Barking and Dagenham: Unplanned Admissions (falls)’
Direct care use case: linking Council adult social care with GP and hospital data
Introduction:
We are writing to inform the Group Practitioners (GPs) in London Borough of Barking and Dagenham (LBBD) area about a significant initiative in collaboration with the NEL ICB Data Service that involves the use of patient data for individuals at risk of falls in the London Borough of Barking and Dagenham aged 65 years and older.
Use Case – Purpose:
LBBD has observed a rising number of non-elective admissions associated with falls among individuals aged 65 and older. To address this, LBBD aims to reduce the risk of falls through increased awareness, collaboration across the ICB, and proactive management of the at-risk population.
LBBD is utilising its OneView analytics platform to predict residents at risk of falling. This model is used widely across many areas. LBBD will be the first to link this data with health data. By linking health data with social care data, LBBD can better assess risk factors and enable targeted outreach to at-risk residents. This information will be used by LBBD’s Adult Triage/Intake Team to contact individuals identified as at risk, providing proactive support and preventing crisis points.
How is the processing of information necessary to the work?
This initiative involves the sharing of pseudonymised patient data for the at risk cohort,), from LBBD with the NEL ICB Data Service, who will link it with the identified GP and secondary data from the Data Discovery System (DDS)
The key aspects of this collaboration include:
Data Sharing: LBBD will share a cohort of pseudonymised patient data with NEL ICB Data Service.
Data Linking: NEL ICB will link LBBD resident data with GP and Acute data in DDS, and the linked dataset will be shared with LBBD for the purpose of direct care. The data feeds will be updated regularly.
Outcome(s):
Proactive contact with at-risk residents can prevent falls, maintain independence, and reduce unplanned hospital admissions. The initiative aims to offer support through individual assessments, including falls prevention awareness, physiotherapy, medical reviews, vision checks, home adaptations, and community referrals. Fulfilling this use case will enable more targeted approaches to prevention, benefiting a larger number of individuals. By minimising hospital admissions, the initiative aims to alleviate the burden on secondary care, providing a cost benefit to the NHS and ensuring more efficient use of healthcare resources.
A patient leaflet will be provided to support this work.
We have been working with the NEL Integrated Care Service IG Team and your Data Protection Officers to establish a Data Protection Impact Assessment (DPIA) and Data Sharing Agreement to facilitate this export and invitation. These were recommended for approval by the NHS North East London (NEL ICB) Data Access Group and this decision was ratified by the NEL ICB) Information Governance Steering Group to provide you with reassurance.
Please could you take the following actions (once you receive the alert from the Data Controller Console) to confirm (as Controller(s)) that you are happy for the information about your patients to be shared with London Borough of Barking & Dagenham.
1. Log on to the Data Controller Console
2. Review and accept the: I
- Data Protection Impact Assessment (DPIA), and
- Data Sharing Agreement (DSA)
3. Update the Practice’s Privacy Notice to include this processing.
Please note that by accepting the DSA on the Data Controller Console, you are responsible for:
• putting in place effective procedures to manage data subject access requests (from your patients) about the processing; and
• managing your own data breach(es).
Please contact your relevant Data Protection Officer If you have any information governance concerns.
Should you wish to discuss further about the programme, please contact Jeni.mower@nhs.net
We look forward to welcoming you to the programme and thank you for your ongoing support.