| Public Health and Screening Services-Local Provider Flows: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information' | |
| SUS for Commissioners: legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information'; Health and Social Care Act 2012 – s261(7); National Health Service Act 2006 - s251 - 'Control of patient information'. |
Datasets: + Adult Social Care; + Medicines dispensed in Primary Care (NHSBSA data); + Personal Demographic Service; + Summary Hospital-level Mortality Indicator (SHMI); + e-Referral Service for Commissioning
Objective for processing
[8 paragraphs unchanged]
Risk Stratification will be conducted by NHS Nottingham and Nottinghamshire CCG / Nottinghamshire Health Informatics Service (via the GP Repository for Clinical Care -
GPRCC).
GPRCC) & Prescribing Services Ltd.
[30 paragraphs unchanged]
- e-Referral Service (eRS)
- Personal Demographics Service (PDS)
- Summary Hospital-level Mortality Indicator (SHMI)
- Medicines Dispensed in Primary Care (NHSBSA Data)
- Adult Social Care Data
Processing of the Medicines Dispensed in Primary Care (NHSBSA Data) dataset is only permitted to provide intelligence about the safety and effectiveness of medicines, as specified by the NHS Business Services Authority (NHSBSA) Medicines Data Directions 2019.
[1 paragraph unchanged]
§
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
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
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
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
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
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
Service redesign
§ Health Needs Assessment – identification of underlying disease prevalence within the local population
Health Needs Assessment – identification of underlying 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
Patient stratification and predictive modelling - to identify specific patients at risk of requiring hospital admission and other avoidable factors such as risk of falls, computed using algorithms executed against linked de-identified data, and identification of future service delivery models
§ Demand Management - to improve the care service for patients by predicting the impact on certain care pathways and support the secondary care system in ensuring enough capacity to manage the demand.
§ Support measuring the health, mortality or 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.
[2 paragraphs unchanged]
Processing activities
[5 paragraphs unchanged]
NHS Digital reminds all organisations party to this agreement of the need
[17 words unchanged]
that use) by “Personnel” (as defined within the Data Sharing Framework Contract
i.e.:
ie:
employees, agents and contractors of the Data Recipient who may have access to that data)
[2 paragraphs unchanged]
The
only
identifier available in the data set is the NHS numbers. Any further
[14 words unchanged]
own systems for the purpose of direct care with a legitimate relationship.
Onward Sharing
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.
There is no requirement for the analytical teams to re-identify patients, but in the development of cohorts of patients considered to be at risk, the data controllers may need the facility to provide identifiable results back to direct healthcare professionals or local authority direct care staff only for the purpose of direct care. All re-id requests will be processed and authorised by the DSCRO on a case by case basis. 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.
An example of a request for the re-id of patients for direct care may be;
A&E High Attendance usage
The CCG can filter data to show for example the number of A&E attendances in a given period for each patient. The CCG 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.
Polypharmacy re-IDs
CCG's can request re-ID of a list of patients to be sent to the relevant GP with a high number of medications (ingredient count) and review the medication for these patients. This can help address the risk of polypharmacy which is recognised as an adverse risk factor for patient safety. A by-product of such reviews may be to reduce costs of medication.
The Re-identification process for direct care is as follows:
1. The CCG identifies a patient cohort (typically small numbers) to be re-identified for the purpose of direct care.
2. The CCG sends a re-id request to the DSCRO. This may be done through the CCG or CSU’s Business Intelligence (BI) Tool, or through a manual form.
3. The DSCRO (either through an automated system or manual checking in line with the request) assesses as to whether the request passes the specified re-identification process checks. Checks include if the requester is authorised to access identifiable data, if the number of patients in the cohort is appropriate, and that the request does not seem inappropriate or outside of expected parameters, including for example around timings and the requestor’s relationship with patients in the data
4. If successful/approved, the DSCRO re-identifies the relevant data item(s) for the appropriate patients and returns the identifiable fields to Health or care professional(s) with a legitimate relationship to the patient. The CCG does not see the identifiable record.
5. DSCROs retain an audit trail of all re-id requests
6. National Data opt outs are not applied for the purpose of direct care
[1 paragraph unchanged]
Segregation
SEGREGATION:
[28 paragraphs unchanged]
Risk Stratification
[7 paragraphs unchanged]
Data Processor - Prescribing Services Ltd
1. Identifiable SUS+ data is obtained from the SUS Repository to the Data Services for Commissioners Regional Office (DSCRO).
2. Data quality management and standardisation of data is completed by the DSCRO and the data identifiable at the level of NHS number is transferred securely to Prescribing Services Ltd, who securely hold the SUS+ data.
3. Identifiable GP Data is securely sent from the GP system to Prescribing Services Ltd.
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 Prescribing Services Ltd has completed the processing, the CCG can access the online system via a secure connection to access the data pseudonymised at patient level.
[29 paragraphs unchanged]
16. e-Referral Service (eRS)
17. Personal Demographics Service (PDS)
18. Summary Hospital-level Mortality Indicator (SHMI)
19. Medicines Dispensed in Primary Care (NHSBSA Data)
20. Adult Social Care Data
[2 paragraphs unchanged]
1. Pseudonymised SUS+, Local Provider data, Mental Health data (MHSDS, MHMDS, MHLDDS),
[32 words unchanged]
Set (CWT), Civil Registries Data (CRD) (Births and Deaths), National Diabetes Audit
(NDA) and
(NDA),
Patient Reported Outcome Measures
(PROMs)
(PROMs), e-Referral Service (eRS), Personal Demographics Service (PDS), Summary Hospital-level Mortality Indicator (SHMI), Medicines Dispensed in Primary Care (NHSBSA Data) and Adult Social Care data
only is securely transferred from the DSCRO to North of England Commissioning Support Unit.
[27 paragraphs unchanged]
In addition to the dissemination of Cancer Waiting Times Data via the DSCRO, the CCG is able to access reports held within the CWT system in NHS Digital directly. Access within the CCG is limited to those with a need to process the data for the purposes described in this agreement.
Expected output
[23 paragraphs unchanged]
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.
[40 paragraphs unchanged]
19. Manage demand, by understanding the quantity of assessments required CCGs 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.
20. Monitor the timing of key actions relating to referral letters. CCG’s are unable to see the contents of the referral letters.
21. 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.
22. Allow Commissioners to better protect or improve the public health of the total local patient population
23. Allow Commissioners to plan, evaluate and monitor health and social care policies, services, or interventions for the total local patient population
24. Allow Commissioners to compare their providers (trusts) mortality outcomes to the national baseline.
25. Investigate mortality outcomes for trusts.
26. Identify medication prescribing trends and their effectiveness.
27. Linking prescribing habits to entry points into the health and social care system
28. Identify, quantify and understand cohorts of patient’s high numbers of different medications (polypharmacy)
29. Monitoring, at a population level, particular cohorts of service users and designing analytical models which support more effective interventions in health and adult social care
30. Monitoring service and integrated care outcomes across a pathway or care setting involving adult social care
Expected measurable benefits
[68 paragraphs unchanged] 18. Allow reporting to drive changes and improve the quality of commissioned services and health outcomes for people. 19. Assists commissioners to make better decisions to support patients and drive changes in health care 20. Allows comparisons of providers performance to assist improvement in services – increase the quality 21. Allow analysis of health care provision to 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. 22. To evaluate the impact of new services and innovations (e.g. if commissioners implement a new service or type of procedure with a provider, they can evaluate whether it improves outcomes for patients compared to the previous one). 23. Monitoring of entire population, as opposed to only those that engage with services 24. Enable Commissioners to be able to see early indications of potential practice resilience issues in that an early warning marker can often be a trend of patients re-registering themselves at a neighbouring practice. 25. Monitor the quality and safety of the delivery of healthcare services. 26. Allow focused commissioning support based on factual data rather than assumed and projected sources 27. Understand admissions linked to overprescribing. 28. Add value to the population health management workstream by adding prescribing data into linked dataset for segmentation and stratification. 29. Developing, through evaluation of person-level data, more effective prevention strategies and interventions across a pathway or care setting involving adult social care 30. Designing and implementing new payment models across health and adult social care 31. Understanding current and future population needs and resource utilisation for local strategic planning and commissioning purposes including for health, social care and public health needs.
Benefits reported
[4 paragraphs unchanged]
Identification of patients at higher risk of hospital admission/readmission to prioritise the work of GP Practices
and
[1 paragraph unchanged]
Better understanding of patients' needs in order to plan and commission preventative services to support people
living longer independently at home
living longer independently at home
The CCG has worked collaboratively with our local GPs and have implemented a number of care pathways including oxygen and blood pressure monitoring at home aiming to prevent hospital admissions, Long Covid Clinics supporting patient recovery and rehabilitation, Emergency Department in-reach including additional
mental health support within A&E, discharge to assess, working with Bassetlaw Community Voluntary Service in relation to social prescribing within the Emergency Department/discharge support for patients, Digital Inclusion, Mental Health Directory of Services), increased Mental Health Service provision including Crisis Sanctuaries, Bereavement services, Community Ophthalmology.
DARS-NIC-90700-V8P0C-v5.2 1 April 2020 to 31 March 2023
- Title
- DSfC - NHS Bassetlaw CCG; RS, IV & Comm.
- Commercial
- No
- Sublicensing
- No
- Datasets
- 27
- Files released
- 0
Datasets: Acute-Local Provider Flows; Ambulance-Local Provider Flows; Children and Young People Health; Civil Registration - Births; Civil Registrations of Death; Community Services Data Set (CSDS); Community-Local Provider Flows; Demand for Service-Local Provider Flows; Diagnostic Imaging Data Set (DID); Diagnostic Services-Local Provider Flows; Emergency Care-Local Provider Flows; Experience, Quality and Outcomes-Local Provider Flows; Improving Access to Psychological Therapies (IAPT) v1.5; Maternity Services Data Set; Mental Health and Learning Disabilities Data Set (MHLDDS); Mental Health Minimum Data Set (MHMDS); Mental Health Services Data Set (MHSDS); Mental Health-Local Provider Flows; National Cancer Waiting Times Monitoring DataSet (NCWTMDS); National Diabetes Audit; Other Not Elsewhere Classified (NEC)-Local Provider Flows; Patient Reported Outcome Measures (PROMs); Population Data-Local Provider Flows; Primary Care Services-Local Provider Flows; Public Health and Screening Services-Local Provider Flows; SUS for Commissioners; SUS for Commissioners
What changed from DARS-NIC-90700-V8P0C-v4.7
Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.
| Field | Was | Became |
|---|---|---|
| Start date | 2020-04-01 | |
| End date | 2023-03-31 |
Objective for processing
[8 paragraphs unchanged]
Risk Stratification will be conducted by
The eMBED Health Consortium / Dr Foster Limited, &
NHS
Rushcliffe
Nottingham and Nottinghamshire
CCG / Nottinghamshire Health Informatics Service (via the GP Repository for Clinical Care - GPRCC).
After 31st March, once eMBED contract finishes, Risk Stratification will be carried out NHS Rushcliffe CCG and NHIS.
[44 paragraphs unchanged]
Processing for commissioning will be conducted
by NHS Bassetlaw CCG, North of England Commissioning Support Unit, the eMBED Health Consortium (Kier Business Services and Dr Foster Limited), Attain Health Management & NHS Doncaster CCG. Once the eMBED contract finishes on 31st March 2020, eMBED / Kier / Dr Foster will be removed from this list and processing for commissioning will be carried out
by NHS Bassetlaw CCG, North of England Commissioning Support Unit, Attain Health Management & NHS Doncaster CCG.
Processing activities
[29 paragraphs unchanged]
For clarity, any access by Pulsant, Telecity, Telstra and Calderdale and Huddersfield NHS Foundation Trust to 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.
[1 paragraph unchanged]
Data Processor
4
- NHS Rotherham CCG
[10 paragraphs unchanged]
Risk Stratification
Data Processor - NHS Nottingham and Nottinghamshire CCG / Nottinghamshire Health Informatics Service
The following processing activities are only permitted up to and including 31 March 2020, after which the eMBED Consortium (Kier Services and Dr Foster Limited) will be removed as a data processor and Risk Stratification will be provided by NHS Rushcliffe CCG and Nottinghamshire Health Informatics Service:
Data processor 2 - The eMBED Health Consortium (Kier Business Services and Dr Foster Limited)
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 eMBED Health Consortium (Kier Business Services and Dr Foster Limited), who hold the SUS+ data.
3. Identifiable GP Data is securely sent from the GP system to eMBED Health Consortium (Kier Business Services and Dr Foster Limited).
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 eMBED Health Consortium (Kier Business Services and Dr Foster Limited) has completed the processing, the CCG can access the online system via a secure connection to access the pseudonymised data at patient level.
Data Processor 5&6 - NHS Rushcliffe CCG / Nottinghamshire Health Informatics Service
[4 paragraphs unchanged]
5. NHS
Rushcliffe
Nottingham and Nottinghamshire
CCG host an electronic information portal with secure role-based access control. GPs
[65 words unchanged]
the patients will be completed by the GP using their own systems.
[31 paragraphs unchanged]
Data Processors - North of England Commissioning Support Unit (NECSU), the eMBED Health Consortium (Kier Business Services and Dr Foster Limited) & NHS Doncaster CCG. The eMBED Health Consortium will be removed as a data processor from the 31st March 2020 as that is when the contract finishes. NHS Doncaster CCG is going to be providing Business Intelligence Services as a replacement but need to be setup prior to end of eMBED contract as part of the transition activities.
1. Pseudonymised SUS+, Local Provider data, Mental Health data (MHSDS, MHMDS, MHLDDS), Maternity data (MSDS), Improving Access to Psychological Therapies data (IAPT), Child and Young People’s Health data (CYPHS), Community Services Data Set (CSDS), Diagnostic Imaging data (DIDS), National Cancer Waiting Times Monitoring Data Set (CWT), Civil Registries Data (CRD) (Births and Deaths), National Diabetes Audit (NDA) and Patient Reported Outcome Measures (PROMs) only is securely transferred from the DSCRO to North of England Commissioning Support Unit.
2. North of England Commissioning Support Unit add derived fields by using existing data, link data and provide analysis.
3. Allowed linkage is between the data sets contained within point 1 only.
4. North of England Commissioning Support Unit then pass the processed, pseudonymised and linked data to the CCG.
5. North of England Commissioning Support Unit also securely pass the pseudonymised data to the eMBED Health Consortium (Kier Business Services and Dr Foster Limited).
6. Data is analysed 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. Understand cohorts of residents who are at risk
7. The eMBED Health Consortium (Kier Business Services and Dr Foster Limited) then pass the processed, pseudonymised and linked data to the CCG.
8. The CCG then analyse the data to see patient journeys for pathways or service design, re-design and de-commissioning.
9. Aggregation of required data for CCG management use will be completed by North of England Commissioning Support Unit, the eMBED Health Consortium (Kier Business Services and Dr Foster Limited) or the CCG as instructed 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.
11. The CCG securely transfer Pseudonymised data back to the provider to:
a. confirm how patients are reported in SUS, and how the commissioner can reliably group these patients into categories for points of delivery;
b. allow for granular data validation whereby a commissioner may query the SUS record, and need to pass it back to the provider for checking; and
c. to allow the provider to undertake further analysis of a cohort of their patients as requested and specified by the commissioner.
12. The data transferred to the provider is only that which relates directly to the data previously uploaded by that particular provider.
After the 31st March 2020 activities will look as follows:
Data quality management and pseudonymisation is completed within the DSCRO and is then disseminated as follows:
[30 paragraphs unchanged]
Once Kier Business Services and Dr Foster (hosting eMBED) have ceased processing after 31 March 2020, the CCG must ensure that a data destruction certificate is submitted to NHS Digital covering both organisations within one month.
Expected measurable benefits
[19 paragraphs unchanged]
GPRCC (NHS
Rushcliffe
Nottingham and Nottinghamshire
CCG / NHIS)
[48 paragraphs unchanged]
Unchanged: Expected output, Benefits reported.
Objective for processing
Invoice Validation
Invoice validation is part of a process by which providers of care or services get paid for the work they do.
Invoices are submitted to the Clinical Commissioning Group (CCG) so the CCG is are able to ensure that the activity claimed for each patient is their responsibility. This is done by processing and analysing Secondary User Services (SUS+) data, which is received into a secure Controlled Environment for Finance (CEfF). The SUS+ data is identifiable at the level of NHS number. The NHS number is only used to confirm the accuracy of backing-data sets (data from providers) and will not be used further.
Invoice Validation will be conducted by NHS Rotherham CCG.
Bassetlaw CCG are advised by NHS Rotherham CCG whether payment for invoices can be made or not.
Risk Stratification
Risk stratification is a tool for identifying and predicting which patients are at high risk (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 Nottingham and Nottinghamshire CCG / Nottinghamshire Health Informatics Service (via the GP Repository for Clinical Care - GPRCC).
Commissioning
To use pseudonymised data to provide intelligence to support the commissioning of health services. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the CCG area.
The CCGs commission services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.
The following pseudonymised datasets are required to provide intelligence to support commissioning of health services:
- Secondary Uses Service (SUS+)
- Local Provider Flows
o Acute
o Ambulance
o Community
o Demand for Service
o Diagnostic Service
o Emergency Care
o Experience, Quality and Outcomes
o Mental Health
o Other Not Elsewhere Classified
o Population Data
o Primary Care Services
o Public Health Screening
- Mental Health Minimum Data Set (MHMDS)
- Mental Health Learning Disability Data Set (MHLDDS)
- Mental Health Services Data Set (MHSDS)
- Maternity Services Data Set (MSDS)
- Improving Access to Psychological Therapy (IAPT)
- Child and Young People Health Service (CYPHS)
- Community Services Data Set (CSDS)
- Diagnostic Imaging Data Set (DIDS)
- National Cancer Waiting Times Monitoring Data Set (CWT)
- Civil Registries Data – Births and Deaths (CRD)
- National Diabetes Audit (NDA)
- Patient Reported Outcome Measures (PROMs)
The pseudonymised data is required to for the following purposes:
Population health management:
• Understanding the interdependency of care services
• Targeting care more effectively
• Using value as the redesign principle
Data Quality and Validation – allowing data quality checks on the submitted data
Thoroughly investigating the needs of the population, to ensure the right services are available for individuals when and where they need them
Understanding cohorts of residents who are at risk of becoming users of some of the more expensive services, to better understand and manage those needs
Monitoring population health and care interactions to understand where people may slip through the net, or where the provision of care may be being duplicated
Modelling activity across all data sets to understand how services interact with each other, and to understand how changes in one service may affect flows through another
Service redesign
Health Needs Assessment – identification of underlying disease prevalence within the local population
Patient stratification and predictive modelling - to identify specific patients at risk of requiring hospital admission and other avoidable factors such as risk of falls, computed using algorithms executed against linked de-identified data, and identification of future service delivery models
The pseudonymised data is required to ensure that analysis of health care provision can be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets.
Processing for commissioning will be conducted by NHS Bassetlaw CCG, North of England Commissioning Support Unit, Attain Health Management & NHS Doncaster CCG.
Expected output
Invoice Validation
1. The Controlled Environment for Finance (CEfF) will enable the CCG to challenge invoices and raise discrepancies and disputes.
2. Outputs from the CEfF will enable accurate production of budget reports, which will:
a. Assist in addressing poor quality data issues
b. Assist in business intelligence
3. 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.
4. Budget control of the CCG.
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:
• Patients at highest risk of admission
• Most expensive patients (top 15%)
• Frail and elderly
• Patients that are currently in hospital
• Patients with most referrals to secondary care
• Patients with most emergency activity
• Patients with most expensive prescriptions
• Patients recently moving from one care setting to another
i. Discharged from hospital
ii. Discharged from community
13. Validation for payment approval, ability to validate that claims are not being made after an individual has died, like Oxygen services.
14. Validation of programs implemented to improve patient pathway e.g. High users unable to validate if the process to help patients find the best support are working or did the patient die.
15. Clinical - understand reasons why patients are dying, what additional support services can be put in to support.
16. Understanding where patients are dying e.g. are patients dying at hospitals due to hospices closing due to Local authorities withdrawing support or is there a problem at a particular trust.
17. Removal of patients from Risk Stratification reports.
18. Re births provide a one stop shop of information, Births are recorded in multiple sources covering hospital and home births, a chance to overlook activity.
Benefits reported
Invoice Validation
Improved data quality;
Financial assurance and financial savings
Risk Stratification
Identification of patients at higher risk of hospital admission/readmission to prioritise the work of GP Practices and
Community Care Teams;
Better understanding of patients' needs in order to plan and commission preventative services to support people
living longer independently at home
DARS-NIC-90700-V8P0C-v4.7 6 February 2020 to 5 February 2023
- Title
- DSfC - NHS Bassetlaw CCG; RS, IV & Comm.
- Commercial
- No
- Sublicensing
- No
- Datasets
- 27
- Files released
- 0
Datasets: Acute-Local Provider Flows; Ambulance-Local Provider Flows; Children and Young People Health; Civil Registration - Births; Civil Registrations of Death; Community Services Data Set (CSDS); Community-Local Provider Flows; Demand for Service-Local Provider Flows; Diagnostic Imaging Data Set (DID); Diagnostic Services-Local Provider Flows; Emergency Care-Local Provider Flows; Experience, Quality and Outcomes-Local Provider Flows; Improving Access to Psychological Therapies (IAPT) v1.5; Maternity Services Data Set; Mental Health and Learning Disabilities Data Set (MHLDDS); Mental Health Minimum Data Set (MHMDS); Mental Health Services Data Set (MHSDS); Mental Health-Local Provider Flows; National Cancer Waiting Times Monitoring DataSet (NCWTMDS); National Diabetes Audit; Other Not Elsewhere Classified (NEC)-Local Provider Flows; Patient Reported Outcome Measures (PROMs); Population Data-Local Provider Flows; Primary Care Services-Local Provider Flows; Public Health and Screening Services-Local Provider Flows; SUS for Commissioners; SUS for Commissioners
What changed from DARS-NIC-90700-V8P0C-v3.3
Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.
| Field | Was | Became |
|---|---|---|
| Start date | 2020-02-06 | |
| End date | 2023-02-05 | |
| SUS for Commissioners: legal basis | Health and Social Care Act 2012 – s261(2)(b)(ii); Health and Social Care Act 2012 – s261(7); National Health Service Act 2006 - s251 - 'Control of patient information'. |
Objective for processing
[8 paragraphs unchanged]
Risk Stratification will be conducted by The eMBED Health Consortium / Dr
[7 words unchanged]
Nottinghamshire Health Informatics Service (via the GP Repository for Clinical Care -
GPRCC)
GPRCC). After 31st March, once eMBED contract finishes, Risk Stratification will be carried out NHS Rushcliffe CCG and NHIS.
[44 paragraphs unchanged]
Processing for commissioning will be conducted by
NHS Bassetlaw CCG,
North of England Commissioning Support Unit,
The
the
eMBED Health Consortium (Kier Business Services and Dr Foster Limited), Attain Health
Management.
Management & NHS Doncaster CCG. Once the eMBED contract finishes on 31st March 2020, eMBED / Kier / Dr Foster will be removed from this list and processing for commissioning will be carried out by NHS Bassetlaw CCG, North of England Commissioning Support Unit, Attain Health Management & NHS Doncaster CCG.
Processing activities
[3 paragraphs unchanged]
All access to data is managed under Role-Based Access Controls. Users can only access data authorised by their
role.
role and the tasks that they are required to undertake.
Patient level data will not be linked other than as specifically detailed
[16 words unchanged]
will only be used for the purposes laid out in the application/agreement.
The data to be released from NHS Digital will not be national data.
NHS Digital reminds all organisations party to this agreement of the need
[17 words unchanged]
that use) by “Personnel” (as defined within the Data Sharing Framework Contract
ie:
i.e.:
employees, agents and contractors of the Data Recipient who may have access to that data)
[2 paragraphs unchanged]
(RS)
The only identifier available in the data set is the NHS numbers.
[16 words unchanged]
own systems for the purpose of direct care with a legitimate relationship.
[5 paragraphs unchanged]
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.
[2 paragraphs unchanged]
Data Minimisation in relation to the data sets listed within section 3 are listed below. This also includes the purpose on which they would be applied -
Data Minimisation
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 -
[1 paragraph unchanged]
• Patients who are normally registered and/or resident within NHS Bassetlaw CCG
region
(including historical activity where the patient was previously registered or resident in another commissioner).
[5 paragraphs unchanged]
• Patients who are normally registered and/or resident within
the
NHS Bassetlaw CCG
region
(including historical activity where the patient was previously registered or resident in another commissioner
[1 paragraph unchanged]
• CCG of residence and/or registration.
• Patients who are resident and/or registered within the CCG region.
For clarity, any access by Pulsant, Telecity,
Yeadon Community Health Centre,
Telstra and Calderdale and Huddersfield NHS Foundation Trust to data held under
[9 words unchanged]
agreement. This includes granting of access to the database[s] containing the data.
[3 paragraphs unchanged]
2. The DSCRO pushes a one-way data flow of SUS+ data into the Controlled Environment for Finance (CEfF) located in
the
NHS Rotherham CCG.
[3 paragraphs unchanged]
b. Once the
provider
backing information is received,
this
it
will be checked against national NHS and local commissioning
policies
policies,
as well as being checked against system access and reports provided by NHS Digital to confirm the payments are:
[1 paragraph unchanged]
ii. In relation to a patient registered with the
CCG
CCG,
GP or resident within the CCG area.
[3 paragraphs unchanged]
The following processing activities are only permitted up to and including 31 March 2020, after which the eMBED Consortium (Kier Services and Dr Foster Limited) will be removed as a data processor and Risk Stratification will be provided by NHS Rushcliffe CCG and Nottinghamshire Health Informatics Service:
[2 paragraphs unchanged]
2. Data quality management and standardisation of data is completed by the
[18 words unchanged]
Consortium (Kier Business Services and Dr Foster Limited), who hold the SUS+
data within the secure Data Centre on N3.
data.
3. Identifiable GP Data is securely sent from the GP system to
the
eMBED Health Consortium (Kier Business Services and Dr Foster Limited).
[2 paragraphs unchanged]
6. Once
the
eMBED Health Consortium (Kier Business Services and Dr Foster Limited) has completed the processing, the CCG can access the online system via a secure connection to access the
pseudonymised
data
pseudonymised
at patient level.
Data Processor
5&6 -
NHS Rushcliffe CCG / Nottinghamshire Health Informatics Service
[1 paragraph unchanged]
2. Data quality management and standardisation of data is completed by the
[5 words unchanged]
at the level of NHS number is transferred securely to NHIS, who
securely
hold the SUS+
data within the secure Data Centre on N3.
data.
[3 paragraphs unchanged]
6. Access by NHIS is only for identification and authentication. NHIS host the risk stratification system that holds SUS data and access is limited to those administrative staff with authorised user accounts and only substantive employees of the organisation. Data stored for risk stratification purposes is stored separately from other data and this cannot be linked to other data.
6. Once NHIS has completed the processing, the CCG can access the online system via a secure connection to access the data pseudonymised at patient level.
7. Access by NHS Rushcliffe CCG, who host the secure electronic information portal, is limited to those administrative staff with authorised user accounts used for identification and authentication.
8. Once NHIS has completed the processing, the CCG can access the online system via a secure connection to access the data pseudonymised at patient level.
[24 paragraphs unchanged]
11. National Cancer Waiting Times
Monitoring Data Set
(CWT)
12. Civil Registries Data
– Births and Deaths
(CRD)
(Births)
13. National Diabetes Audit (NDA)
13. Civil Registries Data (CRD) (Deaths)
14. Patient Reported Outcome Measures (PROMs)
14. National Diabetes Audit (NDA)
15. Patient Reported Outcome Measures (PROMs)
[1 paragraph unchanged]
Data Processor 1 and 2 – North of England Commissioning Support Unit (NECSU) and the eMBED Health Consortium (Kier Business Services and Dr Foster Limited).
Data Processors - North of England Commissioning Support Unit (NECSU), the eMBED Health Consortium (Kier Business Services and Dr Foster Limited) & NHS Doncaster CCG. The eMBED Health Consortium will be removed as a data processor from the 31st March 2020 as that is when the contract finishes. NHS Doncaster CCG is going to be providing Business Intelligence Services as a replacement but need to be setup prior to end of eMBED contract as part of the transition activities.
1)
1.
Pseudonymised SUS+, Local Provider data, Mental Health data (MHSDS, MHMDS, MHLDDS), Maternity data (MSDS), Improving Access to Psychological Therapies data (IAPT), Child and Young People’s Health data (CYPHS),
Community Services Data Set (CSDS), Diagnostic Imaging data (DIDS),
National Cancer Waiting Times Monitoring Data Set (CWT),
Community Services Data Set (CWT). Diagnostic Imaging data (DIDS),
Civil Registries Data
– Births
(CRD) (Births
and
Deaths (CRD),
Deaths),
National Diabetes Audit (NDA) and Patient Reported Outcome Measures (PROMs) only is securely transferred from the DSCRO to North of England Commissioning Support Unit.
2)
2.
North of England Commissioning Support Unit add derived
fields,
fields by using existing data,
link data and provide analysis.
3)
3.
Allowed linkage is between the data sets contained within point 1 only.
4)
4.
North of England Commissioning Support Unit then pass the processed, pseudonymised and linked data to the CCG.
5)
5.
North of England Commissioning Support Unit also securely pass the pseudonymised data to the eMBED Health Consortium (Kier Business Services and Dr Foster Limited).
6)
6.
Data is analysed to:
[3 paragraphs unchanged]
7)
7.
The eMBED Health Consortium (Kier Business Services and Dr Foster Limited) then pass the processed, pseudonymised and linked data to the CCG.
8)
8.
The CCG then analyse the data to see patient journeys for pathways or service design, re-design and de-commissioning.
9)
9.
Aggregation of required data for CCG management use will be completed by North of England Commissioning Support Unit, the eMBED Health Consortium (Kier Business Services and Dr Foster
Limited)or
Limited) or
the CCG as instructed by the CCG.
10)
10.
Patient level data will not be shared outside of the CCG and
[21 words unchanged]
Sharing Agreement. External aggregated reports only with small number suppression can be
shared.
shared as set out within NHS Digital guidance applicable to each data set.
11)
11.
The CCG securely transfer Pseudonymised data back to the provider to:
a)
a.
confirm how patients are reported in SUS, and how the commissioner can reliably group these patients into categories for points of delivery;
b)
b.
allow for granular data validation whereby a commissioner may query the SUS record, and need to pass it back to the provider for checking; and
c)
c.
to allow the provider to undertake further analysis of a cohort of their patients as requested and specified by the commissioner.
12.
The data transferred to the provider is only that which relates directly to the data previously uploaded by that particular provider.
After the 31st March 2020 activities will look as follows:
Data quality management and pseudonymisation is completed within the DSCRO and is then disseminated as follows:
Data Processors - North of England Commissioning Support Unit (NECSU), NHS Bassetlaw CCG & NHS Doncaster CCG.
1. Pseudonymised SUS+, Local Provider data, Mental Health data (MHSDS, MHMDS, MHLDDS), Maternity data (MSDS), Improving Access to Psychological Therapies data (IAPT), Child and Young People’s Health data (CYPHS), Community Services Data Set (CSDS), Diagnostic Imaging data (DIDS), National Cancer Waiting Times Monitoring Data Set (CWT), Civil Registries Data (CRD) (Births and Deaths), National Diabetes Audit (NDA) and Patient Reported Outcome Measures (PROMs) only is securely transferred from the DSCRO to North of England Commissioning Support Unit.
2. North of England Commissioning Support Unit add derived fields by using existing data, link data and provide analysis.
3. Allowed linkage is between the data sets contained within point 1 only.
4. North of England Commissioning Support Unit then pass the processed, pseudonymised and linked data to the CCGs (Bassetlaw & Doncaster).
5. Data is analysed 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. Understand cohorts of residents who are at risk
6. Bassetlaw CCG & Doncaster CCG then analyse the data to see patient journeys for pathways or service design, re-design and de-commissioning.
7. Aggregation of required data for CCG management use will be completed by North of England Commissioning Support Unit, or the CCG’s as instructed by the CCG.
8. 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.
9. The CCG securely transfer Pseudonymised data back to the provider to:
a. confirm how patients are reported in SUS, and how the commissioner can reliably group these patients into categories for points of delivery;
b. allow for granular data validation whereby a commissioner may query the SUS record, and need to pass it back to the provider for checking; and
c. to allow the provider to undertake further analysis of a cohort of their patients as requested and specified by the commissioner.
10. The data transferred to the provider is only that which relates directly to the data previously uploaded by that particular provider .
[4 paragraphs unchanged]
4.
This data is kept secure and separate from any other data and is pseudonymised once it has entered the CSU. Any identifiable data is then destroyed.
4.
5.
North of England Commissioning Support Unit then link and process the pseudonymised data and pass the processed, pseudonymised and linked data to Attain.
5.
6.
Attain add derived fields, link data and provide analysis to:
a. See patient journeys for pathways or service design, re-design and de-commissioning. More specifically: Attain provide consultancy support to the South Yorkshire and Bassetlaw Sustainable Transformation Partnership
(SYB)
(SYB).
A hospital services review has been carried out to look at certain pathways across the SYB footprint
(eg
(e.g.
Hyper Acute Stroke).
6.
7.
Allowed linkage is between the data sets contained within point 1.
7.
8.
Attain then pass the processed, pseudonymised and linked data to the CCG.
8.
9.
Aggregation of required data for CCG management use will be completed by Attain or the CCG as instructed by the CCG.
9.
10.
Patient level data will not be shared outside of the CCG and
[34 words unchanged]
as set out within NHS Digital guidance applicable to each data set.
In addition to the dissemination of Cancer Waiting Times Data via the DSCRO, the CCG is able to access reports held within the CWT system in NHS Digital directly. Access within the CCG is limited to those with a need to process the data for the purposes described in this agreement.
Once Kier Business Services and Dr Foster (hosting eMBED) have ceased processing after 31 March 2020, the CCG must ensure that a data destruction certificate is submitted to NHS Digital covering both organisations within one month.
Expected output
[16 paragraphs unchanged]
8. Set up capitated
budgets.
budgets – budgets based on care provided to the specific population.
[4 paragraphs unchanged]
13. Production of Theographs
– a visual timeline of a patients encounters with hospital providers.
14. Analyse based on specific
diseases.
diseases
[1 paragraph unchanged]
-
•
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.
GPRCC (Rushcliffe / NHIS)
1. As part of the risk stratification processing activity detailed above, GPs have access to the risk stratification tool which highlights patients for whom the GP is responsible and have been classed as at risk. The only identifier available to GPs is the NHS numbers of their own patients. Any further identification of the patients will be completed by the GP on their own systems.
2. Output from the risk stratification tool will provide aggregate reporting of number and percentage of population found to be at risk.
3. Record level output will be available for commissioners (of the CCG), pseudonymised at patient level.
4. GP Practices will be able to view the risk scores for individual patients with the ability to display the underlying SUS+ data for the individual patients when it is required for direct care purposes by someone who has a legitimate relationship with the patient.
5. The CCG will be able to target specific patient groups and enable clinicians with the duty of care for the patient to offer appropriate interventions. The CCG will also be able to:
o Stratify populations based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost
o Plan work for commissioning services and contracts
o Set up capitated budgets
o Identify health determinants of risk of admission to hospital, or other adverse care outcomes.
[24 paragraphs unchanged]
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
[5 paragraphs unchanged]
16. Understanding where patients are dying e.g. are patients dying at hospitals due to hospices closing due to Local authorities withdrawing
support,
support
or is there a problem at a particular trust.
[2 paragraphs unchanged]
Benefits reported
[6 paragraphs unchanged]
Better understanding of
patients
patients'
needs in order to plan and commission preventative services to support people
[1 paragraph unchanged]
Unchanged: Expected measurable benefits.
Objective for processing
Invoice Validation
Invoice validation is part of a process by which providers of care or services get paid for the work they do.
Invoices are submitted to the Clinical Commissioning Group (CCG) so the CCG is are able to ensure that the activity claimed for each patient is their responsibility. This is done by processing and analysing Secondary User Services (SUS+) data, which is received into a secure Controlled Environment for Finance (CEfF). The SUS+ data is identifiable at the level of NHS number. The NHS number is only used to confirm the accuracy of backing-data sets (data from providers) and will not be used further.
Invoice Validation will be conducted by NHS Rotherham CCG.
Bassetlaw CCG are advised by NHS Rotherham CCG whether payment for invoices can be made or not.
Risk Stratification
Risk stratification is a tool for identifying and predicting which patients are at high risk (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 The eMBED Health Consortium / Dr Foster Limited, & NHS Rushcliffe CCG / Nottinghamshire Health Informatics Service (via the GP Repository for Clinical Care - GPRCC). After 31st March, once eMBED contract finishes, Risk Stratification will be carried out NHS Rushcliffe CCG and NHIS.
Commissioning
To use pseudonymised data to provide intelligence to support the commissioning of health services. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the CCG area.
The CCGs commission services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.
The following pseudonymised datasets are required to provide intelligence to support commissioning of health services:
- Secondary Uses Service (SUS+)
- Local Provider Flows
o Acute
o Ambulance
o Community
o Demand for Service
o Diagnostic Service
o Emergency Care
o Experience, Quality and Outcomes
o Mental Health
o Other Not Elsewhere Classified
o Population Data
o Primary Care Services
o Public Health Screening
- Mental Health Minimum Data Set (MHMDS)
- Mental Health Learning Disability Data Set (MHLDDS)
- Mental Health Services Data Set (MHSDS)
- Maternity Services Data Set (MSDS)
- Improving Access to Psychological Therapy (IAPT)
- Child and Young People Health Service (CYPHS)
- Community Services Data Set (CSDS)
- Diagnostic Imaging Data Set (DIDS)
- National Cancer Waiting Times Monitoring Data Set (CWT)
- Civil Registries Data – Births and Deaths (CRD)
- National Diabetes Audit (NDA)
- Patient Reported Outcome Measures (PROMs)
The pseudonymised data is required to for the following purposes:
Population health management:
• Understanding the interdependency of care services
• Targeting care more effectively
• Using value as the redesign principle
Data Quality and Validation – allowing data quality checks on the submitted data
Thoroughly investigating the needs of the population, to ensure the right services are available for individuals when and where they need them
Understanding cohorts of residents who are at risk of becoming users of some of the more expensive services, to better understand and manage those needs
Monitoring population health and care interactions to understand where people may slip through the net, or where the provision of care may be being duplicated
Modelling activity across all data sets to understand how services interact with each other, and to understand how changes in one service may affect flows through another
Service redesign
Health Needs Assessment – identification of underlying disease prevalence within the local population
Patient stratification and predictive modelling - to identify specific patients at risk of requiring hospital admission and other avoidable factors such as risk of falls, computed using algorithms executed against linked de-identified data, and identification of future service delivery models
The pseudonymised data is required to ensure that analysis of health care provision can be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets.
Processing for commissioning will be conducted by NHS Bassetlaw CCG, North of England Commissioning Support Unit, the eMBED Health Consortium (Kier Business Services and Dr Foster Limited), Attain Health Management & NHS Doncaster CCG. Once the eMBED contract finishes on 31st March 2020, eMBED / Kier / Dr Foster will be removed from this list and processing for commissioning will be carried out by NHS Bassetlaw CCG, North of England Commissioning Support Unit, Attain Health Management & NHS Doncaster CCG.
Expected output
Invoice Validation
1. The Controlled Environment for Finance (CEfF) will enable the CCG to challenge invoices and raise discrepancies and disputes.
2. Outputs from the CEfF will enable accurate production of budget reports, which will:
a. Assist in addressing poor quality data issues
b. Assist in business intelligence
3. 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.
4. Budget control of the CCG.
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:
• Patients at highest risk of admission
• Most expensive patients (top 15%)
• Frail and elderly
• Patients that are currently in hospital
• Patients with most referrals to secondary care
• Patients with most emergency activity
• Patients with most expensive prescriptions
• Patients recently moving from one care setting to another
i. Discharged from hospital
ii. Discharged from community
13. Validation for payment approval, ability to validate that claims are not being made after an individual has died, like Oxygen services.
14. Validation of programs implemented to improve patient pathway e.g. High users unable to validate if the process to help patients find the best support are working or did the patient die.
15. Clinical - understand reasons why patients are dying, what additional support services can be put in to support.
16. Understanding where patients are dying e.g. are patients dying at hospitals due to hospices closing due to Local authorities withdrawing support or is there a problem at a particular trust.
17. Removal of patients from Risk Stratification reports.
18. Re births provide a one stop shop of information, Births are recorded in multiple sources covering hospital and home births, a chance to overlook activity.
Benefits reported
Invoice Validation
Improved data quality;
Financial assurance and financial savings
Risk Stratification
Identification of patients at higher risk of hospital admission/readmission to prioritise the work of GP Practices and
Community Care Teams;
Better understanding of patients' needs in order to plan and commission preventative services to support people
living longer independently at home
DARS-NIC-90700-V8P0C-v3.3 15 June 2019 to 14 June 2022
- Title
- DSfC - NHS Bassetlaw CCG; RS, IV & Comm.
- Commercial
- No
- Sublicensing
- No
- Datasets
- 27
- Files released
- 0
Datasets: Acute-Local Provider Flows; Ambulance-Local Provider Flows; Children and Young People Health; Civil Registration - Births; Civil Registrations of Death; Community Services Data Set (CSDS); Community-Local Provider Flows; Demand for Service-Local Provider Flows; Diagnostic Imaging Data Set (DID); Diagnostic Services-Local Provider Flows; Emergency Care-Local Provider Flows; Experience, Quality and Outcomes-Local Provider Flows; Improving Access to Psychological Therapies (IAPT) v1.5; Maternity Services Data Set; Mental Health and Learning Disabilities Data Set (MHLDDS); Mental Health Minimum Data Set (MHMDS); Mental Health Services Data Set (MHSDS); Mental Health-Local Provider Flows; National Cancer Waiting Times Monitoring DataSet (NCWTMDS); National Diabetes Audit; Other Not Elsewhere Classified (NEC)-Local Provider Flows; Patient Reported Outcome Measures (PROMs); Population Data-Local Provider Flows; Primary Care Services-Local Provider Flows; Public Health and Screening Services-Local Provider Flows; SUS for Commissioners; SUS for Commissioners
What changed from DARS-NIC-90700-V8P0C-v2.11
Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.
| Field | Was | Became |
|---|---|---|
| Start date | 2019-06-15 | |
| End date | 2022-06-14 | |
| Acute-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Ambulance-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Children and Young People Health: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Civil Registration - Births: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Civil Registrations of Death: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Community Services Data Set (CSDS): common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Community-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Demand for Service-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Diagnostic Imaging Data Set (DID): common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Diagnostic Services-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Emergency Care-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Experience, Quality and Outcomes-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Improving Access to Psychological Therapies Data Set_v1.5: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Maternity Services Data Set v1.5: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Mental Health Minimum Data Set (MHMDS): common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Mental Health Services Data Set (MHSDS): common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Mental Health and Learning Disabilities Data Set (MHLDDS): common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Mental Health-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| National Cancer Waiting Times Monitoring DataSet (NCWTMDS): common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Other Not Elsewhere Classified (NEC)-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Population Data-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Primary Care Services-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| Public Health and Screening Services-Local Provider Flows: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) | |
| SUS for Commissioners: legal basis | Health and Social Care Act 2012 – s261(2)(b)(ii); Health and Social Care Act 2012 – s261(7) | |
| SUS for Commissioners: common law duty of confidentiality | Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s) |
Datasets: + National Diabetes Audit; + Patient Reported Outcome Measures (PROMs)
Objective for processing
[2 paragraphs unchanged]
Invoices are submitted to the Clinical Commissioning Group (CCG) so
they
the CCG is
are able to ensure that the activity claimed for each patient is
[37 words unchanged]
NHS number is only used to confirm the accuracy of backing-data sets
(data from providers)
and will not be used further.
Invoice Validation
with
will
be conducted by NHS Rotherham CCG.
[2 paragraphs unchanged]
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
[23 words unchanged]
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
[5 words unchanged]
also enables General Practitioners (GPs) to better target intervention in Primary Care.
Risk Stratification will be conducted by The eMBED Health Consortium / Dr Foster
Limited.
Limited, & NHS Rushcliffe CCG / Nottinghamshire Health Informatics Service (via the GP Repository for Clinical Care - GPRCC)
[26 paragraphs unchanged]
- National Cancer Waiting Times Monitoring Data Set (CWT)
[1 paragraph unchanged]
- National Diabetes Audit (NDA)
- Patient Reported Outcome Measures (PROMs)
[15 paragraphs unchanged]
Processing activities
Data must only be used
as
for the purposes
stipulated within this Data Sharing Agreement.
Any additional disclosure / publication will require further approval from NHS Digital.
[2 paragraphs unchanged]
Patient level data will not be shared outside of the CCG unless it is for the purpose of Direct Care, where it may be shared only with those health professionals who have a legitimate relationship with the patient and a legitimate reason to access the data.
All access to data is managed under Role-Based Access Controls. Users can only access data authorised by their role.
All access to data is managed under Roles-Based Access Controls
Patient level data will not be linked other than as specifically detailed within this Data Sharing Agreement. Data released will only be shared with those parties listed and will only be used for the purposes laid out in the application/agreement. The data to be released from NHS Digital will not be national data.
No patient level data will be linked other than as specifically detailed within this agreement. Data will only be shared with those parties listed and will only be used for the purposes laid out in the application/agreement. The data to be released from NHS Digital will not be national data, but only that data relating to the specific locality and that data required by the applicant.
[3 paragraphs unchanged]
(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.
[20 paragraphs unchanged]
3. The CEfF conduct the following processing activities for invoice validation purposes:
3. The CEfF also receive backing data from the provider.
4. The CEfF conduct the following processing activities for invoice validation purposes:
[5 paragraphs unchanged]
4.
5.
The CCG are notified by the CEfF that the invoice has been validated and can be paid. Any discrepancies or non-validated invoices are investigated and resolved
[8 paragraphs unchanged]
Data Processor NHS Rushcliffe CCG / Nottinghamshire Health Informatics Service
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 NHIS, who hold the SUS+ data within the secure Data Centre on N3.
3. Identifiable GP Data is securely sent from the GP system to NHIS.
4. SUS+ data is linked to GP data in the risk stratification tool by the data processor.
5. NHS Rushcliffe CCG host an electronic information portal with secure role-based access control. GPs have access to the data (exclusively through the portal) for patients with whom the GP has a legitimate direct care relationship. The portal shows the individual risk of admission scores, highlighting those patients classed as at risk. The only identifier available to GPs in the Risk Stratification data is the NHS number, and this is only shown for their own patients. Any further identification of the patients will be completed by the GP using their own systems.
6. Access by NHIS is only for identification and authentication. NHIS host the risk stratification system that holds SUS data and access is limited to those administrative staff with authorised user accounts and only substantive employees of the organisation. Data stored for risk stratification purposes is stored separately from other data and this cannot be linked to other data.
7. Access by NHS Rushcliffe CCG, who host the secure electronic information portal, is limited to those administrative staff with authorised user accounts used for identification and authentication.
8. Once NHIS has completed the processing, the CCG can access the online system via a secure connection to access the data pseudonymised at patient level.
[26 paragraphs unchanged]
13. National Diabetes Audit (NDA)
14. Patient Reported Outcome Measures (PROMs)
[2 paragraphs unchanged]
1) Pseudonymised SUS+, Local Provider data, Mental Health data (MHSDS, MHMDS, MHLDDS),
[21 words unchanged]
Monitoring Data Set (CWT), Community Services Data Set (CWT). Diagnostic Imaging data
(DIDS) and
(DIDS),
Civil Registries Data – Births and Deaths
(CRD)
(CRD), National Diabetes Audit (NDA) and Patient Reported Outcome Measures (PROMs)
only is securely transferred from the DSCRO to North of England Commissioning Support Unit.
[29 paragraphs unchanged]
Expected output
[26 paragraphs unchanged] GPRCC (Rushcliffe / NHIS) 1. As part of the risk stratification processing activity detailed above, GPs have access to the risk stratification tool which highlights patients for whom the GP is responsible and have been classed as at risk. The only identifier available to GPs is the NHS numbers of their own patients. Any further identification of the patients will be completed by the GP on their own systems. 2. Output from the risk stratification tool will provide aggregate reporting of number and percentage of population found to be at risk. 3. Record level output will be available for commissioners (of the CCG), pseudonymised at patient level. 4. GP Practices will be able to view the risk scores for individual patients with the ability to display the underlying SUS+ data for the individual patients when it is required for direct care purposes by someone who has a legitimate relationship with the patient. 5. The CCG will be able to target specific patient groups and enable clinicians with the duty of care for the patient to offer appropriate interventions. The CCG will also be able to: o Stratify populations based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost o Plan work for commissioning services and contracts o Set up capitated budgets o Identify health determinants of risk of admission to hospital, or other adverse care outcomes. [34 paragraphs unchanged] 13. Validation for payment approval, ability to validate that claims are not being made after an individual has died, like Oxygen services. 14. Validation of programs implemented to improve patient pathway e.g. High users unable to validate if the process to help patients find the best support are working or did the patient die. 15. Clinical - understand reasons why patients are dying, what additional support services can be put in to support. 16. Understanding where patients are dying e.g. are patients dying at hospitals due to hospices closing due to Local authorities withdrawing support, or is there a problem at a particular trust. 17. Removal of patients from Risk Stratification reports. 18. Re births provide a one stop shop of information, Births are recorded in multiple sources covering hospital and home births, a chance to overlook activity.
Expected measurable benefits
[10 paragraphs unchanged] 9. Ensuring the avoidance of misappropriation of public funds. [8 paragraphs unchanged] GPRCC (NHS Rushcliffe CCG / NHIS) Risk stratification promotes improved case management in primary care and will lead to the following benefits being realised: 1. Improved planning by better understanding patient flows through the healthcare system, thus allowing commissioners to design appropriate pathways to improve patient flow and allowing commissioners to identify priorities and identify plans to address these. 2. Improved quality of services through reduced emergency readmissions, especially avoidable emergency admissions. This is achieved through mapping of frequent users of emergency services thus allowing early intervention. 3. Improved access to services by identifying which services may be in demand but have poor access, and from this identify areas where improvement is required. 4. Supports the commissioner to meets its requirement to reduce premature mortality in line with the CCG Outcome Framework by allowing for more targeted intervention in primary care. 5. Better understanding of local population characteristics through analysis of their health and healthcare outcomes All of the above lead to improved patient experience through more effective commissioning of services. [30 paragraphs unchanged] 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.
Benefits reported
Not stated in the previous version; added here.
Invoice Validation
Improved data quality;
Financial assurance and financial savings
Risk Stratification
Identification of patients at higher risk of hospital admission/readmission to prioritise the work of GP Practices and
Community Care Teams;
Better understanding of patients needs in order to plan and commission preventative services to support people
living longer independently at home
Objective for processing
Invoice Validation
Invoice validation is part of a process by which providers of care or services get paid for the work they do.
Invoices are submitted to the Clinical Commissioning Group (CCG) so the CCG is are able to ensure that the activity claimed for each patient is their responsibility. This is done by processing and analysing Secondary User Services (SUS+) data, which is received into a secure Controlled Environment for Finance (CEfF). The SUS+ data is identifiable at the level of NHS number. The NHS number is only used to confirm the accuracy of backing-data sets (data from providers) and will not be used further.
Invoice Validation will be conducted by NHS Rotherham CCG.
Bassetlaw CCG are advised by NHS Rotherham CCG whether payment for invoices can be made or not.
Risk Stratification
Risk stratification is a tool for identifying and predicting which patients are at high risk (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 The eMBED Health Consortium / Dr Foster Limited, & NHS Rushcliffe CCG / Nottinghamshire Health Informatics Service (via the GP Repository for Clinical Care - GPRCC)
Commissioning
To use pseudonymised data to provide intelligence to support the commissioning of health services. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the CCG area.
The CCGs commission services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.
The following pseudonymised datasets are required to provide intelligence to support commissioning of health services:
- Secondary Uses Service (SUS+)
- Local Provider Flows
o Acute
o Ambulance
o Community
o Demand for Service
o Diagnostic Service
o Emergency Care
o Experience, Quality and Outcomes
o Mental Health
o Other Not Elsewhere Classified
o Population Data
o Primary Care Services
o Public Health Screening
- Mental Health Minimum Data Set (MHMDS)
- Mental Health Learning Disability Data Set (MHLDDS)
- Mental Health Services Data Set (MHSDS)
- Maternity Services Data Set (MSDS)
- Improving Access to Psychological Therapy (IAPT)
- Child and Young People Health Service (CYPHS)
- Community Services Data Set (CSDS)
- Diagnostic Imaging Data Set (DIDS)
- National Cancer Waiting Times Monitoring Data Set (CWT)
- Civil Registries Data – Births and Deaths (CRD)
- National Diabetes Audit (NDA)
- Patient Reported Outcome Measures (PROMs)
The pseudonymised data is required to for the following purposes:
Population health management:
• Understanding the interdependency of care services
• Targeting care more effectively
• Using value as the redesign principle
Data Quality and Validation – allowing data quality checks on the submitted data
Thoroughly investigating the needs of the population, to ensure the right services are available for individuals when and where they need them
Understanding cohorts of residents who are at risk of becoming users of some of the more expensive services, to better understand and manage those needs
Monitoring population health and care interactions to understand where people may slip through the net, or where the provision of care may be being duplicated
Modelling activity across all data sets to understand how services interact with each other, and to understand how changes in one service may affect flows through another
Service redesign
Health Needs Assessment – identification of underlying disease prevalence within the local population
Patient stratification and predictive modelling - to identify specific patients at risk of requiring hospital admission and other avoidable factors such as risk of falls, computed using algorithms executed against linked de-identified data, and identification of future service delivery models
The pseudonymised data is required to ensure that analysis of health care provision can be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets.
Processing for commissioning will be conducted by North of England Commissioning Support Unit, The eMBED Health Consortium (Kier Business Services and Dr Foster Limited), Attain Health Management.
Expected output
Invoice Validation
1. The Controlled Environment for Finance (CEfF) will enable the CCG to challenge invoices and raise discrepancies and disputes.
2. Outputs from the CEfF will enable accurate production of budget reports, which will:
a. Assist in addressing poor quality data issues
b. Assist in business intelligence
3. 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.
4. Budget control of the CCG.
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.
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
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.
GPRCC (Rushcliffe / NHIS)
1. As part of the risk stratification processing activity detailed above, GPs have access to the risk stratification tool which highlights patients for whom the GP is responsible and have been classed as at risk. The only identifier available to GPs is the NHS numbers of their own patients. Any further identification of the patients will be completed by the GP on their own systems.
2. Output from the risk stratification tool will provide aggregate reporting of number and percentage of population found to be at risk.
3. Record level output will be available for commissioners (of the CCG), pseudonymised at patient level.
4. GP Practices will be able to view the risk scores for individual patients with the ability to display the underlying SUS+ data for the individual patients when it is required for direct care purposes by someone who has a legitimate relationship with the patient.
5. The CCG will be able to target specific patient groups and enable clinicians with the duty of care for the patient to offer appropriate interventions. The CCG will also be able to:
o Stratify populations based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost
o Plan work for commissioning services and contracts
o Set up capitated budgets
o Identify health determinants of risk of admission to hospital, or other adverse care outcomes.
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
13. Validation for payment approval, ability to validate that claims are not being made after an individual has died, like Oxygen services.
14. Validation of programs implemented to improve patient pathway e.g. High users unable to validate if the process to help patients find the best support are working or did the patient die.
15. Clinical - understand reasons why patients are dying, what additional support services can be put in to support.
16. Understanding where patients are dying e.g. are patients dying at hospitals due to hospices closing due to Local authorities withdrawing support, or is there a problem at a particular trust.
17. Removal of patients from Risk Stratification reports.
18. Re births provide a one stop shop of information, Births are recorded in multiple sources covering hospital and home births, a chance to overlook activity.
Benefits reported
Invoice Validation
Improved data quality;
Financial assurance and financial savings
Risk Stratification
Identification of patients at higher risk of hospital admission/readmission to prioritise the work of GP Practices and
Community Care Teams;
Better understanding of patients needs in order to plan and commission preventative services to support people
living longer independently at home
DARS-NIC-90700-V8P0C-v2.11 30 March 2019 to 29 March 2022
- Title
- DSfC - NHS Bassetlaw CCG; RS, IV & Comm.
- Commercial
- No
- Sublicensing
- No
- Datasets
- 25
- Files released
- 0
Datasets: Acute-Local Provider Flows; Ambulance-Local Provider Flows; Children and Young People Health; Civil Registration - Births; Civil Registrations of Death; Community Services Data Set (CSDS); Community-Local Provider Flows; Demand for Service-Local Provider Flows; Diagnostic Imaging Data Set (DID); Diagnostic Services-Local Provider Flows; Emergency Care-Local Provider Flows; Experience, Quality and Outcomes-Local Provider Flows; Improving Access to Psychological Therapies (IAPT) v1.5; Maternity Services Data Set; Mental Health and Learning Disabilities Data Set (MHLDDS); Mental Health Minimum Data Set (MHMDS); Mental Health Services Data Set (MHSDS); Mental Health-Local Provider Flows; National Cancer Waiting Times Monitoring DataSet (NCWTMDS); Other Not Elsewhere Classified (NEC)-Local Provider Flows; Population Data-Local Provider Flows; Primary Care Services-Local Provider Flows; Public Health and Screening Services-Local Provider Flows; SUS for Commissioners; SUS for Commissioners
Objective for processing
Invoice Validation
Invoice validation is part of a process by which providers of care or services get paid for the work they do.
Invoices are submitted to the Clinical Commissioning Group (CCG) so they are able to ensure that the activity claimed for each patient is their responsibility. This is done by processing and analysing Secondary User Services (SUS+) data, which is received into a secure Controlled Environment for Finance (CEfF). The SUS+ data is identifiable at the level of NHS number. The NHS number is only used to confirm the accuracy of backing-data sets and will not be used further.
Invoice Validation with be conducted by NHS Rotherham CCG.
Bassetlaw CCG are advised by NHS Rotherham CCG whether payment for invoices can be made or not.
Risk Stratification
Risk stratification is a tool for identifying and predicting which patients are at high risk or are likely to be at high risk and prioritising the management of their care in order to prevent worse outcomes.
To conduct risk stratification Secondary User Services (SUS+) data, identifiable at the level of NHS number is linked with Primary Care data (from GPs) and an algorithm is applied to produce risk scores. Risk Stratification provides focus for future demands by enabling commissioners to prepare plans for patients. Commissioners can then prepare plans for patients who may require high levels of care. Risk Stratification also enables General Practitioners (GPs) to better target intervention in Primary Care.
Risk Stratification will be conducted by The eMBED Health Consortium / Dr Foster Limited.
Commissioning
To use pseudonymised data to provide intelligence to support the commissioning of health services. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the CCG area.
The CCGs commission services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.
The following pseudonymised datasets are required to provide intelligence to support commissioning of health services:
- Secondary Uses Service (SUS+)
- Local Provider Flows
o Acute
o Ambulance
o Community
o Demand for Service
o Diagnostic Service
o Emergency Care
o Experience, Quality and Outcomes
o Mental Health
o Other Not Elsewhere Classified
o Population Data
o Primary Care Services
o Public Health Screening
- Mental Health Minimum Data Set (MHMDS)
- Mental Health Learning Disability Data Set (MHLDDS)
- Mental Health Services Data Set (MHSDS)
- Maternity Services Data Set (MSDS)
- Improving Access to Psychological Therapy (IAPT)
- Child and Young People Health Service (CYPHS)
- Community Services Data Set (CSDS)
- Diagnostic Imaging Data Set (DIDS)
- Civil Registries Data – Births and Deaths (CRD)
The pseudonymised data is required to for the following purposes:
Population health management:
• Understanding the interdependency of care services
• Targeting care more effectively
• Using value as the redesign principle
Data Quality and Validation – allowing data quality checks on the submitted data
Thoroughly investigating the needs of the population, to ensure the right services are available for individuals when and where they need them
Understanding cohorts of residents who are at risk of becoming users of some of the more expensive services, to better understand and manage those needs
Monitoring population health and care interactions to understand where people may slip through the net, or where the provision of care may be being duplicated
Modelling activity across all data sets to understand how services interact with each other, and to understand how changes in one service may affect flows through another
Service redesign
Health Needs Assessment – identification of underlying disease prevalence within the local population
Patient stratification and predictive modelling - to identify specific patients at risk of requiring hospital admission and other avoidable factors such as risk of falls, computed using algorithms executed against linked de-identified data, and identification of future service delivery models
The pseudonymised data is required to ensure that analysis of health care provision can be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets.
Processing for commissioning will be conducted by North of England Commissioning Support Unit, The eMBED Health Consortium (Kier Business Services and Dr Foster Limited), Attain Health Management.
Expected output
Invoice Validation
1. The Controlled Environment for Finance (CEfF) will enable the CCG to challenge invoices and raise discrepancies and disputes.
2. Outputs from the CEfF will enable accurate production of budget reports, which will:
a. Assist in addressing poor quality data issues
b. Assist in business intelligence
3. 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.
4. Budget control of the CCG.
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.
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
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
Register history
When this agreement appeared in, or was edited in, each monthly edition of the register. Built by comparing every edition this site holds, the earliest of which is July 2021.
-
July 2021 —
already listed in the earliest edition this site holds, so it may be older. 4 versions: DARS-NIC-90700-V8P0C-v2.11, DARS-NIC-90700-V8P0C-v3.3, DARS-NIC-90700-V8P0C-v4.7, DARS-NIC-90700-V8P0C-v5.2
-
June 2022
1 version added: DARS-NIC-90700-V8P0C-v6.2
-
October 2022
Succeeded Applicant organisation: NHS Bassetlaw CCG succeeded by NHS Nottingham and Nottinghamshire ICB from 1 July 2022, according to NHS ODS. Not counted as a change.Succeeded Data controllers: NHS Bassetlaw CCG succeeded by NHS Nottingham and Nottinghamshire ICB from 1 July 2022, according to NHS ODS. Not counted as a change.
-
December 2022
Register-wide edit DARS-NIC-90700-V8P0C-v2.11, DARS-NIC-90700-V8P0C-v3.3, DARS-NIC-90700-V8P0C-v4.7, DARS-NIC-90700-V8P0C-v5.2 — Datasets: legal basis: “
s261(1) and” taken out. Made to 639 agreements in this edition, so it is reported once, on the changes page, and not counted as an amendment of this agreement.
Cite this page
NHS England (2026) Data Uses Register, September 2026 edition, agreement DARS-NIC-90700-V8P0C, “DSfC - NHS Bassetlaw CCG; RS, IV & Comm.”. Read via NHS Data Access Explorer (unofficial), https://healthdatauses.uk/agreements/dars-nic-90700-v8p0c/ (accessed [date]).
This address stays the same, but the page is rebuilt with each monthly edition, so the citation names the edition it shows. Every edition's data is kept in the facts store.
Source: datausesregister_september2026.xlsx, September 2026 edition of the NHS England Data Uses Register. Search that workbook for DARS-NIC-90700-V8P0C to see the original rows.