Supporting Primary Care and GP Cluster Information Needs Across Scotland
GP Cluster Interactive Map
GP Cluster Interactive Map is an interactive map showing the GP Clusters that LIST has engaged with and the main themes of work undertaken jointly between LIST and GP Clusters. The map is updated on a monthly basis.
Our Stories - Making an Impact with data locally showcases some of the work carried out by LIST, including a section on how LIST can help support GP Clusters. One example has included the management of appointments, whereby a practice wanted to ensure the most appropriate professionals saw the patients at the right time to ensure quality and timely care was provided. LIST provided meaningful intelligence to support staff to better understand demand and capacity.
A video overview of the LIST Our Stories document:
Reports to View
Scottish Primary Care Information Resource (SPIRE)
SPIRE is the Scottish Primary Care Information Resource. It is a service which allows information to be requested from GP practice records and collected centrally to produce statistics for Scotland as a whole. SPIRE also provides a platform for practices to see information about their patients, through reports on topics such as practice activity, vaccination uptake and multimorbidity.
More information about SPIRE and the current status of its deployment are available on the SPIRE website.
SPIRE uses a different model for data collection than is used for other ISD datasets. There is not a central dataset containing all of the GP practice information for Scotland. Instead, individual requests for small amounts of information relating to specific purposes will be sent to practices. All such information requests need to be approved by the SPIRE Strategy and Oversight Group prior to being sent out to GP practices. The practices can then choose whether or not they want to opt-in to the request. Patients can also ask their GP for their data to be excluded from any patient identifiable extracts. Information is not stored for longer than necessary, and any information is safely destroyed after use.
If you wish to request data through SPIRE please complete the data request form either on the SPIRE website or the offline version.
Patient Leaflet about SPIRE
Poster about SPIRE
Primary Care Information Dashboards
The PCI dashboards provide a single access point for GPs and practice staff to see health care information for their GP Practice and Cluster. The information is delivered through a set of Tableau dashboards, and show comparisons at Scotland, NHS Board and HSCP.
The dashboards include:
- Disease Prevalence
- “High Health Gain” patient listings
- Health and Social Care "Pathways Population Matrix"
How to Access PCI Dashboards
The latest release includes the most recent data available for each of the measures, the latest being the fourth quarter of 2018-19 (January to March). The next update will be at the end of July 2019.
Instructions for GPs on how to access PCI can be viewed in our How-To-Access-PCI Guide. Once access has been granted, the dashboards can be viewed by entering the username and password at https://viz.nhsnss.scot.nhs.uk/.
The following videos provide further information and user guidance on how to navigate the PCI dashboards:
“The system that we use for Primary Care Dashboard, through “tableau”, however is simplicity itself. If more could be added to it then we would use it weekly.” - General Practitioner
“We are using data from SPARRA, Bluebay CT, PCI dashboard and developing data to support a number of QI programmes with various partners and their data bases” - Cluster Quality Lead
For any enquiries please contact nss.isdGeneralPractice@nhs.net
NSS Discovery and the GP Cluster Dashboard
What is NSS Discovery?
NSS Discovery is an information system that provides approved users with access to a range of comparative information (indicators) to support benchmarking, performance and quality improvement. Access to the system is dependent on individual users requesting and receiving appropriate authorisation.
The information within NSS Discovery can help users to review performance, benchmark against peers and identify areas where resources could be targeted to address local health and care needs.
Guide for Requesting Access to Discovery
GP Cluster Dashboard
Case Study: - Discovery use to support change in practice
Topic: -Variation in New Outpatient Referral Rates
ISD has held data on medicines prescribed within NHS Scotland for several decades. These data are generated as part of prescription processing for the payment of dispensing contractors by the Practitioner and Counter Fraud Services in NHS National Services Scotland. We currently have data on over one billion prescriptions primarily written by GPs but also by other authorised prescriber types, which we make available to customers through routine reporting and publications, online tools and bespoke analysis to support customers with specific information needs.
Our Prescribing Team provide a national information and intelligence service for customers in NHS Boards, Government, Academia and Industry and through our work we support improved health and ensure efficient and effective use of public money.
In addition to these services, the ISD Prescribing team have recently started producing a range of prescribing data Open Data releases under the Open Government Licence, which encourages the use and re-use of public sector data. This allows interested parties to interrogate according to their own interests and requirements, in line with Open Data guidelines. ISD Prescribing has also focussed on engaging with a range of data users to design and produce a number of online data visualisation tools. These allow users to review and aggregate large datasets according to their requirements or focus on the specific data that is of interest to them.
You can find out more about all our services by e-mailing: email@example.com. Our Guide to Prescribing Services describes how we support key aspects of prescribing, catalogues the information that is available routinely and outlines the help we can offer.
Prescribing Data Visualisations
Prescribing Open Data Dashboard. This dashboard allows exploration of the most recent Monthly Prescriptions In The Community data file at a national and NHS health board level. It presents four views each asking different questions of the data file with subsequent information to help understand what the visualisation shows. These questions are:
- Which are the highest cost therapeutic areas in terms of prescriptions in the community?
- How do individual GP Practices contribute to overall prescribing by GP Practices?
- What is the variation in prescribing within BNF Chapters among the 10 biggest practices?
- Where are the most prescriptions being written?
Summary Statistics. This dashboard presents data on the volume, which is the count of all prescriptions dispensed in the community, and on cost, which is the reimbursement cost of those prescriptions. This is measured as Gross Ingredient Cost (GIC) and is based on the list price for a given medicine at the time of dispensing. Data can be viewed at a National and NHS health board level.
Contractor Activity Interactive Dashboard. ISD Prescribing have created an interactive dashboard on Shiny, a package within the open source statistics software R which can be used to build interactive web apps from data held in R, based on the Community Pharmacy - Contractor Activity open data. This app pulls in data from the quarterly data releases and allows interactive comparison of multiple community pharmacies on a range of measures held within the data for the time periods of data released to date. This can be built as charts, a populated interactive map or as data tables.
Polypharmacy Outcome Measures: ISD Prescribing have produced a new set of polypharmacy related outcome measures in Discovery. These have been produced in collaboration with the NHS Scotland Effective Prescribing and Therapeutics Branch, and are intended to allow measurement of adherence to guidelines on preferred combined use of medications or on combinations to be avoided. More information on polypharmacy guidance can be found on the Branch website. Please note access to Discovery is restricted to NHS Scotland users with a user account.
National Therapeutics Indicator dashboard: ISD have recently produced an interactive dashboard allowing users to look at National Therapeutics Indicators and a Practice and GP Cluster level. These indicators have also been produced in collaboration with the NHS Scotland Effective Prescribing and Therapeutics Branch.
Scottish Patients at Risk of Readmission and Admission (SPARRA)
What is SPARRA?
SPARRA (Scottish Patients at Risk of Readmission or Admission) is a risk prediction tool developed by ISD which predicts an individual's risk of having an emergency admission to hospital in the next year.
There is a need for the NHS to shift its healthcare delivery away from reactive, hospital-based treatment, and to move towards preventative and anticipatory care provided in the community.
A SPARRA risk score of 1-99% is calculated every month for 80% of the population using patient level hospital and prescribing data. (The other 20% of the population have no hospital or prescribing data).
The SPARRA risk scores and accompanying hospital and prescribing data are displayed at patient level (one row per person) in a secure online Business Objects system which can only be viewed by professional healthcare workers once approval is granted by the appropriate Information Governance authorisers.
The SPARRA patient list is updated every week to remove information on people who have died. Have a look at a Sample GP Practice Report to see the format of the list of monthly SPARRA patients.
What is the purpose of SPARRA?
SPARRA data can help health care professionals identify patients with complex care needs who may benefit from anticipatory health care, including a medicine review. SPARRA data can also be used to help plan services by highlighting groups of patients who would benefit from those services.
Methodology of SPARRA risk score calculation.
The SPARRA model uses logistical regression methodology to calculate the SPARRA risk scores. Details of the development of the SPARRA Version 3 algorithm, including the methodology, data sources use, risk factors identified, and model performance can be found in A Report on the Development of SPARRA Version 3.
How do I get access to SPARRA data in Business Objects?
To access SPARRA data, please register online via the User Access System (UAS) https://useraccess.nhsnss.scot.nhs.uk/ and choose the SPARRA data mart.
One page UAS guides are available.
Access requests are sent to your Caldicott guardian or GP practice authoriser for approval.
Once you are granted approval to access and view SPARRA data, you can run one of ISD’s pre-built reports in Business Objects. A guide on how to run these reports is available here: SPARRA-User-Guide-V4.2
History of the development of SPARRA
The first SPARRA model was launched in 2006 (with scores for people aged 65 & over who already had 1 or more emergency admission to hospital in the previous 3 years). This model was replaced with version 2 in 2009 (for people of all ages who had already had 1 or more emergency admission to hospital). That model was replaced with version 3 in 2012 (for people of all ages whether or not they had an emergency admission to hospital in the previous 3 years). This is also when SPARRA became available via the secure online Business Objects system.
ISD are currently developing version 4 of the SPARRA model with the Alan Turing Institute to further improve the accuracy of prediction of emergency admissions, and this is planned to go live later in 2019.
As part of the redevelopment, ISD will look into the presentation of this information including the use of the Primary Care Information (PCI) dashboard.
SPARRA Data Visualisation
Transparency of the SPARRA v3 Model
A SPARRA Risk Score Calculator is available to see how a SPARRA risk score will vary depending on a person’s age and their previous hospital and/or prescribing activity.
High Health Gain Individuals
What is the High Health Gain (HHG) tool?
The Scottish General Practitioners Committee and Scottish Government supported ISD to develop a predictive tool to help identify complex and vulnerable patients with the potential for improvement through intervention in primary care or health and social care partnerships. The tool is called the High Health Gain tool (HHG).
This tool can help GPs and allied health professionals identify people who may benefit from an Anticipatory Care Plan (ACP) and/or additional support e.g. social care in their own home, medicine review.
Currently in Scotland, 2% of the population use 50% of health and social care resources, and 5% of the population use 65% of health and social care resources. The HHG risk prediction tool currently uses data which are available to ISD- hospital and prescribing data (and the costs associated with these)- to predict the risk (0-99%) of a person in a GP practice in Scotland having complex, high cost, needs in the next 12 months.
When primary care data, through SPIRE, and social care data become available these will be included to improve the HHG tool.
How do I access HHG data?
HHG data are available at by practice at an individual patient level. They are available to GPs via ISD’s PCI (primary care information) dashboard.
To apply for access to view the confidential patient level HHG data, please follow instructions at: https://www.isdscotland.org/Health-Topics/General-Practice/PCI/Accessing-PCI/
If you have any problems, contact our product support team at NSS.isdSHIS@nhs.net or 0131 275 7050.
Your LIST (local ISD analyst) can help you access the PCI dashboard. (http://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Local-Intelligence-Support-Team/)
Data Visualisation of HHGs
Information used to calculate the HHG risk score
The following data are used at present to calculate the HHG risk score:- acute hospital data (emergency admissions, elective admissions, psychiatric admissions, A&E attendances, and out-patient attendances), hospital and community prescribing, the costs associated with the hospital and prescribing data, and age of patient. When primary care data, through SPIRE, and social care data become available these will be included to improve the HHG tool.
Information on the HHG data fields presented in the output can be found here.
ISD’s HHG information is constantly being improved and developed. If you have any feedback or questions on the HHG dashboard, please email NSS.HighHealthGain@nhs.net.
Health and Social Care Data Integration – Future for GP Clusters?
How Social Care data collection has been developed
An ambition to establish a common national dataset on social care clients available for multiple health and social care uses, both local and national, has existed since 2010. Achieving this ambition is now being realised with the merger of two existing datasets – the Social Care Survey (SCS) and the Source Social Care dataset (SourceSC).
In April 2017 a decision was taken by the Scotland Government and Information Services Division (ISD) to merge the SCS and the SourceSC data collections, using the Source approach (i.e. using ISD’s data processes) as the primary solution to meet the combined needs in future.
The collection of social care data through ISD offers the prospect and advantage of linking these data to health related data. Social care data captured includes home care, care home, telecare/community alarms, self directed support, meals, housing support and identifying clients that receive a social worker or who live alone. With linking this data comes the opportunity to develop more comprehensive analyses to inform decisions based on a broader and more meaningful view of the pathway of care.
How can Source data be used?
The dataset for Health and social Care Data Integration (Source) is a routine collection which can be used to provide information on social care activity and be linked with routinely collected health data including; acute, mental health and geriatric long stay hospital admissions, A&E attendances, hospital outpatient appointments, community prescribing, delayed discharges, GP Out of Hours and community health along with NRS deaths.
The linked dataset aims to provide the basis for a wide array of analysis of resource consumption and outcomes across health and social care from individual level up to national level.
Source: Understanding Care Pathways
Source: Health & Social Care Linkage
How can GP Clusters use this information?
Linked health and social care information within Source can be broken down to GP Cluster or individual practice level. If GP appointment data were to become available in the future then there is the possibility this could also be linked to provide a more comprehensive understanding of the profile and needs of patients and their pathways of care.
Care Home Census
Care Home Census (CHC)
The care home census is an annual publication by ISD Scotland which contains data on all adult care homes in Scotland that are registered with the Care Inspectorate (the regulatory body of care homes).
The data are presented at local council and Scotland level (not at care home level), in Excel data tables accompanied by a summary (pdf) and a full report (pdf). In addition, all data displayed in the data tables are published as one ‘open data’ csv file. The most recent publication (published on 11 September 2018) includes trend data.
Care Home Census – Trend Data
The most recent publication (published on 11 September 2018) includes the following trend data:
Trend data, as at 31 March of each year, 2007-2017.
- Number of care homes.
- Number of registered places.
- Number of residents (split by long stay, short stay, and respite stay residents).
- Percentage occupancy.
- Percentage of male and female residents.
- Percentage of long stay residents with a certain health characteristic (i.e. requires nursing care, visual impairment, hearing impairment, acquired brain injury, other physical disability or chronic illness, dementia (medically diagnosed), dementia (not medically diagnosed), mental health problem, learning disability, alcohol related problems, drugs related problems). Numbers are provided at Scotland level and percentages are provided at local authority level.
- Number of registered places in care homes for older people (aged 65+) in Scotland, per 1,000 of the population aged 65+.
- Average gross weekly charge for self funded residents and local authority funded residents in care homes for older people (aged 65+).
- Percentage of long stay residents by source of funding (self funded or local authority funded) in care homes for older people (aged 65+).
Trend data, covering full financial years, 2006/07- 2016/17.
- Number of admissions into care homes.
- Number of discharges from care homes.
- Number of deaths in care homes.
- Complete length of stay in care homes.
- Incomplete length of stay in care home.
- Mean and median age on admission to care home, and on discharge from care home.
- Source of admission for long stay residents in care homes for older people (aged 65+).
- Destination on discharge of long stay residents in care homes for older people (aged 65+).
Most of the trend data listed above are split by main type of care (i.e. adults with learning disabilities, adults with physical disabilities, adults with mental health problems, and older people aged 65+). They are also split by sector (private sector, voluntary sector, and local authority and NHS sector).
The care home census data can help local authorities plan the provision of the most appropriate care homes and health care services in their area.
Care Home Census – Data Visualisation
The Scottish Public Health Observatory (ScotPHO)
The Scottish Public Health Observatory (ScotPHO) collaboration is co-led by ISD Scotland and NHS Health Scotland, and includes the Glasgow Centre for Population Health, National Records of Scotland, Health Protection Scotland, the MRC/CSO Social and Public Health Sciences Unit and the Scottish Learning Disabilities Observatory.
Through our work we ensure that all those working to improve health and reduce health inequalities in Scotland can find the data and information they need to help them achieve these goals.
We do this by:
- Pointing users to key relevant data sources and providing a clear picture of the health of the Scottish population and the factors that affect it
- Contributing to improved collection and use of routine data on health outcomes, risk factors, behaviours and wider health determinants
- Taking a lead in determining Scotland’s future public health information needs, and ensuring these are met.
Our website, www.scotpho.org.uk, points users to key data sources on health and its determinants and provides overviews and commentary. We publish a variety of one-off reports, and contribute to and lead national public health data projects. Our widely-used Online Profiles Tool provides access to public health related indicators grouped in a suite of specialist profiles at different geographies including NHS boards, local authorities and Health & Social Care Partnerships.
Follow us on twitter: @scotpho
Service Access – Mental Health
We work in partnership to ensure that services are relevant to key stakeholders (e.g. policy makers, practitioners, academics, media) to help improve mental wellbeing, producing and sharing information on mental health, in addition to producing high quality technical advice on using information relating to mental health.
Mental Health Workstreams
Child and Adolescent Mental Health Access Target
The above link directs you to the Child and Adolescent Mental Health home page where you can access the latest publication of the Child and Mental Health Services Waiting Times in Scotland report.
Dementia Post-diagnostic Support
In 2010’s ‘Scotland’s National Dementia Strategy’, the Scottish Government made a commitment to improving post-diagnostic support for individuals receiving a diagnosis of dementia. The Scottish Government endorsed a 12 month post-diagnosis support model that used The Five Pillars methodology developed by Alzheimer Scotland, and concluded with a person-centred support plan. The Scottish Government published their third national dementia strategy in 2017 which continues to support the post-diagnostic support entitlement.
The link above will direct you to further information on Dementia Post-diagnostic Support.
Mental Health Benchmarking Project
The principle objective of the Mental Health Benchmarking project is to improve Mental Health Services by using benchmarking to understand and compare services and their outcomes and to promote best practice.
Psychological Therapies Mental Health Access Target
The Scottish Government has set a target for the NHS in Scotland to deliver a 18 week wait from referral to treatment for Psychological therapies from December 2014.
Psychology Workforce Planning Project and the Child and Adolescent Mental Health Services Workforce Project
National workforce statistics relating to NHS Scotland Psychology and CAMHS workforce are published quarterly and can be viewed on the above links.
Scottish Suicide Information Database (ScotSID)
By linking data on deaths from ‘probable suicide’ with health service and other records, a fuller picture can be obtained of the lives of people who have died by suicide and their contact with services before death. This will help identify factors which may increase or decrease the likelihood of suicide, and assist in suicide prevention.
Psychiatric Inpatient Activity – September 2018
Service Access – System Watch
The aim of System Watch is to monitor and predict the emergency activity in hospitals, and to provide supporting information gathered from sources across the NHS to help users to plan how best to meet those demands.
NHS Scotland is subject to seasonal variation in public demand for medical services and demand increases particularly during the winter period.
System Watch Suite of Dashboards
System Watch Dashboards
As well as providing information on the predicted number of emergency admissions by board, hospital & specialty group up to 6 weeks ahead, users also have access to supporting information on activity up to the previous week by health board, from the Scottish Ambulance Service, NHS 24, Primary Care Out of Hours service, A&E services and Health Protection Scotland. This allows users to gain insight into the current picture across unscheduled care providers in their area, as well as across Scotland.
The System Watch suite of dashboards currently includes:
- Daily & weekly emergency admissions activity & predictions – updated weekly – Board, hospital & specialty group level
- Primary Care OOH contacts by day & hour – updated weekly with data up to the previous day (Board level)
- Scottish Ambulance Service incidents by day and hour - updated daily with data up to two days previous (Board level)
- NHS 24 calls by day and hour – updated daily with data up to the previous day (Board level)
- A&E attendances by day and hour – updated monthly (Board level)
- GP consultation rates for influenza-like-illness - updated weekly (Board level)
- NHS24 episodes of care for respiratory illnesses and diarrhoea & vomiting – updated weekly (Board level)
Development work also includes:
- Hospital admissions by specialty & HSCP up to the previous week
- Admissions & discharges information up to previous week
- Feasibility of emergency admissions predictions by HSCP
The System Watch tableau dashboards showing activity, trends and predictions is available, and colleagues in the NHS and in Health and Social Care Partnerships can apply for access to System Watch dashboard through the User Access System.
What You Can Do With System Watch
- Day to day management of bed resources: See how many emergency admissions there have been each day at a NHS Board / hospital and how many are predicted for each day in the near future.
- Capacity planning: View a full year of emergency and elective admission numbers at a NHS Board/hospital by Speciality Group including predictions for the next six weeks and expected seasonal levels for the next 12 weeks.
- Comparison with neighbouring boards: Compare the number of emergency admissions there have been in a month between boards.
- Workforce planning for Primary Care Out of Hours’ service: View the number of daily contacts at Primary Care Out of Hours Services along with the seasonal number for your NHS Board.
- Keep up to date with recent trends across emergency and urgent care services: View number of hourly and daily contacts with the Scottish Ambulance Service, NHS 24, A&E and Primary Care OOHs services along with the longer term trends for your NHS Board.
- Monitor Developing Trends in Syndromic Data: Compare HPS data on flu consultation rates over a number of years. Target periods of interest for closer examination and comparison. Compare developing trends between health boards. Compare trends in HPS flu consultation data with NHS24 respiratory calls.
- Set up an alert to notify you if threshold values are exceeded: Alerts can be set on any indicator (number of admissions, flu rates, A&E attendances) if a chosen value is exceeded.
- Create Personalised Data Views: Views specific to your needs can be created and saved for future reference. Alerts can be set on these views allowing maximum flexibility.
- Share Views: Facilitate discussion by emailing charts of interest.
A user guide provides a comprehensive introduction for navigating the System Watch Suite of Dashboards. Most information is at board level with emergency admissions and predictions at hospital level, but information relating to Primary Care Out of Hours Services may be of interest and there are plans to incorporate HSCP level information on admissions and the option to develop emergency admission predictions for HSCPs as well as hospitals is being explored, but this is still in the planning stage at the moment.
System Watch Dashboard User Guide
System Watch Leaflet
Service Access – Unscheduled Care
As individuals in Scotland make contact with Unscheduled Care Services, data about who they are, where they have come from, what is wrong with them and what happens to them are collected, mainly to inform their care. This provides a good picture of the potential unscheduled care journeys that an individual may travel through.
In order to gain more of an understanding of the interaction between unscheduled care services and the patient journey, ISD in conjunction with NHS 24 and the Scottish Ambulance Service (SAS) have developed the Unscheduled Care Data Mart (UCD).
Unscheduled Care Data Mart
The aim of the UCD is to provide information on patient outcomes following their unscheduled care journey as well as providing additional information to NHS24, Primary Care Out of Hours Services and the SAS on subsequent activity following contacts with their service.
The UCD also allows comparison of patient flows between different geographic areas and for providing evidence to help identify areas where there is potential for service improvement.
Data Included in UCD
The data contained in the UCD data mart includes information on:
- A&E attendances
- Acute Emergency Inpatients admissions
- NHS 24 calls
- Primary Care Out of Hours Services
- SAS incidents
For all the data sources contained in the UCD (except Primary Care Out of Hours), data is included from the 1st of January 2011 to the present period. Primary Care Out of Hours data is available from the 1st of April 2014. More detailed information on what data can be found in the UCD can be found in the following document: Unscheduled Care Data Mart Background Paper
NHS Board access to the Unscheduled Care Datamart
Since July 2014, authorised NHS Board colleagues can access the data mart to run reports that have been pre-built by ISD. Please note ISD are currently reviewing the content and format of these reports.
If you have any questions or would like more information, please contact firstname.lastname@example.org