NHS Digital Data Release Register - reformatted

NHS Norfolk And Waveney Ccg

🚩 NHS Norfolk And Waveney Ccg received multiple files from the same dataset, in the same month, both with optouts respected and with optouts ignored. NHS Norfolk And Waveney Ccg may not have compared the two datasets, but the identifiers are consistent between datasets for the same recipient, and NHS Digital does not know what their recipients actually do.

Project 1 — DARS-NIC-362208-G8K6D

Opt outs honoured: No - data flow is not identifiable, Yes - patient objections upheld (Mixture of confidential data flow(s) with support under section 251 NHS Act 2006 and non-confidential data flow(s))

Sensitive: Sensitive

When: 2020/04 — 2020/05.

Repeats: Frequent Adhoc Flow

Legal basis: Health and Social Care Act 2012 – s261(1) and s261(2)(b)(ii), National Health Service Act 2006 - s251 - 'Control of patient information'.

Categories: Anonymised - ICO code compliant, Identifiable

Datasets:

  • Acute-Local Provider Flows
  • Ambulance-Local Provider Flows
  • Children and Young People Health
  • Civil Registration - Births
  • Civil Registration - Deaths
  • Community Services Data Set
  • Community-Local Provider Flows
  • Demand for Service-Local Provider Flows
  • Diagnostic Imaging Dataset
  • Diagnostic Services-Local Provider Flows
  • Emergency Care-Local Provider Flows
  • Experience, Quality and Outcomes-Local Provider Flows
  • Improving Access to Psychological Therapies Data Set
  • Maternity Services Data Set
  • Mental Health and Learning Disabilities Data Set
  • Mental Health Minimum Data Set
  • Mental Health Services Data Set
  • Mental Health-Local Provider Flows
  • National Cancer Waiting Times Monitoring DataSet (CWT)
  • National Diabetes Audit
  • Other Not Elsewhere Classified (NEC)-Local Provider Flows
  • Patient Reported Outcome Measures
  • Population Data-Local Provider Flows
  • Primary Care Services-Local Provider Flows
  • Public Health and Screening Services-Local Provider Flows
  • SUS for Commissioners

Objectives:

INVOICE VALIDATION Invoice validation is part of a process by which providers of care or services get paid for the work they do. Invoices are submitted to the Clinical Commissioning Group (CCG) so the CCG is are able to ensure that the activity claimed for each patient is their responsibility. This is done by processing and analysing Secondary User Services (SUS+) data, which is received into a secure Controlled Environment for Finance (CEfF). The SUS+ data is identifiable at the level of NHS number. The NHS number is only used to confirm the accuracy of backing-data sets (data from providers) and will not be used further. The CCG are advised by the appointed CEfF whether payment for invoices can be made or not. Invoice Validation will be conducted by Arden and Greater East Midlands Commissioning Support Unit RISK STRATIFICATION Risk stratification is a tool for identifying and predicting which patients are at high risk (of health deterioration and using multiple services) or are likely to be at high risk and prioritising the management of their care in order to prevent worse outcomes. To conduct risk stratification Secondary User Services (SUS+) data, identifiable at the level of NHS number is linked with Primary Care data (from GPs) and an algorithm is applied to produce risk scores. Risk Stratification provides focus for future demands by enabling commissioners to prepare plans for both individual and groups of vulnerable patients.  Commissioners can then prepare plans for patients who may require high levels of care. Risk Stratification also enables General Practitioners (GPs) to better target intervention in Primary Care. Risk Stratification will be conducted by Prescribing Services Ltd COMMISSIONING To use pseudonymised data to provide intelligence to support the commissioning of health services. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the CCG area. The CCGs commission services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers. The following pseudonymised datasets are required to provide intelligence to support commissioning of health services: - Secondary Uses Service (SUS+) - Local Provider Flows o Acute o Ambulance o Community o Demand for Service o Diagnostic Service o Emergency Care o Experience, Quality and Outcomes o Mental Health o Other Not Elsewhere Classified o Population Data o Primary Care Services o Public Health Screening - Mental Health Minimum Data Set (MHMDS) - Mental Health Learning Disability Data Set (MHLDDS) - Mental Health Services Data Set (MHSDS) - Maternity Services Data Set (MSDS) - Improving Access to Psychological Therapy (IAPT) - Child and Young People Health Service (CYPHS) - Community Services Data Set (CSDS) - Diagnostic Imaging Data Set (DIDS) - National Cancer Waiting Times Monitoring Data Set (CWT) - Civil Registries Data (CRD) (Births) - Civil Registries Data (CRD) (Deaths) - National Diabetes Audit (NDA) - Patient Reported Outcome Measures (PROMs) The pseudonymised data is required to for the following purposes:  Population health management: • Understanding the interdependency of care services • Targeting care more effectively • Using value as the redesign principle  Data Quality and Validation – allowing data quality checks on the submitted data  Thoroughly investigating the needs of the population, to ensure the right services are available for individuals when and where they need them  Understanding cohorts of residents who are at risk of becoming users of some of the more expensive services, to better understand and manage those needs  Monitoring population health and care interactions to understand where people may slip through the net, or where the provision of care may be being duplicated  Modelling activity across all data sets to understand how services interact with each other, and to understand how changes in one service may affect flows through another  Service redesign  Health Needs Assessment – identification of underlying disease prevalence within the local population  Patient stratification and predictive modelling - to highlight patients at risk of requiring hospital admission and other avoidable factors such as risk of falls, computed using algorithms executed against linked de-identified data, and identification of future service delivery models The CCGs wish to include pseudonymised primary care data in the population health management and patient stratification analyses to enable more comprehensive and patient/pathway focussed analyses (using the ‘pseudo at source model’). The pseudonymised data is required to ensure that analysis of health care provision can be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets. Processing for commissioning, including the pseudo at source processing for patient stratification and population health management, will be conducted by NHS Arden and GEM Commissioning Support Unit

Expected Benefits:

INVOICE VALIDATION The invoice validation process supports the ongoing delivery of patient care across the NHS and the CCG region by: 1. Ensuring that activity is fully financially validated. 2. Ensuring that service providers are accurately paid for the patients treatment. 3. Enabling services to be planned, commissioned, managed, and subjected to financial control. 4. Enabling commissioners to confirm that they are paying appropriately for treatment of patients for whom they are responsible. 5. Fulfilling commissioners duties to fiscal probity and scrutiny. 6. Ensuring full financial accountability for relevant organisations. 7. Ensuring robust commissioning and performance management. 8. Ensuring commissioning objectives do not compromise patient confidentiality. 9. Ensuring the avoidance of misappropriation of public funds. RISK STRATIFICATION Risk stratification promotes improved case management in primary care and will lead to the following benefits being realised: 1. Improved planning by better understanding patient flows through the healthcare system, thus allowing commissioners to design appropriate pathways to improve patient flow and allowing commissioners to identify priorities and identify plans to address these. 2. Improved quality of services through reduced emergency readmissions, especially avoidable emergency admissions. This is achieved through mapping of frequent users of emergency services thus allowing early intervention. 3. Improved access to services by identifying which services may be in demand but have poor access, and from this identify areas where improvement is required. 4. Supports the commissioner to meets its requirement to reduce premature mortality in line with the CCG Outcome Framework by allowing for more targeted intervention in primary care. 5. Better understanding of local population characteristics through analysis of their health and healthcare outcomes All of the above lead to improved patient experience through more effective commissioning of services. COMMISSIONING 1. Supporting Quality Innovation Productivity and Prevention (QIPP) to review demand management, integrated care and pathways. a. Analysis to support full business cases. b. Develop business models. c. Monitor In year projects. 2. Supporting Joint Strategic Needs Assessment (JSNA) for specific disease types. 3. Health economic modelling using: a. Analysis on provider performance against 18 weeks wait targets. b. Learning from and predicting likely patient pathways for certain conditions, in order to influence early interventions and other treatments for patients. c. Analysis of outcome measures for differential treatments, accounting for the full patient pathway. d. Analysis to understand emergency care and linking A&E and Emergency Urgent Care Flows (EUCC). 4. Commissioning cycle support for grouping and re-costing previous activity. 5. Enables monitoring of: a. CCG outcome indicators. b. Financial and Non-financial validation of activity. c. Successful delivery of integrated care within the CCG. d. Checking frequent or multiple attendances to improve early intervention and avoid admissions. e. Case management. f. Care service planning. g. Commissioning and performance management. h. List size verification by GP practices. i. Understanding the care of patients in nursing homes. 6. Feedback to NHS service providers on data quality at an aggregate and individual record level – only on data initially provided by the service providers. 7. Improved planning by better understanding patient flows through the healthcare system, thus allowing commissioners to design appropriate pathways to improve patient flow and allowing commissioners to identify priorities and identify plans to address these. 8. Improved quality of services through reduced emergency readmissions, especially avoidable emergency admissions. This is achieved through mapping of frequent users of emergency services and early intervention of appropriate care. 9. Improved access to services by identifying which services may be in demand but have poor access, and from this identify areas where improvement is required. 10. Potentially reduced premature mortality by more targeted intervention in primary care, which supports the commissioner to meets its requirement to reduce premature mortality in line with the CCG Outcome Framework. 11. Better understanding of the health of and the variations in health outcomes within the population to help understand local population characteristics. 12. Better understanding of contract requirements, contract execution, and required services for management of existing contracts, and to assist with identification and planning of future contracts 13. Insights into patient outcomes, and identification of the possible efficacy of outcomes-based contracting opportunities. 14. Providing greater understanding of the underlying courses and look to commission improved supportive networks, this would be ongoing work which would be continually assessed. 15. Insight to understand the numerous factors that play a role in the outcome for both datasets. The linkage will allow the reporting both prior to, during and after the activity, to provide greater assurance on predictive outcomes and delivery of best practice. 16. Provision of indicators of health problems, and patterns of risk within the commissioning region. 17. Support of benchmarking for evaluating progress in future years.

Outputs:

INVOICE VALIDATION 1. The Controlled Environment for Finance (CEfF) will enable the CCG to challenge invoices and raise discrepancies and disputes. 2. Outputs from the CEfF will enable accurate production of budget reports, which will: a. Assist in addressing poor quality data issues b. Assist in business intelligence 3. Validation of invoices for non-contracted events where a service delivered to a patient by a provider that does not have a written contract with the patient’s responsible commissioner, but does have a written contract with another NHS commissioner/s. 4. Budget control of the CCG. RISK STRATIFICATION 1. As part of the risk stratification processing activity detailed above, GPs have access to the risk stratification tool which highlights patients for whom the GP is responsible and have been classed as at risk. The only identifier available to GPs is the NHS numbers of their own patients. Any further identification of the patients will be completed by the GP on their own systems. 2. GP Practices will be able to view the risk scores for individual patients with the ability to display the underlying SUS+ data for the individual patients when it is required for direct care purposes by someone who has a legitimate relationship with the patient. CCGs will be able to: 3. Target specific vulnerable patient groups and enable clinicians with the duty of care for the patient to offer appropriate interventions. 4. Reduce hospital readmissions and targeting clinical interventions to high risk patients. 5. Identify patients at risk of deterioration and providing effective care. 6. Reduce in the difference in the quality of care between those with the best and worst outcomes. 7. Re-design care to reduce admissions. 8. Set up capitated budgets – budgets based on care provided to the specific population. 9. Identify health determinants of risk of admission to hospital, or other adverse care outcomes. 10. Monitor vulnerable groups of patients including but not limited to frailty, COPD, Diabetes, elderly. 11. Health needs assessments – identifying numbers of patients with specific health conditions or combination of conditions. 12. Classify vulnerable groups based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost. 13. Production of Theographs – a visual timeline of a patients encounters with hospital providers. 14. Analyse based on specific diseases In addition: • The risk stratification tool will provide aggregate reporting of number and percentage of population found to be at risk. • Record level output (pseudonymised) will be available for commissioners (of the CCG), pseudonymised at patient level. Onward sharing of this data is not permitted. COMMISSIONING 1. Commissioner reporting: a. Summary by provider view - plan & actuals year to date (YTD). b. Summary by Patient Outcome Data (POD) view - plan & actuals YTD. c. Summary by provider view - activity & finance variance by POD. d. Planned care by provider view - activity & finance plan & actuals YTD. e. Planned care by POD view - activity plan & actuals YTD. f. Provider reporting. g. Statutory returns. h. Statutory returns - monthly activity return. i. Statutory returns - quarterly activity return. j. Delayed discharges. k. Quality & performance referral to treatment reporting. 2. Readmissions analysis. 3. Production of aggregate reports for CCG Business Intelligence. 4. Production of project / programme level dashboards. 5. Monitoring of acute / community / mental health quality matrix. 6. Clinical coding reviews / audits. 7. Budget reporting down to individual GP Practice level. 8. GP Practice level dashboard reports. 9. Comparators of CCG performance with similar CCGs as set out by a specific range of care quality and performance measures detailed activity and cost reports 10. Data Quality and Validation measures allowing data quality checks on the submitted data 11. Contract Management and Modelling 12. Patient Stratification, such as: o Patients at highest risk of admission o High cost activity uses (top 15%) o Frail and elderly o Patients that are currently in hospital o Patients with most referrals to secondary care o Patients with most emergency activity o Patients with most expensive prescriptions o Patients recently moving from one care setting to another i. Discharged from hospital ii. Discharged from community 13. Validation for payment approval, ability to validate that claims are not being made after an individual has died, like Oxygen services. 14. Validation of programs implemented to improve patient pathway e.g. High users unable to validate if the process to help patients find the best support are working or did the patient die. 15. Clinical - understand reasons why patients are dying, what additional support services can be put in to support. 16. Understanding where patient are dying e.g. are patients dying at hospitals due to hospices closing due to Local authorities withdrawing support, or is there a problem at a particular trust. 17. Removal of patients from Risk Stratification reports. 18. Re births provide a one stop shop of information, Births are recorded in multiple sources covering hospital and home births, a chance to overlook activity.

Processing:

PROCESSING CONDITIONS: Data must only be used for the purposes stipulated within this Data Sharing Agreement. Any additional disclosure / publication will require further approval from NHS Digital. Data Processors must only act upon specific instructions from the Data Controller. Data can only be stored at the addresses listed under storage addresses. All access to data is managed under Role-Based Access Controls. Users can only access data authorised by their role and the tasks that they are required to undertake. Patient level data will not be linked other than as specifically detailed within this Data Sharing Agreement. Data released will only be shared with those parties listed and will only be used for the purposes laid out in the application/agreement. NHS Digital reminds all organisations party to this agreement of the need to comply with the Data Sharing Framework Contract requirements, including those regarding the use (and purposes of that use) by “Personnel” (as defined within the Data Sharing Framework Contract ie: employees, agents and contractors of the Data Recipient who may have access to that data) The DSCRO (part of NHS Digital) will apply National Opt-outs before any identifiable data leaves the DSCRO only for the purpose of Risk Stratification. CCGs should work with general practices within their CCG to help them fulfil data controller responsibilities regarding flow of identifiable data into risk stratification tools. The only identifier available in the data set is the NHS numbers. Any further identification of the patients will only be completed by the patient’s clinician on their own systems for the purpose of direct care with a legitimate relationship. ONWARD SHARING: Patient level data will not be shared outside of the CCG unless it is for the purpose of Direct Care, where it may be shared only with those health professionals who have a legitimate relationship with the patient and a legitimate reason to access the data. Aggregated reports only with small number suppression can be shared externally as set out within NHS Digital guidance applicable to each data set. SEGREGATION: Where the Data Processor and/or the Data Controller hold both identifiable and pseudonymised data, the data will be held separately so data cannot be linked. Where the Data Processor and/or the Data Controller hold identifiable data with opt outs applied and identifiable data with opt outs not applied, the data will be held separately so data cannot be linked. All access to data is auditable by NHS Digital. Data for the purpose of Invoice Validation is kept within the CEfF, and only used by staff properly trained and authorised for the activity. Only CefF staff are able to access data in the CefF and only CefF staff operate the invoice validation process within the CefF. Data flows directly in to the CefF from the DSCRO and from the providers – it does not flow through any other processors. DATA MINIMISATION: Data Minimisation in relation to the data sets listed within the application are listed below. This also includes the purpose on which they would be applied - For the purpose of Commissioning: •Patients who are normally registered and/or resident within the NHS Norfolk and Waveney CCG region (including historical activity where the patient was previously registered or resident in another commissioner). and/or •Patients treated by a provider where NHS Norfolk and Waveney CCG is the host/co-ordinating commissioner and/or has the primary responsibility for the provider services in the local health economy – this is only for commissioning and relates to both national and local flows. and/or •Activity identified by the provider and recorded as such within national systems (such as SUS+) as for the attention of NHS Norfolk and Waveney CCG - this is only for commissioning and relates to both national and local flows. For the purpose of Risk Stratification: •Patients who are normally registered and/or resident within the NHS Norfolk and Waveney CCG region (including historical activity where the patient was previously registered or resident in another commissioner For the purpose of Invoice Validation: •Patients who are resident and/or registered within the CCG region. In addition to the dissemination of Cancer Waiting Times Data via the DSCRO, the CCG is able to access reports held within the CWT system in NHS Digital directly. Access within the CCG is limited to those with a need to process the data for the purposes described in this agreement. A CCG user will be able to access the provider extracts from the portal for any provider where at least 1 patient for whom they are the registered CCG for that individuals GP practice appears in that setting Although a CCG user may have access to pseudonymised patient information not related to that CCG, users should only process and analyse data for which they have a legitimate relationship (as described within Data Minimisation). NHS Midlands and Lancashire Commissioning Support Unit (Hosted by NHS Oldham CCG) supply IT infrastructure and are therefore listed as a data processor. They supply support to the system, but do not access data. Therefore, any access to the data held under this agreement would be considered a breach of the agreement. This includes granting of access to the database[s] containing the data. Ilkeston Community Hospital, The Bunker Secure Hosting Ltd, and Wrightington, Wigan and Leigh NHS Foundation Trust do not access data held under this agreement as they only supply the building. Therefore, any access to the data held under this agreement would be considered a breach of the agreement. This includes granting of access to the database[s] containing the data. INVOICE VALIDATION (CEfF in CSU or 3rd Party) 1. Identifiable SUS+ Data is obtained from the SUS+ Repository to the Data Services for Commissioners Regional Office (DSCRO). 2. The DSCRO pushes a one-way data flow of SUS+ data into the Controlled Environment for Finance (CEfF) in the NHS Arden and Greater East Midlands Commissioning Support Unit. 3. The CEfF also receive backing data from the provider. 4. NHS Arden and Greater East Midlands Commissioning Support Unit carry out the following processing activities within the CEfF for invoice validation purposes: a. Validating that the Clinical Commissioning Group are responsible for payment for the care of the individual by using SUS+ and/or provider backing flow data. b. Once the provider backing information is received, this will be checked against national NHS and local commissioning policies as well as being checked against system access and reports provided by NHS Digital to confirm the payments are: i. In line with Payment by Results tariffs ii. are in relation to a patient registered with a CCG GP or resident within the CCG area. iii. The health care provided should be paid by the CCG in line with CCG guidance.  5. The CCG are notified that the invoice has been validated and can be paid. Any discrepancies or non-validated invoices are investigated and resolved between NHS Arden and Greater East Midlands Commissioning Support Unit CEfF team and the provider, meaning that no identifiable data needs to be sent to the CCG. The CCG only receives notification to pay and management reporting detailing the total quantum of invoices received pending, processed etc. RISK STRATIFICATION (Risk Stratification tool in CSU or 3rd Party) 1. Identifiable SUS+ data is obtained from the SUS Repository to the Data Services for Commissioners Regional Office (DSCRO). 2. Data quality management and standardisation of data is completed by the DSCRO and the data identifiable at the level of NHS number is transferred securely to Prescribing Services Ltd, who securely hold the SUS+ data. 3. Identifiable GP Data is securely sent from the GP system to Prescribing Services Ltd. 4. SUS+ data is linked to GP data in the risk stratification tool by the data processor. 5. As part of the risk stratification processing activity, GPs have access to the risk stratification tool within the data processor, which highlights patients with whom the GP has a legitimate relationship and have been classed as at risk. The only identifier available to GPs is the NHS numbers of their own patients. Any further identification of the patients will be completed by the GP on their own systems. 6. Once Prescribing Services Ltd has completed the processing, the CCG can access the online system via a secure connection to access the data pseudonymised at patient level COMMISSIONING The Data Services for Commissioners Regional Office (DSCRO) obtains the following data sets: - Secondary Uses Service (SUS+) - Local Provider Flows o Acute o Ambulance o Community o Demand for Service o Diagnostic Service o Emergency Care o Experience, Quality and Outcomes o Mental Health o Other Not Elsewhere Classified o Population Data o Primary Care Services o Public Health Screening - Mental Health Minimum Data Set (MHMDS) - Mental Health Learning Disability Data Set (MHLDDS) - Mental Health Services Data Set (MHSDS) - Maternity Services Data Set (MSDS) - Improving Access to Psychological Therapy (IAPT) - Child and Young People Health Service (CYPHS) - Community Services Data Set (CSDS) - Diagnostic Imaging Data Set (DIDS) - National Cancer Waiting Times Monitoring Data Set (CWT) - Civil Registries Data (CRD) (Births) - Civil Registries Data (CRD) (Deaths) - National Diabetes Audit (NDA) - Patient Reported Outcome Measures (PROMs) Data quality management and pseudonymisation is completed within the DSCRO and is then disseminated as follows: Data Processor 1 – NHS Arden and GEM Commissioning Support Unit 1. Pseudonymised SUS+, Local Provider data, Mental Health data (MHSDS, MHMDS, MHLDDS), Maternity data (MSDS), Improving Access to Psychological Therapies data (IAPT), Child and Young People’s Health data (CYPHS), Community Services Data Set (CSDS). Diagnostic Imaging data (DIDS), National Cancer Waiting Times Monitoring Data Set (CWT), Civil Registration Birth and Death Data (CRD), National Diabetes Audit (NDA) and Patient Reported Outcome Measures (PROMS) only is securely transferred from the DSCRO to Arden and GEM Commissioning Support Unit once points 2 to 6 are completed. 2. NHS Arden and Greater East Midlands Commissioning Support Unit also receive GP data. It is received as follows: a. Identifiable GP data is submitted to NHS Arden and Greater East Midlands Commissioning Support Unit. b. The data lands in a ring-fenced area for GP data only. c. A specific named individual within NHS Arden and Greater East Midlands Commissioning Support Unit acts on behalf of the GP practice. This person has access to a closed black box type system (which includes a pseudonymisation process). d. The individual requests a pseudonymisation key from the DSCRO to use with the black box system. There will be a separate key specific to the pseudonymisation request and the key will only be used for that specific project. The key is specific to the pseudonymisation request. The access controls around the individual’s role does not give them access to the data once it has been passed on to the NHS Arden and Greater East Midlands Commissioning Support Unit. e. The GP data is then pseudonymised using the black box and DSCRO issued key. The identifiable GP data is then deleted from the ring-fenced area. f. The data moves to point 3. 3. Pseudonymised GP data is held. NHS Arden and Greater East Midlands Commissioning Support Unit make a request to NHS Digital (DSCRO). 4. The DSCRO send a mapping table to NHS Arden and Greater East Midlands Commissioning Support Unit. 5. NHS Arden and Greater East Midlands Commissioning Support Unit overwrite the organisations specific pseudonymisation keys with the DSCRO provided keys. 6. The mapping table is then deleted. 7. NHS Arden and Greater East Midlands Commissioning Support Unit receive the data listed within point 1. 8. Data listed within point 1 is then linked to the pseudonymised GP data and analysis is provided to: a. See patient journeys for pathways or service design, re-design and de-commissioning. b. Check recorded activity against contracts or invoices and facilitate discussions with providers. c. Undertake population health management d. Undertake data quality and validation checks e. Thoroughly investigate the needs of the population f. Understand cohorts of residents who are at risk g. Conduct Health Needs Assessments 9. NHS Arden and Greater East Midlands Commissioning Support Unit then pass the processed, pseudonymised and linked data to the CCG. 10. Aggregation of required data for CCG management use will be completed by NHS Arden and Greater East Midlands Commissioning Support Unit or the CCG as instructed by the CCG. 11. Patient level data will not be shared outside of the CCG and will only be shared within the CCG on a need to know basis, as per the purposes stipulated within the Data Sharing Agreement. External aggregated reports only with small number suppression can be shared as set out within NHS Digital guidance applicable to each data set. 12. GP Practices may only re-identify data when they need to do so for direct care purposes. Any combination of pseudonymised data set released by NHS Digital under this agreement may be linked to GP and/or Social Care data only where the GP and/or Social Care data has been consistently pseudonymised by an NHS Digital approved method.