FGM Data Collection NHS Digital CAP

FGM Data Collection - NHS Digital Document name: FGM Data Collection NHS Digital CAP Project / Programme: FGM Enhanced Data set NHS Digital / Data upload Project Managers: NWLCCGS: Sonia Spiteri Sharon Twydell: 020 3350 4050 NHS Digital: Sam Sibeko Barbara Stearn: 0300 303 5678 Version: 1.0 Version issue date: 19/07/2017 Authors: Sonia Spiteri, Dr. Tamsin Robinson, Furiha Chaudry, Barbara Stearn NWLCCGs SystmOne FGM Clinical Template Design: Sharon Twydell, Dr. Richard Baxter, Dr. Tamsin Robinson Owner: Primary Care Systems Team NWLCCGs Status: Approved by NWLCCGs CAB (Clinical Approval Board) Primary Care Systems Team Supporting Clinical Systems across North West London CCGs Primary Care Systems Team Ferguson House 15 Marylebone Road LONDON NW1 5JD Pa Page 1 of 16 e 1 of 16

Contents 1. Introduction... 3 2. Aims & Objectives... 3 3. Key Principles for Collecting FGM Enhanced Dataset... 3 4. There are four stages to this process:... 4 5. Stage 1 FGM Clinical Template... 5 6. Stage 2 NHS Digital CAP Registration... 6 7. Stage 3 FGM SystmOne Reporting (Pages 7-10)... 7 8. Stage 4 Upload SystmOne Reporting data to NHS Digital CAP (Pages 11-13)... 11 9. Appendix 1... 14 10. Links for NHS Digital FGM data upload:... 14 11. Useful Reading:... 14 12. Appendix 2... 15 13. FAQ s... 15 14. Help and Support (NHS Digital FGM team)... 15 15. Appendix 3 FGM Step to Step Guide to CAP Registration... 16 Page 2 of 16

FGM Data Collection - NHS Digital CAP Introduction Female Genital mutilation (FGM) has been recognised as a crime in the England since 1985 and when performed on a girl under the age of 18 is a form of child abuse. FGM can cause physical, mental and emotional harm. The FGM Enhanced Dataset collection aims to develop a greater understanding of the extent and issue of FGM in England to support appropriate health service commissioning and development. GPs are recognised to be in a strong position to identify potential FGM in their patients, and record FGM status using specific codes. Practices have been expected to submit data under the FGM Enhanced Dataset information standard since October 2015. It has been identified that GPs would benefit from additional support to submit data. This guidance booklet has been developed to support practice staff through the uploading process. Aims & Objectives The improvements and benefits resulting from the information standard are expected to be: a greater understanding of the extent and issue of FGM in England; evidence to justify why the range of FGM support and care services need to be commissioned; the production of reports to inform quality and compliance checks to identify when and where patients with FGM are identified and treated, and subsequently support service development NHS England and Trusts will be able to use the information to highlight areas needing further investigation, therefore supporting service development Key Principles for Collecting FGM Enhanced Dataset Outlined below is a reminder about the key principles for the collection of FGM information: Every clinician from within any clinical setting who encounters a woman or girl who confirms that they have FGM must record the FGM on the patients medical notes and submit the information to NHS Digital using the clinical audit platform where the FGM Enhanced dataset *1 collection is held. Under fair processing the woman/girl should be informed that this information is being submitted. It is NOT a requirement for every clinician to undertake an examination in order to fulfil the central return. A clinical examination should only be undertaken as part of a routine, usual or requested provision of care encounter, and if FGM is then identified, it must be recorded. When FGM is identified *2, all FGM information should be recorded if and when possible, with at least the mandatory items being recorded for each patient. The mandatory items are outlined below: Page 3 of 16

o o o NHS Number Forename & Surname Date of Birth o Postcode of usual address *3 o Care contact date o FGM Type If the risk of FGM occurring to a girl or woman is suspected or identified then existing local safeguarding protocols to protect the girl must be followed. There are four stages to this process: Stage Task Responsibility Frequency Page 1 FGM Clinical Template Clinician As required 5 2 NHS Digital CAP Registration Practice Manager and Caldicott Guardian Once 6 3 FGM SystmOne Reporting Practice to decide but usually the Practice Manager Monthly or Quarterly 7-10 4 Upload of Data to NHS Digital CAP Practice to decide but usually the Practice Manager Monthly or Quarterly 11-13 *1 Note 1: The full dataset available in Appendix 1 under Useful Reading. Point 8. *2 Note 2: FGM activity identified was initially a mandatory item, but this was changed to Required on the 1 st October 2015. *3 Note 3: The reason for the name and address of the patient is to verify that the NHS number provided for that patient is correct. CAP can validate an NHS number (i.e. the right format of the NHS number), but cannot verify that the NHS number entered is for the patient stated. Once an NHS number has been verified, all patient information is deleted, and no patient identifiable information is ever published Page 4 of 16

Stage 1 FGM Clinical Template 1. The FGM clinical template can be found in SystmOne here: Auto-Consultation>NWLCCGs Other Templates>Female Genital Mutilation (FGM) 2. The template consists of four sections or tabulations, as circled in red above. 3. Please fill out as much of the information asked for in the template as you can and use the family relationship section to link the patient to other family members. 4. Health professionals are reminded of their statutory duty to follow safeguarding procedures and Mandatory Reporting duties if they become aware of a child who may be at risk of or a victim of FGM. If the girl is under 18yrs of age a risk assessment and indictor should be placed on the summary care record See http://content.digital.nhs.uk/6678. Page 5 of 16

Stage 2 NHS Digital CAP Registration 1. To be able to submit data to the Clinical Audit Platform (CAP) your practice must Register with NHS Digital: a. Follow the steps on the FGM Enhanced Dataset CAP User Registration Form: http://content.digital.nhs.uk/media/22986/fgm-enhanced-dataset-cap-user- Registration- Form/doc/FGM_Enhanced_Dataset_CAP_User_Registration_Form_v1.7.doc FGM Enhanced Dataset CAP User Regi i. Create an NHS Digital CAP login: Follow Step 1 on page 1 of above document ii. Create an NHS Digital CAP Reporting login for FGM Enhanced Dataset: Follow Step 2 on page 1, 2 and 3 of above document iii. Your practice s Caldicott Guardian needs to: Follow Step 3 Part C on page 4 of above document iv. The registration form must be sent to:enquiries@nhsdigital.nhs.uk from the Caldicott Guardians NHS.net email address, when this is processed you will receive a confirmation email that access has been granted 2. The registration page: https://login.hscic.gov.uk/ will look like this: 3. Once you have successfully completed the registration process follow the crib sheet in Stage 3 FGM SystmOne Reporting (Pages 7-10) which will allow you to run the reports in SystmOne. a. Frequency suggestion for running reports: Monthly. i. Also see FAQs (Page 14). 4. Once you have successfully run the FGM report in SystmOne you are now ready to upload the data to the NHS Digital CAP. See Stage 4 Upload of SystmOne Reporting data to NHS Digital CAP (Pages 11-13). 5. Log into the NHS Digital platform https://clinicalaudit.hscic.gov.uk/fgm/ which will take you to the FGM CAP platform. Follow the set of instructions for uploading your data to the CAP. See Stage 4 Upload of SystmOne Reporting data to NHS Digital CAP (Pages 11-13). Page 6 of 16

Stage 3 FGM SystmOne Reporting (Pages 7-10) The purpose of this section is to guide you through the process of: 1. Running the FGM report from within SystmOne Page 7 of 16

1. Navigate your way to the FGM report: Reporting>Miscellaneous>FGM Report 2. The following reporting screen opens up: Page 8 of 16

3. Select the dates that you want to search between. Then click on the Run Report button: 4. Once you have clicked on Run Report, data will be returned if you have anything to display within the selected data range as below, although in this instance all of the patient identifiable data (PID) has been blanked out. See below screen shot. 5. If running the report returns nothing you can stop here, as you do not have any data to upload to the NHS Digital CAP 6. If however, the report returns some data then continue to point (7) A 7. As what you are about to export contains PID (Patient Identifiable Data) we strongly recommend that you create a new folder on your shared drive (and delete the items in the folder at the end of the process, including from your recycle bin if necessary) 8. Once this new folder has been created, click on the Export Files button. The following window Choose export directory will appear Page 9 of 16

9. Once this window appears, navigate to the new folder that you have just created on the Shared drive and click Select. 10. The following window will appear listing three Excel spread sheets that have been saved to your chosen location. 11. Click OK : 12. At this point you will now need to log into the NHS Digital CAP reporting website and follow the instructions in the following section. Step 4. Page 10 of 16

Stage 4 Upload SystmOne Reporting data to NHS Digital CAP (Pages 11-13) The purpose of this section is to guide you through the process of: 1. Uploading the report data from SystmOne to NHS Digital CAP Page 11 of 16

FGM Enhanced Dataset : SubmittingData via File Upload efore you start Submitting data to the FGM Enhanced Dataset using file upload is done via the Clinical Audit Platform (CAP); a secure, web based platform supported and hosted by NHS Digital. In order to submit data to the collection, you must first register by creating an NHS Digital Single Sign On (SSO) account and submitting the FGM User Registration Form. Please refer to the FGM website - http://content.digital.nhs.uk/fgm for further information. Step 3: Access File Submission Dashboard Click on File Submission Dashboard from either the top bar menu or the main menu on the FGM homepage. Step 1: og into your NHS Digital Account In order to access the Clinical Audit Platform and submit data, you must start by signing into the clinical audit platform https://clinicalaudit.hscic.gov.uk/ Enter your Username (your registered email address), your password and click Sign in. The email address used for Signing in must be the same as the one submitted on the User Registration Form. If these email addresses are not the same, you will not be able to access the Clinical Audit Platform. The File Submission Dashboard will be displayed. See Section 6 of the CAP Operational Guidance: Viewing File Submission Details for further information. The lower section of the dashboard is where your submission files can be uploaded. The upper section of the dashboard shows details of files which have recently been uploaded, including the Job ID, who uploaded it and when it was uploaded. Only uploaded files for your organisation will be displayed. Step 2: Access the FGM Enhanced Dataset Once you are signed in the following screen will be displayed click on FGM Enhanced Dataset under My Available Audits. The FGM Home page screen will be displayed as shown in step 3. Details on the success of the upload, including the number of records submitted and details of any errors or warnings can be found by clicking on View Job Details for each upload. Pa Page 12 of 16 e 12 of 16

Step 4: Uploading a File On the lower section of the File Submission Dashboard, click on the first Browse button. Then Choose File to Upload dialogue box will be displayed. Step 5: Processing Files Once you have selected your files and clicked on Upload, a pop up box will be displayed once the upload is complete. Click on Click here to view details on the success of the upload. Select the file you wish to upload, and click Open. The file path will now be displayed in the Filename field. It is recommended that the files are uploaded one at a time and must be in order (Patient, Attendance, FGM) to ensure all errors and warnings are addressed sequentially, however, it is possible to upload all files together by repeating the process described. Once you have selected all the files you wish to upload, click on the Upload button at the bottom of the screen. File Validation Please note that only valid files are able to be uploaded into CAP via the File Submission Dashboard. ALL files must be.csv files and must match the csv specification described in the dataset published on the FGM website - http://content.digital.nhs.uk/fgm. The header row for each file is optional. If one is used, then the name of the first column has to be preceded by the word HEADER_ Each file must be saved using the correct filename; Patient_abc.csv, Attendance_abc.csv and FGM_abc.csv (where abc can be anything to help identify the file locally, e.g. patient_july 2015.csv). Opening.csv files in Excel may lead to some data items being unintentially amended, e.g. the removal of leading zeros. Please refer to the FGM dataset published on the FGM website for further details. Step 6: Viewing File Submission Details The file submission details can be accessd immediately after the file has been uploaded (see Step 5) or via the File Submission Dashboard (see Step 3). Details of all submissions must be checked for errors and changes made where necessary. The file submission details show: Records successfully imported into CAP which had no errors with their data. Records successfully imported with warnings, meaning that the record has been submitted to CAP, but there were issues with some data items, e.g a non-required data item has been submitted or a data item has an invalid value. Records unsuccessfully imported into CAP, meaning that the record has not been submitted to CAP, possibly because a required data item is missing or has an invalid value. The data items must be corrected and uploaded again to ensure a successful submission. Details of the errors and warnings are displayed and should be selfexplanatory. Corrections to data can either be done by amending and reuploading the csv file, or be done manually within the patient record. Further Information For further information please visit the FGM website (http://content.digital.nhs.uk/fgm) or contact the NHS Digital Contact Centre on 0300 303 5678 or email enquiries@nhsdigital.nhs.uk (please enter FGM Collection in the subject field of your email). Page 13 of 16

Appendix 1 inks for NHS Digital FGM data upload: 1. NHS Digital FGM home page: https://clinicalaudit.hscic.gov.uk/fgm/ 2. Registering for NHS Digital CAP (Clinical Audit Platform): http://content.digital.nhs.uk/media/22986/fgm-enhanced-dataset-cap-user- Registration- Form/doc/FGM_Enhanced_Dataset_CAP_User_Registration_Form_v1.7.docx Useful Reading: 1. DH Guidance FGM: Mandatory reporting in healthcare https://www.gov.uk/government/publications/fgm-mandatory-reporting-in-healthcare 2. DH Guidance to assess the potential risk of FGM: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/418564/29 03800_DH_FGM_Accessible_v0.1.pdf 3. DH Guidance: Resources and guidance for healthcare staff https://www.gov.uk/government/collections/female-genital-mutilation-fgm-guidance-forhealthcare-staff 4. NHS Choices: http://www.nhs.uk/conditions/female-genital-mutilation/pages/introduction.aspx 5. NHS England: https://www.england.nhs.uk/ourwork/safeguarding/our-work/fgm/ 6. RCGP (Royal College of General Practitioners): http://www.rcgp.org.uk/policy/rcgp-policy-areas/female-genital-mutilation.aspx 7. RCN (Royal College of Nursing): https://www.rcn.org.uk/news-and-events/news/school-nurses-vital-to-tackling-fgm 8. FGM Enhanced Dataset http://content.digital.nhs.uk/media/24187/fgmenhanceddatasetv14/xls/fgm_en hanced_dataset_v1.4 Pa Page 14 of 16 e 14 of 16

Appendix 2 FAQ s Q1. Who is best placed to carry out the S1 reporting and upload the data to the CAP Clinician/PM/Nurse/all/joint responsibility between various? A1: The practice has to decide but in most practices it seems to be the Practice Manager that submits to CAP but obviously the clinicians would be typing into the template in the patient record. Q2. Can you confirm how often the reports should be run? Weekly/monthly/quarterly? A2. The data has to be submitted to NHS Digital quarterly but can be submitted monthly if they would prefer. Remember if they don t have any patients they don t have to do anything in CAP Q3. If our SystmOne report returns no data do I need to carry on any further? A3. No. If you have not entered any FGM data into your clinical system or have not seen any patients there will not be anything to upload. But we advise running the report regularly to check this. Q4. Where can the FGM clinical template be located in SystmOne? A4. Auto-Consultation>NWLCCGs Other Templates>Female Genital Mutilation (FGM) Help and Support (NHS Digital FGM team) Email: fgm@nhs.net Telephone number: 0300 303 5678 Page 15 of 16

Appendix 3 FGM Step to Step Guide to CAP Registration Organisation required to submit data DPN Access to CAP granted to designated user to submit patient data using their e-mail address and password As per local processes Organisation identifies a primary contact/lead and local data collection process Details on form reviewed and CG name validated by Contact Centre reviewing Organisation identifies designated staff to submit data to NHS Digital DP/IG Responsible person submits details to National Caldicott Guardian Register Designated staff complete a CAP registration form identifying email address to gain access to the clinical audit platform and form sent in from Practice Caldicott Guardian email to NHS Digital To assure NHS Digital that appropriate staff are submitting data as it is possible for them to see patient identifiable information through linked patient records (specific event). If named person is not on the NCG register they will need to complete a form and submit to exeter.helpdesk@nhs.net Any errors/breaches can be linked to user email. This part of IT security. Quarterly data submitted by designated organisation users either manually or upload by csv file generated by clinical information system into CAP Data recorded by user can be seen on screen as part of the record tree. Any other attendance data for that woman entered by other organisations can also be seen and edited but only deleted by the creator. Users can run reports in CAP to check their data submissions. Practices are not required to submit nil return. They only need to submit data if they have seen relevant patients in the reporting quarter KEY: Light blue user actions Dark Blue NHS Digital process Dark green - explanation Pa Page 16 of 16 e 16 of 16