2 x research projects: The funding pressures facing health care in England for the next 15-20 years, and how service transformation can lead to greater sustainability and Assessing patients with long-term, complex conditions

The Health Foundation is an independent charity working to improve health and the quality of health care in the United Kingdom. The original application from Health Foundation was requesting access to data for four research projects that aim to inform public discussions about the focus, design and effects of policies intended to improve the quality of health care in the United Kingdom or reduce costs. The projects will inform policy makers and the NHS about the variability in quality and costs of health care in England, and thus help to identify priority areas for improving health and social care. The original four projects are:

1) The funding pressures facing health care in England for the next 15-20 years, and how service transformation can lead to greater sustainability.

2) Phenotyping English Hospitals

3) Penalising readmission: success or failure

4) Analysis of factors associated with the performance of A&E departments in England

[Project 5) 'Assessing patients with long-term, complex conditions' added in the last amendment of this DSA]

The Health Foundation requires HES data to continue with ongoing project 1 (The funding pressures facing health care in England for the next 15-20 years, and how service transformation can lead to greater sustainability) and project 5 Assessing patients with long-term, complex conditions (added in the previous amendment).

No further processing is required for the purposes of project 2 (phenotyping English hospitals) or project 3 (penalising readmission: success or failure) and a number of scientific papers have been submitted for publication. For this reason, the Health Foundation require to retain the data for an additional year to allow enough time to peer review this work and ensure publication. Please note that project 4 (Analysis of factors associated with the performance of A&E departments in England) was closed in a previous amendment and a working paper has been produced.

The Health Foundation require HES data to complete the following ongoing projects and to allow peer review of the work produced so far.

The data series will be used for the remaining two projects:

1. The funding pressures facing health care in England for the next 15-20 years, and how service transformation can lead to greater sustainability

5. Assessing patients with long-term, complex conditions

PROJECT 1 analyses HES data within an economic model of the person level factors that determine use of hospital services to i) estimate of how spending pressures on these services will grow in the future, and ii) estimate the potential impact of policies to reduce these pressures.

PROJECT 5: As the population ages, more people are living with long-term, complex conditions. These conditions result in substantial burden for patients and their families and in high need for health care. The Health Foundation are considering three high-need patient personas:

• an older person with advancing illness

• a frail older person

• a person with major complex chronic conditions

The way these high-need patients are managed within the health system varies across countries. This international study will describe what kind of health care these patients use and the costs and quality of that care. Information from England will be compared with information from another 10 countries. Taking account of differences in the cost of living, the analysis will highlight countries which have particularly high or low total health care costs, or high or low costs in certain parts of the health system (e.g. costs arising from patients being admitted to hospital, or from medications they are prescribed). It will also highlight countries which have particularly high quality of care. This will help policymakers target aspects of health care that can be changed and that either make up a large burden of cost or make an important difference to the quality of care that these patients receive.

SUMMARY OF THE FOUR ORIGINAL PROJECTS TO DATE:

PROJECT 1. The funding pressures facing health care in England for the next 15-20 years, and how service transformation can lead to greater sustainability:

To create an economic model of the person level factors that determine use of hospital services to i) estimate of how spending pressures on these services will grow in the future, and ii) estimate the potential impact of policies to reduce these pressures.

Progress to date:

Until now, results of the projections model using the HES data have been referenced in several Health Foundation publications including NHS Finances briefing (1) Filling the Gap (2) and Funding in a Nutshell (3). This analysis has provided The Health Foundation with the opportunity to collaborate in 2018 with the Institute for Fiscal Studies (IFS) with the aim to produce a further piece of analysis to be published in time with the NHS’ 70th anniversary.

IFS staff have no access to data in their role is advising on methodology, to get the most benefit out of the processing as possible and on peer reviewing the preliminary findings and policy implications.

Finally, month and year of death is required to improve the accuracy of the current method for measuring mortality, which now only records death as a cause of discharge from hospital. Without the information from the mortality registry, the model is likely to underestimate the impact of mortality (and mortality of those who died in hospital) on use of NHS services.

Along with the impact of mortality on NHS funding pressures, The Health Foundation would also take account of many more variables including overall changes in population and changes in the rate of chronic conditions over time. People who had chronic conditions who then died at home will likely have been high-cost users in their last year of life. If the Health Foundation run the projections model without fully accounting for those patients who suffered from chronic conditions and died shortly after their visit to hospital, then the full impact of the chronic conditions and their mortality rates will not be captured.

The Health Foundation continue to undertake analyses, and after presenting and speaking to colleagues inside and outside of The Health Foundation, they are making amendments. Therefore, they would like to continue working on the data for this objective.

PROJECT 2. Phenotyping English Hospitals: ***Project now finished, no further processing required***

Variations in hospital performance and quality of care are substantial in the English NHS. This project aims to classify English hospitals based on their trends in length of stay and 30-day readmission rates for elderly and frail patients. The study follows the phenotyping approach used by Xu et al. (2014) and identifies elderly and frail patients based on a frailty index developed by Soong et al. (2016). Once phenotypes are identified, logistic regression analysis will test for hospital characteristics that might explain observed variations in quality between hospitals.

Progress to date:

The research team experienced some degree of delay in pursuing with the project due to difficulties in identifying and agreeing on an appropriate patient cohort. As this has now been sorted, the Health Foundation ran the final analysis soon when the final years of 2015/16 HES data was received. In February 2019 this work had been completed, and no processing will continue.

PROJECT 3. Penalising readmission: success or failure: ***Project now finished, no further processing required***

Readmission rates have been increasing over the past decades. Various policies have been implemented to revert this trend, including the introduction of financial penalties on hospitals for re-admissions from 2011. However, its effectiveness has never been evaluated. Thus, this project will assess changes in readmission rates following the policy implementation period.

Progress to date:

The Health Foundation used the most recent years of HES to understand pressures affecting changes in readmission rates (as factors related to workload, i.e., admission rates, occupancy rates and bed occupancy rates). This work has all been completed and three papers have been submitted for publication in scientific journals (see Specific Outputs Expected, Including Target Date section).

The Health Foundation have submitted a final journal article for publication. The Health Foundation have spoken to the journal and are confident that this will be published in summer 2019. It is unlikely that changes will be required, however, this cannot be guaranteed, so would like to continue to be able to work on this objective.

PROJECT 4. Analysis of factors associated with the performance of A&E departments in England: ***Project now finished, no further processing required***

A&E departments have been under pressure, and this could be because of changes in demand, supply, the resilience of departments, or wider contextual factors (e.g. health policy). The Health Foundation will use record level HES data to assess changes in the characteristics of patients attending A&E departments over time. The Health Foundation will also assess the relationships between A&E activity and the volume of patients admitted as inpatients.

The Health Foundation will use patients͛ clinical information to derive risk-adjusted variables at the Trust level, which will be used within a panel data model that relates these to variables relating to the supply and demand of health care.

Progress to date:

This project is now completed. Initial analysis identifying factors associated with A&E performance was presented to the NHS England analytical team in October 2015. A working paper on “Analysing the Demand for Accident and Emergency care with a benchmarking approach” has been produced as well.

The Health Foundation will not combine the requested HES data with any other data source that might result in increased re-identification risk.

This agreement is for a research, the lawful basis for processing data is GDPR article 6(1)(f): Processing is necessary for the purposes of the legitimate interests pursued by the controller or by a third party except where such interests are overridden by the interests or fundamental rights and freedoms of the data subject which require protection of personal data, in particular where the data subject is a child. As the research involves health data, which is included in the definition of special categories of personal data, it requires an additional condition for processing.

Processing personal data is necessary for The Health Foundation's legitimate interests. The data to which access is requested are proportionate and necessary to achieve those interests. The Health Foundation have completed a legitimate interests assessment (LIA) and NHS Digital are satisfied that the interests of the data subjects do not override the Heath Foundation's legitimate interests; that they would reasonably expect the processing and it would not cause unjustified harm. The data subjects interests and fundamental rights are protected through appropriate minimisation of fields and patient records being processed; pseudonymisation to minimise any risk of identifying individuals; protection of the data in a secure environment, and guaranteeing secure destruction at any stage at the request of NHS Digital or after a defined period on completion of the project.

Based on guidance, for health research this also includes GDPR article 9(2)(j), which details that processing is necessary for scientific and research purposes, subject to appropriate safeguards.

In case of both project 1 and 5, data will be processed by a limited number of analysts within the Health Foundation’s secure environment. All analysts with access to the data will be substantive employees of the Health Foundation.

All analysts accessing the data will have completed an accreditation course on data protection legislation and statistical disclosure control, completed an information security training specific to the Health Foundation’s infrastructure, and signed a non-disclosure agreement and the terms of use of the secure environment. All data will be analysed in line with the HES analysis guide.

HES Data will be analysed on the Health Foundation’s premises via a virtual server supplied by UKCloud Ltd and any publication derived from the data will be subjected to best practice guidelines on Statistical Disclosure Control (SDC) including the Code of Practice on Confidential Information, the Anonymisation Standard for Publishing Health and Social Care Data and the code of practice published by the ICO, Anonymisation: managing data protection risk code of practice before being released from the environment.

UKCloud Ltd do not access data held under this agreement as they only supply the physical storage. 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.

Only the required relevant data is used for each project noted in the agreement the Health Foundation will review whether they require all of the held data as each project comes to an end and if necessary carry out data destruction.

All data requested will be used exclusively for the purposes stated in this application.

The largest amount of data is being requested for the funding pressures facing health care in England for the next 15-20 years, looking at how service transformation can lead to greater sustainability͛ in terms of geography, time coverage and population base. Each of the dimensions is discussed below in the context of this project.

- 'Geographyʹ healthcare utilisation displays a lot of regional variation. In order to produce accurate projections England wide all geographical areas need to be covered in the research data.

- 'Time coverageʹ the aim of the project it to predict long term healthcare use (15-20 years). In order to accurately predict variation over time (including seasonal variation, business cycles and long term trends) rich historic data is required.

- 'Populationʹ the projects aims to cover hospital utilisation for all conditions. Whole population data gives good coverage (in terms of numbers) on rare conditions. It would be inequitable to narrow the research down to only certain population groups because these groups would then not be considered in important research to inform future budget decisions about the NHS.

Project specific processing of data is outlined below.

PROJECT 1: The funding pressures facing health care in England for the next 15-20 years, and how service transformation can lead to greater sustainability

For this project, the Health Foundation require person level data linked across for inpatient (Elective, non-elective and day case), outpatient and A&E. The critical care dataset will be used separately (rather than linked to the other data).

The project aims to project cost pressure over the next 15-20 years; therefore the Health Foundation needs to track historic trends over a similar period for the whole population. The Health Foundation will initially estimate the demand pressures for each service type separately, to allow for the differences in the time periods covered by the relevant data sets. The data required within this project are:

- Inpatients between 1997/98 and 2020/21

- Outpatients between 2003/04 and 2020/21

- A&E between 2007/08 and 2020/21

- Critical Care between 2008/09 and 2020/21

Since this involves modelling the evolution of health care utilisation for people with various specific health conditions in the different government office regions, it will need comprehensive data coverage for these time periods.

For each service type, the Health Foundation will explore how service use is affected by factors including age, sex, residence (LSOA), treatment provider (site and trust), commissioner, diagnosis and procedure codes, treatment function, admission method and time.

The Health Foundation will also explore how the level of use of one service affects demand for other services (excluding critical care). As this will require an overlapping time period, the Health Foundation can only explore these interactions for shorter periods. The Health Foundation are comfortable with this limitation as the information will be used to create scenarios for analysis on how policy decisions might impact on total cost projections in addition to the overall projections. The primary models will be independent service-specific linear, or log-linear person-level models of the trends in the level of activity for emergency inpatients, elective inpatients, outpatients, A&E and critical care. The results of the models will be used to create projections for future use of these services at a national level, and by government office regions (or other similar sized areas as appropriate). The Health Foundation will therefore apply the results of the analysis of historic trends to publicly available population projections produced by the ONS.

The Health Foundation will also measure how service use differs between people with various chronic conditions, namely diabetes, COPD, asthma, coronary heart disease, cancer, arthritis, dementia, epilepsy, renal disease and stroke. The Health Foundation will identify these groups using the diagnosis codes present within the inpatient dataset. Again, as The Health Foundation plan to project the numbers of patients in these groups, The Health Foundation will explore the trend over time for inpatient admissions between 1997/98 and 2015/16. These will be done using a linear regression, with transformations applied where appropriate to ensure the best fit for each condition. By producing trends in this way, The Health Foundation is able to explore the trends for certain co-morbidities, instead of using single condition prevalence projections. However, The Health Foundation will compare their estimates to national data on prevalence of these conditions where possible for assurance.

The projections for costs on these services will be combined with projections for other NHS services, such as GP attendances and community pharmacies, produced using publicly available data. The combining of data in this way will primarily be done at a national level, and will not be done at a level lower than government office region.

Having established the models and projections, The Health Foundation will use the results to test the impact of a series of assumptions around future changes in NHS delivery. This will take the form of modelling assumptions on how service delivery might change at a national level. For example, The Health Foundation will test the potential impact on total NHS spending of a substantial investment in GP practices, which might be expected to lead to a reduction in hospital admissions. More complex policies are likely to impact on multiple hospital services for certain types of people. In these cases, The Health Foundation will need to understand the relationship between the different hospital service types. For example, if a new community diabetes service is set up that includes additional outpatient appointments, but might reduce the need for inpatient care, The Health Foundation will produce summaries of the current levels of use for these services for people with diabetes, to understand the full impact of the change. Again, these results will only be published at a level no lower than government office regions.

The Health Foundation will also explore the impact of likely productivity growth on the projected growth. The Health Foundation will base this on evidence on recent and longer-term levels of productivity growth by running random effects, fixed effects and stochastic frontier analysis on weighted activity of different types of providers. As with other analysis, results will be used at a national or large regional level.

Fact of death will provide further value to the work produced for this project, as it will improve the accuracy of the projections model. The projections model currently uses the discharge destination code within HES to identify if a patient died in hospital, using this to create indicator variable for when a patient died in each financial year. However, as this method does not capture cases where a patient died at home after leaving hospital, The Health Foundation are missing approximately 55% of deaths in 2015/16. As many of these cases are likely to have had higher hospital use it is important to properly account for them in the model.

PROJECT 2: ***Project now finished, no further processing required*** Phenotyping English Hospitals

PROJECT : ***Project now finished, no further processing required*** Penalising readmission: success or failure

PROJECT 4: ***Project now finished, no further processing required*** Analysis of factors associated with the performance of A&E departments in England

PROJECT 5: Assessing patients with long-term, complex conditions.

To date, The Health Foundation have already undertaken this work using patient-level data from a linked CPRD-HES sample (in a separate data application approved CPRD), i.e. The Health Foundation have undertaken analysis of patient records from GP practices. However, the CPRD-HES linked sample is small; The Health Foundation would like to use HES data to replicate the results, to ensure they are robust, as HES provides a nationally representative sample. This is to help guarantee that they do not publish misleading results, and that the results that have been produced already using the CPRD-HES sample are statistically sound. As the data in this existing agreement would fit the above purpose ideally, the Health Foundation would like to amend this agreement to include this additional usage.

The objective of this processing activity is to replicate work the Health Foundation have already undertaken on a sample of GP records (CPRD) linked to HES (approved by CPRD). The Health Foundation do not need to link the HES data in order to do the comparison with earlier work. This is to look at patients with long-term complex conditions. However, they only used a small sample for this work, and would like to replicate the work using HES, as it is a nationally representative sample. The Health Foundation wish to do this work in order to check the robustness of the results that were produced using the linked CPRD-HES data.

This is an internationally facing project but no data will be shared internationally. The statistical results (outputs) generated using the English data (HES) will be compared with the statistical results generated in other countries.

They will be comparing their results from a small CPRD-HES sample that has already been obtained from MHRA , to the work they do with the HES data alone (which will be better nationally represented and larger). The HES data to be used for the new processing will not be linked with any other data. The Health Foundation do not need to link the data in order to do the comparison with earlier work. The Health Foundation will compare the statistical results obtained from the analyses of each data source and see what difference there is in the results.

There will be no data linkage undertaken with NHS Digital data provided under this agreement.

All organisations party to this agreement must 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 Health Foundation’s secure processing environment holds dedicated projects folders that will be used for projects using HES data, as specified in The Health Foundation’s information security policy. Users have access only to data that relates to their project, and the content of all project folders is reviewed regularly to make sure The Health Foundation deliver on this commitment. The process for moving additional data sources on to the secure environment is a carefully controlled process monitored by the Data Manager, part of this process is to review the purpose statement of each project and restrictions on the use of specific datasets.

As outlined above, outputs for the two remaining projects will be in line with best practice guidelines on statistical disclosure control and privacy protection.

The outputs for each project are as follows:

PROJECT 1. The funding pressures facing health care in England for the next 15-20 years, and how service transformation can lead to greater sustainability

**UPDATE JUL 2019: work is progressing to deliver the outputs stated below.

It is believed that the joint work with the Institute for Fiscal Studies would make a substantial contribution to understanding the challenges NHS faces over the next 15 years. A report has been published and was released in time for the NHS 70th anniversary in July 2018. This was based on the original primary output, a Health Foundation report similar to the report on Decade of Austerity, Nuffield Trust 2012.

The aim of the work will be to provide an update to the funding pressures that are expected by the NHS over the next 15-20 years. This report was made available through the Health Foundation's website in 2018 and was co-authored by analysts from the Health Foundation and Institute of Fiscal Studies.

In addition, The Health Foundation will be using HES admissions data to derive productivity estimates of Trusts over time since 2010/11. The work is expected to be completed by the end of the year, with the aim of publishing an academic journal paper in 2020.

The Health Foundation will also measure how service use differs between people with various chronic conditions, namely diabetes, COPD, asthma, coronary heart disease, cancer, arthritis, dementia, epilepsy, renal disease and stroke. The Health Foundation will identify these groups using the diagnosis codes present within the inpatient dataset. Again, as The Health Foundation plan to project the numbers of patients in these groups, The Health Foundation will explore the trend over time for inpatient admissions between 1997/98 and 2015/16. These will be done using a linear regression, with transformations applied where appropriate to ensure the best fit for each condition. By producing trends in this way, The Health Foundation is able to explore the trends for certain co-morbidities, instead of using single condition prevalence projections. However, The Health Foundation will compare their estimates to national data on prevalence of these conditions where possible for assurance.

Having established the models and projections, The Health Foundation will use the results to test the impact of a series of assumptions around future changes in NHS delivery. This will take the form of modelling assumptions on how service delivery might change at a national level. For example, The Health Foundation will test the potential impact on total NHS spending of a substantial investment in GP practices, which might be expected to lead to a reduction in hospital admissions. More complex policies are likely to impact on multiple hospital services for certain types of people. In these cases, The Health Foundation will need to understand the relationship between the different hospital service types. For example, if a new community diabetes service is set up that includes additional outpatient appointments, but might reduce the need for inpatient care, The Health Foundation will produce summaries of the current levels of use for these services for people with diabetes, to understand the full impact of the change. Again, these results will only be published at a level no lower than government office regions.

The Health Foundation will also explore the impact of likely productivity growth on the projected growth. The Health Foundation will base this on evidence on recent and longer-term levels of productivity growth by running random effects, fixed effects and stochastic frontier analysis on weighted activity of different types of providers. As with other analysis, results will be used at a national or large regional level.

PROJECT 2. ***Project now finished, no further processing required*** Phenotyping English Hospitals

The study was completed by the end of 2018 and ultimately published in peer-reviewed international journals. These were a mixture of health services research journals (e.g. Health Services Research and Policy) and economics journals (e.g. the Journal of Health Economics). These journals are read by policy makers, nationally and internationally, who wish to identify and classify hospitals according to the level of quality of care that they provide. The Health Foundation produced a full draft for a scientific article, which was published at the end of 2018.

The research will also be presented at conferences and events aimed at policy makers. The Health Foundation will present internally at The Health Foundation and to statutory bodies such as the Department of Health and Monitor. The Health Foundation will publish a summary of the research on the Health Foundation’s website.

PROJECT 3. ***Project now finished, no further processing required***Penalising readmission: success or failure

(final journal article with publisher, due to be published summer 2019)

The Health Foundation finished all major analyses for this project. In 2017, three research papers were produced, which are currently at different stages of the publication process:

- National trends in emergency readmission rates: A longitudinal analysis of administrative data for England between 2006 and 2016.

- The implications of high bed occupancy rates on readmission rates in England: A longitudinal study.

- Do financial penalties reduce readmission rates? A continuous treatment effect evaluation.

4. ***Project now finished, no further processing required*** Analysis of factors associated with the performance of A&E departments in England

The findings of this study have been disseminated through meetings with senior policy makers and NHS leaders, and a working paper has been produced on “analysing the demand for A&E care with a bench marking approach”.

PROJECT 5. Assessing patients with long-term, complex conditions.

The output from this objective will be to ensure that previous results undertaken are robust, using the nationally representative sample from HES (see 'Processing' for more detail). This will result in a Health Foundation report and journal article.

Each of the projects listed in the application will produce a number of publications. These publications typically take the form of:

- Reports aimed at policy makers, disseminated through the Foundation’ website

- Peer-reviewed journal articles

- Blogs on the Foundation’ website or others (e.g. Health Service Journal)

- Conferences and presentations

- Press releases

The Health Foundation’s approach to dissemination includes not only publications but also engagement with national policy makers, practitioners and researchers. Each project has member of the Foundation’s Communications team leading on dissemination of findings.

The Foundation works closely with key stakeholders and has strong link with NHS teams, national policymakers (e.g., NHS England) and patient advocacy groups. Examples of these links are:

- The Health Foundation is currently working on projects for, or jointly with, organisations including NHS England. For example, The Health Foundation have jointly funded an evaluation of the Patient Activation Measure in the NHS, and work together on the ͚5000 Safety Fellows Programme͛.

-People across the Health Foundation regularly engage with policy makers at all levels on a range of topics where The Health Foundation has particular expertise: policy, data analytics, economics, patient safety and person-centered care. The Health Foundation’s views are regularly sought on health policy and practice, meaning that the findings from these HES-based analyses will be communicated directly with policymakers.

-The Health Foundation has a long history of funding programmes across the NHS that help to improve the quality of health care. For example, The Health Foundation have funded work on the relationship between patient flow, costs and outcomes in two NHS hospital trusts, which is related to the new project on understanding the drivers of A&E attendances.

-The Health Foundation have an active audience of professionals working in the NHS, many of whom are fellows sponsored by the Health Foundation, award-holders or part of The Health Foundation’s alumni.

The Health Foundation has strong links with NHS teams, national policymakers (e.g., NHS England) and patient advocacy groups. Examples of these links are:

•Senior members of Health Foundation staff regularly meet with senior representatives from across government, including the Treasury, Department of Health and Arms-Length Bodies (e.g. Monitor, CQC, NHS England, HEE).

•The Health Foundation is currently working on projects for, or jointly with, organisations including NHS England. For example, we have jointly funded an evaluation of the Patient Activation Measure in the NHS, and work together on the ‘5000 Safety Fellows Programme’

•People across the Health Foundation regularly engage with policy makers at all levels on a range of topics where the Health Foundation has particular expertise: policy, data analytics, economics, patient safety and person-centred care. The Health Foundation views are regularly sought on health policy and practice, meaning that the findings from these HES-based analyses will be communicated directly with policymakers.

•The Health Foundation has a long history of funding programmes across the NHS which help to improve the quality of health care. For example, the Health Foundation have funded work on the relationship between patient flow, costs and outcomes in two NHS hospital trusts, which is related to the new project on understanding the drivers of A&E attendances.

•The Health Foundation have an active audience of professionals working in the NHS, many of whom are fellows sponsored by the Health Foundation, award-holders or part of the Health Foundation’s alumni.

The Health Foundation provides leadership and advice on quality improvement as well as commentary on health care policy. The Health Foundation’s analysis of HES data will inform these activities. The Health Foundation assess their impact using objective measures (e.g., number of publication downloads, publication citations and attendances at events and seminars) as well as record specific instances where their work has informed decision making for the NHS and improved the quality of care ultimately delivered to patients.

Due to these strong links with the health service, the Health Foundation is in a good position to reach as much beneficiaries as possible for each of the four projects.

Each project is expected to have the following impact:

PROJECT 1. The funding pressures facing health care in England for the next 15-20 years, and how service transformation can lead to greater sustainability

Following the analysis, The Health Foundation will discuss the results of the scenarios of different models of delivery to inform policy makers on the impact that different decisions would have. These will mostly be discussions of the national situation, with some regional analysis at a level similar to government office regions.

To maximise the benefit of the work on this project, it is important that information provided to the Department of Health and Monitor is based on the latest available data. Health Foundation will update the existing work on the basis of the latest available data, that is up to and including 2015/16, providing a comprehensive overview of NHS funding challenges and transformation programmes.

Progress to date:

The Health Foundation aim to publish a joint report with the Institute of Fiscal Studies by mid-2018. This report will use the findings of the costing model, which will be obtained by processing the HES data in the Health Foundation’s secure environment. This report was made available through the Health Foundation's website in 2018 and was co-authored by analysts from The Health Foundation and Institute of Fiscal Studies.

The aim of the work is to provide an easily accessible summary of the challenges faced by the NHS over the medium term for both the public and policy makers. This report will be an analytical summary of past trends and future projections, and a discussion about how future pressures could be addressed. It will make no recommendations for the NHS, but will list potential options for methods of raising additional funding with the aim to provide useful evidence to support the NHS and inform policy.

PROJECT 2. Phenotyping English Hospitals [COMPLETE]

The study was completed by the end of 2018 and ultimately published in peer-reviewed international journals. These were a mixture of health services research journals (e.g. Health Services Research and Policy) and economics journals (e.g. the Journal of Health Economics). These journals are read by policy makers, nationally and internationally, who wish to identify and classify hospitals according to the level of quality of care that they provide. The Health Foundation produced a full draft for a scientific article, which was published at the end of 2018.

This project will help to identify issues surrounding the quality of care of providers for elderly patients via mapping the relationship between length of stay and readmission rates. Identifying poorly performing providers will be of interest for the Care Quality Commission as it may inform the selection of trusts for inspection. On the other hand, identifying providers who perform well, offers the opportunity to conduct qualitative research to understand reasons for such good performance. Good performance processes can be collected and inform best-practice.

This work will also use the latest financial years of data requested (i.e. 2013/14-2015/16). Health Foundation believe this would add additional value and make our findings more relevant for policy. The demographics for England are rapidly changing towards an older and frailer population. Subsequently, demand for health services within this subset of the population is rising, putting increasing pressure on hospitals. The value of receiving more updated data is to allow the Health Foundation to investigate how healthcare providers responded to this change in demographics. Similar to the workload project, by using the most recent data, Health Foundation will be able to make a stronger contribution to the ongoing debate about care for the elderly and frail.

Experts from Nuffield Trust, Dr. Foster Unit and health Economics Research Unit at Imperial College have also been contacted to maximise policy relevance for this study.

PROJECT 3. Penalising readmission: success or failure [COMPLETE]

This project is now completed. In 2017, the following scientific papers have been produced and submitted for publication (SEE YIELDED BENEFITS):

1. National trends in emergency readmission rates: A longitudinal analysis of administrative data for England between 2006 and 2016

2. The implications of high bed occupancy rates on readmission rates in England: A longitudinal study

3. Do financial penalties reduce readmission rates? A continuous treatment effect evaluation.

The penalisation of readmissions has been in place since 2011/2012, yet, has rarely been studied. The Health Foundation’s study will inform policy makers about the likely effectiveness of the chosen financial tool and draw comparisons to the Affordable Care Act in the US. This will inform Monitor and other organisations involved with the policy debate about changes to the way that hospitals are reimbursed for emergency care in the NHS.

PROJECT 4. Analysis of factors associated with the performance of A&E departments in England [COMPLETE]

This project is now completed. Initial analysis identifying factors associated with A&E performance was presented to the NHS England analytical team in October 2015. Following the meeting with NHS England, a number of refinements were identified. The findings of this study have been disseminated through meetings with senior policy makers and NHS leaders, and a working paper has been produced on "analysing the demand for A&E care with a bench marking approach".

This project focuses on A&E attendances for the whole population of England, and will cover the time period 2007 present. In addition to A&E data, The Health Foundation has used inpatient and outpatient data at episode level to characterise patients in terms of their demographics, diagnoses, number of previous attendances, and missed appointments. This information has been used within a series of panel data models to investigate how the performance of an A&E department varies with factors related to demand and supply of health care, and the characteristics of patients.

This project will provide guidance that is urgently needed by NHS England and other policy makers regarding which factors impact most on A&E performance, in particular waiting times. This is needed because an increasing proportion of departments have not met waiting time targets. The project will provide insight about how performance can be improved.

NEW PROJECT 5. Assessing patients with long-term, complex conditions.

The results from this work will provide a picture of take-up and demand for NHS services from patients with long-term conditions, and the characteristics of these patients. It will help NHS policymakers plan for the resources required to treat patients with long-term conditions.

This is an example of some of the work produced so far.

- National trends in emergency readmission rates: A longitudinal analysis of administrative data for England between 2006 and 2016

The aim of this paper was to provide a descriptive analysis of readmission rates over time and changes in the degree of ‘unwarranted’ variation between NHS trusts. The Health Foundation found that readmission rates remained stable across the 10-year period, with variation across clinical subgroups. Moreover, variation decreased consistently, suggesting overall improvements in health care quality in England. A revised version of the produced article has been submitted to BMJ Open, with an acceptance decision expected in the next few weeks. Furthermore, the article forms part of a PhD chapter in Dynamics in Quality of Care: The Case of Readmission Rates at Imperial College London.

- The implications of high bed occupancy rates on readmission rates in England: A longitudinal study

The aim of this paper was to examine the relationship between bed occupancy rates, hospital behaviour and quality care. Hospital behaviour was measured through daily discharge rates, whereby quality of care was measured through readmission rates. The Health Foundation found that following nights of high bed occupancy, hospitals are more likely to discharge patients on the following day, but with no substantial impact on the patients’ risk of being readmitted. The research paper is currently under peer-review at Health Policy, and has been submitted to several conferences for presentation. These include AcademyHealth in Seattle (US), the American Health Economics Conference in Atlanta (US), the European Health Economics Conference in Maastricht (NL), and IRDES in Paris (F).

- Do financial penalties reduce readmission rates? A continuous treatment effect evaluation.

The aim of this paper was to estimate a causal relationship between different levels of financial penalties on future readmission rates in the English NHS. The Health Foundation used the endogeneity that resulted from setting financial penalty thresholds and following the adjustment using the generalised propensity score; it is estimated dose-response functions to determine the optimal employed financial penalty rate to maximise impact on readmission rates. This work has been presented at numerous conferences, including IRDES in Paris (F), the International Health Economics Association Conference in Boston (US), and at several internal meetings at The Health Foundation and Imperial College London. Moreover, it forms part of the thesis of an analyst from the Health Foundation and is prepared for submission to Health Economics – one of the two best journals for health economics research.