Document filename: SCCI2026 Implementation Plan
Cross Government
Programme
Project
FGM Prevention
Programme
Project Manager
Richard Steele
Status
Final
Owner
Richard Steele
Version
1.0
Author
Sam Sibeko
Version issue date
01 Oct 2014
Directorate / Programme
Document Reference
FGM Enhanced Dataset
Implementation Plan
Copyright ©2014 Health and Social Care Information Centre
Document Management
Revision History
Version
0.1
Date
18th Sept 2014
Summary of Changes
Initial Draft
1.0
01 Oct 2014
Final version incorporating early CAP testing in November 2014
Reviewers
This document must be reviewed by the following people: author to indicate reviewers
Reviewer name
Title / Responsibility
Date
Richard Steele
HSCIC FGMP Programme Manager
18/09/2014
Version
0.1
Approved by
This document must be approved by the following people: author to indicate approvers
Name
Astrid Fairclough
Page 2 of 30
Signature
Title
Date
DH FGMP Programme
Manager
30/09/2013
Version
1.0
Copyright ©2014 Health and Social Care Information Centre
Glossary of Terms
Term / Abbreviation
What it stands for
DH
Department of Health
FGM
Female Genital Mutilation
FGMP
Female Genital Mutilation Prevention (Programme)
HSCIC
Health and Social Care Information Centre (new name for NHS Connecting
for Health as from April 1st 2013)
ICD
International Statistical Classification of Diseases and Related Health
Problems
Read Codes
Standard clinical terminology system used in general practice
SNOMED CT
Classification of medical terms providing codes, terms, synonyms and
definitions used.
WHO
World Health Organisation
Document Control:
The controlled copy of this document is maintained in the HSCIC corporate network. Any
copies of this document held outside of that area, in whatever format (e.g. paper, email
attachment), are considered to have passed out of control and should be checked for
currency and validity.
Page 3 of 30
Copyright ©2014 Health and Social Care Information Centre
Contents
1
Contacts
5
2
Background
6
3
Purpose
7
4
Scope
8
5
Strategic Assumptions
11
6
Change Required
12
6.1
Current Situation
12
6.2
Success Criteria
12
7
Implementation Strategy
13
7.1
Implementation Approach
13
7.1
Pilot
15
7.2
Full Implementation
16
Project work streams
20
8
8.1
Governance
20
8.2
Communications and support
20
8.3
Conformance monitoring
21
Roles and responsibilities
22
9
9.1
Department of Health
22
9.2
HSCIC
22
10
Funding
23
11
Information governance and Clinical safety
24
12
Measuring Conformance
25
13
FGM Enhanced Dataset Adoption
27
14
Implementation Timetable
28
14.1 FGM Enhanced Dataset Pilot Test Plan
15
Maintenance and Review
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29
30
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1 Contacts
For information on the dataset please contact Sam Sibeko
FGM Enhanced Dataset Developer
Name
Sam Sibeko
Organisation
HSCIC
Email Address
Sam.sibeko@hscic.gov.uk
Sponsor
Name
Flora Goldhill
Organisation
Department of Health
Email Address
Flora.goldhill@dh.gsi.gov.uk
Copyright ©2014 Health and Social Care Information Centre
2 Background
Currently there is the FGM Prevalence dataset which is being collected at a national
level across all Acute Trusts (Foundation and non-Foundation) across England. The
FGM Prevalence dataset will be retired from April 2015, and as such the FGM
Enhanced dataset will be implemented from April 2015 to ensure;
 A continuation of FGM information being collected nationally within England
 The provision of more detailed FGM information regarding a patient, to better
support;
a. Identification of commissioned FGM services where required
b. Identifiy risk of FGM occurring to young girls and vulnerable women
Successful implementation is based on the following elements:
1. Data Recording:
 a standard approach to recording FGM information when this is identified
and ensuring that this information is appropriately shared locally
 a standard and consistent approach to submit FGM information centrally
to HSCIC
2. Data Collection and Flow: routine collection and recording of the Enhanced
dataset in all NHS Acute Trusts (Foundation and Non Foundation), Mental
Health Trusts and General Practices, in order to extract this information and
submit this to the HSCIC on a monthly basis
3. Analysis and Intelligence: processing and analysis of the data to transform it
into intelligence and then exploitatiing that intelligence to help inform the
capability to identify potential FGM services, development of improved care
pathways and the improvement in safeguarding approaches
4. FGM Enhanced Dataset Publication: using the intelligence identified to
publish the findings (at an aggregate level only), and sharing this intelligence
with other government agencies, to support safeguarding practices and
increase prosecutions against FGM
These elements must be underpinned by recognition of the shared goal of reducing
FGM by all healthcare workers where FGM is identified and the establishment of
routine working relationships and governance to sustain this with the DH.
Achieving this requires action at a national level.
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3 Purpose
This document aims to set out the plans to implement the FGM Enhanced Dataset as
across all Acute Trusts (Foundation and non-Foundation), Mental Health Trusts and
GP Practices in England. These plans include all the activities required to support all
applicable organisations, to implement the FGM Enhanced dataset, and the
governance structures that will be required to ensure that the appropriate steps are
clearly defined in order to support the implementation locally.
The purpose of the FGM Enhanced dataset is to build on the FGM Prevalence
Dataset, providing more detailed FGM information at the patient level, when FGM is
identified by clinical staff, and subsequently return this to HSCIC on a monthly basis.
In addition to the FGM Enhanced dataset, clinical engagement with Trusts will ensure
that there is consistent communication about identifying FGM and its impacts on
health to the patient, in conjunction with how this should be recorded within clinical
notes locally to support monthly submissions to the HSCIC. This will further be
supported by the work undertaken by the Department of Health’s FGM Prevention
Programme of work.
Limited knowledge of FGM for health professionals is a known issue, however, the
introduction of the FGM Prevalence dataset, has laid the foundations for increasing
that knowledge locally and provide a blue print for;
 How FGM information should be recorded
 How FGM information can be collected
 How FGM information can be submitted
The full FGM Enhanced dataset suite, will continue to direct readers to the multiagency guidelines which are the current and best resource available.
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Copyright ©2014 Health and Social Care Information Centre
4 Scope
This information standard mandates the recording of FGM information when it is
identified, to better support local processes in raising the awareness of the potential
risks of FGM occurring to young girls and vulnerable women. In addition to this, the
central flow of administrative and clinical information will be used for secondary uses
purposes.
The standard defines the data items to be recorded and extracted from existing
clinical systems, and also additional information identified as part of any consultation,
clinical diagnosis or clinical procedure.
The scope includes all activity undertaken by all clinical settings funded, and/ or
provided by the NHS. In summary, this includes the following organisations which
MUST return the FGM Enhanced dataset;



NHS Hospital Trusts (Foundation and Non Foundation NHS Trusts)
NHS Mental Health Trusts
General Practitioners
o All NHS funded providers are required to conform to this standard
For clarity the FGM Enhanced Dataset is outlined in full below;
Standard
Standard Number
SCCI2026
Standard Title
Female Genital Mutilation (FGM) Enhanced Dataset
Description
The FGM Enhanced Dataset requires organisations to record collect and return
more detailed information about FGM within the patient population, as treated by
the NHS in England.
Female Genital Mutilation (FGM) is illegal in the UK, as is taking a child abroad to
undergo FGM, as legislated in the 2003 Female Genital Mutilation Act. FGM is
medically unnecessary, extremely painful and has serious health consequences
both at the time when the mutilation is carried out and in later life. Whilst there
have been no prosecutions, it is believed that the practice continues both in the
UK and that girls are taken abroad for the purpose of FGM.
FGM must also be treated as child abuse.
There are UK government multi-agency guidelines:
https://www.gov.uk/government/publications/female-genital-mutilation-guidelines
Particular note should be given to guidelines for health professionals.
The NHS is in a unique position to identify detailed information about women
where FGM has been undertaken, including family history information to help
identify potential risks of occurring to girls and vulnerable women. There are multiagency guidelines in place detailing what to do but there is recognition that this is
not happening in all cases. Further to this is the existing FGM Prevalence dataset,
which mandates that FGM must be recorded within all clinical settings. This
standard builds upon the 1610 FGM Prevalence Dataset.
There is a programme of work, led by the Department of Health, to improve the
NHS response to FGM, and subsequent management of women and
safeguarding for girls at risk.
This standard introduces additional requirements to that of the FGM Prevalence
dataset about information that must be captured and must be centrally returned.
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Recording FGM Information
The FGM information captured is needed to help provide a consistent approach to
sharing FGM information locally and specifically includes the following;
1. All clinicians, regardless of organisation type, to record in clinical notes when
FGM is identified, and what type it is following clinical examination, using the
FGM clinical codes, published in April 2014 (also detailed later in this
document). This builds upon the FGM Prevalence dataset, but clinical
terminology MUST be used to record the FGM information within all settings.
2. All Maternity Discharges, must include relevant FGM information identified,
prior to and post-delivery of baby, informing the GP and Health Visitor of the
FGM identified during the provision of care.
3. All babies born to a mother with FGM, must have the relevant FGM
information recorded in the babies patient healthcare record to help identify
the potential risk of FGM facing the young girl
Where FGM is identified, all referrals made by General Practitioners MUST
include FGM information when referring to relevant services where FGM
may be applicable e.g.;
Urology, Paediatric Urology, Paediatric Dermatology, Dermatology,
Genitourinary Medicine, Obstetrics, Gynaecology, Gynaecology Oncology,
Midwifery Service or Psychiatric Services – this list is not exhaustive
4. When FGM is identified this MUST be included within screening returns,
immunisation notes and also included within the Red Book following the birth
of a child. When FGM is identified health promotion MUST also be provided.
Submitting FGM Information
The FGM Enhanced dataset collection will specifically require the stated
organisations to return the FGM information for each patient.
The collection and submission of this information aims to support improvements
in;
 the identification of FGM and the wider social issues that impact upon the
victim and thus improve public awareness and inform the development of
training for clinicians
 data quality by promoting more detailed recording of FGM when it is
identified; and provide better evidence for potential prosecutions of those
who carry out FGM
 supporting the sharing of women’s information to other referred services
 aligning prevention (through risk identification) and support for the women,
identifying where support is needed most.
 provide secondary use data to support aggregated studies on the
prevalence of FGM in detail
 informing local and cross government organisations to the prevalence of
FGM and therefore support the ability to target specific areas for the
commissioning of appropriate services, and training needs
 a more informed collection of the risk of FGM to young girls and vulnerable
women, resulting in improved safeguards against FGM, including early
intervention by relevant organisations to reduce and work towards the
eradication of FGM
 opportunities to facilitate greater and more comprehensive academic
research, including the potential to support the identification of community
education programmes
Applies to
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Recording FGM information – all NHS funded providers
Returning FGM information – all Acute (Foundation and Non-Foundation Trusts),
Mental Health Trusts and GP Practices
Copyright ©2014 Health and Social Care Information Centre
Release
Release Number
SCCI2026
Release Title
FGM Enhanced Dataset
Description
The recording and submission of detailed FGM information when this is identified
from within Acute, Mental Health and GP Practices
Voluntary
Implementation
Date
 1 April 2015 to submit FGM information to HSCIC
 1 April 2015 to Record and Share FGM information locally when identified
Mandatory
Implementation
Date
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 1 Aug 2015 to Record the FGM Enhanced dataset items
 1 Oct 2015 to Submit FGM information to HSCIC.
(This will require the FGM Enhanced dataset information to be Recorded
locally from 1st August 2015)
Copyright ©2014 Health and Social Care Information Centre
5 Strategic Assumptions








All applicable health organisations, will be collecting the dataset and
submitting this with HSCIC on a monthly basis
Most Trusts will require some support to implement the dataset to the
specified standard
The priority for this release is to ensure the standard and the more detailed
FGM information can build on, and implement, the data collection and flow
mechanisms.
Governance for implementation and beyond will be provided by the HSCIC
Once the standard has been implemented, the DH will have strategic
oversight and provide governance for future developments including periodic
review of the standard, changes and future development of the standard and
eventual withdrawal of the standard;
Future developments might include:
o The standardisation of flow mechanisms and data formats
o Changes to the data items
o The migration of the audit function (currently the responsibility of DH) to
NHS England
Trusts are already expected to follow the FGM multi-agency guidelines in
relation to recording FGM in clinical records.
Acute Trusts (Foundation and non Foundation) are already submitting monthly
FGM information
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6 Change Required
6.1 Current Situation
Whilst Acute Trusts (Foundation and non-Foundation), are currently collecting FGM
Prevalence information, this collection does not go far enough to support specific
risks of FGM and in addition, not only where FGM is identified, but where patients are
currently residing (which can be used to better to support the need for FGM services
across various regions).
There are some organisations which have a particular interest in the identification
and treatment of FGM, and with the FGM Prevalence dataset, awareness of FGM is
growing, in addition to understanding the appropriate clinical pathways to follow.
6.2 Success Criteria





All applicable organisations recording FGM on patient records when identified
in accordance with the FGM multi-agency guidelines.
All applicable healthcare organisations sharing FGM information locally,
included alongside existing referral and discharge information
All applicable healthcare organisations understand the benefits of collecting
and sharing the FGM Enhanced dataset information
All applicable healthcare organisations are collecting the FGM Enhanced
dataset on a monthly basis, with a high level of data quality and are submitting
this via the Clinical Audit Platform tool
A sufficient level of quality data is being collated in order to;
o continue with the collection of FGM prevalence information nationally
o identify where additional FGM support services may be required
o develop improved safeguarding processes based on the information
identified
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7 Implementation Strategy
7.1 Implementation Approach
The technical aspects of implementing the FGM enhanced dataset are expected to
be minimal. Whilst it would be welcome for the NHS to develop automated capture of
the FGM Enhanced dataset, this is by no means anticipated to have been developed
nationally, by April 2015
The FGM implementation guidance will specifically include the following and will be
further updated and detailed accordingly. This will specifically include clinical, with
wider input required from Dept of Health in agreement with various Royal College
approvals as part of the wider FGM Prevention Programme of work.
It is anticipated that the FGM Enhanced dataset implementation guidance will
specifically include the following information which will be developed further in
following further stakeholder consultation and CAP development;
1. Trust Readines & Communication
 Guidance outlining that it will be essential for clinicians and information
teams (GPs and Practice Managers), communicate locally, and ideally
have implementation plans in place to support;
o Awareness of the FGM Enhanced dataset information standard
implementation and submission timescales
o Which mechanisms will be used by which clinicians within the
organisaton
o How the information will be collected by the Information Teams
or GP Practice managers, e.g. manual spreadsheet collections
or code queries


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Overview on the schedules for submission, including;
o The date periods with which FGM information is to be recorded
by clinicians
o The associated collection period and when this needs to be
made available to the Information Team or GP Practice
managers
o The time period to collect this information locally
o The data quality and confirmation of complete information locally
o The submission period to HSCIC via CAP
Provision of the FGMP Upload too, which will require the following
agreement locally;
o Confirmation locally of how this can be accessed, by whom and
when
Copyright ©2014 Health and Social Care Information Centre
2. Clinical Guidance
This will be outlined and expanded to specifically support the different clinical
groups;
 General Practitioners
o Guidance on the FGM codes to be used and when
o Guidance to help determine who will be responsible within the
GP Practice for submitting the monthly return to HSCIC
o Guidance on how to ask questions about FGM – this will be
provided by Department of Health

Midwives, FGM specialist clinicians, all other clinicians
o Guidance on the FGM codes to be used and when
o The mechanisms available to record the FGM information
o Guidance to support the data dictionary model content
o Guidance about what FGM is and the provision of links to wider
FGM documentation
3. Information Teams and Practice Managers
 Overview of the CAP Registration process for Acute and Mental Health
Trusts
 Overview of the CAP Implementation Guidance for Acute and Mental
Health Trusts
 The mechanism used to submit the FGM information to HSCIC
 Guidance to about the storage of patient lists locally, whilst adhering to
existing protocols around patient data and the safe and secure storage
of the information
 Specific guidance outlining how the FGM information recorded by
clinicians can be recorded within CAP, specifically the options to;
o Run FGM code queries against local patient databases to extact
the relevant FGM information
o Use of spreadsheets and how this will be stored, accessed and
who they will be available to
 Data quality requirements
o Avoidance of duplications
o Confirmation of returns within the organisation from all relevant
clinicians and departments
o Where clinicians have direct access to CAP and where FGMP
Upload tools are also used, to ensure that all records are
complete locally
o Assessment of newly identified records for that recording period
o Assessment of active cases locally that have been previously
submitted and have ongoing care needs
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4. HSCIC Support Guidance
 Support on how to retrieve the FGM information for each Trust
 Support on how to retrieve and create the relevant FGM reporting
capability
o Whilst it is anticipated that the FGM information will result in the
production of Official Statistics, it is not known at this time, the
detail of this information
 Support and guidance in analysing the data received
 Identification of trends as a result of the FGM information received
 Guidance on ensuring the quality of the data is fit for purpose and that
any anomalies are appropriately identified, with the appropriate checks
in place to help determine the accuracy of the information.
Provision of Trust contacts as part of the registration process to ensure a contacts list
is available to analysts.
7.1 Pilot
A short pilot will be run, prior to the Implemention date in April 2015. This is expected
to be undertaken in Dec 2014, lasting a month to allow for early submission to the
SCCI Committee. The Test Strategy is outlined further within the FGM Enhanced
Dataset Draft Requirements Specification.
The pilot will have the following aims:
1.
2.
3.
4.
Introduce the new FGM enhanced processes and collection tools to the
Trusts, leading to a higher uptake of the standard at the earliest possible
dates.
Prolonged review of support materials.
Learning and preparation for the project team in anticipation of the
publication of the standard Feb 2015. Early exposure to the reporting
cycle will improve the preparedness for the full publication.
Early identification of any key issues. Any advance warning of
complications will be highly beneficial.
The outcome of the pilot will be provided to SCCI in Jan 2015.
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7.2 Full Implementation
Patient identifiable information when FGM has been identified will be submitted to
HSCIC via the Clinical Audit Platform tool, the clinical audit collection tool, owned and
supported by the HSCIC.
The CAP system can be accessed following registration to the service, providing
opportunity for it to be determined locally who will require access to the submission
tool.
The CAP tool is already used within Trusts, although guidance will be required to
detail the specific FGM information to be uploaded on a monthly basis.
The FGM Enhanced dataset will be collected and submitted 2 months following
collection, on the 5th working day of the following 2 months. This will allow time for
the appropriate information to be collected locally, for appropriate data quality activity
to be undertaken. This will also be required where no FGM has been identified by the
Trust within a reporting period.
The high level dates outlined in the table below, outline when the FGM Enhanced
dataset MAY and MUST be implemented, for both the recording of FGM information
and sharing this locally, and also the central submission of FGM information to
HSCIC;
Voluntary Implementation Date
1 April 2015 to Submit FGM information to HSCIC
Mandatory Implementation Date
1 April 2015 to Record FGM information locally
1 Oct 2015 to submit FGM information to HSCIC
Current Expected End Date
31st Mar 2020
Copyright ©2014 Health and Social Care Information Centre
The following collection schedule outlines the responsibility, activity and dates for the Submission of the FGM Enhanced dataset
from all applicable organisations, including the responsibility for Recording, Collecting, Analysing and Submitting the FGM
Enhanced information.
The Highlighted sections outline when it will be Mandatory for the FGM Enhanced dataset to be undertaken.
Month
Clinicians & GPs
Information Team
Analysts & Practice
Managers
Information Team
Analysts & Practice
Managers
HSCIC
HSCIC
Local Identification
and Recording
(Between)
Local Collecting and
Compiling of Data
(Completed Between)
Local Submission of
Enhanced Dataset
(Submitted Between)
Receipt of FGM
Enhanced Dataset
(Received By)
Quality Review, Analysis
& Data Preparation
(Completed By)
Apr 2015
1st Apr – 30th Apr
May 2015
1st May – 31st May
1st May – 31st May
(Apr data)
Jun 2015
1st Jun – 30th Jun
1st Jun – 30th Jun
(May data)
1st – 5th Jun 2015
(Apr data)
5th Jun 2015
(Apr data)
30th June 2015
(Apr data)
Jul 2015
1st Jul – 31st Jul
1st Jul – 31st Jul
(Jun data)
1st – 7th Jul 2015
(May data)
7th Jul 2015
(May data)
31st July 2015
(May data)
7th
31st
1st
Aug –
Aug
(Jul data)
31st
3rd
–
Aug 2015
(Jun data)
7th
Aug 2015
(Jun data)
Aug 2015
(Jun data)
Aug 2015
1st Aug – 31st Aug
Sept 2015
1st Sept – 30th Sept
1st Sept – 30th Sept
(Aug data)
1st – 7th Sept 2015
(Jul data)
7th Sept 2015
(Jul data)
30st Sept 2015
(Jul data)
Oct 2015
1st Oct – 31st Oct
1st Oct – 31st Oct
(Sept data)
1st – 7th Oct 2015
(Aug data)
7th Oct 2015
(Aug data)
31st Oct 2015
(Aug data)
Nov 2015
1st Nov – 30th Nov
1st Nov – 30th Nov
(Oct data)
2nd – 6th Nov 2015
(Sept data)
6th Nov 2015
(Sept data)
30th Nov 2015
(Sept data)
Dec 2015
1st Dec – 31st Dec
1st Dec – 31st Dec
(Nov data)
1st – 7th Dec 2015
(Oct data)
7th Dec 2015
(Oct data)
31st Dec 2015
(Oct data)
HSCIC
Official Statistics
Publication
(Released On)
Voluntary Submission Period:
Internal Management Reports
1st October 2015;
(Q1:1st Apr – 30th Jun Data)
Copyright ©2014 Health and Social Care Information Centre
Jan 2016
1st Jan – 31st Jan
1st Jan – 31st Jan
(Dec data)
4th – 8th Jan 2016
(Nov data)
8th Jan 2016
(Nov data)
31st Jan 2016
(Nov data)
Feb 2016
1st Feb - 29th Feb
1st Feb – 29th Feb
(Jan data)
1st – 5th Feb 2016
(Dec data)
5th Feb 2016
(Dec data)
29th Feb 2016
(Dec data)
Mar 2016
1st Mar – 31st Mar
1st Mar – 31st Mar
(Feb data)
1st – 7th Mar 2016
(Jan data)
7th Mar 2016
(Jan data)
31st Mar 2016
(Jan data)
Apr 2016
1st Apr – 30th Apr
1st Apr – 30th Apr
(Mar data)
1st – 7th Apr 2016
(Feb data)
7th Apr 2016
(Feb data)
30th Apr 2016
(Feb data)
May 2016
1st May – 31st May
1st May – 31st May
(Apr data)
2nd – 6th May 2016
(Mar data)
6th May 2016
(Mar data)
31st May 2016
(Mar data)
Jun 2016
1st Jun – 30th Jun
1st Jun – 30th Jun
(May data)
1st – 7th Jun 2016
(Apr data)
7th Jun 2016
(Apr data)
30th Jun 2016
(Apr data)
Jul 2016
1st Jul – 31st Jul
1st Jul – 31st Jul
(Jun data)
1st – 7th Jul 2016
(May data)
7th Jul 2016
(May data)
31st Jul 2016
(May data)
Aug 2016
1st Aug – 31st Aug
1st Aug – 31st Aug
(Jul data)
1st – 5th Aug 2016
(Jun data)
5th Aug 2016
(Jun data)
31st Aug 2016
(Jun data)
Sept 2016
1st Sept – 30th Sept
1st Sept – 30th Sept
(Aug data)
1st – 7th Sept 2016
(Jul data)
7th Sept 2016
(Jul data)
30th Sept 2016
(Jul data)
Oct 2016
1st Oct – 31st Oct
1st Oct – 31st Oct
(Sept data)
3rd – 7th Oct 2016
(Aug data)
7th Oct 2016
(Aug data)
31st Oct 2016
(Aug data)
Nov 2016
1st Nov – 30th Nov
1st Nov – 30th Nov
(Oct data)
1st – 7th Nov 2016
(Sept data)
7th Nov 2016
(Sept data)
30th Nov 2016
(Sept data)
Dec 2016
1st Dec – 31st Dec
1st Dec – 31st Dec
(Nov data)
1st – 7th Dec 2016
(Oct data)
7th Dec 2016
(Oct data)
31st Dec 2016
(Oct data)
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Copyright ©2014 Health and Social Care Information Centre
1st Jan 2016 including;
(Q2: 1st Jul – Sept 30th Data)
1st April 2016 including;
(Q3: 1st Oct – 31st Dec Data)
1st Jul 2016 including;
(Q4: 1st Jan – 30th Mar Data)
1st Oct 2016 including;
(Q1: 1st Apr – 30th Jun Data)
The bulk of the work lies in:



Ensuring that the Trusts are communicated to effectively in order to understand what needs to be captured and when
Informing the NHS staff about the FGM Enhanced dataset and how this differs to the FGM Prevalence dataset collection
approach
Developing the necessary working relationships and networks locally to sustain the flow of information and underpin data
quality
The implementation methodology is focused on:





Communications to get the key messages to the right people via the most appropriate channels
Provision of guidance and support documentation to propagate best practice including use of the FGM multi-agency
guidelines [ref 1] pages 27 – 29.
Establishment of local working relationships and feeding back intelligence on the progress of implementation and any
blockages
The mobilisation of the formal levers available to help ensure successful implementation
Audit processes to gauge success and inform future development.
Building on the pilot implementation there will be an initial focus on the Trusts with an interest in FGM to help support through the
implementation phases of the first few months.
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Copyright ©2014 Health and Social Care Information Centre
8 Project work streams
The main project work streams are set out below.
8.1 Governance
Robust governance and project management is required to ensure the objectives
outlined above are realised. The Department of Health will continue to have the
overarching lead role, with a programme board directing the programme, reflecting
the partnership between DH, NHS England and HSCIC.
The DH will monitor progress and act as the point of escalation for any risks and
issues that may threaten the collection of data. Once the standard has been
implemented, the DH will lead on the successful outcome of the implementation and
make decisions about future directions.
8.2 Communications and support
This work stream addresses the existing risk that clinical staff are following the latest
existing FGM multi-agency guidelines, in relation to recording details of FGM in
clinical notes.
The effort takes into account the plan for a significant training and awareness
campaign to begin in October 2014. The intention therefore is to enable all well
intentioned Trusts to be able to adhere to the standard with the least possible
burden, therefore ensuring efficiency. By introducing simple measures, this exercise
will inform the future work of the programme through targeting and raising
awareness.
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8.3 Conformance monitoring
DH will remain responsible for conformance monitoring with 2 audits to be
undertaken:


Initial Trusts submitting – following the initial submission period July 2015
Initial Stage Audit – at the end of the initial mandatory submission period Nov
2015
These audits will review and identify which Trusts have been submitting information
and help determine how successful the implementation plan has been in practice. It
will collect enough information to determine whether additional implementation
activity is required beyond the end of the SCCI approved window.
In addition, the following will be monitored to ensure the successful implementation of
the standard.
#
Criteria
1
All components of the FGM Enhanced dataset MUST be collected as specified.
2
The FGM Enhanced dataset MUST be input into the Clinical Audit Platform (CAP) as
made available to each applicable organisation for the specified reporting periods.
3
Centrally issued guidance and FAQs SHOULD be used to steer decisions.
4
Providers MUST apply data validation processes to assure the quality and
completeness of the data prior to submission to HSCIC.
5
Quality assurance MUST be undertaken by Information Teams to ensure that a
patient is not counted twice within a submission, and therefore avoid duplicate
recording of information.
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9 Roles and responsibilities
9.1 Department of Health


Provide governance, setting up the necessary representation to oversee
implementation, maintenance and strategic development
Provision of funding to support the implementation, collection, analysis and
publication of FGM information received from the applicable healthcare
organisations.
9.2 HSCIC



Business analyst, to support the development of the FGM Enhanced Dataset
Audit Manager support to provide the relevant resource to analyse
submissions received, undertake quality assurance, develop publications
Project team to lead the implementation plan and support of the FGM
Enhanced Dataset with applicable healthcare organisations.
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10 Funding
Most of the implementation activity described will be absorbed within the business as
usual activities of the organisations involved. There will be no specific funding made
available to NHS Trusts to support the implementation of the standard.
A small budget has been secured to support the central Implementation work, and
Department of Health are aware of the ongoing costs to support the development of
CAP, the collection, analysis and publication of FGM information.
Whilst these costs are not fully detailed at this time, as further development is
undertaken in this area, DH will be funding this.
.
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11 Information governance and Clinical safety
There are no clinical safety issues identified with the FGM Enhanced Dataset
collection following clinicical safey initial asssessment.
With regards to the local collection of patient’s FGM information, this will be patient
identifiable information in order to ensure;
Data quality and avoid the duplication of counting patients twice
Data linkage with information extracted from General Practitioners
Support transition of this dataset into the existing Maternity, Child and Adolescent
Mental Health Services and Children and Young People’s datasets
To support the collection of this patient identifiable information, patient consent will
be required to support the sharing of this information.
Whilst implied consent will be obtained, to support the recording of FGM information
locally with other clinicians to support the provision of care, following the consultation
with the clinician, when this information is to be shared with HSCIC, this will require
patient consent in order to do so, and this must be explicitly recorded
The collection and storage of FGM information, will need to adhere to a Trust’s
existing patient information security principles, namely Confidentiality: NHS Codes of
Practice policy, built in conjunction with the existing 3 principles around information
security;

Information must be secured against unauthorised access - confidentiality

Information must be safeguarded against unauthorised modification - integrity

Information must be accessible to authorised users at times when they require
it - availability
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12 Measuring Conformance
In order to measure conformance to the FGM Enhanced dataset and as outlined as
part of the FGM Enhanced Dataset Data Quality criteria, the following will be
expected;
Conformance Criteria
The threshold on the coverage of organisations submitting the FGM
Enhanced dataset is still to be determined, but initial expectations are that;
 95% of all FGM specialist clinics will submit data
 70% of all remaining Trusts will submit data
 It still to be determined what the percentage of GPs will be required to
support the usability of the FGM information received
The threshold on the completeness of initial submissions from organisations
is still to be determined.
It is expected that all mandatory FGM Enhanced dataset items will be 100%
validated, when manually entering the data into the FGMP Collection Tool.
It is expected that all mandatory FGM Enhanced dataset items will be 100%
validated, when clinician’s directly enter the data into CAP.
It is expected that all NHS numbers will be 100% validated, when clinician’s
manually record data in the FGMP CollectionTool, or, directly record data
within CAP, as a result of the modulus 11 check undertaken within the FGMP
collection tool.
It is acknowledged that Required data items will not have the same validation
restrictions to ensure completeness, but analysis will be undertaken within
HSCIC to help identify, where the same submitting organisation omits any
Required or Optional FGM information.
Whilst it will be legitimate to submit non mandatory FGM dataset items,
continual omission of this information ‘could’ provide an indication to non
compliance of the dataset.
The threshold on the omission of Required and Optional dataset items is still
to be determined.
The FGM Enhanced dataset will be provided by all Acute (Foundation and
Non Foundation) Trusts, Mental Health Trusts and General Practices, on a
monthly basis. Where no FGM information was identified locally, it will still be
mandatory to provide a Nil return.
Initial analysis of FGM Type Unknowns being received within the dataset, will
provide a baseline figure, used to help identify where additional training and
FGM awareness may be required. Further to this, the initial baseline will be
used to confirm the improvements in training, although the threshold on the
expected reduction in the number of FGM Type Unknown is still to be
determined.
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13 FGM Enhanced Dataset Adoption
The adoption process will vary depending on the state of development of the FGM
process in each specific locality. However, a high level generic approach will be:
1. Assessment of the applicable health organisations data collection, recording,
extraction and transmission process against the published standards
documentation
2. Assessment of the setup and governance arrangements against the
implementation guidance
3. Development of an implementation plan locally that includes as a minimum:
o The establishment of routine governance arrangements
o Agreement on the data format and transmission mechanisms to be used
locally
o Agreement and communication on the timetable for delivery of data and the
receiving organisation
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14 Implementation Timetable
The proposed timetable for implementing the FGM Enhanced dataset and
establishing the support arrangements are set out below.
Task
Responsible
Due by
Communications & Support
Particular Interest sites (pilot) early engagement and
communication
DH
Sept - 2014
On-going public consultation via existing Patient, Survivor
and Victim Groups in conjunction with DH engagement
DH
Oct - 2014
Clinical guidance preparation (All applicable healthcare
organisations)
DH
Nov - 2014
Information Team analyst guidance preparation (All
applicable healthcare organisations)
DH
Nov - 2014
Engagement with Royal Colleges
DH
Nov - 2014
Circulation to all stakeholders in DH FGM network
DH
Nov - 2014
Guidance to NHS Trusts published
DH
Mar - 2015
FGM Enhanced dataset communication (All applicable
healthcare organisations)
DH
Apr - 2015
Circulation via Royal Colleges to professionals
DH
Apr - 2015
Recording: FGM Enhanced dataset – Mandatory
NHS
Organisations
Apr - 2015
Submitting: FGM Enhanced dataset – Voluntary
(this will require the collection of FGM information from Mar
2015)
NHS
Organisations
Apr - 2015
Submitting: FGM Enhanced dataset – Mandatory
(this will require the collection of FGM information from Aug
2015)
NHS
Organisations
Aug - 2015
Trusts initially submitting identification
DH
June - 2015
Trusts not submitting identification
DH
Oct - 2015
HSCIC
Oct - 2015
Conformance Monitoring
FGM Enhanced dataset Official Statistic publication
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14.1
FGM Enhanced Dataset Pilot Test Plan
The table below outlines the high level plan for the Piloting of the FGM Enhanced
dataset.
Task
Responsible
Due by
Clinical Audit Platform development to begin; (including
FGMP Upload Tool and FGMP Collection Tool)
HSCIC
Oct -2014
Identification of FGM Enhanced dataset Pilot Sites,
including named contacts
HSCIC
Oct -2014
Pilot site confirmation (including; clinicians and
information team analysts)
HSCIC
Early Nov - 2014
Circulate FGM Enhanced dataset Pilot documentation;
(Overview, Objectives, Approach, Timescales, Test
Criteria & Questionnaire/ Survey)
HSCIC
Late Nov - 2014
Clinical Audit Platform development completed
HSCIC
Mid Nov - 2014
FGM Enhanced dataset pilot start
HSCIC
Late Nov - 2014
FGM Enhanced dataset pilot end
HSCIC
Late Dec – 2014
Submission of Pilot Test Report
HSCIC
Late Dec - 2014
FGM Enhanced dataset extended pilot review
HSCIC
Feb – 2015
Testing and Piloting
If there is any delay in the development of CAP and piloting of the dataset by Dec
2014, then the contingency will include;
- Provision of the test report without the findings, outlining acceptance of all
known risks and issues and confirmation of acceptance from DH.
- Provision of a statement, rather than the inclusion of the complete report
findings with regards to the testing outcome. Further to this however, will be
consideration of the following if and where applicable;
o Reduction in the Pilot testing time frame
o Re-prioritise development of CAP to support direct entry by clinicians.
If direct entry by clinicians is still not possible for 1st April 2015,
communications will be provided to remove this method of submission
from 1st April 2015 to 1st October 2015.
Dependent on the outstanding issues, to proceed with the Implementation Date of 1 st
April 2015 with acceptable issues to DH and the FGMP Programme
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15 Maintenance and Review
Department of Health will have the operational ownership of the Standard and
manage any future development work, including:




Changes to data items either to include additional data or redact specific fields
Changes to the recommended extraction and transfer schedule
Introduction of standardised flow mechanisms including data formats
Introduction of alternative data collection mechanisms (e.g. collection by
Primary Care or Community Health teams)
 Withdrawal of the standard when it is no longer required.
No changes to the standard will be made without the explicit approval of DH.
Copyright ©2014 Health and Social Care Information Centre