Learning objectives:You will learn about the Exeter system and consider primary and secondary care activity. This section also looks at the following:
- Quality and Outcomes framework
- Healthcare Resource Groups
- Caldicott Guardians
- Data protection act
- Freedom of information act
Read the resource text below.
Identifying patients to the system
The Exeter system records every registration of a patient to a GP practice. Data include patient's full name and address, including postcode, date of birth, sex, date of registration, place of birth (free text), and some data on date of entry to the UK. Data are partitioned so that PCTs are given access to their resident patients, plus aggregate data for their registered patients who live outside the PCT. PCTs can set up mutual exchange arrangements to enable each other to have full details. The Exeter system was originally intended to enable GPs to be paid, when the main determinant of the pay was a capitation fee.
Derived from the NHS Central Register, in theory a patient can only be recorded once. In practice, an estimated 5.6% inflation is encountered.
GP systems vary, but as most GPs are now on contracts where their remuneration depends on recording activity performed for patients, their current systems reflect this. The systems record appointments, tests requested (with results when these are available), physiological measurements, prescriptions and referrals. In general, without special arrangements, GPs' data at patient level are not available to PCTs, but anonymised and nationally analysed data in terms of the Quality and Outcomes Framework (QOF) contract data are available at practice level.
The QOF itemises those data items thought by the Department of Health to be sufficiently important to affect a GP's fees. These include blood pressure measurement, smoking, body mass index, diabetic lab results, proportions of children immunised, and various other items that may change from year to year.
Getting patients into the secondary care (hospital) system: A main plank of the current Connecting for Health strategy is Choose and Book, intended to allow patients choice of potential hospital providers and to book appointments directly on line rather than relying on the hospital to prioritise and allocate a slot. This is in partial operation (as at September 2008).
Accident and Emergency: A&E systems track patients from first arrival through encounters with NHS staff, through diagnosis and (possibly) intervention to outcome (discharge, admission etc). A&E systems have risen in prominence since major political emphasis was placed on quick attention and maximum time spent in A&E. Diagnostic codes are limited to one or two per visit, so underlying issues such as substance abuse may be under-counted.
Patient Administration System (PAS): The hospital's master system for recording what happens to their patients. Administers outpatient clinics, capacity, list sizes, appointments & attendance, level of medical staff per appointment. Administers elective admission lists (waiting lists), recording date placed on list, category of urgency, intended treatment and management, specialty, consultant, and any periods of suspension from waiting list. Tracks admitted patients through hospital, including specialty, consultant, dates, intended management, ward admissions and transfers, discharges; after discharge data is clinically coded for diagnostics (using ICD10 codes) and surgical interventions (using OPCS4 codes), and assigned an HRG (Healthcare Resource Group) for payment. Anonymised extracts from PAS admitted patients data and (recently) outpatients data go to the national Secondary User Service, where the data are partitioned for registered and resident PCT, and certain fields are taken off to the Hospital Episode Statistics (HES) database, which is used by the Department of Health for NHS planning purposes. These partitioned files enable PCTs to analyse their patient's care wherever they are treated within the NHS, and allow for benchmarking (using appropriate age/sex standardisation) against national or selected counterpart organisations.
Clinical Audit/Research Systems: Can be part of a central hospital database or locally run by a department, or as part of a national audit process. These record clinical aspects in more detail than PAS. The National Service Framework for Cardiovascular disease is recorded on a national standard system, Myocardial Ischaemia National Audit Project (MINAP).
Laboratory Systems: These record requests for and results of laboratory tests.
Community Health Care
Systems vary but PCTs run systems to manage community child health services (recording immunisation, health visitors, birth weights etc), screening services (eg cervical screening), some community-based healthcare activity such as physiotherapy & podiatry, and also anonymised sexual health and teenage pregnancy data.
These record patient data at catchment area level, and are not permitted to report at other levels. These data are subject to certain extra-statutory protection.
Public health departments are allowed full details of the births and death registration relevant to their areas. Although these data are in the public domain (via the public registry office) users are required to treat them as personal data that should not be disclosed.
Geographic Information Systems (GIS)
Most NHS data has geographic data indirectly attached, usually as the postcode of the patient. The Office of National Statistics, working with the Post Office, produces the NHS Postcodes file, which includes mapping coordinates for the centroid of each postcode polygon to the nearest 100 metres, and for a fee a version accurate to 1 metre can be obtained. The file is updated four times per year. This file also allocates the postcode to every possible level, current and obsolete, of administrative geography, including PCT, Local Authority, ward, Super Output Area, and others. In combination with software that is designed to display maps, this data can be presented in ways that cast a great deal of light on the health issues faced by a PCT, or SHA.
The Quality & Outcomes Framework
QOF was introduced into primary care in 2004 and contains 4 clinical domains.
- Patient experience
- Additional services
If patients are not suitable they may be excluded by clinicians. The QMAS system is used to manage the financial aspects of QOF.
Healthcare Resource Groups (HRGs)
These provide a means of categorising the treatment of patients in order to monitor and evaluate the use of resources. They were originally developed for use in the acute sector. However, they can be applied to any speciality.
HRGs represent groups of clinically similar treatments and diagnoses, which consume similar levels of healthcare resource, but they are not included in the ICD-10 classification codes.
Data Protection Act
The Data Protection Act of 1998 sets out the following points:
1. Personal data shall be processed fairly and lawfully, and, in particular, shall not be processed unless:
(a) at least one of the conditions in Schedule 2 is met, and
(b) in the case of sensitive personal data at least one of the conditions in Schedule 3 is also met.
2. Personal data shall be obtained only for one or more specified and lawful purposes, and shall not be further processed in any manner incompatible with that purpose or those purposes.
3. Personal data shall be adequate, relevant and not excessive in relation to the purpose or purposes for which they are processed.
4. Personal data shall be accurate and, where necessary, kept up to date.
5. Personal data processed for any purpose or purposes shall not be kept for longer than is necessary for that purpose or those purposes.
6. Personal data shall be processed in accordance with the rights of data subjects under this Act.
7. Appropriate technical and organisational measures shall be taken against unauthorised or unlawful processing of personal data and against accidental loss or destruction of, or damage to, personal data.
8. Personal data shall not be transferred to a country or territory outside the European Economic Area unless that country or territory ensures an adequate level of protection for the rights and freedoms of data subjects in relation to the processing of personal data.
For further information
A review was commissioned in 1997 by the Chief Medical Officer of England "owing to increasing concern about the ways in which patient information is being used in the NHS in England and Wales and the need to ensure that confidentiality is not undermined. Such concern was largely due to the development of information technology in the service, and its capacity to disseminate information about patients rapidly and extensively."
A committee was established under the chairmanship of Dame Fiona Caldicott, Principal of Somerville College Oxford, and previously President of the Royal College of Psychiatrists. Its findings were published in December 1997. The report highlighted six key principles, and made 16 specific recommendations. The six key principles are as follows:
i. Justify the purpose(s) - Every proposed use or transfer of patient identifiable information within or from an organisation should be clearly defined and scrutinised, with continuing uses regularly reviewed, by an appropriate guardian.
ii. Don't use patient identifiable information unless it is absolutely necessary - Patient identifiable information items should not be included unless it is essential for the specified purpose(s) of that flow. The need for patients to be identified should be considered at each stage of satisfying the purpose(s).
iii. Use the minimum necessary patient-identifiable information - Where use of patient identifiable information is considered to be essential, the inclusion of each individual item of information should be considered and justified so that the minimum amount of identifiable information is transferred or accessible as is necessary for a given function to be carried out.
iv. Access to patient identifiable information should be on a strict need-to-know basis - Only those individuals who need access to patient identifiable information should have access to it, and they should only have access to the information items that they need to see. This may mean introducing access controls or splitting information flows where one information flow is used for several purposes.
v. Everyone with access to patient identifiable information should be aware of their responsibilities - Action should be taken to ensure that those handling patient identifiable information - both clinical and non-clinical staff - are made fully aware of their responsibilities and obligations to respect patient confidentiality.
vi. Understand and comply with the law - Every use of patient identifiable information must be lawful. Someone in each organisation handling patient information should be responsible for ensuring that the organisation complies with legal requirements.
The Freedom Of Information Act
The Freedom Of Information Act (2000) gives a general right of access to all types of recorded information held by public authorities and places obligations on public authorities to disclose this information. Exemptions to this disclosure include:
- personal information about individual staff members and patients
- information which would endanger the health of individuals
- if the provision of information is likely to cost the organisation more than £450. Information may be withheld if its provision is likely to involve compliance costs exceeding the prescribed limit, which is currently £450 for most NHS bodies.
- research findings intended for future publication