NHS Number
Your unique patient identifier
Guidance on categories of complex case
Introduction and purpose
The NHS Operating Framework and NHS
Standard Contract highlight the importance of
including the NHS Number within patient data
submitted between Providers and
Commissioners is in. Commissioners may, at
their discretion, withhold a proportion of
monthly payments for patient services where
the NHS Number has not been supplied. The
maximum proportion that can be withheld will
be defined in individual contracts between
Commissioners and Providers.
Commissioners will need to determine with
their Providers the circumstances where it is
reasonable for payment to be withheld for
services where the NHS Number has not been
captured. Commissioners may, as they
already do, query and challenge the absence
of the NHS Number on the basis that the
payment requested cannot be confirmed as
relating to a patient for whom they are
responsible. In most instances a patient’s
NHS Number will be made available to the
Provider from the organisation referring the
patient for treatment in line with existing
guidance and the NHS Number Safer Practice
Notice, or will be readily available via tracing
on the Personal Demographics Service
(PDS).
Those instances where it is sometimes difficult
to determine the NHS Number for a patient
are referred to as ‘complex cases’. Different
categories of complex case are described
from page 3 onwards, but they normally have
one of the following causes:
• the patient does not have an NHS Number or
has one that cannot be reliably used;
• the patient’s PDS record (and associated NHS
Number) is invalidated and a new PDS record
created;
• the patient’s demographic details are out of
date on the PDS and cannot be safely matched
to those supplied by the organisation; or
• the patient does not supply demographics that
can be used to identify them accurately.
Note that for the majority of these cases a
patient will have an NHS Number, although
finding it may require some effort.
There are circumstances, however, in which
the NHS Number may be difficult to obtain.
This guidance identifies and explains these
circumstances to help Commissioners to
determine when the absence of the NHS
number may be permissible for contracting
purposes.
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Categorising a case as complex
Prior to categorising an inability to retrieve an
NHS Number for a patient as a complex case,
organisations should ensure that they have
taken all necessary steps to obtain it.
Except for certain types of treatment where
the patient refers him/herself for care (e.g.
Emergency Department and Minor Injuries
Unit), the referral should first be checked to
see if it includes the NHS Number. If it does
not contain the NHS Number then the referrer
should be contacted by the Provider
organisation and asked to provide it. If the
referrer cannot supply this they should be able
to provide details on why they cannot, and this
may help identify an appropriate category of
complex case (e.g. a referring Emergency
Department may confirm that the patient has
already been identified as a Foreign National).
All patients will need to be traced on the PDS
by an organisation providing care (either to
retrieve the NHS Number where it has not
been provided by the referrer or to confirm
demographic details). An inability to trace a
patient at a specific point in time does not
necessarily mean that the patient does not
have an NHS Number, but it may be difficult to
find (e.g. MOD and prisoner cases are likely to
have an NHS Number, but their record on the
PDS may have demographic details that do
not match with those supplied). In a review of
patient records without an NHS Number 1
almost 50% of these records were
successfully traced using a systematic
approach. More detailed advice on tracing
can be found in the document entitled “Finding
patient records on the Personal Demographic
Service”
Categories of complex case
As explained above, there are normally four
types of circumstances that may mean an
NHS Number is not retrievable. These are not
necessarily mutually exclusive, i.e. there may
be more than one factor making it difficult to
find the NHS Number for a particular patient.
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samples provided by 14 acute, community and mental
health service providers
Patient does not have an NHS
Number or has one that cannot be
reliably used
If the patient:
•
•
has never registered with a GP practice
and never attended for treatment at
another organisation that allocated them
an NHS Number; and
did not have a PDS record created for
them automatically at birth (all babies born
in England, Wales and the Isle of Man
have been automatically assigned an NHS
Number since October 2002)
then it will not be possible to retrieve that
patient’s NHS Number during the provision of
care.
However, it may be possible to trace them
afterwards, as they may subsequently register
with a GP Practice. Continuing to retrace for
patients after treatment will increase the
retrieval of NHS Numbers (as patients may
have an NHS Number assigned to them
afterwards or have their demographic details
updated on the PDS).
Some patients will have an NHS Number (and
potentially more than one) that cannot be used
reliably as a unique identifier for that patient,
as the same NHS Number may be used by
multiple patients or a patient may have
multiple NHS Numbers. Such data quality
issues generally result from organisations
allocating a new NHS Number to a patient
who already has one (see Guidance for trusts
allocating NHS Numbers) or other data
administration errors.
There are five different categories of complex
case where the patient does not have a
(reliable) NHS Number:
•
•
•
•
•
Overseas visitor
Patient has only ever registered in
Scotland or Northern Ireland
Private patients
Long term mental health patients
Data quality issues
These are covered in the tables below:
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Complex Case Category
OVERSEAS VISITOR
Issue
• The patient is normally resident in an overseas country. They may never have registered
with a GP practice or other organisation that can allocate an NHS Number.
• However, some overseas visitors will previously have registered with the NHS and will have
an NHS Number.
• If these patients do not have an NHS Number then they cannot be traced and this
demographic item cannot be included in their records.
Likely to Impact
• This category of complex case most commonly affects the acute setting (and in particular
Emergency Department episodes) but any service where care is provided without a referral
can be impacted (e.g. Minor Injuries Unit).
• Infrequently, overseas visitors will be referred to other services (e.g. an Emergency
Department may refer them to the Inpatient Department).
How these patients could be identified and their NHS Number retrieved
• If the overseas visitor is paying for their own treatment then there will be no need to include
an NHS Number in payment flows to Commissioners.
• Overseas visitors should be identified through the use of a “ZZ99 ***” default postcode
(excluding “ZZ99 3VZ” which is used for patients of no fixed abode and “ZZ99 3WZ” for
patients of unknown address).
• Overseas visitors who have had previous NHS contact may have a record on the PDS with
the default ZZ99 postcode included and can be traced as normal.
• An overseas visitor may register with the NHS after initial treatment. Retracing after the
episode has completed may increase coverage.
• Where a valid GP practice code is available, the GP practice can be contacted to confirm
demographics and determine if the patient has an NHS Number.
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Complex Case Category
PATIENT HAS ONLY EVER REGISTERED IN
SCOTLAND OR NORTHERN IRELAND
Issue
• The patient has only ever registered with NHS organisations in Scotland or Northern Ireland
and does not have an NHS Number (Scotland uses Community Health Index (CHI)
Numbers and Northern Ireland uses Health and Care (H&C) Numbers).
• Normally, these patients will not cause an issue with payment as treatments are cross
charged to the relevant country (Scotland/Northern Ireland). However, Emergency
Department episodes are paid for by the local commissioner and so agreement will need to
be reached on these cases.
Likely to impact
• This type of patient can attend for treatment at any organisation, not just those that are
based near the border with Scotland.
• Any organisation or service can have this group of patients.
How these patients could be identified and their NHS Number retrieved
• These patients can normally be identified through their referral source (e.g. a GP based in
Scotland) or postcode.
• The patient should be able to confirm whether they have previously registered for healthcare
in England, Wales or the Isle of Man.
• Patients resident in Scotland or Northern Ireland may have previously registered for
healthcare in England, Wales or the Isle of Man and have an NHS Number.
• The fact that a patient is normally resident in Scotland or Northern Ireland should not
prevent organisations from attempting to trace that patient.
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Complex Case Category
PRIVATE PATIENT
Issue
• A patient:
- born outside England, Wales or the Isle of Man or
- born in England, Wales or the Isle of Man before October 2002
that has never registered with the NHS will not have an NHS Number.
• However, most patients relying mainly on private or non-NHS care provision will have had
some contact with the NHS and are therefore likely to have an NHS Number.
Likely to impact
• Any organisation or service.
How these patients could be identified and their NHS Number retrieved
• If the patient has been referred then the referrer can be contacted for confirmation that
they belong to this complex case category.
• If the referrer cannot confirm this as the appropriate complex case category, the
organisation should try to establish with the patient whether they have only ever received
private care and whether they are likely to have an NHS Number.
• Regardless, all patients should be traced if an NHS Number is not received from a
referrer.
• As with all cases where the patient does not have an NHS Number, the patient may
register with the NHS after the provision of care and retracing may prove helpful.
Complex Case Category
LONG TERM MENTAL HEALTH PATIENTS
Issue
• There are a small number of patients who have been in residential mental health care for
many years and do not have a record on the PDS or an NHS Number.
Likely to impact
• Any organisation or service but particularly mental health service providers.
How these patients could be identified and their NHS Number retrieved
• If the patient has been referred then the referrer could be contacted for confirmation that
they belong to this complex case category.
• If not then the organisation will need to confirm directly with the patient that they belong to
this complex case category.
• As with all cases where the patient does not have an NHS Number, the patient may
register with the NHS after the provision of care and subsequent retracing may prove
helpful.
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Complex Case Category
DATA QUALITY ISSUES
Issue
• A small percentage of patients will have a record on the PDS that organisations will be
unable to reliably match due to problems with the quality of data, in particular:
- Confusions – the same NHS Number is being used for more than one patient and a
PDS record contains data that applies to more than one patient.
- Duplicates – the patient has more than one PDS record and hence more than one
NHS Number
- Sensitive record – the patient, or someone acting on behalf of the patient, has
requested that the details of their PDS record are hidden from view.
- Absence of any geographic or historic details in some PDS records.
Likely to impact
• Any organisation or service. The number of records impacted by these issues is very
small.
How these patients could be identified and their NHS Number retrieved
• Confusions and duplicates should be raised with the PDS National Back Office (for further
information see http://nww.connectingforhealth.nhs.uk/demographics/backoffice).
• Further information on how sensitive records or records with data quality issues are
identified can be found at
http://nww.connectingforhealth.nhs.uk/demographics/backoffice/flag/what
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The patient has their record on the PDS and associated NHS Number
invalidated and a new one created
Although most patients will have an NHS Number and associated record on the PDS
assigned to them for life, in certain specific circumstances a new record and NHS Number
will be created for a patient and their previous record(s) invalidated.
Any record will still be traceable using the correct demographics prior to the record being
invalidated.
There are three categories of complex case where a patient may have their previous record
on PDS invalidated and new ones created:
•
•
•
Identity change
Adoption cases
Gender re-assignment
Complex Case Category
IDENTITY CHANGE
Issue
• The patient has their identity changed (e.g. because of identity protection). Their previous
record and NHS Number on the PDS are invalidated and new ones created.
Likely to impact
• Any organisation or service.
How these patients could be identified and their NHS Number retrieved
• The patient will be traceable prior to their PDS record and NHS Number being invalidated.
Tracing them after their record has been invalidated using either their previous NHS Number
or out of date demographics will not be successful.
• This category of complex case will only be an issue for organisations that seek to validate or
retrieve the NHS Number after the patient has completed the identity change process and
the organisation only has their previous details.
• Could liaise with the PCT in cases where there are issues with retrieving the NHS Number
as a result of a possible identity change.
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Complex Case Category
ADOPTION CASES
Issue
• The patient is adopted. In some cases, upon completion of the adoption process the
patient’s previous record and NHS Number on the PDS is invalidated and new ones
created.
• The adoption process may also result in the patient’s demographic details changing (e.g.
their names and addresses).
Likely to impact
• Any organisation or service but particularly likely to impact those which treat children.
How these patients could be identified and their NHS Number retrieved
• Providing that the patient has their NHS Number supplied/verified/traced during the
provision of care there should be no issue as the patient will have a record on the PDS
(although it will change at some point in time).
• This category of complex case will only be an issue for organisations that seek to validate or
retrieve the NHS Number after the patient has completed the adoption process and the
organisation only has their previous details.
• The Adoption Agency should notify the relevant PCT and GP practice of changes to an
individual’s details after the adoption process has completed. The PCT or GP practice could
be contacted in cases where the patient cannot be traced due to a possible adoption.
Further information
• Further detail on the adoption process can be found at
http://www.connectingforhealth.nhs.uk/systemsandservices/demographics/pds/ig/access.
• The Department for Education is currently reviewing the policy of issuing new NHS Numbers
for adoption cases.
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Complex Case Category
GENDER REASSIGNMENT
Issue
• The patient changes gender. Upon the completion of the gender reassignment process the
patient’s previous record and NHS Number on the PDS is invalidated and a new PDS record
created.
Likely to impact
• Any organisation or service.
How these patients could be identified and their NHS Number retrieved
• The patient will be traceable prior to their PDS record and NHS Number being invalidated.
Tracing them after their record has been invalidated using either their previous NHS Number
or out of date demographics will not be successful.
• This category of complex case will only be an issue for organisations that seek to validate or
retrieve the NHS Number after the patient has completed the gender reassignment process
and the organisation only has their previous details.
• The PCT will be notified of any changes to a patient’s details. However, to protect patient
privacy they may not be able to confirm that a specific patient has changed gender.
Further information
Further information is available from
http://www.connectingforhealth.nhs.uk/systemsandservices/demographics/pds/ig/access.
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The patient has demographic details that are out of date on the PDS and
which cannot be safely matched to those supplied to the organisation
The majority of patients that belong to the complex case categories below will have an NHS
Number. However, the demographics supplied to the organisation (either by the patient or
the referrer) are unlikely to match with the record on the PDS.
As with all cases, if available, the referrer should be contacted to clarify a patient’s
demographics or to help determine why they cannot be traced.
There are four categories of complex case where the patient’s demographic details may be
out of date on PDS:
• Armed forces personnel and service dependants
• Prisoners
• Demographic details out of date on the PDS
• No fixed abode
Complex Case Category
ARMED FORCES PERSONNEL AND SERVICE
DEPENDENTS
Issue
• The patient has their primary care provided by the Defence Medical Services (DMS). These
patients are typically armed forces personnel, sometimes their dependants and other
relevant groups.
• The PDS is likely to reflect their address details and GP practice code prior to DMS
assuming primary responsibility for their healthcare.
• Some members of the armed forces could also be considered as an overseas visitor and
may not have an NHS Number, but these form a minority of cases.
Likely to impact
• Predominantly likely to impact the acute sector (although community and mental health may
be impacted). Treatment could either be through referral or by the patient attending for
treatment at an Emergency Department.
How these patients could be identified and their NHS Number retrieved
• DMS stipulates the use of the NHS Number when communicating with the NHS and should
include it on any referrals. DMS know the NHS Number for over 90% of their patients and
will attempt to proactively allocate one, if necessary, prior to referring for treatment.
• Where a DMS referral is received without an NHS Number, the referrer should be contacted
for this information as they are likely to have it.
• If the patient attends for treatment without being referred, then tracing should be performed
with the patient present to confirm their previous address and GP’s details and allow a safe
match to be made.
Further information
Further information is available from
http://nww.connectingforhealth.nhs.uk/demographics/modfaqs
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Complex Case Category
PRISONERS
Issue
• The patient is currently detained in prison.
• The patient’s details on the PDS are likely to be out of date (as it may contain details of their
address and GP practice code prior to their detention).
• A prison may not know the NHS Number for a prisoner when referring them for treatment to
the NHS as it is not routinely used as a primary patient identifier.
• It is likely that use of the NHS Number will not be made compulsory across prison
healthcare until the technology and supporting processes are available to support its
inclusion.
Likely to impact
• The acute sector is most likely to be impacted and could have prisoner referrals for a
number of different services. Other sectors may be impacted to a lesser extent.
How these patients could be identified and their NHS Number retrieved
• As with all cases the referrer should be queried for further information and assistance in
retrieving the NHS Number for patients where it has not been passed on. Usage of the NHS
Number within prisons is increasing, and prison healthcare teams are being advised to
include the NHS Number on referrals, so there is an improved likelihood that it will be
available.
• Tracing with the patient present to confirm previous address and general practitioner details
is likely to be able to retrieve a match from the PDS if the referring prison is not aware of
their NHS Number.
Further information
• The Use of the NHS Number in prison healthcare guidance contains information on the use
of the NHS Number in prisons.
• The Frequently Asked Questions on Managing referrals from prison health to secondary
care give further information on when a prisoner’s address should be updated on the PDS to
reflect their current location.
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Complex Case Category
DEMOGRAPHIC DETAILS OUT OF DATE ON THE
PDS
Issue
• The PDS contains out of date values for the patient (e.g. the patient has moved or changed
names but not updated their details with their GP practice).
• Students may belong to this complex case category (as the PDS may have their address
prior to starting their studies).
• The local and PDS records may not match within Commissioners’ timescales.
Likely to impact
• Any organisation or service. However, where the organisation is providing long term care
there is more likely to be knowledge of previous and current address details.
How these patients could be identified and their NHS Number retrieved
• These patients do have an NHS Number and can be traced successfully providing the
organisation confirms historic details with the patient.
• Where historic details have not been confirmed, it is good practice to retrace at regular
intervals to capture the NHS Number when the PDS has been updated to match their
supplied demographics.
Complex Case Category
NO FIXED ABODE
Issue
• The patient has no permanent address and may not be registered with a GP practice.
• This may make it difficult to match to a record in the PDS.
• These patients may have registered in different locations using different details and have
more than one record on the PDS.
Likely to impact
• Any organisation and service.
How these patients could be identified and their NHS Number retrieved
• If the patient attends through referral, contacting the referrer may enable better
understanding of the patient’s circumstances.
• In a review of episodes without an NHS Number Providers were able to identify this complex
case easily. The default code “ZZ99 3VZ” could be used to identify this type of complex
case in flows between Providers and Commissioners.
• Tracing the patient while they are present may allow a match to be made to a record on the
PDS through historic details (they may previously have had a permanent address).
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The patient does not supply demographics that can be used to identify
them accurately
This category most significantly impacts those cases where a patient attends for treatment
without a referral. The patient does not, either through inability or choice, supply
demographics that can match to any record in the PDS although they are still likely to have
an NHS Number.
There are two categories of complex case where the patient may not supply demographics
that can be used to identify them accurately:
•
•
Patient unable to supply demographics
Patient deliberately obscures their demographics
Complex Case Category
PATIENT UNABLE TO SUPPLY DEMOGRAPHICS
Issue
• The patient cannot supply demographics at the point of receiving care due to trauma,
unconsciousness or diminished mental capacity. This prevents them being matched to any
record in the PDS.
Likely to impact
• Any service that does not require referral.
How these patients could be identified and their NHS Number retrieved
• It is expected that most of this group of patients could be traced successfully at some point
(either upon regaining consciousness or when a carer arrives for the patient).
Complex Case Category
PATIENT DELIBERATELY OBSCURES THEIR
DEMOGRAPHICS
Issue
• The patient deliberately obscures their demographic details to prevent their successful
identification whilst attending for treatment.
• Mental Health service providers have confirmed this as a particular problem for their care
setting, in particular for addiction services.
Likely to impact
• Any service that does not require referral, particularly services dealing with conditions
considered to carry social stigma, or where contact with a patient who is hiding illegal
activity is possible (e.g. drink driving and Emergency Department episodes).
How these patients could be identified and their NHS Number retrieved
• Tracing with the patient present to confirm demographic details may help in finding the
correct record.
• However, if the patient is deliberately obscuring their details it is unlikely that these patients
will be accurately identified.
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List of referenced documents and their purpose
The following table details the documents referenced within this guidance and gives their
purpose.
Document Title
Purpose
Operating Framework
Sets out the business and planning
arrangements for the NHS
NHS Standard Contract
The standard contract between
Commissioners and care providers
Safer Practice Notice (CAS Ref:
NPSA/2009/SPN002)
An alert that emphasises the need to use the
NHS Number as the national identifier for all
patients.
Finding patient records on the Personal
Demographic Service
This document details how records can be
traced on the PDS
Allocation Guidance
This gives information on when the NHS
Number should be allocated and how to avoid
duplicate records
Use of the NHS Number in prison healthcare
guidance
This guidance details how the NHS Number
can be used and retrieved within the prison
healthcare arena
If you have any questions visit www.connectingforhealth.nhs.uk/nhsnumber
© Crown copyright July 2012
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