With specialised commissioning growing at a rapid pace and requiring some of the most costly interventions, the reliance on advanced data analysis to understand, monitor and manage care is increasing.
Specialised commissioning has grown at a faster pace than the core services commissioned by Clinical Commissioning Groups (CCGs). In the last four years alone, the budget for specialised commissioning services has grown from £13.5 billion in 2014/15, to £17.6 billion in 2018/19.1,2 This level of growth puts greater responsibility on the NHS to monitor and manage the impact of services and treatments which can benefit patients. This is where Business Intelligence (BI) has an important role to play—not just in understanding activity and its financial implications, but in supporting the commissioning and delivery of care.
The high value, low volume services covered by specialised commissioning have traditionally been commissioned by NHS England, with much of the service delivery taking place in specialist tertiary care centres. Patient pathways are often fragmented, with multiple contracts and separate arrangements in place with different providers across the country. When faced with so many variables, managing the finances to make sure they balance is crucial. The pressure to identify significant quality, innovation, productivity, and prevention (QIPP) savings is ever present, and yet negotiating power can be limited when dealing with such highly specialised, low volume treatments.
The pressure to identify significant quality, innovation, productivity, and prevention (QIPP) savings is ever present
Providing commissioners with the data and analysis to enable them to manage these complex contracts and identify QIPP savings is a core BI service. This requires significant number crunching—processing large volumes of data to show what treatments are being applied where, to whom and with what outcomes.
That need was the rationale behind the creation of the National Commissioning Data Repository (NCDR) which NHS England commissioned in 2014/15 financial year. The NCDR, built and hosted by NHS Arden & GEM CSU, provides comprehensive information on a wide range of commissioning and clinical data which is used across the country to support specialised commissioning. The system enables commissioners to:
- explain potentially unwanted variation
- explore clinical pathways
- flag non-contracted services
- improve data quality
- identify QIPP opportunities
- manage healthcare provider contracts.
This central database brings together a wide range of data including Commissioning Data Sets (CDS) submitted to Secondary Uses Service (SUS Plus), Aggregate Contract Monitoring, Patient Level Contract Monitoring, Drugs and Device MDS information. The database enables event linkage at a patient level, allowing the clinical pathway experienced by the patient to be monitored. It provides a single source of truth, enabling commissioners to collaborate on specialised commissioning across STP footprints, track trends, benchmark performance and make informed decisions. To date, the NCDR has been used to identify and deliver millions of pounds in savings within specialised commissioning and is a vital tool in managing contracts against budgets and intended outcomes.
Using analytics to understand specialist conditions
As data science becomes more advanced, we are now able to apply analytics beyond the numbers, to assess clinical data and develop a deeper understanding of specialist conditions, to improve patient outcomes and deliver more cost-effective treatments.
This is already having a positive impact on NHS England’s programme to eliminate viral hepatitis C by 2025 (see Box 1). By drawing together a range of tools and techniques, we have been able to provide accurate information about patients with chronic hepatitis C and the effectiveness of treatments. The quality of the data and the advanced analysis we are able to apply has not only enabled NHS England to monitor and assess the effectiveness of treatments, but has informed a strategic procurement with pharmaceutical companies to expand available treatments and assist in case finding within the community.
Capturing outcome information for specialised services is key and is one of the most challenging elements of building a clinical registry. Access to information is often difficult because of stringent governance arrangements which have to be in place to protect patient data. However, in the case of the hepatitis C project—as with all high cost specialised commissioning—outcome data is vital in determining progression with eradicating the disease. By working with clinicians to build a more detailed understanding of how BI can validate commissioning decisions, support specialist procurement and quantify treatment success, the value of these purpose-built registries is becoming clearer, helping to break down barriers to sharing information.
From number crunching to better patient care
The Long Term Plan sets out ambitious targets for the NHS covering a wide range of service areas. One of its key principles is to move care towards prevention, with support from population health analysis. Policy makers have recognised that the separation between local and national commissioning has, in some areas, impacted opportunities to intervene at an earlier stage in certain conditions, reducing opportunities to avoid the need for specialist care. However, there is now a move to enable integration of Specialised Commissioning into place-based care planning, with local Sustainability and Transformation Partnerships and Integrated Care Systems sharing responsibility for patient outcomes with NHS England.3
As the NHS becomes more skilled at data analysis, so the opportunities to improve specialised commissioning increase. Population health analysis allows us to combine complex sets of data to accurately predict likely outcomes and plan services accordingly. This is particularly important for services where patient outcomes may not be straightforward.
Understanding clinical requirements
One of the challenges for the NHS is the sheer scale of data available and the many options for analysis. This has been an important consideration for us in building portals such as the NCDR and clinical registries such as the hepatitis C patient registry and treatment outcome system. These solutions must be intuitive to use if we are to enable time-pressured clinicians and commissioners to benefit from them.
Engaging with intended user groups as we develop a new system enables us to design it in a way which allows people to access dashboards and reports across a range of common requirements. This was particularly evident during the unveiling of the NCDR—specialist commissioners and clinicians could immediately see how the tool would support their decision-making. But it’s also about making smart choices as new systems are developed. The system behind the hepatitis C patient registry and treatment outcome system can be adapted relatively easily to suit different requirements, opening up opportunities to support other specialised commissioning initiatives.
With the move towards place-based care and shared commissioning for specialised services, we need to make best use of the advanced data collection and analysis tools that combine financial and operational reporting together with clinical and patient reported outcomes. While crunching the numbers to manage contract performance and overall spend remains a priority, there are exciting developments in advanced BI which can help shift the focus of specialised commissioning towards prevention and improved service planning, in line with the NHS Long Term Plan.
Box 1: Hepatitis C case study
Hepatitis C is a blood-borne virus affecting the liver. Four-fifths of those infected develop chronic hepatitis C, which can cause fatal cirrhosis and liver cancer if untreated.4 However, hepatitis C is preventable, treatable and curable for the majority of patients.
The NHS England national Hepatitis C (HCV) programme aims to eliminate viral hepatitis, by 2025, through increasing diagnosis and treatment rates, promoting joined-up working across the commissioning pathway and preventing new infections.
Arden & GEM was commissioned to create a national clinical registry and patient outcome treatment system to hold information on:
- patients engaging with secondary care services following confirmed diagnosis of chronic hepatitis C
- patient treatment, from commencement to cure
- treatment outcomes and instances of retreatment.
Working closely with clinical experts in the field and front line administrative we developed a clinical system that minimises administration while ensuring that the data collected delivers against sophisticated reporting requirements.
Data collection was incentivised by NHS England offering a Commissioning for Quality and Innovation (CQUIN) to healthcare providers to encourage population of the system.
The hepatitis C patient registry and treatment outcome system is enabling the oversight of patients with HCV, their infection history and the setting in which they are engaging with care. This is enabling the creation of new clinical service models, for example developing a ‘test and treat’ service for the more chaotic patient cohort.
According to a report by Public Health England, the registry contained more than 32,600 entries for over 32,400 people by the end of April 2018.6 This data has helped Public Health England (PHE) to better understand the sociodemographic, infection and clinical characteristics of people in England who have been diagnosed with chronic HCV and have accessed treatment services. The report also found 95% of people who received and completed hepatitis C treatment have been cured of the serious and potentially life-threatening infection in the last 3 years.6
Over the past year, PHE has updated the modelled estimates of chronic prevalence, and the numbers diagnosed. Latest figures estimate around 113,000 are chronically infected with hepatitis C7—down from original estimates of 160,000.
Latest figures estimate around 113,000 are chronically infected with hepatitis C
The registry data is also informing a national strategic procurement exercise to secure large volume of treatments at a competitive price which will deliver cost efficiencies. Information and analysis about the success of treatments is enabling the adjustment of treatment regimens (where appropriate) to maximise effectiveness and minimise duration.
Built to be adaptable, the system is currently being modified for use by Armed Forces intervention and mental health services in their support of veterans.
The hepatitis C patient registry and treatment outcome system is the only one of its kind in the world. This application is becoming a pivotal information system, supporting the interaction of all agencies involved in the diagnosis, treatment, monitoring, and cure of patients with hepatitis C in England.
- NHS England. Allocation of resources to NHS England and the commissioning sector for 2014/15 and 2015/16. NHS England, 2013. Available at: england.nhs.uk/wp-content/uploads/2013/12/bm-item7.pdf
- NHS England. Allocation of resources to NHS England and the commissioning sector for 2019/20 to 2023/24. NHS England, 2019. Available at: england.nhs.uk/wp-content/uploads/2019/01/04-pb-31-01-2019-ccg-allocations-board-paper.pdf
- NHS England. Preparing for 2019/20 operational planning and contracting: annex E—integration of specialised services with local health and care systems. NHS England, 2019. Available at: england.nhs.uk/wp-content/uploads/2018/12/ANNEXE1.pdf
- The Hepatitis C Trust. Speak up for elimination: General Election 2017. The Hepatitis C Trust, 2017. Available at: hepctrust.org.uk/sites/default/files/General%20election%20manifesto.pdf
- Harris R, Ramsay M, Hope V et al. Hepatitis C prevalence in England remains low and varies by ethnicity: an updated evidence synthesis. Eur J Public Health, 2012; 22 (2): 187–192.
- Harris H, Costella A, Mandal S and contributors. Hepatitis C treatment monitoring in England: Content, completeness and preliminary findings from the Hepatitis C patient registry and treatment outcome system. London: Public Health England, 2018. Available at: gov.uk/government/publications/hepatitis-c-treatment-monitoring-in-england
- Harris H, Costella A, Harris R, Mandal S and contributors. Hepatitis C in England 2019—working to eliminate hepatitis C as a major public health threat. Public Health England, 2019. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/793584/HCV_in_England_2019_report.pdf