Document Record ID Key Programme Sub-Prog / Project Prog. Director Owner Author NPFIT NPFIT-NCR-SUSPBR-xxxx.

xx Secondary Uses Service Payment by Results Andy Burn Version 0.3 Andy Burn Status Final Draft Paul Bates Version Date 19/04/2011

Reconciliation of SUS PbR with local systems Generic Guidelines

Amendment History:
Version 0.1 0.2 0.3 Date 29/03/11 04/04/11 19/04/11 Amendment History Initial In-Progress Draft Review Draft Final Draft

Forecast Changes:
Anticipated Change When

Reviewers:
This document must be reviewed by the following: Name Signature Title / Responsibility Stuart Richardson Programme Manager Craig Walker Simon Robinson Section Head Principal Information Analyst Date 7/4/2011 7/4/2011 7/4/2011 Version

Approvals:
This document must be approved by the following: Name Signature Title / Responsibility Andy Burn Director for NIRS Engagement and SUS Date Version

Document Status:
This is a controlled document. Whilst this document may be printed, the electronic version maintained in FileCM is the controlled copy. Any printed copies of the document are not controlled.

Related Documents:
Generic SUS Reconciliation Guidelines Crown Copyright 2011

These documents will provide additional information. Ref no Doc Reference Number Title NHSIC-SUS-PBR-R9-0001.01 SUS PbR R9 Technical Guidance SUS Best Practice Guide

Version 1.0 1.0

Glossary of Terms:
Term Accident and Emergency Admitted Patient Care Commissioning Data Set Acronym A&E APC CDS Definition Accident and Emergency Medicine

Currency

The national data sets sent to SUS to support the exchange of data between providers and commissioners and national statistics; the data source used by SUS PbR. The basis for calculating PbR payments, derived from the characteristics of an activity such as hospital provider spell or an outpatients attendance. An admission arranged in advance, excluding maternity and emergency admissions and admissions from other hospitals identified by Method of Admission codes 10-13. Admissions which are unpredictable and at short notice because of clinical need identified by Method of Admission codes 21-28 Time spent in admitted patient care beyond the trimpoint associated with the HRG and method of admission, after account is taken any excluded periods (such as critical care). The excess bed days attract an additional a daily payment dependent on the HRG. A grouping consisting of patient events that have been judged to consume a similar level of resource based on clinical coding (ICD-10 and OPCS-4), age and other factors The date by which the provider needs to submit data for the month in question for inclusion in the report available for monthly reconciliation. The Trust specific uplift to tariff made to adjust for local variations in pay and prices

Department of Health Elective Admission

DH

Emergency Admission

Excess Bed Days

XBD

Healthcare Resource Group

HRG

Inclusion Point

Market Forces Factor NHS Information Centre Non-elective Admission Out Patient Patient Administration System Post Reconciliation Point Reconciliation Point

MFF NHS IC

Comprise emergency, maternity and other admissions. identified by Method of Admission codes greater than 20. OP PAS The date when the final reconciliation report is available for the month in question. This was formerly known as the freezedate. The date when the PbR activity is available to the commissioner to facilitate reconciliation between provider and commissioner. This was formerly known

Generic SUS Reconciliation Guidelines Crown Copyright 2011

Term Secondary Uses Service SUS Payment by Results SUS Extract Mart

Acronym as the flexdate. SUS SUS PbR

Definition

SEM

Trim-point

The SUS module which derives PbR currencies and applies national tariffs to relevant activity sent via the CDS Gives Providers and Commissioners access to current CDS data sent through SUS (subject to security constraints) The number of days into a hospital provider spell beyond which hospital stays attract an additional per diem payment.

Generic SUS Reconciliation Guidelines Crown Copyright 2011

1 IntroductionandBackground...........................................................................6
1.1 1.2 1.3 2.1 2.2 2.3 2.4 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 4.1 5.1 5.2 PurposeofThisDocument................................................................................6 SecondaryUsesService(SUS) ............................................................................6 SUSPbRProcessingin2011/12..........................................................................7 WhyReconcile..................................................................................................7 ReconciliationMethodology.............................................................................7 ConsistencyofData ..........................................................................................10 SUSDataMarts................................................................................................11 SummaryofKnownIssues...............................................................................12 SUSInputErrors...............................................................................................12 DataConsistency ..............................................................................................13 IdentifyingOrganisationsandReasonsforAccess ............................................13 SpellConstruction............................................................................................14 IncorrectPreparationofDataforLocalHRGGrouping......................................16 IdentificationofActivitytoTariff......................................................................16 CriticalCareLengthofStay............................................................................... 17 SUSPbRProcessingIssues.............................................................................18 LocalProcessingvs.SUSPbR............................................................................19 SUSExtractMart(SEM).................................................................................... 20 SUSPbR........................................................................................................... 20

2 ReconciliationApproach...................................................................................7

3 KnownReconciliationIssues............................................................................12

4 Conclusions.....................................................................................................19 5 AppendixASEMandSUSPbRMartsOverviewofKeyFeatures.................... 20

6 AppendixBSummaryofKeyLessonsLearnt..............................................22

Generic SUS Reconciliation Guidelines Crown Copyright 2011

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1.1
1.1.1

IntroductionandBackground
PurposeofThisDocument
Following on from detailed SUS PbR reconciliation exercises undertaken during 2009and2010this documentseeksto provideaset ofgenericguidelinesthat NHS organisations can use to inform local reconciliation activity. It is primarily concerned with the reconciliation of priced activity within local systems to that identifiedinoutputsfromSUSPbR. It highlights both the commonly found issues that are known to cause difficulty with the reconciliation process and the lessons learnt from the detailed analysis whichaimto: MakeroutinereconciliationbetweenPCTandProviderTrustsimpler. Identify likely areas for the review and improvement of existing local processes. Provide assurance to providers and commissioners that SUS PbR providesasoundbasisforundertakingcontractreconciliation,accurately calculatingpricedactivityatnationaltariff EncouragecommissionersandprovidersnotalreadyusingSUStodoso.

1.1.2

1.1.3

The document draws on learning points emerging from a joint reconciliation exerciseundertakenbytheNHSSUSPbRteamandalocalhealthcommunityduring 2009 and 2010. These guidelines are, however, generic and there are no specific detailsofthisexerciseincludedwithinthem. The document will be of interest to commissioning, information and finance teams withinbothNHSCommissionerandProviderorganisations.

1.1.4

1.2
1.2.1

SecondaryUsesService(SUS)
The NHS Secondary Uses Service (SUS) is the central repository which supports the flow of Commissioning Data Sets (CDS) between providers and commissioners. The useofSUShasbeenmandatedintheOperatingFrameworkfor2011asfollows: TheNHSshouldusetheSecondaryUsesService(SUS)asthestandardrepository forperformancemonitoringreconciliationandpaymentsbyApril2012operating inshadowformfromOctober2011.During2011/12progressondeliveryofthis willbeperformancemanagedandcommissionerswillbeexpectedtouse contractsanctionsiftheyarenotsatisfiedaboutthecompletenessandqualityof aprovidersdata.

1.2.2 SUSusesthesubmittedCommissioningDataSets(CDS)toprovidethefollowing:

SUS Payment by Results (PbR) which uses derivations, tariffs and business rules agreed with the DH PbR team to provide a common and consistentmechanism to supportreconciliationbetweenCommissioners and Providers. SUS PbR versions the data to provide static snapshots at both the reconciliation and final reconciliation inclusion points. It can additionallyprovideacurrentviewofthedatawithinSUS.

Generic SUS Reconciliation Guidelines Crown Copyright 2011

SUS Extract Mart (SEM) which returns the data submitted to SUS as a bulk extract with a limited number of additional derivations. These derivations include the core spell and episode HRG derived by SUS PbR andtheGPpracticeandPCTcodesderivedbythePersonalDemographic Service (PDS). SEM reflects the position within SUS at the time the extractistakenthusprovidingachangingviewovertime.

1.3
1.3.1

SUSPbRProcessingin2011/12
For readers requiring further guidance on the operation and outputs of SUS PbR in 2011/12aseparatedocumentSUSPbRRelease9TechnicalGuidance 1 isavailable that provides details of SUS PbR processing as implemented in 2011/12. It summarises the key areas of DH PbR policy and provides details of the additional functionalityintroducedin2011/12tosupportthenationalpolicyonreadmissions, bestpracticeandthemanagementofCriticalCaredays.

2
2.1
2.1.1

ReconciliationApproach
WhyReconcile
Reconciliation between SUSPbR and local systems is most commonly undertaken as part of the invoice validation and approval process that is managed between commissionersandproviders. Aproviderwillgenerateaninvoicebasedontheactivity,rulesandtariffsembodied in national guidance and local contracts. The provider invoice will typically be generated by a local system and be supported by a statement of activity at an aggregate level. The detail of the activity will be independently available to the commissioner through the data maintained on the Commissioning Data Sets which flowintoSUSfromproviderorganisations. As this process underpins the basis of contractual payment between the organisations it should be subject to the appropriate assurance expected by a financialsystem.Thisshouldincludetheabilitytosupportanaudittrailbacktothe eventswhichgeneratedtheclaimforpayment. The amounts invoiced depend primarily upon the volume of activity, as expressed through the relevant contract currency, the rules associated with creating that currency and the tariffs applied. These base amounts may then be subject to variation to reflect national aggregate adjustments (e.g. the thresholds set for emergencyadmittedpatientcare)orcontractualrequirements.

2.1.2

2.1.3

2.1.4

2.2
2.2.1

ReconciliationMethodology
Thenormalapproachtoreconciliation istoadopta combinationoftopdown and bottomupprocessestoidentifyandexplainareasofdifference: The topdown comparison is used to highlight and spotlight the areas of activitywheredifferencesoccurand

http://www.connectingforhealth.nhs.uk/systemsandservices/sus/supports/pbr/pbrguidance/r9techguide.pdf

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2.2.2

Record level comparison and (where necessary) checks on calculation areusedtoinvestigateunexplaineddifferences.

Using this approach the key elements to be considered in achieving reconciliation arelikelytobe: Activity are SUS and local processes looking at the same set of activity andisdataofthesamematurity? Currenciesarecurrencyderivationsconsistentwithactivitytypes?(The key currencies being APC Spells, APC excess bed days, outpatient and A&EattendancesandtheirassociatedHRGs). Pricedcurrencyhavetariffsbeenappliedcorrectlyandconsistently?

2.2.3

Experienceofpreviousworkundertakenonreconciliationhasshownthatthemost effective approach to identifying differences within the PbR process is to consider eachofthemainprocessingblocksidentifiedinFigure1below.

Figure1PbRProcessingOverview

Generic SUS Reconciliation Guidelines Crown Copyright 2011

Spell Construction & Grouping

Construct Spells

For APC, spells are constructed from the data for constituent episodes; this step is not required for Outpatients and A&E. Although it should be possible to construct spell data from the supplied NHS Spell Number, SUS creates spells using an algorithm, because the spell number is known to be unreliably implemented by some providers. Under HRG4 activity is grouped over the spell; core inputs are diagnosis, procedure, age and (adjusted) length of stay. For APC, some episodes may be excluded prior to grouping. For SUS this reflects national rules and is primarily on the basis of TFC. HRG 4 gives rise to a core HRG. SUS uses an integral version of the NHS IC HRG grouper, whereas local processes must export data to the grouper and re-import it.

Derive grouping Inputs HRG Grouping

Assign to Contract

SUS distinguishes only between activity within and without local tariff. Local systems will also identify activity to local contracts.

Derive Currencies

Relevant currencies are derived; for SUS this involves the application of national rules to activity within national PbR tariff. Local processing also derives the currencies for locally priced activity (which may be commissioner specific). SUS processes currencies at national tariff for activity within the national PbR scheme. Local processing also applies tariff to activity outside of national tariff.

Price Activity

2.2.4

There are two key lessons learnt from the earlier reconciliation exercises to draw fromthisoverallstructure:

LessonLearnt1Overwhelmingly,initialdifferencesbetweenSUSPbRandlocalprocessing arosefromdifferencesintheactivityunderconsideration.Themostcommoncauseof inconsistencyissimplythatprovidersandcommissionersareworkingwithinconsistent versionsofthedata. LessonLearnt2WhilsttheprocessingstructureidentifiedinFigure1providesaneffective approachtoreconciliation,inpracticetherewillbelocalvariationineachofthesestepsand potentiallytheneedforsecondaryreconciliationofbothinternalSUSflows(SEMtoPbR)and internalTrustandPCTflowstoexplainthecauseofdifferences. AsummaryofthekeyLessonsLearntisprovidedinAppendixB.

Generic SUS Reconciliation Guidelines Crown Copyright 2011

2.3
2.3.1 2.3.2

ConsistencyofData
As suggested above inconsistency in the versions of data used is one of the most commonlyidentifiedsourcesofdifferencewithinreconciliationexercises. National contracts and DH PbR guidance imply that invoice validation will be based onaconsistentsnapshot,takenatoneorotherreconciliationinclusionpoint: Reconciliation Point the date when the PbR activity is available to the commissioner to facilitate reconciliation between provider and commissioner; Post Reconciliation Point the date when the final reconciliation report isavailableforthemonthinquestion.

Lesson Learnt 3 Significant changes in data were found to occur between reconciliation and postreconciliation as coding was completed and corrections to activity data were applied. Data becomes relatively stable from post reconciliation and the reconciliation processbecomeseasierwhenconsistentcutsofthedataareused.
2.3.3

SUSPbR versions the data at these points returning all activity for the financial period, whether or not it is in scope of national tariff (thus supporting the local applicationoflocaltariffs). Thisversioningensuresthatallparties accessingagiven snapshot whether provider or commissioner will have a consistent view of the dataattheinclusionpointsdefinedintheNationalContract. In practice many organisations choose to extract data from the SUS Extract Mart (SEM) which will reflect the current position of SUS rather than a consistent snapshotatinclusionpoint.Thiscanleadto: The generation of priced activity and invoices by the provider from a cut ofdatadifferenttothatsubmittedtoSUSattheinclusionpoint; The lack of a copy of the data as used to generate invoices for query purposes. This is a common problem because provider systems need frequent updating to be of local value and many do not provide the abilitytosupportsnapshots.

2.3.4

2.3.5

Historically there have been three main reasons given for using SEM locally. Firstly, thatPbRextractsdidnotreturnalltherequiredattributeswhereasSEMreturnsthe data submitted to SUS as a bulk extract reflecting the current position at the time theextractistaken.Secondly,thattherehavebeendelaysintheavailabilityofdata from SUS PbR compared with SEM. Thirdly, SEM was developed before the PbR mart and consequently local systems have been built to accommodate SEM extractsandhavenotbeensubsequentlyupdatedtousePbR. These issues have been largely addressed in recent SUS PbR releases through the introductionoftheSUSPbRonlineextractservicewhichnowprovides: Access to a wider range of attributes than those available from the managedserviceextracts;

2.3.6

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A current view of the data (in addition to the static snapshots) which allows an extract to be run reflecting the current SUS PbR view 2 . This reflects improvements in PbR processing which is now a continuous ratherthanbatchprocess.

LessonLearnt4 Usersshould makegreateruseoftheadditionalfunctionalityavailable from the SUS PbR online service and to use SUS PbR as the basis of achieving consistent data extracts. SUS Release 9 for 2011/12 PbR now provides for all CDS items to be availablethroughPbROnline.

2.4
2.4.1

SUSDataMarts
Differences arising between the data structures held in each of the SUS SEM and SUS PbR marts are considered further within the known reconciliation issues section of these guidelines below. Additionally Appendix A provides an overview of keyfeaturesinbothSEMandSUSPbR. It is commonly claimed that different results emerge between data extracted from SUS PbR to that taken from SEM and processed locally. On investigation it is, however, typically found that differences can be traced back to a relatively small numberofcommonfactors: Problems with the quality of submitted CDS data duplication being the mostcommonlyfound; The comparison of inconsistent snapshots of the data caused by timing differencesasidentifiedat2.3above; FailuretorecognisethatSUSPbRselectstheAdmittedPatientCare(APC) databyreferencetothespelldischargedateandnotepisodeenddate; Issues with the application of national PbR derivations to SEM data withinlocalsystemstheseareautomaticallyappliedbySUSPbR; IncorrectpreparationoffilespriortosubmissionforlocalHRGgrouping; Inconsistency with the application of the reasons for access codes relatingtoPCTandcommissioner.

2.4.2

Lesson Learnt 5 SUS PbR functionality provides a sound basis for undertaking contract reconciliation. In reconciliation exercises it has been found to accurately calculate priced activity at national tariff (subject to the CDS extract on which it is based being accurate and local adjustment being made to deal with known factors like patients who have spenttimeinrehabilitationseesection3.9) Lesson Learnt 6 Local processing of PbR is complex and cannot be guaranteed to be free from error. To assure local processing the ability to reconcile against a standard benchmarkisneeded.SUSPbRprovidesapricedviewofactivity,togetherwithdetailsof allunderlyingcurrenciesandderivationsreflectingtheprocessingrulessetbyDHintariff guidance.

SUSPbRcurrentviewmaylagSEMslightlybecauseoftheadditionalprocessingtimetakentoaddPbR derivations

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3
3.1
3.1.1

KnownReconciliationIssues
SummaryofKnownIssues
This section draws out the issues most likely to impact upon the reconciliation process between SUS PbR and local systems based upon experience in earlier reconciliation exercises within the NHS. The list below is generic and provides a framework for analysis only, not all issues will apply to individual providers or commissioners: SUSInputErrors DataConsistency IdentifyingOrganisationsandReasonsforAccess SpellConstruction IncorrectpreparationofdataforlocalHRGgrouping IdentificationofActivitytoTariff CriticalCarelengthofstay SUSPbRProcessingIssues

3.2
3.2.1

SUSInputErrors
Input to SUS is made by the submission of Commissioning Data Sets (CDS) using XMLinputwhichallowsforerrorcheckingagainstadatadefinitionheldintheXML schema. Input is validated prior to being sent to SUS with data fields being validatedforconformitywiththedatadictionary. UpdatetoSUScanuseoneoftwosubmissionprotocols: NetChange(Net) BulkReplacement(Bulk)

3.2.2

3.2.3

Themostcommonlyfounderrorimpactingreconciliationstemsfromduplicationor unintended loss of records caused by inconsistent CDS updates. This is a particular riskwherebothBulkandNetsubmissionsaremixedbythesenderorganisation. The net protocol uses a mandatory unique record identifier as a key. This field, the CDS Unique Identifier, provides a basis for crossreferencing the data submitted to SUS with SUS PbR outputs and thus has potential use in supporting reconciliation. However, as this field is not mandatory in Bulk uploads the net protocol cannot be used to replace bulk records that do not have this key. Should this occur the net submission will pass over the bulk records without a CDS Unique identifier and will leadtothecreationofduplicaterecords. Conversely the Bulk protocol will allow an interchange to be sent with many records having the same CDS Unique Identifier. It is therefore possible for a Net submission, from the same sender with a later applicable date, to replace all records for that CDS Unique Identifier leading to the deletion of all the records in theoriginalBulksubmission. The bulk protocol uses bulk update groups rather than CDS type. If Bulk and Net are mixed Bulk will update all Net records in SUS for the sender, prime recipient and date combinations irrespectively for a given bulk update group leading to

3.2.4

3.2.5

3.2.6

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unintended loss of data. A common example of this occurs where maternity data (CDS type 140) is submitted separately to general episodes (CDS type 130). As CDS types 130 and 140 share the same bulk update group then subsequent Bulk submission of maternity records can lead to the unintended deletion of previously submittedgeneralAPCrecords. LessonLearnt7Itisbesttoavoidmixingbulkreplacementandnetchangeinterchangesto reducetheriskofunintendedduplicationorlossofdata.Toassistreconciliationproviders andcommissionersshouldmonitorSUSafterupdatetoensurethedataonthesystemis consistentwithexpectationsandshouldfurtherinvestigatesubstantialchangetodata volumesfortheperiodinquestion.

3.2.7

The NHS Information Centre has issued a SUS Best Practice Guide which provides further guidance and information relating to the data submission process using the BulkandNetprotocol.Thelinktothisdocumentisshownbelow. 3 Other local factors that can impact upon the quality of data submitted to SUS include: Problems with the integration of data drawn from more than one operationalsystem;forexampleaddingcriticalcaredatatoAPCepisodes orforamergedorganisationusingtwoPASsystems. Incorrect mapping of local to national codes, including difficulties in correctlymappingtoTreatmentFunctionCodes(TFC)andMainSpecialty CodesduetoissueswithPASsetupandfunctionality.

3.2.8

3.3
3.3.1

DataConsistency
The overarching importance of working with consistent versions of the data is covered at 2.3 above. Using snapshots of data at the reconciliation and final reconciliation points from SUS PbR provides a consistent view of the data for both providersandcommissioners.

LessonLearnt8TheabilitytocomparelocalsystemsandSUSatrecordlevelcanbean effectivemechanismtoidentifythecauseofinitialreconciliationdifferences.Toachievethis retainingcopiesofthedatasubmittedtoSUSfromlocalsystemswillbebeneficial.

3.4
3.4.1

IdentifyingOrganisationsandReasonsforAccess
A key concern is to ensure that the organisational scope of the data being reconciled is consistent. Commissioners undertaking invoice validation will be concernedtoensurethatpatientshavebeenassignedtothecorrectCommissioner, the primary determinant of which is the patients GP practice at the time of treatment. The CDS maintains a number of fields relating to PCT and commissioner. These include:

3.4.2

http://www.connectingforhealth.nhs.uk/systemsandservices/sus/reference/bestprac.pdf

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Commissioner which should be coded by the provider in accordance withDHguidancesetoutinWhoPays? 4 GP Practice which is both provider submitted and from April 2010 has also been derived in SUS from data held in the Patient Demographic Service (PDS) using the patient NHS number. This in turn provides the basis for the SUS derived PCT of Responsibility code using reference datafromtheOrganisationDataService(ODS) PCT of Residence which is derived from the patient postcode data recordedwiththePatientDemographicService(PDS) Prime and Copy Recipient fields which allows the provider to expand thecommissionerorganisationswhocanseetherecord

Lesson Learnt 9 To support reconciliation a comparison of the SUS derived and CDS submitted practice provides a first check on whether activity has been correctly assigned by the provider. For PbR, Commissioners can confirm that the rules in Who Pays? have beencorrectlyapplied,itisthereforeimportantthat: Providersensurethatthecommissionerfieldiscorrectlycodedandare consistent with the derived practice and PCT values available to them fromSUS; Commissioners ensure they are comparing like with like in terms of organisationandseektoidentifyanyreconciliationdifferencescausedby data based on a practice derived responsible PCT being compared with theprovidercodedcommissionerfield. Lesson Learnt 10 SUS Extract Mart (SEM) and PbR online both provide the ability to access data using all and any reason for access whereas the PbR managed service only returns data for the provider coded provider and commissioner fields. This further indicatestheuseofPbRonlineextractstosupportthereconciliationprocess.

3.5
3.5.1

SpellConstruction
Reconciliation issues can arise from a failure to take account of the fact that for Admitted Patient Care (APC) SUS PbR uses the hospital discharge date (or end of thespell)andnotepisodeenddatetoextractdata. InSEMhoweverdataisextractedbyreferencetotheepisodestartandenddate.

3.5.2

LessonLearnt11Failuretounderstandthisdifferentapproachcanbeafrequentcauseof claimsthatSUSPbRandSEMdonotreconcile.TheSUSPbRepisodeextractwillcontainall episodesrelevanttoPbRfortheperiodinquestion(theyarelinkedtothespellbyan internallygeneratedspellidentifier).Itisthereforepossibletohavedifferentepisodes returnedbyaSUSPbRandSEMextractforthesameperiodmeaningcomparisonisnotona likeforlikebasis.

DHFrameworkforestablishingresponsibilityforcommissioninganindividualscarewithintheNHS http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_079724 .pdf Generic SUS Reconciliation Guidelines Crown Copyright 2011

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3.5.3

Spells are constructed in SUS using an algorithm approach which from 2011/12 identifies a patient by NHS number or a combination of Provider Spell Number, Date of Birth and Sex. 5 Episodes are assigned to a spell by reference to their start andenddates. The algorithm approach gives wholly consistent results when compared to using correctly recorded Hospital Provider Spell Number for spells involving an overnight stay. The quality of local spell construction outside of SUS PbR will be dependent upon the accurate provision of the Hospital Provider Spell Number by the provider organisation.

3.5.4

LessonLearnt12Therearetwolikelyissuesthatmightimpactreconciliationarisingfrom localprocessing: Providers may fail to update all episodes in a spell which continues over anextendedperiod; Commissioners may omit to extract and process all episodes associated withinthespellaspartoftheirlocaldataprocessing. LessonLearnt13HRGstendtobeproceduredriven.Procedurestakingplacewithinalong multiepisodespellwilltypicallyoccurinoneoftheearlierepisodesinthespellmeaningthat thespellHRGwillrelatetotheseearlierepisodes.Therefore: Iftheprovideralwayscodesepisodeproceduresanddiagnosesondischarge, this implies that provider bulk update processes must use an extended CDS reportingperiodtocaptureallrelevantclinicalinformation. Commissioners using SEM rather than SUS PbR must take data from SUS over an extended period to ensure that they have full information and that anylocallyderivedHRGiscorrect. Anomalies can arise within SUS spell construction in certain very rare cases. These have been found in reconciliations not to have material impact. The cases are as follows: When a patient is both admitted and discharged more than once on the same day and for the same provider and neither case is a daycase 6 . Typically, these cases relate to maternity where commissioner contracts frequentlyplacerestrictionsonpaymentformultipleinsandouts.These casesresultintheallocationofaUcodefortheHRG. Multiepisode daycases will give rise to the creation of a spell for each episode.

3.5.5

3.5.6

Therearesimplemechanismstochecklocallywhetheranyofthesecasesmayhave arisen.Forthefirstcase,thespelllevelextractcontainsafieldcontainingthecount of provider HOSPITAL PROVIDER SPELL NUMBERS a value greater than 1 indicating

PreviouslyduetodataqualityissuesrelatingtoprovisionofNHSnumbertwofurtherlayersoflogicwere employedbythealgorithm.AnalysisundertakenbytheNHSICandBThasshownthatthesearenowveryrarely usedandhavethereforebeenremovedfor2011/12. 6 Adaycaseisdefinedasonewherethereisbothintenttoundertakeelectivetreatmentusingahospitalbedbut withoutanovernightstayandwheretheactuallengthofstayiszero(i.e.noovernightstayoccurs).See: http://www.datadictionary.nhs.uk/data_dictionary/attributes/p/pati/patient_classification_de.asp?shownav=1 Generic SUS Reconciliation Guidelines Crown Copyright 2011

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inconsistency. These checks may also identify errors in the CDS data sent by providersandshouldbepartofCommissionersroutinecheckingprocesses.

3.6
3.6.1

IncorrectPreparationofDataforLocalHRGGrouping
Local HRG Grouping is undertaken using the standalone NHS IC Local Payment Grouper.SUSusesmultipleversionsofthisICgrouperutilisingthesameunderlying referencedatatables. The grouper is updated annually in accordance with DH requirements and as SUS receives data which overlaps financial years it has the ability to support and apply thecorrectversionofthegroupertoincomingdata. The grouper expects data to be cleaned prior to being presented for grouping. SUS undertakes this preprocessing in line with DH requirements. These include the removaloftrailingcharactersidentifyinglocalcodingextensionsandtheremovalof daggerandasteriskcodesfromICD10diagnosticcodes. Within SUS the truncation of 5 character ICD 10 codes occurs strictly only where they are absent from the grouper reference data on the assumption that the 5th characterrepresentsalocalextension. Where grouping is undertaken locally for PbR using the standalone grouper, previous reconciliation exercises have indicated that errors can easily exist in the local cleansing process. In particular preserving 5 character ICD 10 codes (unless they are absent from the reference data) is important. Incorrect truncation causes lossofdetailandcanleadtodifferencesinthederivedHRGcomparedtoSUS.

3.6.2

3.6.3

3.6.4

3.6.5

LessonLearnt14Careisneededinlocaldatacleaningroutinespriortopresentingdatato theNHSICLocalPaymentGrouper.TypicallyhoweverthenumberofHRGsaffectedbyany errorsarefew,withnomaterialfinancialimpactarising.Inmanycasesthereareno differencesfoundinHRGscalculatedbySUSandthroughlocalprocessing.

3.7
3.7.1

IdentificationofActivitytoTariff
Where activity and PbR costing are both at a patient level and fall within the scope of national PbR tariff there are few issues associated with this step that impact uponreconciliation. Issues can arise where activity is to be priced at local tariff, either because it is outside national tariff or a local tariff is being applied by agreement. The CommissionerwillneedtobeabletodistinguishwithintheSUSoutputs: Activity which falls within the national scheme that is to be priced locally; Local activity with sufficient information to identify which tariff should beapplied; Activity which is to be excluded from payment e.g. nurse contacts and preoperativeassessments.

3.7.2

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3.7.3

The use of the = sign convention 7 can be helpful. Providers are able to send an = sign as the last character of the CDS data item Commissioning Serial Number forbothAPCandOPCDStypes. Any episodes which have this convention applied are interpreted by SUS as a providerrequestedexclusionfromPbRprocessing. Whilst helpful this convention does not provide sufficient information about how theactivityisbeingpriced,orifitisbeingpricedatall.

3.7.4 3.7.5

LessonLearnt15ExperiencefromreconciliationexercisesundertakenintheNHSsuggest thatlocalpracticecaninvolvetheinclusionofappropriatevalidvaluesinoneorallofthe followingcommissioningfieldsontheCDS: NHSServiceAgreementLineNumber(10ANcharacters) ProviderReferenceNumber(17ANcharacters) CommissionerReferenceNumber(17ANcharacters) Providers and their main Commissioners are likely to be familiar with the values held in these fields and interpretation of the content can be agreed locally to assist with the appropriateapplicationoftariffs.

3.8
3.8.1

CriticalCareLengthofStay
The complexities associated with both the PbR rules related to allocating critical care days to episodes and the way critical care is captured and recorded locally meanthatthishasbeenacommoncauseofissueswithinreconciliationexercises. Themaincausesoftheseissuesare: Failuretofollowdatastandardsandpoordataqualityinsubmitted critical caredata; Lack of understanding around the presentation of correctly submitted CriticalCaredatainSEMbycommissionersusingSEMdataasasource; Failuretocalculatederivationscorrectly.

3.8.2

3.8.3 3.8.4

SUS PbR is designed to minimise the risk of errors from the first of these issues by handlingthedatacorrectlyandapplyingtheadjustmentsasagreedwithDH. Inconsistent submission of the critical period identifiers and start and end dates of criticalcareperiodswithintheCDS,andthesubsequentprocessingofthisdata,has led to the inconsistent allocation of critical care days where the CC period overlaps episodeswithinaspell. In recognition of these issues the handling of Critical Care by SUS PbR in 2011/12 hasbeenextensivelyreviewedto: Increaseitsrobustnesstopoordataquality; Clarify the processing rules for the allocation of Critical Care days across episodeswithinaspell;

3.8.5

Seesection10oftheSUSPbRRelease9TechnicalGuidance http://www.connectingforhealth.nhs.uk/systemsandservices/sus/supports/pbr/pbrguidance/r9techguide.pdf Generic SUS Reconciliation Guidelines Crown Copyright 2011

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Introduce a new Critical Care extract which details the information held on valid Critical Care periods and identifies the relevant number of critical care days for the application of critical care tariffs and for length of stay adjustment Note this extract is available only from the SUS PbR managedextractservice.

3.8.6

The SUS PbR Release 9 Technical Guidance 8 sets out the detail of the revised validation, processing and outputs for Critical Care in 2011/12. In summary the guidancecovers: Additional validations on data quality for incoming records to SUS. TypicallyifarecordfailsthevalidationthenCCprocessingwillcease; Introduction of a new Critical Care Indicator. This will be output where thevalidationidentifiestheunderlyingissue; NewrulesforthecountingandallocationofCCdaystoepisodeswithina spellincludingthemanagementofexcludedepisodes; Spelllengthofstayadjustments

3.8.7 3.8.8

The guidance includes detailed scenarios illustrating the application of these new validationsandprocessingrules. The key change in the processing is that SUS PbR will allocate distinct CC days to episodesandwheretheCCperiodspanstheboundarybetween2episodestheday on the boundary will be allocated to the later episode. Once summed across episodesanewattributeinthePbRextractsTotalCCdayswillcapturetheoverall total.

LessonLearnt16Experiencefromearlierreconciliationexercisessuggeststhattheissues associatedwiththemanagementofCriticalCaredaysbothintermsofdataqualityand submission,complexityandclarityofpolicyandprocessingruleshavecausedproblemsfor bothcommissionersandprovidersinachievingaconsistentunderstandingandreconciled position.The2011/12revisedprocessingrulesandintroductionofanewSUSPbRCritical Careextractprovideanopportunitytoreestablishaclearerandconsistentpictureofthe overallmanagementofcriticalcaredays.

3.9
3.9.1

SUSPbRProcessingIssues
There are a number of known processing issues relating to SUS PbR which need to befactoredintoanyreconciliationexercise.Theseinclude: ManagementofRehabilitationdays; RoundingofMarketForcesFactor(MFF) CorrectprocessingofdataforA&Epatientsdeadonarrival(DOA)

3.9.2

Periods spent in rehabilitation cannot be accurately derived by SUS as they are not identified within the existing CDS flows. Accordingly SUS PbR cannot adjust excess beddaysorcalculatepaymentsrequiringmanualadjustmentstobeundertaken. DHrequirementsare that whena Market ForcesFactor (MFF)isapplied thefigures should be rounded to the nearest at an individual event level. Depending upon

3.9.3

http://www.connectingforhealth.nhs.uk/systemsandservices/sus/supports/pbr/pbrguidance/r9techguide.pdf

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the MFF value for a given Trust and the local method of application variances can arise. The most common cause of difference occurs where an adjustment is made totheaggregatedpricedtarifflocallyratherthanonacasebycasebasis.
3.9.4

The tariff for dead on arrival patients in A&E is generated by a pseudoHRG DOA which is determined by A&E Patient Group Code (value 70). This is not always recognisedinlocalprocessingandcanleadtodifferencesatreconciliation.

LessonLearnt17Experiencefromreconciliationexercisesindicatesthatthedifferences generatedbytheseissuesareunlikelytoprovematerialbuttheyshouldbeidentifiedand factoredintothereconciliationprocess.

4
4.1
4.1.1

Conclusions
LocalProcessingvs.SUSPbR
It is known that many commissioner organisations currently extract data from SEM to undertake local PbR processing. This places a significant dependency upon the accuracy of the provider CDS submissions for key fields like Provider Spell Number and Commissioner. It also in many ways replicates the central SUS PbR processing and reflects an historic lack of confidence in using SUS PbR and in particulartheonlineextractservice. The features of SUSPbR offer a number of advantages in terms of both processing andfunctionalitytosupportPbRreconciliation,theseinclude: Appropriate application of DH business rules for each financial year and abilitytoprocessdistinctlyformultipleyears; Spellingalgorithmandkeyderivationse.g.corespellHRG; DerivedGPPracticeandPCTofResponsibility; Versioningofdataatkeyreconciliationandpostreconciliationpoints; For 2011/12 the management of emergency readmissions, revised Critical Care processing and application of extended best practice tariffs inlinewithDHPbRpolicy; Returningallactivityfortherelevantfinancialperiod,whetherornotitis inscopeofnationaltariff,thushelpingtosupportthelocalapplicationof localtariffs; Online extract service which provides access to a wider range of attributesandistheonlysourceofthecurrentSUSPbRview.

4.1.2

LessonLearnt18ThereconciliationexercisesundertakenbetweenlocalandSUSPbRdata havedemonstratedthatonce: Any inconsistencies between provider data submitted to SUS and data usedlocallyasabasisforinvoicingareunderstood,and Account made for local activity adjustments covering issues like rehabilitationdays then,SUSPbRwasfoundtobeoperatinginaccordancewithDHrequirementsandaccurately calculatingpricedactivityatnationaltariff.

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5
5.1

AppendixASEMandSUSPbRMartsOverviewofKey Features
SUSExtractMart(SEM)

SUSExtractMartreturnsthedatasubmittedtoSUSasabulkextractwithalimitednumber ofadditionalderivations.SEMreflectsthestateofSUSatthetimetheextractistaken,andto thatextentrepresentsamovingtarget. Fromthe2010version,derivationshaveincluded: The core spell and episode HRG4 values derived as part of SUS PbR processing. (Note that processing lags may result in these fields being returnedemptyforashortperiodaftersubmission.) GP practice and PCT codes derived by looking up the Personal Demographic Service (PDS) for the relevant date i.e. by tracing, in addition to the GP practicecodesentbytheProvider. ThedatareturnedbySEMcloselymirrorsthatuploadedtoSUSundertheBulkprotocol(see 3.2above): For Finished Consultant Episodes, data is extracted by reference to the episodestartandenddate. Commissioners can choose to select records by reference to one or more reasons for access for example, commissioner, copy recipient, PCT of residence,(derived)PCTofresponsibility. CriticalCaredatawillreflecttheCDSsubmissionstandardssetoutintheSUS PbR Technical Guidance document i.e. where Critical Care Periods span episodes, there will be entries for the Critical Care Period in more than one episode and the recipient is responsible for applying local business rules to avoiddoublecounting.

5.2

SUSPbR

SUSPbRprovidesextendedfunctionalitydesignedtosupporttheuseofSUStosupportPbR reconciliation.ThesolutionisrefreshedbytheDHandtheICeachyearincloseliaisonwith theDHPbRpolicyteam. Keyfeaturesareasfollows: SUS PbR applies national PbR tariff rules and contains all relevant PbR derivations; including core spell HRG, episode HRG and unbundled HRGs. It also returns the key fields from the CDS. (For 2011/12 this subset has been extended and additional data items added to the online APC, OP and EM extracts). SUS PbR returns all activity for the relevant financial period, whether or not it is in scope of national tariff, and therefore can also be used to support the localapplicationoflocaltariffs. SUSPbRversionsthedata.Thisfunctionalityisusedtoprovide: StaticsnapshotsofthedataatReconciliationpoint StaticsnapshotsofthedataatPostReconciliationpoint

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A current view of the data which reflects the current view of SUS (similartoSEM). For Admitted Patient Care, two core extracts are returned one for spells and one for the constituent episodes of those spells; the two are linked by aninternallygeneratedspellidentifier. For Admitted Patient Care, SUS PbR is extracted by reference to the Hospital Discharge date, and not Episode End Date. This means that the SUS PbR episode extract contains all episodes relevant to PbR for the period in question unlike SEM where this can only be guaranteed by taking an extract for an extended period. It also means that the SUS PbR extract for a given month would contain a different set of episodes to an extract for the sameperiodtakenfromSEM. SUSPbRissupportedthroughbothamanagedandanonlineservice: The SLAs for the managed service reflect the deadlines set by National PbR Guidance and referenced by the National Contract for AcuteServices. The online service provides access to a wider range of attributes and istheonlysourceofthecurrentSUSPBRview. SUSPbRfunctionalityhasbeenenhancedfor2011/12to: Provide information to support policy around readmissions. This is targeted at Commissioners and, with one exception, available only throughthemanagedservice. Flagactivitywhichattractsencouragingbestpracticetariffs. Thisadditionalfunctionalityisdeliveredbothbyaddingnewfieldstoexistingextractsand addinganewCommissionerspecificextracttosupporttheimplementationofpolicyaround readmissions.

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AppendixBSummaryofKeyLessonsLearnt

MainSourcesofReconciliationDifferences
Overwhelmingly,initialdifferencesbetweenSUSPbRandlocalprocessingarosefrom differencesintheactivityunderconsideration.Themostcommoncauseofinconsistencyis simplythatprovidersandcommissionersareworkingwithinconsistentversionsofthedata. Significantchangesindatawerefoundtooccurbetweenreconciliationandpost reconciliationascodingwascompletedandcorrectionstoactivitydatawereapplied.Data becomesrelativelystablefrompostreconciliationandthereconciliationprocessbecomes easierwhenconsistentcutsofthedataareused. UsingSUSPbRasthebasisforContractReconciliation SUSPbRfunctionalityprovidesasoundbasisforundertakingcontractreconciliation.In reconciliationexercisesithasbeenfoundtoaccuratelycalculatepricedactivityatnational tariff(subjecttotheCDSextractonwhichitisbasedbeingaccurateandlocaladjustment beingmadetodealwithknownfactorslikepatientswhohavespenttimeinrehabilitation seesection3.9) LocalprocessingofPbRiscomplexandcannotbeguaranteedtobefreefromerror.Toassure localprocessingtheabilitytoreconcileagainstastandardbenchmarkisneeded.SUSPbR providesapricedviewofactivity,togetherwithdetailsofallunderlyingcurrenciesand derivationsreflectingtheprocessingrulessetbyDHintariffguidance.

UseofPbROnLineExtracts
UsersshouldmakegreateruseoftheadditionalfunctionalityavailablefromtheSUSPbRon lineserviceandtouseSUSPbRasthebasisofachievingconsistentdataextracts.SUS Release9for2011/12PbRnowprovidesforallCDSitemstobeavailablethroughPbROn line.

PbRonlineandSEMbothprovidetheabilitytoaccessdatausingallandanyreasonfor accesswhereasthePbRmanagedserviceonlyreturnsdatafortheprovidercoded providerandcommissionerfields.ThisfurtherindicatestheuseofPbRonlineextracts tosupportthereconciliationprocess.

SpellConstruction
Therearetwolikelyissuesthatmightimpactreconciliationarisingfromlocalprocessing: Providers may fail to update all episodes in a spell which continues over anextendedperiod;

Grouping

Commissioners may omit to extract and process all episodes associated withinthespellaspartoftheirlocaldataprocessing.

CareisneededinlocaldatacleaningroutinespriortopresentingdatatotheNHSICLocal PaymentGrouper.TypicallyhoweverthenumberofHRGsaffectedbyanyerrorsarefew,with nomaterialfinancialimpactarising.InmanycasestherearenodifferencesfoundinHRGs

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calculatedbySUSandthroughlocalprocessing.

CriticalCare
Experiencefromearlierreconciliationexercisessuggeststhattheissuesassociatedwiththe managementofCriticalCaredaysbothintermsofdataqualityandsubmission,complexity andclarityofpolicyandprocessingruleshavecausedproblemsforbothcommissionersand providersinachievingaconsistentunderstandingandreconciledposition.The2011/12 revisedprocessingrulesandintroductionofanewSUSPbRCriticalCareextractprovidean opportunitytoreestablishaclearerandconsistentpictureoftheoverallmanagementof criticalcaredays.

LocalProcessingvs.SUSPbR
ThereconciliationexercisesundertakenbetweenlocalandSUSPbRdatahavedemonstrated thatonce: Any inconsistencies between provider data submitted to SUS and data usedlocallyasabasisforinvoicingareunderstood,and Account made for local activity adjustments covering issues like rehabilitationdays then,SUSPbRwasfoundtobeoperatinginaccordancewithDHrequirementsandaccurately calculatingpricedactivityatnationaltariff.

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