Reconciliation of SUS PbR With Local Systems Generic Guidelines

Programme NPFIT

Document Record ID Key NPFIT-NCR-SUSPBR-xxxx.xx

Sub-Prog / Project

Secondary Uses Service Payment by Results

Prog. Director Andy Burn Version 0.3 Owner Andy Burn Status Final Draft

Author Paul Bates Version Date 19/04/2011

Reconciliation of SUS PbR with local systems

Generic Guidelines

Generic SUS Reconciliation Guidelines Crown Copyright 2011

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Amendment History:

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

Forecast Changes:

Anticipated Change When

Reviewers: This document must be reviewed by the following:

Name Signature Title / Responsibility Date Version Stuart Richardson Programme Manager 7/4/2011

Craig Walker Section Head 7/4/2011

Simon Robinson Principal Information Analyst

7/4/2011

Approvals: This document must be approved by the following:

Name Signature Title / Responsibility Date Version Andy Burn Director for NIRS

Engagement and SUS

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:


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These documents will provide additional information. Ref no Doc Reference Number Title Version

NHSIC-SUS-PBR-R9-0001.01 SUS PbR R9 Technical Guidance 1.0 SUS Best Practice Guide 1.0

Glossary of Terms:

Term Acronym Definition Accident and Emergency

A&E Accident and Emergency Medicine

Admitted Patient Care APC Commissioning Data Set

CDS 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.

Currency The basis for calculating PbR payments, derived from the characteristics of an activity such as hospital provider spell or an outpatients attendance.

Department of Health DH Elective Admission An admission arranged in advance, excluding

maternity and emergency admissions and admissions from other hospitals identified by Method of Admission codes 10-13.

Emergency Admission Admissions which are unpredictable and at short notice because of clinical need identified by Method of Admission codes 21-28

Excess Bed Days XBD Time spent in admitted patient care beyond the trim-point 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.

Healthcare Resource Group

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

Inclusion Point The date by which the provider needs to submit data for the month in question for inclusion in the report available for monthly reconciliation.

Market Forces Factor MFF The Trust specific uplift to tariff made to adjust for local variations in pay and prices

NHS Information Centre

NHS IC

Non-elective Admission

Comprise emergency, maternity and other admissions. identified by Method of Admission codes greater than 20.

Out Patient OP Patient Administration System

PAS

Post Reconciliation Point

The date when the final reconciliation report is available for the month in question. This was formerly known as the freezedate.

Reconciliation Point The date when the PbR activity is available to the commissioner to facilitate reconciliation between provider and commissioner. This was formerly known


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Term Acronym Definition as the flexdate.

Secondary Uses Service

SUS

SUS Payment by Results

SUS PbR The SUS module which derives PbR currencies and applies national tariffs to relevant activity sent via the CDS

SUS Extract Mart SEM Gives Providers and Commissioners access to current CDS data sent through SUS (subject to security constraints)

Trim-point The number of days into a hospital provider spell beyond which hospital stays attract an additional per diem payment.


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1 IntroductionandBackground...........................................................................61.1 PurposeofThisDocument................................................................................61.2 SecondaryUsesService(SUS)............................................................................61.3 SUSPbRProcessingin2011/12..........................................................................7

2 ReconciliationApproach...................................................................................72.1 WhyReconcile..................................................................................................72.2 ReconciliationMethodology.............................................................................72.3 ConsistencyofData..........................................................................................102.4 SUSDataMarts................................................................................................11

3 KnownReconciliationIssues............................................................................123.1 SummaryofKnownIssues...............................................................................123.2 SUSInputErrors...............................................................................................123.3 DataConsistency..............................................................................................133.4 IdentifyingOrganisationsandReasonsforAccess............................................133.5 SpellConstruction............................................................................................143.6 IncorrectPreparationofDataforLocalHRGGrouping......................................163.7 IdentificationofActivitytoTariff......................................................................163.8 CriticalCareLengthofStay...............................................................................173.9 SUSPbRProcessingIssues.............................................................................18

4 Conclusions.....................................................................................................194.1 LocalProcessingvs.SUSPbR............................................................................19

5 AppendixASEMandSUSPbRMartsOverviewofKeyFeatures....................205.1 SUSExtractMart(SEM)....................................................................................205.2 SUSPbR...........................................................................................................20

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


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1 IntroductionandBackground

1.1 PurposeofThisDocument1.1.1 Following on from detailed SUS PbR reconciliation exercises undertaken during

2009and2010thisdocumentseekstoprovideasetofgenericguidelinesthatNHSorganisations can use to inform local reconciliation activity. It is primarilyconcernedwith the reconciliation of priced activitywithin local systems to thatidentifiedinoutputsfromSUSPbR.

1.1.2 It highlights both the commonly found issues that are known to cause difficultywith the reconciliationprocess and the lessons learnt from thedetailed analysiswhichaimto:

MakeroutinereconciliationbetweenPCTandProviderTrustsimpler. Identify likely areas for the review and improvement of existing local

processes.

Provide assurance to providers and commissioners that SUS PbRprovidesasoundbasisforundertakingcontractreconciliation,accuratelycalculatingpricedactivityatnationaltariff

EncouragecommissionersandprovidersnotalreadyusingSUStodoso.

1.1.3 The document draws on learning points emerging from a joint reconciliationexerciseundertakenbytheNHSSUSPbRteamandalocalhealthcommunityduring2009and2010. Theseguidelinesare,however,genericandtherearenospecificdetailsofthisexerciseincludedwithinthem.

1.1.4 Thedocumentwillbeofinteresttocommissioning,informationandfinanceteamswithinbothNHSCommissionerandProviderorganisations.

1.2 SecondaryUsesService(SUS)1.2.1 TheNHSSecondaryUsesService(SUS)isthecentralrepositorywhichsupportsthe

flowofCommissioningDataSets(CDS)betweenprovidersandcommissioners.TheuseofSUShasbeenmandatedintheOperatingFrameworkfor2011asfollows:

TheNHSshouldusetheSecondaryUsesService(SUS)asthestandardrepositoryforperformancemonitoringreconciliationandpaymentsbyApril2012operatinginshadowformfromOctober2011.During2011/12progressondeliveryofthiswillbeperformancemanagedandcommissionerswillbeexpectedtousecontractsanctionsiftheyarenotsatisfiedaboutthecompletenessandqualityofaprovidersdata.

1.2.2 SUSusesthesubmittedCommissioningDataSets(CDS)toprovidethefollowing:

SUS Payment by Results (PbR) which uses derivations, tariffs andbusinessrulesagreedwiththeDHPbRteamtoprovideacommonandconsistentmechanismtosupportreconciliationbetweenCommissionersandProviders.SUSPbRversionsthedatatoprovidestaticsnapshotsatboth the reconciliation and final reconciliation inclusion points. It canadditionallyprovideacurrentviewofthedatawithinSUS.


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SUSExtractMart (SEM)which returns thedata submitted to SUS asabulk extract with a limited number of additional derivations. Thesederivations includethecorespellandepisodeHRGderivedbySUSPbRandtheGPpracticeandPCTcodesderivedbythePersonalDemographicService (PDS). SEM reflects the position within SUS at the time theextractistakenthusprovidingachangingviewovertime.

1.3 SUSPbRProcessingin2011/121.3.1 ForreadersrequiringfurtherguidanceontheoperationandoutputsofSUSPbRin

2011/12aseparatedocumentSUSPbRRelease9TechnicalGuidance1isavailablethat provides details of SUS PbR processing as implemented in 2011/12. Itsummarises thekeyareasofDHPbRpolicyandprovidesdetailsoftheadditionalfunctionalityintroducedin2011/12tosupportthenationalpolicyonreadmissions,bestpracticeandthemanagementofCriticalCaredays.

2 ReconciliationApproach

2.1 WhyReconcile2.1.1 ReconciliationbetweenSUSPbRand localsystems ismostcommonlyundertaken

aspartof the invoice validation and approvalprocess that ismanagedbetweencommissionersandproviders.

2.1.2 Aproviderwillgenerateaninvoicebasedontheactivity,rulesandtariffsembodiedin national guidance and local contracts. The provider invoice will typically begenerated by a local system and be supported by a statement of activity at anaggregate level. The detail of the activitywill be independently available to thecommissionerthroughthedatamaintainedontheCommissioningDataSetswhichflowintoSUSfromproviderorganisations.

2.1.3 As this process underpins the basis of contractual payment between theorganisations it should be subject to the appropriate assurance expected by afinancialsystem.Thisshouldincludetheabilitytosupportanaudittrailbacktotheeventswhichgeneratedtheclaimforpayment.

2.1.4 Theamounts invoiceddependprimarilyuponthevolumeofactivity,asexpressedthrough the relevant contract currency, the rules associated with creating thatcurrency and the tariffs applied. These base amounts may then be subject tovariation to reflect national aggregate adjustments (e.g. the thresholds set foremergencyadmittedpatientcare)orcontractualrequirements.

2.2 ReconciliationMethodology2.2.1 Thenormalapproachtoreconciliationistoadoptacombinationoftopdownand

bottomupprocessestoidentifyandexplainareasofdifference:

Thetopdowncomparisonisusedtohighlightandspotlighttheareasofactivitywheredifferencesoccurand

1http://www.connectingforhealth.nhs.uk/systemsandservices/sus/supports/pbr/pbrguidance/r9techguide.pdf


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Record level comparison and (where necessary) checks on calculationareusedtoinvestigateunexplaineddifferences.

2.2.2 Usingthisapproachthekeyelementstobeconsidered inachievingreconciliationarelikelytobe:

ActivityareSUSandlocalprocesseslookingatthesamesetofactivityandisdataofthesamematurity?

Currenciesarecurrencyderivationsconsistentwithactivitytypes?(Thekey currencies beingAPC Spells,APC excess bed days, outpatient andA&EattendancesandtheirassociatedHRGs).

Pricedcurrencyhavetariffsbeenappliedcorrectlyandconsistently?

2.2.3 Experienceofpreviousworkundertakenonreconciliationhasshownthatthemosteffectiveapproachto identifyingdifferenceswithinthePbRprocess istoconsidereachofthemainprocessingblocksidentifiedinFigure1below.

Figure1PbRProcessingOverview


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2.2.4 Thereare twokey lessons learnt from theearlier reconciliationexercises todrawfromthisoverallstructure:

LessonLearnt1Overwhelmingly,initialdifferencesbetweenSUSPbRandlocalprocessingarosefromdifferencesintheactivityunderconsideration.Themostcommoncauseofinconsistencyissimplythatprovidersandcommissionersareworkingwithinconsistentversionsofthedata. LessonLearnt2WhilsttheprocessingstructureidentifiedinFigure1providesaneffectiveapproachtoreconciliation,inpracticetherewillbelocalvariationineachofthesestepsandpotentiallytheneedforsecondaryreconciliationofbothinternalSUSflows(SEMtoPbR)andinternalTrustandPCTflowstoexplainthecauseofdifferences. AsummaryofthekeyLessonsLearntisprovidedinAppendixB.

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

For APC, spells are constructed from the data for constituent episodes; this step is not required for Out-patients 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.

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

Derive Currencies

Construct Spells

Assign to Contract

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.

Derive grouping

Inputs

HRG Grouping

Spell Construction & Grouping

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.


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2.3 ConsistencyofData2.3.1 Assuggestedabove inconsistency in theversionsofdataused isoneof themost

commonlyidentifiedsourcesofdifferencewithinreconciliationexercises.

2.3.2 NationalcontractsandDHPbRguidanceimplythatinvoicevalidationwillbebasedonaconsistentsnapshot,takenatoneorotherreconciliationinclusionpoint:

ReconciliationPointthedatewhenthePbRactivity isavailabletothecommissioner to facilitate reconciliation between provider andcommissioner;

PostReconciliationPointthedatewhenthefinalreconciliationreportisavailableforthemonthinquestion.

LessonLearnt3Significantchangesindatawerefoundtooccurbetweenreconciliationandpostreconciliationas codingwas completedand corrections toactivitydatawereapplied.Databecomes relatively stable frompost reconciliation and the reconciliationprocessbecomeseasierwhenconsistentcutsofthedataareused.

2.3.3 SUSPbR versions the data at these points returning all activity for the financialperiod,whetherornot it is in scopeofnational tariff (thus supporting the localapplicationoflocaltariffs).ThisversioningensuresthatallpartiesaccessingagivensnapshotwhetherproviderorcommissionerwillhaveaconsistentviewofthedataattheinclusionpointsdefinedintheNationalContract.

2.3.4 Inpracticemanyorganisationschoose toextractdata from theSUSExtractMart(SEM) which will reflect the current position of SUS rather than a consistentsnapshotatinclusionpoint.Thiscanleadto:

ThegenerationofpricedactivityandinvoicesbytheproviderfromacutofdatadifferenttothatsubmittedtoSUSattheinclusionpoint;

The lackof a copyof thedata asused to generate invoices forquerypurposes. This is a common problem because provider systems needfrequent updating to be of local value and many do not provide theabilitytosupportsnapshots.

2.3.5 HistoricallytherehavebeenthreemainreasonsgivenforusingSEMlocally.Firstly,thatPbRextractsdidnotreturnalltherequiredattributeswhereasSEMreturnsthedatasubmittedtoSUSasabulkextractreflectingthecurrentpositionatthetimetheextractistaken.Secondly,thattherehavebeendelaysintheavailabilityofdatafrom SUS PbR comparedwith SEM. Thirdly, SEMwas developed before the PbRmart and consequently local systems have been built to accommodate SEMextractsandhavenotbeensubsequentlyupdatedtousePbR.

2.3.6 These issueshavebeen largelyaddressed inrecentSUSPbRreleases through theintroductionoftheSUSPbRonlineextractservicewhichnowprovides:

Access to a wider range of attributes than those available from themanagedserviceextracts;


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Acurrentviewofthedata (inadditiontothestaticsnapshots)whichallows anextract tobe run reflecting the current SUSPbR view2.Thisreflects improvements in PbR processing which is now a continuousratherthanbatchprocess.

LessonLearnt4UsersshouldmakegreateruseoftheadditionalfunctionalityavailablefromtheSUSPbRonlineserviceandtouseSUSPbRasthebasisofachievingconsistentdata extracts. SUS Release 9 for 2011/12 PbR now provides for all CDS items to beavailablethroughPbROnline.

2.4 SUSDataMarts2.4.1 Differencesarisingbetween thedatastructuresheld ineachof theSUSSEMand

SUS PbR marts are considered further within the known reconciliation issuessectionoftheseguidelinesbelow.AdditionallyAppendixAprovidesanoverviewofkeyfeaturesinbothSEMandSUSPbR.

2.4.2 ItiscommonlyclaimedthatdifferentresultsemergebetweendataextractedfromSUS PbR to that taken from SEM and processed locally. On investigation it is,however, typically found thatdifferences canbe tracedback toa relatively smallnumberofcommonfactors:

ProblemswiththequalityofsubmittedCDSdataduplicationbeingthemostcommonlyfound;

Thecomparisonof inconsistentsnapshotsofthedatacausedby timingdifferencesasidentifiedat2.3above;

FailuretorecognisethatSUSPbRselectstheAdmittedPatientCare(APC)databyreferencetothespelldischargedateandnotepisodeenddate;

Issues with the application of national PbR derivations to SEM datawithinlocalsystemstheseareautomaticallyappliedbySUSPbR;

IncorrectpreparationoffilespriortosubmissionforlocalHRGgrouping; Inconsistency with the application of the reasons for access codes

relatingtoPCTandcommissioner.

LessonLearnt5SUSPbRfunctionalityprovidesasoundbasisforundertakingcontractreconciliation.Inreconciliationexercisesithasbeenfoundtoaccuratelycalculatepricedactivityatnationaltariff(subjecttotheCDSextractonwhich it isbasedbeingaccurateand local adjustment beingmade to dealwith known factors like patients who havespenttimeinrehabilitationseesection3.9)

LessonLearnt6LocalprocessingofPbR iscomplexandcannotbeguaranteed tobefree from error. To assure local processing the ability to reconcile against a standardbenchmarkisneeded.SUSPbRprovidesapricedviewofactivity,togetherwithdetailsofallunderlyingcurrenciesandderivationsreflectingtheprocessingrulessetbyDHintariffguidance.

2SUSPbRcurrentviewmaylagSEMslightlybecauseoftheadditionalprocessingtimetakentoaddPbRderivations


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3 KnownReconciliationIssues

3.1 SummaryofKnownIssues3.1.1 This section draws out the issues most likely to impact upon the reconciliation

process between SUS PbR and local systems based upon experience in earlierreconciliation exerciseswithin theNHS. The listbelow is generic andprovides aframework for analysis only, not all issues will apply to individual providers orcommissioners:

SUSInputErrors DataConsistency IdentifyingOrganisationsandReasonsforAccess SpellConstruction IncorrectpreparationofdataforlocalHRGgrouping IdentificationofActivitytoTariff CriticalCarelengthofstay SUSPbRProcessingIssues

3.2 SUSInputErrors3.2.1 Input toSUS ismadeby the submissionofCommissioningDataSets (CDS)using

XMLinputwhichallowsforerrorcheckingagainstadatadefinitionheldintheXMLschema. Input is validated prior to being sent to SUS with data fields beingvalidatedforconformitywiththedatadictionary.

3.2.2 UpdatetoSUScanuseoneoftwosubmissionprotocols:

NetChange(Net) BulkReplacement(Bulk)

3.2.3 ThemostcommonlyfounderrorimpactingreconciliationstemsfromduplicationorunintendedlossofrecordscausedbyinconsistentCDSupdates.ThisisaparticularriskwherebothBulkandNetsubmissionsaremixedbythesenderorganisation.

3.2.4 Thenetprotocolusesamandatoryuniquerecordidentifierasakey.Thisfield,theCDSUniqueIdentifier,providesabasisforcrossreferencingthedatasubmittedtoSUSwithSUSPbRoutputsandthushaspotentialuse insupportingreconciliation.However,asthisfieldisnotmandatoryinBulkuploadsthenetprotocolcannotbeused to replacebulk records thatdonothave thiskey.Should thisoccur thenetsubmissionwillpassoverthebulkrecordswithoutaCDSUniqueidentifierandwillleadtothecreationofduplicaterecords.

3.2.5 Conversely the Bulk protocol will allow an interchange to be sent with manyrecordshaving the sameCDSUnique Identifier. It is thereforepossible for aNetsubmission, from the same sender with a later applicable date, to replace allrecordsforthatCDSUnique Identifier leadingtothedeletionofalltherecords intheoriginalBulksubmission.

3.2.6 ThebulkprotocolusesbulkupdategroupsratherthanCDStype.IfBulkandNetaremixedBulkwillupdateallNet records inSUS for the sender,prime recipientand date combinations irrespectively for a given bulk update group leading to


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unintended lossofdata.Acommonexampleof thisoccurswherematernitydata(CDStype140)issubmittedseparatelytogeneralepisodes(CDStype130).AsCDStypes 130 and 140 share the same bulk update group then subsequent BulksubmissionofmaternityrecordscanleadtotheunintendeddeletionofpreviouslysubmittedgeneralAPCrecords.

LessonLearnt7Itisbesttoavoidmixingbulkreplacementandnetchangeinterchangestoreducetheriskofunintendedduplicationorlossofdata.ToassistreconciliationprovidersandcommissionersshouldmonitorSUSafterupdatetoensurethedataonthesystemisconsistentwithexpectationsandshouldfurtherinvestigatesubstantialchangetodatavolumesfortheperiodinquestion.

3.2.7 TheNHS InformationCentrehas issuedaSUSBestPracticeGuidewhichprovidesfurtherguidanceandinformationrelatingtothedatasubmissionprocessusingtheBulkandNetprotocol.Thelinktothisdocumentisshownbelow.3

3.2.8 Other local factors that can impact upon the quality of data submitted to SUSinclude:

Problems with the integration of data drawn from more than oneoperationalsystem;forexampleaddingcriticalcaredatatoAPCepisodesorforamergedorganisationusingtwoPASsystems.

Incorrect mapping of local to national codes, including difficulties incorrectlymappingtoTreatmentFunctionCodes(TFC)andMainSpecialtyCodesduetoissueswithPASsetupandfunctionality.

3.3 DataConsistency3.3.1 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 finalreconciliationpointsfromSUSPbRprovidesaconsistentviewofthedataforbothprovidersandcommissioners.

LessonLearnt8TheabilitytocomparelocalsystemsandSUSatrecordlevelcanbeaneffectivemechanismtoidentifythecauseofinitialreconciliationdifferences.ToachievethisretainingcopiesofthedatasubmittedtoSUSfromlocalsystemswillbebeneficial.

3.4 IdentifyingOrganisationsandReasonsforAccess3.4.1 A key concern is to ensure that the organisational scope of the data being

reconciled is consistent. Commissioners undertaking invoice validation will beconcernedtoensurethatpatientshavebeenassignedtothecorrectCommissioner,the primary determinant of which is the patients GP practice at the time oftreatment.

3.4.2 The CDSmaintains a number of fields relating to PCT and commissioner. Theseinclude:

3http://www.connectingforhealth.nhs.uk/systemsandservices/sus/reference/bestprac.pdf


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Commissionerwhich shouldbe codedby theprovider inaccordancewithDHguidancesetoutinWhoPays?4

GPPracticewhichisbothprovidersubmittedandfromApril2010hasalso been derived in SUS from data held in the Patient DemographicService (PDS)using thepatientNHSnumber.This in turnprovides thebasis for theSUSderived PCTofResponsibility codeusing referencedatafromtheOrganisationDataService(ODS)

PCT of Residence which is derived from the patient postcode datarecordedwiththePatientDemographicService(PDS)

PrimeandCopyRecipient fieldswhichallows theprovider toexpandthecommissionerorganisationswhocanseetherecord

Lesson Learnt9To support reconciliationa comparisonof theSUSderivedandCDSsubmittedpracticeprovidesafirstcheckonwhetheractivityhasbeencorrectlyassignedbytheprovider.ForPbR,CommissionerscanconfirmthattherulesinWhoPays?havebeencorrectlyapplied,itisthereforeimportantthat:

Providersensurethatthecommissionerfieldiscorrectlycodedandareconsistentwith the derived practice and PCT values available to themfromSUS;

Commissioners ensure they are comparing like with like in terms oforganisationandseektoidentifyanyreconciliationdifferencescausedbydatabasedonapracticederivedresponsiblePCTbeingcomparedwiththeprovidercodedcommissionerfield.

LessonLearnt10SUSExtractMart (SEM)andPbRonlinebothprovidetheability toaccessdatausingallandanyreasonforaccesswhereasthePbRmanagedserviceonlyreturnsdata for theprovidercodedproviderandcommissioner fields.This furtherindicatestheuseofPbRonlineextractstosupportthereconciliationprocess.

3.5 SpellConstruction3.5.1 Reconciliation issues canarise froma failure to takeaccountof the fact that for

AdmittedPatientCare (APC)SUSPbRuses thehospitaldischargedate (orendofthespell)andnotepisodeenddatetoextractdata.

3.5.2 InSEMhoweverdataisextractedbyreferencetotheepisodestartandenddate.

LessonLearnt11FailuretounderstandthisdifferentapproachcanbeafrequentcauseofclaimsthatSUSPbRandSEMdonotreconcile.TheSUSPbRepisodeextractwillcontainallepisodesrelevanttoPbRfortheperiodinquestion(theyarelinkedtothespellbyaninternallygeneratedspellidentifier).ItisthereforepossibletohavedifferentepisodesreturnedbyaSUSPbRandSEMextractforthesameperiodmeaningcomparisonisnotonalikeforlikebasis.

4DHFrameworkforestablishingresponsibilityforcommissioninganindividualscarewithintheNHShttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_079724.pdf


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3.5.3 Spells are constructed in SUS using an algorithm approach which from 2011/12identifies a patient byNHS number or a combination of Provider SpellNumber,DateofBirthandSex.5Episodesareassignedtoaspellbyreferencetotheirstartandenddates.

3.5.4 The algorithm approach giveswholly consistent resultswhen compared tousingcorrectlyrecordedHospitalProviderSpellNumberforspellsinvolvinganovernightstay.Thequalityof localspellconstructionoutsideofSUSPbRwillbedependentupontheaccurateprovisionoftheHospitalProviderSpellNumberbytheproviderorganisation.

LessonLearnt12Therearetwolikelyissuesthatmightimpactreconciliationarisingfromlocalprocessing:

Providersmayfailtoupdateallepisodesinaspellwhichcontinuesoveranextendedperiod;

Commissionersmayomittoextractandprocessallepisodesassociatedwithinthespellaspartoftheirlocaldataprocessing.

LessonLearnt13HRGstendtobeproceduredriven.ProcedurestakingplacewithinalongmultiepisodespellwilltypicallyoccurinoneoftheearlierepisodesinthespellmeaningthatthespellHRGwillrelatetotheseearlierepisodes.Therefore:

Iftheprovideralwayscodesepisodeproceduresanddiagnosesondischarge,thisimpliesthatproviderbulkupdateprocessesmustuseanextendedCDSreportingperiodtocaptureallrelevantclinicalinformation.

Commissioners using SEM rather than SUS PbRmust take data from SUSoveranextendedperiodtoensurethattheyhavefull informationandthatanylocallyderivedHRGiscorrect.

3.5.5 AnomaliescanarisewithinSUSspellconstructionincertainveryrarecases.Thesehavebeen found in reconciliationsnot tohavematerial impact.Thecasesareasfollows:

Whenapatient isbothadmittedanddischargedmorethanonceon thesame day and for the same provider and neither case is a daycase6.Typically, these cases relate tomaternitywhere commissioner contractsfrequentlyplacerestrictionsonpaymentformultipleinsandouts.ThesecasesresultintheallocationofaUcodefortheHRG.

Multiepisodedaycaseswillgive rise to the creationofa spell foreachepisode.

3.5.6 Therearesimplemechanismstochecklocallywhetheranyofthesecasesmayhavearisen.Forthefirstcase,thespelllevelextractcontainsafieldcontainingthecountof provider HOSPITAL PROVIDER SPELL NUMBERS a value greater than 1 indicating

5PreviouslyduetodataqualityissuesrelatingtoprovisionofNHSnumbertwofurtherlayersoflogicwereemployedbythealgorithm.AnalysisundertakenbytheNHSICandBThasshownthatthesearenowveryrarelyusedandhavethereforebeenremovedfor2011/12.6Adaycaseisdefinedasonewherethereisbothintenttoundertakeelectivetreatmentusingahospitalbedbutwithoutanovernightstayandwheretheactuallengthofstayiszero(i.e.noovernightstayoccurs).See:http://www.datadictionary.nhs.uk/data_dictionary/attributes/p/pati/patient_classification_de.asp?shownav=1


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

3.6 IncorrectPreparationofDataforLocalHRGGrouping3.6.1 Local HRG Grouping is undertaken using the standalone NHS IC Local Payment

Grouper.SUSusesmultipleversionsofthisICgrouperutilisingthesameunderlyingreferencedatatables.

3.6.2 Thegrouper isupdatedannually inaccordancewithDHrequirementsandasSUSreceivesdatawhichoverlapsfinancialyears ithastheabilitytosupportandapplythecorrectversionofthegroupertoincomingdata.

3.6.3 Thegrouperexpectsdatatobecleanedpriortobeingpresentedforgrouping.SUSundertakes this preprocessing in line with DH requirements. These include theremovaloftrailingcharactersidentifyinglocalcodingextensionsandtheremovalofdaggerandasteriskcodesfromICD10diagnosticcodes.

3.6.4 WithinSUS the truncationof5character ICD10codesoccursstrictlyonlywheretheyareabsent from thegrouper referencedataon theassumption that the5thcharacterrepresentsalocalextension.

3.6.5 Where grouping is undertaken locally for PbR using the standalone grouper,previous reconciliationexerciseshave indicated thaterrors caneasilyexist in thelocal cleansingprocess. Inparticularpreserving5 character ICD10 codes (unlesstheyareabsentfromthereferencedata)isimportant.IncorrecttruncationcauseslossofdetailandcanleadtodifferencesinthederivedHRGcomparedtoSUS.

LessonLearnt14CareisneededinlocaldatacleaningroutinespriortopresentingdatatotheNHSICLocalPaymentGrouper.TypicallyhoweverthenumberofHRGsaffectedbyanyerrorsarefew,withnomaterialfinancialimpactarising.InmanycasestherearenodifferencesfoundinHRGscalculatedbySUSandthroughlocalprocessing.

3.7 IdentificationofActivitytoTariff3.7.1 WhereactivityandPbRcostingarebothatapatientlevelandfallwithinthescope

of national PbR tariff there are few issues associatedwith this step that impactuponreconciliation.

3.7.2 Issues can arisewhere activity is tobepriced at local tariff, either because it isoutside national tariff or a local tariff is being applied by agreement. TheCommissionerwillneedtobeabletodistinguishwithintheSUSoutputs:

Activity which falls within the national scheme that is to be pricedlocally;

Localactivitywith sufficient information to identifywhich tariff shouldbeapplied;

Activitywhich is tobeexcluded frompaymente.g.nurse contactsandpreoperativeassessments.


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3.7.3 Theuseofthe=signconvention7canbehelpful.Providersareabletosendan=signasthelastcharacteroftheCDSdataitemCommissioningSerialNumberforbothAPCandOPCDStypes.

3.7.4 Any episodes which have this convention applied are interpreted by SUS as aproviderrequestedexclusionfromPbRprocessing.

3.7.5 Whilsthelpful thisconventiondoesnotprovidesufficient informationabouthowtheactivityisbeingpriced,orifitisbeingpricedatall.

LessonLearnt15ExperiencefromreconciliationexercisesundertakenintheNHSsuggestthatlocalpracticecaninvolvetheinclusionofappropriatevalidvaluesinoneorallofthefollowingcommissioningfieldsontheCDS:

NHSServiceAgreementLineNumber(10ANcharacters) ProviderReferenceNumber(17ANcharacters) CommissionerReferenceNumber(17ANcharacters)

ProvidersandtheirmainCommissionersarelikelytobefamiliarwiththevaluesheldinthese fields and interpretationof the content canbeagreed locally toassistwith theappropriateapplicationoftariffs.

3.8 CriticalCareLengthofStay3.8.1 The complexities associatedwithboth thePbR rules related to allocating critical

care days to episodes and theway critical care is captured and recorded locallymeanthatthishasbeenacommoncauseofissueswithinreconciliationexercises.

3.8.2 Themaincausesoftheseissuesare:

Failuretofollowdatastandardsandpoordataqualityinsubmittedcriticalcaredata;

Lack of understanding around the presentation of correctly submittedCriticalCaredatainSEMbycommissionersusingSEMdataasasource;

Failuretocalculatederivationscorrectly.

3.8.3 SUSPbRisdesignedtominimisetheriskoferrorsfromthefirstoftheseissuesbyhandlingthedatacorrectlyandapplyingtheadjustmentsasagreedwithDH.

3.8.4 InconsistentsubmissionofthecriticalperiodidentifiersandstartandenddatesofcriticalcareperiodswithintheCDS,andthesubsequentprocessingofthisdata,hasledtotheinconsistentallocationofcriticalcaredayswheretheCCperiodoverlapsepisodeswithinaspell.

3.8.5 Inrecognitionof these issues thehandlingofCriticalCarebySUSPbR in2011/12hasbeenextensivelyreviewedto:

Increaseitsrobustnesstopoordataquality; ClarifytheprocessingrulesfortheallocationofCriticalCaredaysacross

episodeswithinaspell;

7Seesection10oftheSUSPbRRelease9TechnicalGuidancehttp://www.connectingforhealth.nhs.uk/systemsandservices/sus/supports/pbr/pbrguidance/r9techguide.pdf


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IntroduceanewCriticalCareextractwhichdetailsthe informationheldon valid Critical Care periods and identifies the relevant number ofcriticalcaredaysfortheapplicationofcriticalcaretariffsandfor lengthofstayadjustmentNotethisextractisavailableonlyfromtheSUSPbRmanagedextractservice.

3.8.6 The SUS PbR Release 9 Technical Guidance 8 sets out the detail of the revisedvalidation, processing and outputs for Critical Care in 2011/12. In summary theguidancecovers:

Additional validations on data quality for incoming records to SUS.TypicallyifarecordfailsthevalidationthenCCprocessingwillcease;

IntroductionofanewCriticalCare Indicator.Thiswillbeoutputwherethevalidationidentifiestheunderlyingissue;

NewrulesforthecountingandallocationofCCdaystoepisodeswithinaspellincludingthemanagementofexcludedepisodes;

Spelllengthofstayadjustments

3.8.7 Theguidance includesdetailedscenarios illustrating theapplicationof thesenewvalidationsandprocessingrules.

3.8.8 Thekeychange in theprocessing is thatSUSPbRwillallocatedistinctCCdays toepisodesandwheretheCCperiodspanstheboundarybetween2episodesthedayon the boundary will be allocated to the later episode. Once summed acrossepisodesanewattributeinthePbRextractsTotalCCdayswillcapturetheoveralltotal.

LessonLearnt16ExperiencefromearlierreconciliationexercisessuggeststhattheissuesassociatedwiththemanagementofCriticalCaredaysbothintermsofdataqualityandsubmission,complexityandclarityofpolicyandprocessingruleshavecausedproblemsforbothcommissionersandprovidersinachievingaconsistentunderstandingandreconciledposition.The2011/12revisedprocessingrulesandintroductionofanewSUSPbRCriticalCareextractprovideanopportunitytoreestablishaclearerandconsistentpictureoftheoverallmanagementofcriticalcaredays.

3.9 SUSPbRProcessingIssues3.9.1 ThereareanumberofknownprocessingissuesrelatingtoSUSPbRwhichneedto

befactoredintoanyreconciliationexercise.Theseinclude:

ManagementofRehabilitationdays; RoundingofMarketForcesFactor(MFF) CorrectprocessingofdataforA&Epatientsdeadonarrival(DOA)

3.9.2 PeriodsspentinrehabilitationcannotbeaccuratelyderivedbySUSastheyarenotidentifiedwithintheexistingCDSflows.AccordinglySUSPbRcannotadjustexcessbeddaysorcalculatepaymentsrequiringmanualadjustmentstobeundertaken.

3.9.3 DHrequirementsarethatwhenaMarketForcesFactor(MFF)isappliedthefiguresshouldberounded to thenearestatan individualevent level.Dependingupon

8http://www.connectingforhealth.nhs.uk/systemsandservices/sus/supports/pbr/pbrguidance/r9techguide.pdf


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theMFFvalueforagivenTrustandthe localmethodofapplicationvariancescanarise.Themostcommoncauseofdifferenceoccurswhereanadjustment ismadetotheaggregatedpricedtarifflocallyratherthanonacasebycasebasis.

3.9.4 ThetarifffordeadonarrivalpatientsinA&EisgeneratedbyapseudoHRGDOAwhich is determined by A&E Patient Group Code (value 70). This is not alwaysrecognisedinlocalprocessingandcanleadtodifferencesatreconciliation.

LessonLearnt17Experiencefromreconciliationexercisesindicatesthatthedifferencesgeneratedbytheseissuesareunlikelytoprovematerialbuttheyshouldbeidentifiedandfactoredintothereconciliationprocess.

4 Conclusions

4.1 LocalProcessingvs.SUSPbR4.1.1 ItisknownthatmanycommissionerorganisationscurrentlyextractdatafromSEM

toundertake localPbRprocessing.Thisplacesasignificantdependencyupon theaccuracy of the provider CDS submissions for key fields like Provider SpellNumberandCommissioner.ItalsoinmanywaysreplicatesthecentralSUSPbRprocessing and reflects an historic lack of confidence in using SUS PbR and inparticulartheonlineextractservice.

4.1.2 ThefeaturesofSUSPbRofferanumberofadvantagesintermsofbothprocessingandfunctionalitytosupportPbRreconciliation,theseinclude:

AppropriateapplicationofDHbusinessrulesforeachfinancialyearandabilitytoprocessdistinctlyformultipleyears;

Spellingalgorithmandkeyderivationse.g.corespellHRG; DerivedGPPracticeandPCTofResponsibility; Versioningofdataatkeyreconciliationandpostreconciliationpoints; For 2011/12 the management of emergency readmissions, revised

CriticalCareprocessingandapplicationofextendedbestpracticetariffsinlinewithDHPbRpolicy;

Returningallactivityfortherelevantfinancialperiod,whetherornotitisinscopeofnationaltariff,thushelpingtosupportthelocalapplicationoflocaltariffs;

Online extract service which provides access to a wider range ofattributesandistheonlysourceofthecurrentSUSPbRview.

LessonLearnt18ThereconciliationexercisesundertakenbetweenlocalandSUSPbRdatahavedemonstratedthatonce:

Any inconsistenciesbetweenproviderdata submitted to SUSanddatausedlocallyasabasisforinvoicingareunderstood,and

Account made for local activity adjustments covering issues likerehabilitationdays

then,SUSPbRwasfoundtobeoperatinginaccordancewithDHrequirementsandaccuratelycalculatingpricedactivityatnationaltariff.


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5 AppendixASEMandSUSPbRMartsOverviewofKeyFeatures

5.1 SUSExtractMart(SEM)SUSExtractMartreturnsthedatasubmittedtoSUSasabulkextractwithalimitednumberofadditionalderivations.SEMreflectsthestateofSUSatthetimetheextractistaken,andtothatextentrepresentsamovingtarget.

Fromthe2010version,derivationshaveincluded:

The core spell and episode HRG4 values derived as part of SUS PbRprocessing. (Note that processing lags may result in these fields beingreturnedemptyforashortperiodaftersubmission.)

GPpracticeandPCTcodesderivedbylookingupthePersonalDemographicService (PDS) for the relevantdate i.e.by tracing, in addition to theGPpracticecodesentbytheProvider.

ThedatareturnedbySEMcloselymirrorsthatuploadedtoSUSundertheBulkprotocol(see3.2above):

For Finished Consultant Episodes, data is extracted by reference to theepisodestartandenddate.

Commissioners can choose to select recordsby reference tooneormorereasons for access for example, commissioner, copy recipient, PCT ofresidence,(derived)PCTofresponsibility.

CriticalCaredatawillreflecttheCDSsubmissionstandardssetoutintheSUSPbR TechnicalGuidance document i.e.where Critical Care Periods spanepisodes,therewillbeentriesfortheCriticalCarePeriod inmorethanoneepisodeandtherecipient isresponsibleforapplying localbusinessrulestoavoiddoublecounting.

5.2 SUSPbRSUSPbRprovidesextendedfunctionalitydesignedtosupporttheuseofSUStosupportPbRreconciliation.ThesolutionisrefreshedbytheDHandtheICeachyearincloseliaisonwiththeDHPbRpolicyteam.

Keyfeaturesareasfollows:

SUS PbR applies national PbR tariff rules and contains all relevant PbRderivations; includingcorespellHRG,episodeHRGandunbundledHRGs. Italsoreturnsthekeyfields fromtheCDS. (For2011/12thissubsethasbeenextendedandadditionaldata itemsadded to theonlineAPC,OPandEMextracts).

SUSPbRreturnsallactivityfortherelevantfinancialperiod,whetherornotitisinscopeofnationaltariff,andthereforecanalsobeusedtosupportthelocalapplicationoflocaltariffs.

SUSPbRversionsthedata.Thisfunctionalityisusedtoprovide: StaticsnapshotsofthedataatReconciliationpoint StaticsnapshotsofthedataatPostReconciliationpoint


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A current view of the datawhich reflects the current view of SUS(similartoSEM).

ForAdmittedPatientCare, two coreextractsare returnedone for spellsandonefortheconstituentepisodesofthosespells;thetwoare linkedbyaninternallygeneratedspellidentifier.

ForAdmittedPatientCare,SUSPbRisextractedbyreferencetotheHospitalDischarge date, and not Episode End Date. Thismeans that the SUS PbRepisode extract contains all episodes relevant to PbR for the period inquestion unlike SEM where this can only be guaranteed by taking anextractforanextendedperiod.ItalsomeansthattheSUSPbRextractforagivenmonthwouldcontainadifferentsetofepisodestoanextractforthesameperiodtakenfromSEM.

SUSPbRissupportedthroughbothamanagedandanonlineservice: The SLAs for the managed service reflect the deadlines set by

NationalPbRGuidanceand referencedby theNationalContract forAcuteServices.

TheonlineserviceprovidesaccesstoawiderrangeofattributesandistheonlysourceofthecurrentSUSPBRview.

SUSPbRfunctionalityhasbeenenhancedfor2011/12to: Provide information to supportpolicy around readmissions. This is

targeted at Commissioners and,with one exception, available onlythroughthemanagedservice.

Flagactivitywhichattractsencouragingbestpracticetariffs.ThisadditionalfunctionalityisdeliveredbothbyaddingnewfieldstoexistingextractsandaddinganewCommissionerspecificextracttosupporttheimplementationofpolicyaroundreadmissions.


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6 AppendixBSummaryofKeyLessonsLearntMainSourcesofReconciliationDifferencesOverwhelmingly,initialdifferencesbetweenSUSPbRandlocalprocessingarosefromdifferencesintheactivityunderconsideration.Themostcommoncauseofinconsistencyissimplythatprovidersandcommissionersareworkingwithinconsistentversionsofthedata.Significantchangesindatawerefoundtooccurbetweenreconciliationandpostreconciliationascodingwascompletedandcorrectionstoactivitydatawereapplied.Databecomesrelativelystablefrompostreconciliationandthereconciliationprocessbecomeseasierwhenconsistentcutsofthedataareused.UsingSUSPbRasthebasisforContractReconciliationSUSPbRfunctionalityprovidesasoundbasisforundertakingcontractreconciliation.Inreconciliationexercisesithasbeenfoundtoaccuratelycalculatepricedactivityatnationaltariff(subjecttotheCDSextractonwhichitisbasedbeingaccurateandlocaladjustmentbeingmadetodealwithknownfactorslikepatientswhohavespenttimeinrehabilitationseesection3.9)LocalprocessingofPbRiscomplexandcannotbeguaranteedtobefreefromerror.Toassurelocalprocessingtheabilitytoreconcileagainstastandardbenchmarkisneeded.SUSPbRprovidesapricedviewofactivity,togetherwithdetailsofallunderlyingcurrenciesandderivationsreflectingtheprocessingrulessetbyDHintariffguidance.UseofPbROnLineExtractsUsersshouldmakegreateruseoftheadditionalfunctionalityavailablefromtheSUSPbRonlineserviceandtouseSUSPbRasthebasisofachievingconsistentdataextracts.SUSRelease9for2011/12PbRnowprovidesforallCDSitemstobeavailablethroughPbROnline.PbRonlineandSEMbothprovidetheabilitytoaccessdatausingallandanyreasonforaccesswhereasthePbRmanagedserviceonlyreturnsdatafortheprovidercodedproviderandcommissionerfields.ThisfurtherindicatestheuseofPbRonlineextractstosupportthereconciliationprocess.SpellConstructionTherearetwolikelyissuesthatmightimpactreconciliationarisingfromlocalprocessing:

Providersmayfailtoupdateallepisodesinaspellwhichcontinuesoveranextendedperiod;

Commissionersmayomittoextractandprocessallepisodesassociatedwithinthespellaspartoftheirlocaldataprocessing.

GroupingCareisneededinlocaldatacleaningroutinespriortopresentingdatatotheNHSICLocalPaymentGrouper.TypicallyhoweverthenumberofHRGsaffectedbyanyerrorsarefew,withnomaterialfinancialimpactarising.InmanycasestherearenodifferencesfoundinHRGs


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calculatedbySUSandthroughlocalprocessing.CriticalCareExperiencefromearlierreconciliationexercisessuggeststhattheissuesassociatedwiththemanagementofCriticalCaredaysbothintermsofdataqualityandsubmission,complexityandclarityofpolicyandprocessingruleshavecausedproblemsforbothcommissionersandprovidersinachievingaconsistentunderstandingandreconciledposition.The2011/12revisedprocessingrulesandintroductionofanewSUSPbRCriticalCareextractprovideanopportunitytoreestablishaclearerandconsistentpictureoftheoverallmanagementofcriticalcaredays.LocalProcessingvs.SUSPbRThereconciliationexercisesundertakenbetweenlocalandSUSPbRdatahavedemonstratedthatonce:

Any inconsistenciesbetweenproviderdata submitted to SUSanddatausedlocallyasabasisforinvoicingareunderstood,and

Account made for local activity adjustments covering issues likerehabilitationdays

then,SUSPbRwasfoundtobeoperatinginaccordancewithDHrequirementsandaccuratelycalculatingpricedactivityatnationaltariff.

1 Introduction and Background1.1 Purpose of This Document1.1.1 Following on from detailed SUS PbR reconciliation exercises undertaken during 2009 and 2010 this document seeks to provide a set of generic guidelines that NHS organisations can use to inform local reconciliation activity. It is primarily concerned with the reconciliation of priced activity within local systems to that identified in outputs from SUS PbR.1.1.2 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 which aim to:1.1.3 The document draws on learning points emerging from a joint reconciliation exercise undertaken by the NHS SUS PbR team and a local health community during 2009 and 2010. These guidelines are, however, generic and there are no specific details of this exercise included within them.1.1.4 The document will be of interest to commissioning, information and finance teams within both NHS Commissioner and Provider organisations.

1.2 Secondary Uses Service (SUS)1.2.1 The NHS Secondary Uses Service (SUS) is the central repository which supports the flow of Commissioning Data Sets (CDS) between providers and commissioners. The use of SUS has been mandated in the Operating Framework for 2011 as follows:1.2.2 SUS uses the submitted Commissioning Data Sets (CDS) to provide the following:

1.3 SUS PbR Processing in 2011/121.3.1 For readers requiring further guidance on the operation and outputs of SUS PbR in 2011/12 a separate document SUS PbR Release 9 Technical Guidance is available 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 functionality introduced in 2011/12 to support the national policy on re-admissions, best practice and the management of Critical Care days.

2 Reconciliation Approach2.1 Why Reconcile2.1.1 Reconciliation between SUS-PbR and local systems is most commonly undertaken as part of the invoice validation and approval process that is managed between commissioners and providers. 2.1.2 A provider will generate an invoice based on the activity, rules and tariffs embodied 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 flow into SUS from provider organisations. 2.1.3 As this process underpins the basis of contractual payment between the organisations it should be subject to the appropriate assurance expected by a financial system. This should include the ability to support an audit trail back to the events which generated the claim for payment.2.1.4 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 emergency admitted patient care) or contractual requirements.

2.2 Reconciliation Methodology2.2.1 The normal approach to reconciliation is to adopt a combination of top-down and bottom-up processes to identify and explain areas of difference:2.2.2 Using this approach the key elements to be considered in achieving reconciliation are likely to be:2.2.3 Experience of previous work undertaken on reconciliation has shown that the most effective approach to identifying differences within the PbR process is to consider each of the main processing blocks identified in Figure 1 below.2.2.4 There are two key lessons learnt from the earlier reconciliation exercises to draw from this overall structure:

2.3 Consistency of Data2.3.1 As suggested above inconsistency in the versions of data used is one of the most commonly identified sources of difference within reconciliation exercises.2.3.2 National contracts and DH PbR guidance imply that invoice validation will be based on a consistent snapshot, taken at one or other reconciliation inclusion point:2.3.3 SUS-PbR 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 application of local tariffs). This versioning ensures that all parties accessing a given snapshot whether provider or commissioner will have a consistent view of the data at the inclusion points defined in the National Contract.2.3.4 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 snapshot at inclusion point. This can lead to:2.3.5 Historically there have been three main reasons given for using SEM locally. Firstly, that PbR extracts did not return all the required attributes whereas SEM returns the data submitted to SUS as a bulk extract reflecting the current position at the time the extract is taken. Secondly, that there have been delays in the availability of data from SUS PbR compared with SEM. Thirdly, SEM was developed before the PbR mart and consequently local systems have been built to accommodate SEM extracts and have not been subsequently updated to use PbR.2.3.6 These issues have been largely addressed in recent SUS PbR releases through the introduction of the SUS PbR on-line extract service which now provides:

2.4 SUS Data Marts2.4.1 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 key features in both SEM and SUS PbR.2.4.2 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 number of common factors:

3 Known Reconciliation Issues3.1 Summary of Known Issues3.1.1 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:

3.2 SUS Input Errors3.2.1 Input to SUS is made by the submission of Commissioning Data Sets (CDS) using XML input which allows for error checking against a data definition held in the XML schema. Input is validated prior to being sent to SUS with data fields being validated for conformity with the data dictionary.3.2.2 Update to SUS can use one of two submission protocols:3.2.3 The most commonly found error impacting reconciliation stems from duplication or unintended loss of records caused by inconsistent CDS updates. This is a particular risk where both Bulk and Net submissions are mixed by the sender organisation.3.2.4 The net protocol uses a mandatory unique record identifier as a key. This field, the CDS Unique Identifier, provides a basis for cross-referencing 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 lead to the creation of duplicate records.3.2.5 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 the original Bulk submission.3.2.6 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 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 submitted general APC records.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 Bulk and Net protocol. The link to this document is shown below.3.2.8 Other local factors that can impact upon the quality of data submitted to SUS include:

3.3 Data Consistency3.3.1 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 providers and commissioners.

3.4 Identifying Organisations and Reasons for Access3.4.1 A key concern is to ensure that the organisational scope of the data being reconciled is consistent. Commissioners undertaking invoice validation will be concerned to ensure that patients have been assigned to the correct Commissioner, the primary determinant of which is the patients GP practice at the time of treatment.3.4.2 The CDS maintains a number of fields relating to PCT and commissioner. These include:

3.5 Spell Construction3.5.1 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 the spell) and not episode end date to extract data.3.5.2 In SEM however data is extracted by reference to the episode start and end date.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. Episodes are assigned to a spell by reference to their start and end dates.3.5.4 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.3.5.5 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:3.5.6 There are simple mechanisms to check locally whether any of these cases may have arisen. For the first case, the spell level extract contains a field containing the count of provider hospital provider spell numbers a value greater than 1 indicating inconsistency. These checks may also identify errors in the CDS data sent by providers and should be part of Commissioners routine checking processes.

3.6 Incorrect Preparation of Data for Local HRG Grouping 3.6.1 Local HRG Grouping is undertaken using the standalone NHS IC Local Payment Grouper. SUS uses multiple versions of this IC grouper utilising the same underlying reference data tables.3.6.2 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 the correct version of the grouper to incoming data.3.6.3 The grouper expects data to be cleaned prior to being presented for grouping. SUS undertakes this pre-processing in line with DH requirements. These include the removal of trailing characters identifying local coding extensions and the removal of dagger and asterisk codes from ICD 10 diagnostic codes.3.6.4 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 character represents a local extension.3.6.5 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 loss of detail and can lead to differences in the derived HRG compared to SUS.

3.7 Identification of Activity to Tariff3.7.1 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 upon reconciliation.3.7.2 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 Commissioner will need to be able to distinguish within the SUS outputs:3.7.3 The use of the = sign convention can be helpful. Providers are able to send an = sign as the last character of the CDS data item Commissioning Serial Number for both APC and OP CDS types.3.7.4 Any episodes which have this convention applied are interpreted by SUS as a provider requested exclusion from PbR processing.3.7.5 Whilst helpful this convention does not provide sufficient information about how the activity is being priced, or if it is being priced at all.

3.8 Critical Care Length of Stay3.8.1 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 mean that this has been a common cause of issues within reconciliation exercises.3.8.2 The main causes of these issues are:3.8.3 SUS PbR is designed to minimise the risk of errors from the first of these issues by handling the data correctly and applying the adjustments as agreed with DH.3.8.4 Inconsistent submission of the critical period identifiers and start and end dates of critical care periods within the CDS, and the subsequent processing of this data, has led to the inconsistent allocation of critical care days where the CC period overlaps episodes within a spell. 3.8.5 In recognition of these issues the handling of Critical Care by SUS PbR in 2011/12 has been extensively reviewed to:3.8.6 The SUS PbR Release 9 Technical Guidance sets out the detail of the revised validation, processing and outputs for Critical Care in 2011/12. In summary the guidance covers:3.8.7 The guidance includes detailed scenarios illustrating the application of these new validations and processing rules.3.8.8 The key change in the processing is that SUS PbR will allocate distinct CC days to episodes and where the CC period spans the boundary between 2 episodes the day on the boundary will be allocated to the later episode. Once summed across episodes a new attribute in the PbR extracts Total CC days will capture the overall total.

3.9 SUS PbR Processing Issues3.9.1 There are a number of known processing issues relating to SUS PbR which need to be factored into any reconciliation exercise. These include: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 bed days or calculate payments requiring manual adjustments to be undertaken.3.9.3 DH requirements are that when a Market Forces Factor (MFF) is applied the figures should be rounded to the nearest at an individual event level. Depending upon 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 to the aggregated priced tariff locally rather than on a case-by-case basis.3.9.4 The tariff for dead on arrival patients in A&E is generated by a pseudo-HRG DOA which is determined by A&E Patient Group Code (value 70). This is not always recognised in local processing and can lead to differences at reconciliation.

4 Conclusions4.1 Local Processing vs. SUS PbR4.1.1 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 particular the on-line extract service.4.1.2 The features of SUS-PbR offer a number of advantages in terms of both processing and functionality to support PbR reconciliation, these include:

5 Appendix A SEM and SUS PbR Marts Overview of Key Features5.1 SUS Extract Mart (SEM)5.2 SUS PbR

6 Appendix B Summary of Key Lessons Learnt

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