Opportunities and
Challenges of SUS
Roger Dewhurst
Director of Operations, Information Centre for
health and social care
What are “secondary”
uses ?
 A considerable amount of information is collected
during the provision of care and supporting services
 The primary purpose of this information is to support
and improve individual patient care
 However, this information is of value for many other
purposes to support healthcare and providing
appropriate steps are taken to meet confidentiality
obligations, this information can legitimately be used to
support these other purposes.
These are called “secondary uses”
[amended from CRDB Secondary Uses Report, August 2007]
Primary and Secondary
Uses
Operational
Direct Care
Business
Operations
Commissioning Analysis /
Service Planning
Strategic /
Policy / Research
Examples of characteristics of requirements
•Individual records
•Selected “lists” of records
•Immediate access
•Dynamic, up to date
•Workflow, rules based alerts
Identifiable
• Frequent abstracts
•Focus on classes
of persons
•Time series
•Short time intervals
•Prospective indicators
•Focus on classes
of persons
•Actual compared with
expected
(inputs, outcomes)
• Ongoing
• Indicators
•Focus on classes or cohorts
of persons
• Disease, Service and
population
based
• Forecasting
•Periodic
Pseudonymised or Anonymised
Objectives of SUS
 Improve access to data to support the business requirements of
the NHS and its stakeholders
 Provide a range of software tools and functionality which enable
users to analyse report and present this data
 Be the single, authoritative and comprehensive source of high
quality data to
 enable linkage of data across all care settings
 ensure the consistent derivation of data items and construction
of indicators for analysis
 improve the timeliness of data for analysis purposes
 Provide a secure environment which enables patient
confidentiality to be maintained according to national standards
What is SUS?
 A single repository of person and care event level data
relating to the NHS care of patients.
 Data is submitted by all organisations providing NHS care
 At present SUS receives data submissions (CDS)
relating to:





Accident and emergency attendances
Outpatient attendances
Admitted patient care, including maternity care
Elective admission waiting lists
Mental health care “spells”
 In 2007/8 SUS will also receive data from Choose and
Book and the Patient Demographics Service, as well as
new CDS relating to future appointments and diagnostic
events
 In future SUS may receive data relating to patients’
prescriptions and may have the capability of managing
data relating to the primary and social care provided to
patients and service users.
What is SUS?
 SUS comprises:
 A common and consistent information
governance model
 Access control
 Use of pseudonyms to replace identifiers
 Design (e.g. small number suppression etc.)
 A core data warehouse and data marts
 Consistent metadata and reference data
 Associated applications utilising data from
the core warehouse
 Consistent analysis and reporting tools
Current SUS Components
Security and confidentiality ensured by consistent access control and design
Staging
Landing
Universal Data
Warehouse
A Core Warehouse and Data Marts
Data submitted by
all providers of
NHS “acute” and
Mental Health Care
PBR
NHS CDS
Extract
Other
Extract
NHS
Comparators
HES
Clinical
Audit
Consistent metadata – business and technical
Extracts for Non NHS
organisations
Extracts and Reports to all PCTs, Trusts, SHAs
Web based
application for
Practices, PCTs,
SHAs
HES reports and
extracts
What has been achieved?
 First release in 2005, with core NWCS and PbR
functionality but suffered from:
 Poor performance
 Difficulties with interchange catch-up
 SUS “get well” programme of work
 PbR 06/07 delivered in March 2006
 Decommissioning of NWCS required focus on Release
2006-B-1 in November 2006
 Further defects and issues some of which still need to
be addressed
 BUT … SUS is still dependent on NHS organisations
for timeliness and quality of data
SUS Releases in 2007/8
 Release 1 for PBR 07/08 and data for PBC comparators
(April 2007) – completed
 Release 2 giving non-functional upgrade to Oracle 10g
and uplift for more users – completed
 Release 3L providing “landing” capability for cds v6,
plus loads from PDS and Choose and Book (CAB)–
December 07
 Release 3R providing processing and reporting for 18
weeks and further reporting for CAB and PDS, includes
changes necessary for PbR 2008/9 – April 08
SUS Releases in 2007/8
 NHS Comparator releases (April and September) – completed
 Early reporting of comparative referral to treatment waiting
times and elective pathways – early January
 Additional comparators and presentation of practice level
data, with particular emphasis on support for practice based
commissioning resource allocation and budget setting – end
January
 Extended range of comparators and refresh underlying data,
including dispensed prescriptions (Detailed content to be
agreed with DH and NHS users) – end March
 Data quality dashboard - initial release December, subsequent
releases during January –March, sponsored by the DH 18 week
team
2007
ID
Oct
Nov
2008
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
2009
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
PBC Comparators
R4 Scope and
timing to be
confirmed
4
Clinical Audit
SUS October Patch
R3L NFRs
CDS Version 6
PDS daily update
PbR HRG 4
PDS/CDS
(ex R3L)
ETP transactions
CDS
Authentication
SUS Release 3L
CHRIS
Functionality
18W DQ
Reports
Cohort
Management
18W aggregate
reports
18W drill down
reports
1
18W upgrades
Splits/Mergers
(ex R3L)
CAB landing
Ad Hoc
Pseudonym’n
Pilot 18W reporting
PbR algorithm
for 08/09
18W Linkage
Algorithm
R3R
NFRs
NSTS
reporting
PDS
reporting
PDS daily
update
CAB
reporting
Static 18W reports
BO
Infrastructure
Live BO 18W
reports
P1
P2
Specialised
commissioning
PDS 2008B
DQ reporting
MHMDS – schema
and extracts
SUS Release 4
SUS Release 5
Cancer waiting
times
NHAIS
functionality
Access to WEIS
PSIS DU and
reporting
Birth notification
data
Mortality
data
Primary
care
Renal registry
audit
ADS
CAB version
update
R&D data
PDS daily update
upgrade
Improved DR
R4 NFRs
SUS Release 3R
R5 Scope and
timing to be
confirmed
Core warehouse
updates
Jul
Aug
Sep
SUS Opportunities
Opportunities
 A single secure data management
environment provides an
opportunity to reduce “transaction
costs” of implementing systems
reforms through:
 Enabling access to data
 Deriving essential data items
consistently and once
 Undertaking standard processing
Opportunities
 A single secure data management
environment provides the ability to
construct consistent comparators
and indicators
A framework for developing indicators
for an “NHS Scorecard”
Quality Indicators
Indicators relate to / cover:
“Population”
Needs
Identified
Population
Needs
Health Status Indicators
Indicators are constructed for:
Populations
or groups
of patients
Providers
Services
Commissioners
Service
Outputs
Expressed
demand
for
services
Demand
Indicators
Service Activities
Service
Inputs
Efficiency /
Productivity
Indicators
“Population”
Outcomes
Effectiveness
Indicators
Data to construct indicators
Operational data
• person and activity specific
(e.g. CDS)
•aggregated returns.
• dispensed prescriptions
“Population”
Needs
Identified
Population
Needs
Health Status Indicators
Expressed
demand
for
services
Demand
Indicators
Local and national “disease / disability
Registers” (within GP Clinical
Systems (QOF) etc., Cancer Registries)
provide identified
prevalence
Population based surveys, which
are required to
•establish unidentified need
•calibrate local measures of
identified need
Quality Indicators
Service
Outputs
Population and target group
based surveys, including
Patient experience
Temporal analysis of outputs
• subsequent revisions etc.
Service Activities
“Population”
Outcomes
Service
Inputs
Effectiveness
Indicators
Efficiency /
Productivity
Indicators
Operational data
• person and activity specific
(e.g. CDS)
•aggregated returns.
Operational data
• included or implied in activity
specific (CDS)
• Employee data from ESR
• Financial returns and accounts
How SUS might support indicator construction
and presentation
SUS warehouse includes
• operational data on outputs and their
value /cost
NHS Comparators
• includes indicators of quality of
service, based on linkage of outputs
“Population”
Needs
Expressed
demand
for
services
Identified
Population
Needs
Demand
Indicators
Health Status Indicators
NHS Comparators
• uses data on identified need from QOF in
construction of indicators
• Future releases will compare identified
prevalence and predicted prevalence
from population survey information
SUS functionality in 2008/9 to support
Cohort Management and PDS based
linkage
• could enable “longitudinal” association of
operational data with survey population (s)
• PDS copy may allow construction of
prevalence models as well as linkage
Quality Indicators
SUS functionality in 2008/9
• could enable “longitudinal”
association of operational data
with survey population (s)
Service
Outputs
Service Activities
“Population”
Outcomes
Service
Inputs
Effectiveness
Indicators
Efficiency /
Productivity
Indicators
SUS warehouse includes
• operational data on activities and
expressed demand (e.g. CDS)
NHS Comparators
• enables comparisons of demand indicators
and quality indicators covering variation in
•access to services
Original SUS vision and NASP
contract scope includes
workforce data as well as (costed)
activity data
• could enable construction and
comparative analysis of efficiency
or productivity indicators
SUS 2008/9 releases
• provide for capture and management
of prescriptions issued
SUS Challenges
Challenges
 Ensuring that the data currently
submitted to and managed within
SUS is:




Comprehensive
Timely (for different uses)
Consistent with agreed standards
Accurate
Immediate Data Quality
Challenges
 Improving the coverage of data
 Missing data
 Creation of duplicate records
 Improving the content of individual records





Linkage of data
Correct access to and exchange of data
Correct financial payments
Correct comparators and indicators
Reduction in the unnecessary use of identifiable data
Addressing Data Quality
Challenges
 IC / CfH
 Ensure improved functionality in SUS
 Tracker
 eDQRS
 Data Deletions
 Publish guidance and provide support
 Publish data on quality and enable comparison
 DH / SHAs
 Performance manage organisations to improve quality
 Regulators and Auditors
 Audit and review data quality
 Commissioners
 Secure improvements through contract processes
 Care Providers
 Implement quality assurance programmes
Immediate local
implementation challenges
 Achieving the migration to XML
submissions
 Improving the timeliness of data
submissions
 Migrating from the use of bulk
protocols for data submission
Context for more
timely submissions
 Timely data to support achievement of
18 weeks target for referral to treatment
 Linkage of activity into elective care
pathways
 Multiple providers within pathways
 Prospective analysis and reporting
 Ensure at least monthly submission of
comprehensively coded CDS to support
PbR
 Mandate of SUS as authoritative source of
information for payments
Context
 Operating framework for 2008/9
 Submission of finished activity within 5
working days of activity “finish” date
 X % by July 2008
 Y % by January 2009
 Submission of completed (fully coded)
data within 22 days of the activity
“finish” date from April 2008
Current Situation
Current CDS Submission Protocols
70
60
50
40
Number of Trusts
Bulk & Net
30
Net
Bulk
20
10
0
North East North West Yorkshire
East Mid
West Mid
SHA
East
London
South East
South
Central
South West
Interchange
submissions
Interchanges received
4000
3500
3000
2500
Net
2000
Bulk
1500
1000
500
0
Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun05
05
05
05
06
06
06
06
06
06
Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun06
06
06
06
06
06
07
07
07
07
07
07
Jul07
Aug- Sep- Oct07
07
07
Interchange
rejection rates
% Interchanges Rejected
14.00%
12.00%
10.00%
8.00%
Total % failed
Net fail
Bulk fail
6.00%
4.00%
2.00%
0.00%
Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct07 07
07 07 07
05 05 05 05 06 06 06 06 06 06 06 06 06 06 06 06 07 07 07 07 07
Benefits
 Reduces processing time and
complexity
 90% of records replaced in bulk
updates are unchanged
 Quicker access to data
 Improved linkage
 Reduces interchange rejection
rates
 Reduces the risks of duplicate
records
Challenges
 Supporting NHS analysis requirements,
while ensuring the security and
confidentiality of identifiable data:
 Meeting the Government’s commitment to
minimise the use of such data for non-direct
care purposes
Information Governance
Governance - develop & manage consistent,
cohesive policies, processes and decision rights
NHS IG - ways & means of handling patient
information in legal, secure, efficient & effective
manner
Balance - sharing information and privacy
Impact - Encourage & enable improvements in
quality and handling of information
Context
Common law of confidence
Data Protection Act
DH Policy Guidance Confidentiality
Care Record Guarantee
 This guarantee is our commitment that we will use records
about you in ways that respect your rights and promote
your health and wellbeing
Care Record Development Board
 Secondary Uses Working Group
CRDB Principles for
Secondary Uses
1. Default - use of data not linked back to individuals
 Unidentifiable data (aggregate or anonymise)
 Where linkage required - pseudonymise
 If patient identifiable, informed consent if feasible
2. Patient right - to determine no identifiable
information about them should be used for
secondary purposes (legal exceptions)
 Participation in research - approach through GP or
relevant clinician
CRDB Principles for
Secondary Uses
3. Identifiable data is required, if consent not feasible,
then formal justification for access is required
 Section 60 H&SC Act 2001 (now S251 Health
Consolidation Act 2006)
 PIAG Approval may be granted if:
 Benefit to patients
 Not feasible to gain consent or use anonymous data
4. All users of data for secondary care purposes
should be subject to enforceable standards
regarding confidentiality and security of data
Use of patient
identifiable data
Originating clinician – e.g. GP in their practice
Relevant clinician – e.g. GP in their practice
Section 60/251 approval from PIAG
Role allows – e.g. 18 weeks manager
Patient’s consent – e.g. research
Legal basis – e.g. court orders
Implications
De facto use of pseudonymisation for patient record
level data for secondary use
For PCTs - data for commissioning - pseudonymise
For Providers - analysis of performance,etc pseudonymise
For practices - for practice based commissioning pseudonymise
Where primary use of secondary use data, then
patient identifiable data is OK, depending on user’s
rights
CRG Requirements
 CRG enables patients to use
 Dissent to Store
 Dissent to Share
 Sealed and Locked Envelopes
 Sealed Envelopes
For secondary uses
 Dissent to store & Sealed and Locked Envelopes - no data
available
 Dissent to share & Sealed Envelopes - data available but not
attributable to patient
Current SUS Data
Flows
HES
HES Reports and
Extracts
Pseudon
Land
Stage
CDS
Reports and extracts
for Commissioners
and Providers
PbR
SHA and national
PbR extracts
Commissioning
Dataset Submissions
CDS Activity Warehouse
Extracts for non NHS Organisations
With PIAG approval
Future SUS Data
Flows
Other Data Flows
e.g. Clinical Audits
SUS IG Components
Pseudon
Cohort
Linkage
Geo Derive
Other
Systems
e.g. Audit
Reports, extracts
and analyses from
other systems and HES
SUS PDS Copy
PDS Tracing
HES
18 week
CDS
Commissioning
Dataset Submissions
Land
Stage
PbR
CAB
CDS and CAB Activity Warehouse
Reports and extracts for
SHAs, commissioners and
Providers
Pseudonymised extracts
for non-NHS organisations
Challenges
 Ensuring that the data submitted to
and available within SUS in the
future meets requirements
 “redefining the information model”
 “filling the gaps”
Questions and Answers