Work on Healthcare at the Institute for Fiscal Studies

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Objective for processing

[18 paragraphs unchanged] The Institute for Fiscal Studies is the controller as the organisation responsible for ensuring that the Data will only be processed for the purpose described above. The lawful basis for processing personal data under the UK GDPR is: Article 6(1)(f) - processing is necessary for the purposes of the legitimate interests pursued by the controller or by a third party. The Institute for Fiscal Studies has determined the processing is necessary for its legitimate interests in conducting research into the effects of economics of health and the health care system with the aim to better inform policy makers, practitioners and the general public. The lawful basis for processing special category data under the UK GDPR is: Article 9(2)(j) - processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject. This processing is in the public interest because this research aims to investigate and better understand the effects of economics of health and the health care system. The funding comes from multiple sources. Current funders include: · Nuffield Foundation · Economic & Social Research Council (ERSC) . National Institute for Health Research (NIHR) . British Academy Funding to continue the work described will be sought on an ongoing basis. The funder(s) will have no ability to suppress or otherwise limit the publication of findings. Microsoft Limited provides IT hosting services to the Institute for Fiscal Studies and will store the Data as contracted by the Institute for Fiscal Studies. [52 paragraphs unchanged]

Processing activities

[5 paragraphs unchanged] IFS stores Data on the Cloud provided by Microsoft Limited. [2 paragraphs unchanged] For remote access: [7 paragraphs unchanged] Remote processing will be from secure locations within England/Wales. The Data data will not leave: leave England/Wales at any time. [5 paragraphs unchanged]

Expected output

[3 paragraphs unchanged] UPDATE: A second working paper was published in June 2018 on the IFS [49 words unchanged] on end-of-life medical spending – is currently under review at Health Economics. [1 paragraph unchanged] Update (June 2021): The second paper (previous work delayed) has recently been was published by the Journal of Health Economics (https://www.sciencedirect.com/science/article/pii/S016762962100062X). The third paper was rejected by Health Economics and is currently being prepared for submission to Social Science and Medicine. [38 paragraphs unchanged]

Unchanged: Expected measurable benefits, Benefits reported.

Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.

Datasets: + Emergency Care Data Set (ECDS); + HES-ID to MPS-ID HES Accident and Emergency; + HES-ID to MPS-ID HES Admitted Patient Care; + HES-ID to MPS-ID HES Outpatients

Objective for processing

The Institute for Fiscal Studies was founded as an independent research institute, with the principal aim of better informing public debate on economics in order to promote the development of effective fiscal policy. Its research impacts policy makers, think tanks and practitioners and is communicated widely on a national and international scale. On healthcare, IFS focuses on the increased use of market mechanisms within the NHS. They examine the responses of patients, GPs and other healthcare workers to market incentives, and the impacts upon recorded NHS activity and hospital outcomes. The Institute for Fiscal Studies requires access to NHS England data for the purpose of the following research programme: The Institute for Fiscal Studies is the sole Data Controller and Data Processor for this application and all work programmes are funded by the Economic and Social Research Council (ESRC) Institute for Public Policy at the IFS. In addition, project (5) is funded by the Nuffield Foundation, and Project B and iii are funded by an ESRC grant ‘The impact of medical labour on variation in patient outcomes: evidence from English public hospitals’. IFS confirm that none of the funders exert any influence over the projects and outputs. Work on Healthcare at the Institute for Fiscal Studies This Agreement covers data from 1997/98 to 2017/18. It is important to have data that covers this period for three key reasons. First, a number of the research aims are to investigate the impact associated with different policy changes that have taken place during this period. In each case, IFS need data from before and after the policy change. For example, project (2) studies the impact of introducing private providers into the NHS market for elective care, which took place as part of a set of reforms throughout the 2000s. Having data from before, during and after this period is essential in understanding the changes that took place as a result of these reforms. The following is a summary of the aims of the research programme provided by the Institute for Fiscal Studies: Second, data from 1997/98 to 2017/18 will provide the longest time series possible. This will allow IFS to better understand trends in NHS activity over time (e.g. in project (a) this allows IFS to examine how NHS activity has developed across birth cohorts, and in project (1) to examine whether the impact of competition has changed over this period. Finally, using data from multiple years helps to maximise sample size. This is crucial in boosting the statistical power of the research, helping to accurately identify and estimate effects. As a result, these data requirements are essential in allowing IFS to carry out the proposed research. - Use NHS England data to conduct economics research in the health and social care system, with the aim of providing evidence to policymakers that will improve health policy making and health service delivery in England. The IFS process data in accordance with their legitimate interests under GDPR (Article 6(1)(f) and Article 9(2)(j)), as summarised below: The Institute for Fiscal Studies was founded as an independent research institute, with the principal aim of better informing public debate on economics in order to promote the development of effective fiscal policy. Its research impacts policy makers, think tanks and practitioners and is communicated widely on a national and international scale. On healthcare, IFS focuses on the increased use of market mechanisms and the role that the workforce plays within the NHS. They examine the responses of patients and staff to market incentives, and the impacts upon recorded NHS activity and hospital outcomes. 1. Purpose test: are you pursuing a legitimate interest? The overall aim of the IFS programme of work is to use the Hospital Episode Statistics (HES) to conduct economics research in the health and social care system, with the aim of providing evidence to policymakers that will improve health policy making and health service delivery in England. The following NHS England Data will be accessed: 2. Necessity test: is the processing necessary for that purpose? The processing of individual level data is necessary because IFS are unable to address their research questions using aggregate level data. In the absence of processing these data, their research questions would remain unanswered. IFS would therefore be unable to deliver any benefits to the health and social care system. • Hospital Episode Statistics – Necessary to study population health and the organisation of health care in the UK. 3. Balancing test: do the individual’s interests override the legitimate interest? Individuals may consider their data private. It is therefore important to comply with the conditions of the data use Agreement that researchers should not seek to identify any individuals in the data. HES contain the whole population, including children. There will also be vulnerable individuals, as defined by their diagnoses. There should be no direct impact of processing on patients in HES; there may however be indirect benefits from the findings of the research, which may be used to improve patient care. The research will not require any action on behalf of patients, or be intrusive in any way, as IFS will be using data that has already been collected. IFS will process the data under the conditions that it is supplied by NHS Digital, which requires that any published results cannot be used to identify individuals and that individuals cannot identify themselves using any published material o Admitted Patient Care IFS have a number of research projects being conducted at once. IFS has received data from NHS Digital to complete these projects. This Agreement numbers and describes each project aim, processing, outputs and benefits individually. Each project will only make use of the data necessary for that particular purpose. o Accident & Emergency o Outpatients o Emergency Care Data Set (ECDS) • Civil Registrations of Death – Secondary Care Cut - Necessary to study patient’s longer-term mortality outcomes. This is important as it allows researchers to better understand how different treatments, organisation of care, and an array of targets and regulations, ultimately influence NHS patients’ health. • Patient Reported Outcome Measures (PROMS) - Necessary to understand how the clinical benefits following joint replacement surgery has changed over time, particularly in light of the independent sector reforms. The level of the Data will be: • Pseudonymised The Data will be minimised as follows: • Limited to data between 1997/98 and 2022/23. • Minimised for each individual project, in datasets accessed, and the range of years accessed. IFS have a number of research projects being conducted at once. IFS has received data from NHS England to complete these projects. This Agreement numbers and describes each project aim, processing, outputs and benefits individually. Each project will only make use of the data necessary for that particular purpose. [1 paragraph unchanged] (1) To Project 0.1 (Completed): The objectives of this project were to produce a model of choice that can be used to simulate and evaluate potential future policies. The focus will be was on how potential policies affect where different types of patient patients (by age, location, or area level deprivation) are treated. STATUS (June 2021): A working paper was produced in August 2017 (published on the IFS website here: https://www.ifs.org.uk/uploads/publications/wps/WP201715.pdf). A paper has recently been published in Health Economics (https://onlinelibrary.wiley.com/doi/full/10.1002/hec.4223). A non-technical review is currently being written and will be published and disseminated shortly. No new data are requested for this project. Project 0.2 (Completed): The objectives of this project were (i) to understand the impact of the introduction and expansion of the role of independent sector providers on demand for NHS-funded joint replacements and (ii) to assess how this impact varies across England, and the area level deprivation. DATA: PROMS and Inpatient records (01/04/2009 to 31/03/2013). Covers patients with an elective inpatient admission and an OPCS code of W37, W38, W39, W40, W41, W42, W53, W93, W94, or W95. Project 0.3: The objectives of this project are (i) to produce profiles of public-funded medical expenditure in England over the life cycle (and examine how this evolves over time), (ii) examine correlations in the concentration of medical spending over time (i.e. how much does spending on health care in a given year determine the amount of healthcare received in the future), and (iii) examine the share of medical spending attributed to patients in the last year of life. Data from 2009/10 to 2011/12 are required to provide a large and up-to-date sample (for the 2012/13 data on which estimation of the model takes place) with which to construct hospital choice sets for each GP practice. 2012/13 data are used to estimate the model. The data request has been minimized by only requesting enough years with which to estimate the model (while still ensuring sufficient statistical power) and by only requesting information about patients with affected diagnoses. DATA: Inpatient data from 01/04/1997 onwards, outpatient data from 01/04/2005 onwards and A&E data from 01/04/2007. This data was required to maximise the period of time that can be analysed for each type of care. This is essential particularly for part (iii) of the project (looking at spending at the end of life) as it maximises both the length of time that individuals are observed in the data, and the number of deaths observed in the data (therefore boosting statistical power). (2) The objectives of this project are (i) to understand the impact of the introduction and expansion of the role of independent sector providers on demand for NHS-funded joint replacements and (ii) to assess how this impact varies across England, and the area level deprivation. Project 0.4 (Closed, outputs not realised): To investigate how the demand for, and quality of NHS services have changed in areas where population has experienced rapid changes. In particular, IFS examined whether areas with a high number or concentration of residents who are foreign born greater demand for two types of NHS services: (i) Accident and Emergency care and (ii)NHS maternity services. STATUS (June 2021): A working paper was initially published on the IFS website in August 2015, and an updated version published in August 2016 (https://www.ifs.org.uk/publications/8451). The paper was submitted to several economics journal but was not published. A separate, but related, second working paper was published on the IFS website in January 2020 (https://ifs.org.uk/publications/14667) and published in the Journal of Health Economics in September 2020 (https://ifs.org.uk/publications/15249). A non-technical summary of the use of private providers in the NHS was published in November 2019 (https://ifs.org.uk/publications/14593). Project 0.5: To estimate the health effects of Sure Start, a large national programme to improve early childhood development and integrate health, education, childcare, social care, and other support services to better serve families. The HES data will be used to: (i) investigate whether access to Sure Start services between birth and age 4 reduced all-cause and cause-specific hospitalisations and outpatient visits; (ii) understand the rollout of the Sure Start programme. This project can be completed with existing data. DATA: Inpatient records (HES APC) (01/04/2000 to 31/03/2018). Covers patients with an elective inpatient admission with OPCS code of W37, W38, W39, W40, W41, W42, W53, W93, W94, or W95. Data for this period are required to cover the period prior to the expansion of the ISP programme, and all to track the subsequent expansion of the use of ISPs since then. Additional data (after 2012/13) are required to update the analysis to cover changes over the last 5 years. IFS have minimised the amount of data requested by only requesting data for patients with relevant procedure codes (i.e. those undergoing specific elective procedures). (3) The objectives of this project are (i) to produce profiles of public-funded medical expenditure in England over the life cycle (and examine how this evolves over time), (ii) examine correlations in the concentration of medical spending over time (i.e. how much does spending on health care in a given year determine the amount of healthcare received in the future), and (iii) examine the share of medical spending attributed to patients in the last year of life. STATUS (June 2021): These data have been used to produce two peer-reviewed articles, published in Fiscal Studies in 2016 (https://www.ifs.org.uk/publications/8759) and the Journal of Health Economics in 2021 (https://www.sciencedirect.com/science/article/pii/S016762962100062X). Work is ongoing on a third paper: the first is a working paper was published in September 2019 (https://ifs.org.uk/publications/14326) and is currently undergoing revisions before being submitted to a journal (Social Science and Medicine). During the research process IFS have liaised with the Department of Health to shape the work and present findings among policymakers (IFS presented the findings of the second paper in November 2018, and have been invited back for more discussions). DATA: Inpatient data from 01/04/1997 onwards, outpatient data from 01/04/2005 onwards and A&E data from 01/04/2007. These data are required to maximise the period of time that can be analysed for each type of care. This is essential particularly for part (iii) of the project (looking at spending at the end of life) as it maximises both the length of time that individuals are observed in the data, and the number of deaths observed in the data (therefore boosting statistical power). (4) To investigate how the demand for, and quality of NHS services have changed in areas where population has experienced rapid changes. In particular, IFS will examine whether areas with a high number or concentration of residents who are foreign born greater demand for two types of NHS services: (i) Accident and Emergency care and (ii)NHS maternity services. STATUS (June 2021): Work began on this project in late 2014, and a draft working paper and non-technical report were prepared in Summer 2016, in addition to a number of conference presentations in 2015 and 2016. Initial work focused on both maternity and A&E departments, but the focus was sharpened to maternity care only when a paper looking at the impact of immigration on A&E departments was published by other researchers at the University of Oxford (a working paper version of which is here: https://www.bsg.ox.ac.uk/sites/default/files/2018-05/BSG-WP-2015-005.pdf). Work stopped afterwards due to changes in staffing at IFS, and subsequent progress has been slow. This was further delayed by reduced staffing during the COVID pandemic, but work is expected to resume soon. DATA: This project uses inpatient data between April 2003 and March 2018. Data is required back to 2003 in order to capture the period both before and after the expansions of the EU in 2004 and 2007 (after which immigration increased notably), and periods when births where increasing (2003 – 2011) and decreasing (2012 onwards). The most current data are requested in order to make the paper most up to date for submission and most relevant for current policymaking decisions. IFS have minimised the data requested by focusing only on inpatient admissions for women who experience delivery episodes during the sample period, and new-born children. (5) To estimate the health effects of Sure Start, a large national programme to improve early childhood development and integrate health, education, childcare, social care, and other support services to better serve families. The HES data will be used to: (i) investigate whether access to Sure Start services between birth and age 4 reduced all-cause and cause-specific hospitalisations and outpatient visits; (ii) understand the rollout of the Sure Start programme. This project can be completed with existing data. STATUS (June 2021): This report was launched in June 2019 (available here: https://www.ifs.org.uk/publications/14139). The academic paper has been presented widely at conferences in the UK, Europe and the US. It has been well received, and IFS have received many comments from other academics. IFS received additional supplementary funding from the Nuffield Foundation to continue the work going forward. IFS expects to complete a working paper by the end of 2021, and will submit to a top economics journal as well as carrying out further non-technical policy dissemination. . [1 paragraph unchanged] (6) Project 0.6 (Completed): IFS request requested linked HES and mortality data to examine the impacts of the national [6 words unchanged] accident and emergency (A&E) departments. In particular IFS will examine three questions: [3 paragraphs unchanged] STATUS (June 2021): A working paper was published in March 2018 and a revised paper was accepted for publication in the Review of Economics and Statistics in February 2021 (https://direct.mit.edu/rest/article/doi/10.1162/rest_a_01044/100991/Saving-Lives-by-Tying-Hands-The-Unexpected-Effects). IFS have also engaged in a number of dissemination activities, which are ongoing, including presenting at NHS Improvement and holding discussions with the teams responsible for reviewing the 4-hour target at NHS England. The analysis now being extended to examine the potential consequences of changing the 4-hour target in A&E targets in England (as has recently been announced) and a second paper is expected over the next two years. Project 0.7 (Completed): The objective of this project was to estimate the effect of the UNICEF Baby Friendly Initiative on children’s health and health care use. The UNICEF Baby Friendly Initiative is a worldwide program that promotes breastfeeding through improving breastfeeding support services in hospitals and community services (i.e. health visiting teams). Improving breastfeeding might have effects on health and health care consumption. Although some benefits of breastfeeding are well recognised, the evidence on some other benefits is weaker. IFS will study whether the implementation of The UNICEF Baby Friendly Initiative in either a hospital or community service is associated with improvements in child and maternal health, as well as health care use. DATA: This project will use A&E records from April 2010 to March 2018, and inpatient admissions over the same period of time for the sample of patients who had an A&E admission during this period. IFS will also use mortality records for patients who attended A&E during this period of time. IFS have minimised the data requirements by only analysing data during the period in which the 95% A&E target was in force in English hospitals, and by only requesting inpatient and mortality data for relevant patients (i.e. you have to have visited A&E at least once between April 2010 and March 2018 to appear in the sample). Project 0.8 (Closed, outputs not realised): The objective of this project was to understand whether hospitals that are more research intensive take up treatment innovations sooner, and whether this is translated in better health outcomes for patients and/or reduced costs for providers to achieve a given patient outcome. (9) Project 0.9 (Closed, outputs not reaslied): The aim of this project to was quantify the benefits of breastfeeding on children's health and cognitive development. Children [11 words unchanged] be breastfed due to poorer breastfeeding support at the weekend. The project aims aimed to use the variation in day of birth to set out the returns (in terms of patient health) to being breastfed. STATUS (June 2021): A working paper was published in March 2018 and a revised paper was accepted for publication in the Review of Economics and Statistics in February 2021 (https://direct.mit.edu/rest/article/doi/10.1162/rest_a_01044/100991/Saving-Lives-by-Tying-Hands-The-Unexpected-Effects). IFS have also engaged in a number of dissemination activities, which are ongoing, including presenting at NHS Improvement and holding discussions with the teams responsible for reviewing the 4-hour target at NHS England. The analysis now being extended to examine the potential consequences of changing the 4-hour target in A&E targets in England (as has recently been announced) and a second paper is expected over the next two years. Project 0.10 (Completed): The overall objective of the project is to evaluate how emergency admissions affect hospital production and patient outcomes in trauma and orthopaedic departments. There are three sub-objectives: (i) quantify how changes in emergency admissions have affected NHS hospitals across a range of outcomes including readmissions, cancellations of elective surgery, and length of stay; (ii) compare how the relationship between emergency admissions and these outcomes has changed in response to past NHS policies including Payment by Results, Referral To Treatment targets and NHS Choices; and (iii) assess how future policies relating to ambulance referral patterns and hospital closures may impact the relationship between emergency admissions and these outcomes. DATA: This project requires all inpatient admissions for the period between September 2000 and October 2001, for all children born in an NHS hospital between September 2000 and August 2001. These data are required to calculate 30-day readmission rates and in-hospital mortality rates for babies born within the school-year cohort covered by the Millennium Cohort Study (September 2000 to August 2001). IFS have minimised the amount of data requested by only requesting data for children born within the birth cohort of analysis. Revised Projects highlighted in v4 of the agreement: (10) The overall objective of the project is to evaluate how emergency admissions affect hospital production and patient outcomes in trauma and orthopaedic departments. There are three sub-objectives: (i) quantify how changes in emergency admissions have affected NHS hospitals across a range of outcomes including readmissions, cancellations of elective surgery, and length of stay; (ii) compare how the relationship between emergency admissions and these outcomes has changed in response to past NHS policies including Payment by Results, Referral To Treatment targets and NHS Choices; and (iii) assess how future policies relating to ambulance referral patterns and hospital closures may impact the relationship between emergency admissions and these outcomes. Project 4.1 (Closed, outputs not realised): The objective is to examine the impact of percutaneous coronary intervention (PCI) treatment for acute myocardial infarction (AMI) patients on mortality and subsequent hospital admissions, by exploiting the rapid roll out of 24/7 PCI centres across England between 2008 and 2011. Standalone HES data enables IFS to calculate in hospital mortality and readmissions. However, to complete this project, IFS request linked HES and mortality data, to include in hospital and out of hospital mortality. This is needed to consider the longer run impact of treatment, as clinical trials show that much of the benefit of PCI may occur in the years following an AMI, and many deaths after the first 30 days will occur outside hospital. STATUS (June 2021): A draft paper was submitted to the American Economic Journal: Economic Policy. IFS received a response from the journal editor in May 2019 (after being submitted in November 2018) and was granted a revise and resubmit. The paper was resubmitted on 31 July 2019 the paper has now been conditionally accepted. The data are required to make any changes required during the last part of the peer review process. No additional data have been requested for this purpose. Project 4.2 (Completed): The aim of this project was to consider the impact of daily variation in crowding in maternity units on the outcomes of mothers and babies. On days where maternity units are busier, staff and physical resources will be spread more thinly. IFS's objective is to assess whether this affects outcomes. This is a revised version of an earlier project on choice in maternity care. DATA: This project uses inpatient data between April 1997 and March 2010, and A&E data between April 2007 and March 2010, for patients with inpatient admissions within orthopaedics and trauma. The data are required for this length of time to examine changes around the introduction of Payment by Results in 2004, and to maximise sample size. IFS have minimised the amount of data requested by asking only for data on relevant patients (i.e. those with an orthopaedics and trauma episode) and by only asking for data up to 2009/10. Project 4.3: To examine the variation in mortality rates of patient who are treated for AMI or stroke across different consultants and different hospitals. The focus will be to quantify the extent to which different consultants determine the probability of survival for patients, after taking into account the different characteristics of patients treated by different consultants, and the facilities available to consultants in each NHS hospital. This is a revised version of an earlier project on variation in mortality rates across consultants. As in (i) above, IFS requests linked HES and mortality data for AMI and stroke patients, to include both in hospital and out of hospital mortality. This is needed to consider the full impact of treatment by different consultants as some deaths may occur outside hospital. Revised Projects: (i) The objective is to examine the impact of percutaneous coronary intervention (PCI) treatment for acute myocardial infarction (AMI) patients on mortality and subsequent hospital admissions, by exploiting the rapid roll out of 24/7 PCI centres across England between 2008 and 2011. Standalone HES data enables IFS to calculate in hospital mortality and readmissions. However, to complete this project, IFS request linked HES and mortality data, to include in hospital and out of hospital mortality. This is needed to consider the longer run impact of treatment, as clinical trials show that much of the benefit of PCI may occur in the years following an AMI, and many deaths after the first 30 days will occur outside hospital. This is a revised version of a previously listed project that that compared the use of PCI in AMI patients in England and the US. The revision is necessary due to difficulties in obtaining US data. STATUS (June 2021): A draft paper has been completed and presented previously at conferences. The feedback from these presentations indicated that out-of-hospital data are required to fully capture the impacts of the PCI centres. IFS therefore applied for these data as part of this request (previous request) but work was delayed after receiving incorrect mortality data. This has now been received, but work was further delayed due to unavailability of staff during the COVID pandemic. IFS researchers are now updating the results and expect to publish a working paper in late 2021 and then submit to a journal. DATA: Inpatient data from 01/04/2000 and A&E records from 01/04/2007 for all patients with a diagnosis of AMI (ICD10 code I21 or I22) during this period. Data are required for this period to maximise the period of time examined (both before and after the rollout of PCI centres). IFS have minimised the amount of data requested by requesting data only for patients with specific conditions and over the relevant period. (ii) The aim of this project is to consider the impact of daily variation in crowding in maternity units on the outcomes of mothers and babies. On days where maternity units are busier, staff and physical resources will be spread more thinly. IFS's objective is to assess whether this affects outcomes. This is a revised version of an earlier project on choice in maternity care. STATUS (June 2021): This project initially looked at choice in maternity care. After the beginning the work it became clear that limited choice was being used by mothers. However, where patients were treated away from their nearest hospital instead appeared to be the consequence of temporary closures. IFS have therefore refocused the project to directly analyse the impact of crowding in maternity wards on the subsequent outcomes of mothers and babies. Much of this work has been completed, but was delayed when the lead author was on maternity leave, and then further during the COVID pandemic. IFS would expect to finish the project and publish a working paper in early 2020. DATA: Inpatient data from 01/04/2006 to 31/03/2018 for all patients who have a delivery or birth episode (mothers and babies) during this period. These data are required to (i) show which patients have delivery/birth outcomes and (ii) track outcomes for these patients over the next 30 days. IFS have requested data over this period to increase sample size, and also to study different periods of time when NHS funding was increasing quickly (up to 2010) and then more slowly (since 2010) to understand whether crowding pressures have changed over time. IFS have minimised the data requested by requesting data only for mothers and babies over this period of time (rather than all patients). (iii) To examine the variation in mortality rates of patient who are treated for AMI or stroke across different consultants and different hospitals. The focus will be to quantify the extent to which different consultants determine the probability of survival for patients, after taking into account the different characteristics of patients treated by different consultants, and the facilities available to consultants in each NHS hospital. This is a revised version of an earlier project on variation in mortality rates across consultants. As in (i) above, IFS requests linked HES and mortality data for AMI and stroke patients, to include both in hospital and out of hospital mortality. This is needed to consider the full impact of treatment by different consultants as some deaths may occur outside hospital. STATUS (June 2021): A paper has been drafted, and presented at a number of academic economics conferences. Progress on the paper was delayed due to unavailability of staff during the COVID pandemic and is now expected to be completed by the end of 2021 (with data held throughout the peer-review process to answer referee queries). [1 paragraph unchanged] New Projects highlighted added in v5.3 v5 of this Agreement: a) Project 5.1: The project aims to quantify the causal impact of increasing educational attainment [57 words unchanged] can be used to study the impact of education on NHS services. STATUS (June 2021): Progress on this paper was delayed due to unavailability of staff during the COVID pandemic. This has pushed the timeline back on this project by around 12-18 months. [1 paragraph unchanged] b) Project 5.2 (Completed): The objectives of the project are were to examine how changes to the composition of medical teams in NHS hospitals affect their productivity (as measured by patient outcomes). In particular, the project will aimed to examine whether teams with a larger proportion of senior doctors (consultants) produce [8 words unchanged] less input from senior doctors. In order to examine this, the project will aimed to make use of temporary increases in the average experience of medical professionals [7 words unchanged] on particular days following industrial action by some junior doctors in 2016. STATUS (June 2021): Progress on this paper was delayed due to unavailability of staff during the COVID pandemic. We would now expect to publish a working paper in Spring 2022. Project 5.3 (Closed project, outputs not realised): The project aimed to examine the relationship between NHS waiting times for elective treatment and the volume of opioid prescriptions in England by examining changes in waiting times and opioid prescriptions at the GP practice level over time. DATA: Inpatient, outpatient and A&E data from 01/04/2010 to 31/03/2018. IFS have requested data that cover the period in which the industrial action take place, and data that cover a period of time beforehand that do not include any large disruptions to staffing. This will allow us to compare patient outcomes on affected days and a variety of other non-affected days to control for differences in case-mix across different days and hospitals. IFS have minimised the data request by not requesting data from a much earlier period which would be unlikely to provide a relevant comparison group as the more recent data. Project 5.4: To estimate a model of advised hospital choice for elective medical procedures, in order to enable evaluation of existing and potential policy initiatives, for example the investigation of distributional and competition implications of the enhanced role of GPs in a system of equal access for equal needs. c) The project aims to examine the relationship between NHS waiting times for elective treatment and the volume of opioid prescriptions in England by examining changes in waiting times and opioid prescriptions at the GP practice level over time. STATUS (June 2021): Progress on this paper was delayed due to unavailability of staff during the COVID pandemic and has pushed the timeline on the project back by around a year. DATA: Inpatient, outpatient and A&E data from 01/04/2010 to 31/03/2018. IFS have requested the data for the same period that the publicly available GP prescribing data are available, with a few additional months requested in order to examine pre-trends in waiting times and referrals before the prescribing data are available. IFS have minimised the amount of data requested by not asking for additional data before this period. d) To estimate a model of advised hospital choice for elective medical procedures, in order to enable evaluation of existing and potential policy initiatives, for example the investigation of distributional and competition implications of the enhanced role of GPs in a system of equal access for equal needs. STATUS (June 2021): Progress on this work is progressing as expected, with working papers expected to be published in the next 1-2 years. [1 paragraph unchanged] All projects are underwritten by the Economic and Social Research Council (ESRC) Centre for Public Policy at the IFS. In addition, there are some additional funding streams. New projects highlighted in this agreement (v7): i is funded by an ESRC funded grant on Health Network Project 7.1: The project aims to analyse how changes to the health and social care workforce impact the health outcomes of hospital patients. Specifically, IFS will analyse the impacts of various ‘shocks’ to both the hospital and social care workforce that causes temporary or longer-term changes in the availability of staff in these sectors on patient outcomes captured in HES. These shocks include, but are not limited to, the local availability of alternative jobs and wages, Brexit, changes in immigration rules, and hiring practices by NHS hospitals). Patient outcomes include the number of hospital admissions, readmission rates and in-hospital mortality rates. This work will form a key component of IFS’ work programme as part of the Health and Social Care Workforce Policy Research Unit (2024-2028), working closely with the Department of Health and Social Care to design and carry out the research. 5 is funded by the Nuffield Foundation DATA: Inpatient data from 01/04/1997 onwards, outpatient data from 01/04/2004, and A&E data from 01/04/2007 to 31/03/2020; ECDS data from 01/10/2017 onwards. These data are required to maximise the period of time that can be analysed using outcomes for each type of care, and the different types of data are required in order to estimate the effect on different parts of the hospital system. Project B and iii are funded by an ESRC grant ‘The impact of medical labour on variation in patient outcomes: evidence from English public hospitals” Project 7.2 To examine the determinants and impacts of A&E waiting times. The HES data will be used to (i) investigate how variation in A&E waiting times affects the number and types of A&E attendances and (ii) investigate how variation in A&E inputs, particularly staffing and bed occupancy, affects A&E waiting times. IFS confirm that none of the funders exert any influence over the projects and outputs. DATA: A&E data from 01/04/2012 to 31/03/2020; ECDS data from 01/10/2017 onwards. Inpatient data from 01/04/2012 onwards for emergency admissions only. Data is minimised by only requesting data on the necessary types of patients – A&E attendances and emergency admissions – and only requesting the years needed for sufficient pre-pandemic sample size and variation to match other data sources used in the project (2012 onwards). Project 7.3: To evaluate the diffusion of surgical robots and examine their effect on surgeons' performance for the population of prostate cancer patients. The study will answer two specific questions: 1) Does robotic surgery improve the performance of prostate cancer surgeons? 2) Are the effect of robots different for different types of surgeons? The HES inpatient data will be used to study prostate cancer surgeons and their patients, describe the use of robotic surgery by NHS hospitals, and compute two measures of surgeons' performance (i.e., complications from surgery and post-operative length of stay). DATA: Inpatient data from 01/04/2004 to 01/04/2018. Data will be minimised by only focusing on the period where robot diffusion occurred and by only looking at prostate cancer patients (vs all surgical patients). Additional data on the surgical operations of prostate cancer surgeons will be used to perform robustness checks. Project 7.4: To analyse the impacts of policy-induced air quality improvements achieved over the last two decades in England on health outcomes and health spending. Specifically, IFS will analyse the impact of flagship climate and environmental policies implemented in the energy production and transport sector on i) ambient air quality and ii) hospitalisation outcomes. These policies include the introduction of a carbon tax on electricity production in 2013 (the Carbon Price Support), subsidy programs for the electrification of buses, and zoning policies such as ULEZ. DATA: Inpatient data from 01/04/1997 onwards, A&E data (AE/ECDS) from 01/04/2007 onwards. These data are required to maximise the period of time that can be analysed, knowing that we will use air pollution concentration data available from 1998 onwards. IFS requires access to both inpatient and A&E data in order to capture as many outcomes impacted by air pollution as possible. Project 7.5: To analyse the impacts of sewage spills and changes in water quality in England since 2016 on health outcomes and health spending. In particular, IFS will analyse the impact of changes in water quality regulation and sewage spills on i) water quality and ii) hospital outcomes related to gastrointestinal disease. DATA: Inpatient data from 01/04/2010 onwards, A&E data (AE/ECDS) from 01/04/2010 onwards. These data are required to cover the period of time for which we have water quality measures (from 2016 onwards), and provide information on longer-term trends in hospital use (use to predict A&E attendances and inpatient admissions during the period of study). IFS requires access to both inpatient and A&E data in order to capture as many health-related issues associated with poor water quality as possible. All projects are underwritten by the Economic and Social Research Council (ESRC) Centre for Public Policy at the IFS. In addition, there are some additional funding streams. Project 0.5 was funded by the Nuffield Foundation (EYP 42289), the NORFACE DIAL GUODLCCI, and the European Research Council for grants agreement no. 819752 - DEVORHBIOSHIP - ERC-2018COG and ERC-2014-CoG-646917-ROMIA. Project 7.1 is funded by the National Institute for Health Research through the Health and Social Care Workforce Policy Research Unit (funding in place from January 2024 until December 2028) and the British Academy through the Postdoctoral Research Fellowship (October 2023 until September 2025). IFS confirm that none of the funders exert any influence over the projects and outputs Project 7.1 has an oversight committee that is formed of representatives from the Department of Health and Social Care (DHSC) and NHS England. The role of this committee is to provide information on the policy priorities of government (which allow us to design projects to investigate questions that are relevant to policy and maximise impact) and for us to disseminate findings of the work. The oversight committee do not directly design the research, or the methods used, and IFS retain the right to publish all results that are produced as part of the research. None of the other projects have an advisory committee or involve other organisations. Data will be accessed by: • Individuals holding an honorary contract under the supervision of a substantive employee of the Institute of Fiscal Studies (IFS) for the purposes described in this DSA only. IFS must maintain records in a single location that cover the following details of each individual given access under an honorary contract: o Their substantive employer; o Their role in respect of the purpose for the processing specified in the DSA; o The start date and end date of the duration in which the Data will be accessed by the individual under an honorary contract; o The necessity for the Data to be accessed by the person(s) holding an honorary contract, instead of a substantive employee of an organisation named as controller or a processor in this DSA; o Confirmation that an appropriate contract is in place which follows the relevant guidance and is countersigned by the substantive employer of the honorary contract holder. A Public and Patient Involvement and Engagement group helped refine the purpose of a specific project. The group supported the collection of the data for the purposes described above. Project 7.1 involves members of the public and patients. The Health and Social Care Workforce Policy Research Unit, of which IFS are part and through which IFS conduct this work, has its own PPIE group. This group meets 4 times a year to discuss projects and reads and comments on work in both the design and dissemination phase. The team have presented the proposal for project 7.1 to the group and will continue to discuss this with them as the research continues and as results emerge.

Processing activities

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 i.e.: employees, agents and contractors of the Data Recipient who may have access to that data). No data will flow to NHS England for the purposes of this Data Sharing Agreement (DSA). There will be no data linkage undertaken with NHS Digital data provided under this Agreement that is not already noted in the Agreement. NHS England will provide the relevant records from the HES/ECDS, Deaths and PROMS datasets to IFS. The data will: Data will only be accessed and processed by substantive employees of the Institute for Fiscal Studies and will not be accessed or processed by any other third parties not mentioned in this Agreement. · Contain no direct identifying data items. The Data will be pseudonymised and individuals cannot be reidentified through linkage with other data in the possession of the recipient. The data are processed and stored at the Institute for Fiscal Studies on a BitLocker encrypted drive using AES 256 bit encryption. This drive is on the SAN (Storage Area Network) located at the Institute for Fiscal Studies. The Data will not be transferred to any other location. No data (other than aggregated data with small numbers suppressed) will flow outside the UK or be shared with third parties. The Data will be stored on servers at the Institute for Fiscal Studies (IFS). The IFS will not attempt, nor have a requirement to re-identify individuals in the data supplied by NHS Digital The Data will be accessed by authorised personnel via remote access. Processing activities for each project: The Controller must confirm and provide evidence upon audit by NHS England that access via any remote device complies with the data security obligations within this DSA and the Data Sharing Framework Contract. (1) Episode level data on NHS funded elective hip replacements will be used to estimate a statistical model of hospital choice. The model will be extended to take into account observed and unobserved sources of patient heterogeneity (differences in preferences). - Remote access will only be from secure locations situated within the territory of use (as further restricted elsewhere within the DSA if so done) stated within this DSA; As it is expected that clinical need will be a crucial input into individual patient decision making, the HES and PROMS datasets will be linked. This linkage will enable the production of a model that takes patient need into account and therefore provide more accurate analysis and predictions. PROMs data will be analysed in order to understand how the clinical benefits following joint replacement surgery has changed over time, particularly in light of the independent sector reforms. - Access controls granting users the minimum level of access required are in place; This is essential for an analysis which estimates the implications for population health following the huge increases in the volume of joint replacements observed in the ten years prior (i.e. IFS can examine whether the clinical benefit for patients has increased or decreased as a result of greater availability of hip and knee replacements. This will help to analyse whether the independent sector reforms have increased the welfare of NHS patients). - Remote access is only via secure connections (e.g., VPNs or secure protocols) to protect data; DATA: PROMS and Inpatient records (01/04/2009 to 31/03/2013). This covers patients with an elective inpatient admission and an OPCS codes. These codes are briefly explained below. - Multifactor authentication (MFA) is required for required for remote access. Hip replacement codes: W37 (Total hip replacement with acetabular bone graft), W38 (Total prosthetic replacement of hip joint not using cement), W39 (Other total prosthetic replacement of hip joint), W93 (Hybrid prosthetic replacement of hip joint using cemented acetabular component), W94 (Hybrid prosthetic replacement of hip joint using cemented femoral component), W95(Hybrid prosthetic replacement of hip joint using cement). - Device security, including up-to-date software and operating systems, antivirus software, and enabled firewalls are utilised for the remote access; Knee replacement codes: W40 (Total prosthetic replacement of knee joint using cement), W41 (Total prosthetic replacement of knee joint not using cement), W42 (Other total prosthetic replacement of knee joint). - All remote access is undertaken within the scope of the organisation’s DSPT (or other security arrangements as per this DSA) and complies with the organisation’s remote access policy. Partial knee replacement codes: W53 (Prosthetic replacement of articulation of other bone not using cement). The above applies in addition to any condition set out elsewhere within the DSA (e.g. who may carry out processing, and for what purpose). (2) IFS will model the relationship between the total number of NHS funded elective hip replacements in a middle super output area in a given year, and the introduction of Independent Sector Providers. IFS will compare the same area over time, and compare across areas by distance to the nearest independent sector provider offering hip replacements, relative to the nearest Acute Trust providing hip replacements. The Data will not leave: England/Wales at any time. Data will be combined with publicly available area level and GP practice characteristics, in order to examine variation in outcomes or behaviour, or to control for potentially confounding factors at the area level. Publicly available area level data includes measures of population size and levels of deprivation. These variables are used in area-level regressions as control variables. This includes population data (available from the Office for National Statistics and local deprivation scores made available for public use by the Department for Communities and Local Government). IFS require data back until at least 2000, as the policy to increase and formalise the role of the Independent Sector began in 2003, and the ability to study a comparison group is essential to accurately identify the impact of the policy. Data will be accessed by individuals with an honorary contract with IFS. The individuals will act as an agent of IFS at all times under supervision from employees of IFS. Aside from these individuals, access is restricted to employees or agents of IFS who have authorisation from the Principal Investigator. DATA: Inpatient records (01/04/2000 to 31/03/2018). Covers patients with an elective inpatient admission with OPCS code of W37, W38, W39, W40, W41, W42, W53, W93, W94, or W95. All personnel accessing the Data have been appropriately trained in data protection and confidentiality. (3) IFS will examine the age profile of English hospital spending across the period between 1997/98 and 2017/18. Using the Health Resource Group (HRG) variable in the inpatient HES dataset, IFS can allocate costs for all inpatient activities to different age groups. Using publicly available data on the English population, the average spending per individuals of a given age can be derived. The Data will not be linked with any other data. IFS will then examine how this develops over time, providing evidence on whether average spending for individuals of a given age has changed over time (i.e. is the average spend for a 70 year old male in 1997/98 different to a 70 year old male in 2017/18). There will be no requirement and no attempt to reidentify individuals when using the Data. The pseudonymised HES indicator will be used to track the use of hospital care for a random sample of individuals in each year of the data. This will allow an estimate of total healthcare expenditure for individuals over the entire period, providing a measure of “lifetime medical spending” for older individuals. It also allows IFS to examine the correlation between health and social care spending in one year and another (i.e. does health spending in one year predict health spending in the next, or five years later etc). Social care spending is measured using publicly available data on annual spending in the patients’ local authority on social care. Researchers from the IFS will analyse the Data for the purposes described above. Individuals who die in hospital are recorded in HES (through the discharge method variable). For individuals who die in hospital, IFS can examine the amount (and cost) of hospital care received in the final year(s) of life. In this way, IFS can estimate the amount and the share of hospital expenditures that are incurred in the final year of life. These estimates can then be compared to the findings of other researchers who are conducting a comparable analysis on similar data in other countries such as the USA and other European countries (Note: IFS will not combine the data with these other researchers, but only examine regression coefficients and the findings of this research). IFS hold data back to 1997/98 to provide the longest time series possible over which you can track individuals using the HES identifier. This will (i) provide the largest history for individuals (and therefore acts as the best proxy for lifetime use of the service) and (ii) provides a significant period of time over which to examine how the distribution of spending across ages has developed (i.e. IFS can examine whether the average 70 year old in 2017/18 uses more healthcare than a 70 year old in 1997/98). DATA: Inpatient data from 01/04/1997 onwards, outpatient data from 01/04/2005 onwards and A&E data from 01/04/2007. (4) IFS will model the impact of rapid immigration on the demand for maternity services across local authorities with different changes in the concentration of foreign born residents (population data at the local authority level is sourced from the publicly available UK Labour Force Survey). This compares the number of birth episodes recorded by inpatient HES across these regions. IFS will then also examine the number of 30 day readmissions for new-born children across these areas, using the pseudonymised HES identifier, to examine whether the quality of maternity care has deteriorated in an observable way in areas where the population has rapidly grown. This will provide evidence on whether NHS trusts adapts quickly to changes in the size and the characteristics of the population which they treat. HES A&E data is held in order to understand the use of the service during a period which has witnessed significant changes in the size, and composition, of the English population. This provides sufficient variation in the data to attempt to estimate causal impacts of population change on demand for, and quality of, A&E services. DATA: This project uses inpatient data between April 2003 and March 2018. (5) The same personnel who currently process data for projects involving all HES records will create a dataset that contains only admissions for individuals under the age of 30. The dataset will be placed in a separate secure area for the project team to use, so that they are able to access only the data needed for the project. To investigate the relationship between Sure Start and hospital admissions, IFS will merge information on the location of Sure Start Centres into HES using LSOA identifiers. IFS will then test whether cohorts exposed to Sure Start (both overall and accounting for intensity of exposure) are less likely to experience hospitalisations and outpatient visits (all-cause and cause-specific) and A&E admissions (from 2007-08 onwards). The two sets of treatment and control groups will be compared: those who lived at ages 0-4 (i) in areas that implemented Sure Start earlier vs. later and (ii) in areas that experienced larger vs. smaller expansions of Sure Start. To understand the roll out of Sure Start, IFS will examine the determinants of the timing (the year of opening of the first Sure Start Centre in a given Local Authority (LA)) and the intensity (the number of Sure Start Centres in a given LA per year) of the rollout. This will include pre-programme levels and trends in hospitalisations and outpatient visits (all-causes and cause-specific) among the determinants. DATA: Inpatient data from 01/04/1997 onwards, and A&E data from 01/04/2007 onwards, for patients born after 1993 and who are aged between 0 and 20 years old at the time of admission. (6) IFS will use the A&E HES data from 2010/11 - 2017/18 (at record level) only to study whether the probability of inpatient admission changes for patients who are admitted during a period close to the four-hour waiting limit. This will be achieved by computing the counterfactual probability of admission in the absence of the target. IFS will calculate this counterfactual by estimating a polynomial regression (regressing admission on the period of admission) for all patients who are feasibly not affected by the target (e.g. all patients admitted/discharged from A&E between 0 – 180 minutes, and after 240 minutes). IFS will use data on patient characteristics and investigations/symptoms contained in the A&E data, along with diagnosis codes for admitted patients (in their APC HES records) to examine how the characteristics of patients vary with time. APC HES records will be used to examine how treatment intensity varies across patients who are admitted at different points of time. For example, IFS will examine whether length of stay for inpatients admitted after a shorter period of time in the A&E department are different from those who are admitted after waiting for longer. IFS will also examine how the probability of readmission to hospital varies across these individuals. IFS will use the linked HES and mortality data (at patient record level) to examine whether the probability of death varies across individuals who are admitted or discharged after different waiting times. In-hospital mortality could be recovered from unlinked HES. However, out-of-hospital mortality may also change as a result of the policy. The inclusion of the mortality data would therefore allow all-location mortality outcomes to be examined. IFS will also examine the underlying cause of death, to investigate whether cause of death is the same as the major diagnoses when patients recently visited hospital. DATA: This project will use A&E records from April 2010 to March 2018, and inpatient admissions over the same period of time for the sample of patients who had an A&E admission during this period. (9) IFS will calculate the 30-day hospital readmission and in hospital mortality rate for children born on each day of the week, using inpatient HES data from September 2000 to August 2001. IFS will then use these figures to compare readmission and in hospital mortality rates for children born Friday - Sunday, to children born Monday - Thursday. Only aggregate figures will be published (by day of the week), ensuring that large sample sizes are used in all cases. This will be used to supplement existing work on this project which makes use of the Millennium Cohort Study, 2005 Infant Feeding Survey, and 2007 Maternity Users Survey (note, IFS will not link individual level HES records to individual records in any of these surveys). DATA: This project requires all inpatient admissions for the period between September 2000 and October 2001, for all children born in an NHS hospital between September 2000 and August 2001. (10) The project will use inpatient data for the years 1997 to 2010 and A&E data for the years 2007 to 2010. Data will be extracted for trauma and orthopaedic departments, identified using consultant specialty information. Sub-objectives (i) and (ii) will involve building statistical regression models that compare the number of emergency admissions at each hospital with patient outcomes at that hospital. Sub-objective (ii) will assess how this statistical relationship has changed over different time periods and hospitals, for example before and after the introduction of Payment by Results in 2004. Sub-objective (iii) will involve linking the inpatient and A&E data to establish which patients at trauma and orthopaedic departments arrived by ambulance. Statistical models will then be used to evaluate how the number of emergency admissions, and the associated impact on patient outcomes, would change if ambulances were to assign patients to hospitals differently or if certain A&E departments were to close. DATA: This project uses inpatient data between April 1997 and March 2010, and A&E data between April 2007 and March 2010, for patients with inpatient admissions within orthopaedics and trauma. Revised Projects: i) This project will use the inpatient data of all those admitted to NHS hospitals with a heart attack from 2000/01 to 2017/18. IFS will create indicators for whether the patient received a PCI, length of stay, 30 day in-hospital mortality and readmissions in a 30 day and one year period. With linked HES and mortality records, IFS will also calculate all mortality (occurring inside and outside hospital) at a series of intervals, from 30 days to 5 years. This is important because deaths that occur after 30 days are increasingly likely to occur outside hospital. It is therefore essential to have these data to estimate the impact of the PCI roll out on patient health. It will be necessary to calculate rates back to 2000 to understand whether the countries have been converging or diverging overtime as the treatment became more widespread in the early 2000s. IFS require the most recent data as the preferred journal requires data from the past 5 years to be included. IFS will identify the impact of receiving a PCI by using variation in access to a hospital with a PCI centre over time and space, as 24/7 PCI centres were rolled out. IFS will therefore merge information on when 24/7 centres opened, obtained through FOI requests, and calculate the distance between the centroid of each AMI patients LSOA and their nearest PCI centre, on the date that they had the AMI. DATA: Inpatient data from 01/04/2000 and A&E records from 01/04/2007 for all patients with a diagnosis of AMI (ICD10 code I21 or I22) during this period. ii) IFS will calculate for every maternity unit the number of women admitted on each day and the number of women present within the unit, for every day from April 2006 to March 2018. Analysis will be restricted to units that admit at least 500 women per year. IFS will focus on mothers that go into labour spontaneously, as maternity units have very limited control over when these mothers are admitted. IFS will then assess the relationships between these measures of crowding and the outcomes of mothers and babies. Outcomes for mothers will be based on the Royal College of Gynaecologists and Obstetricians quality indicators, including both care received during labour and subsequent health outcomes, such as 30 day emergency readmissions. DATA: Inpatient data from 01/04/2006 to 31/03/2018 for all patients who have a delivery or birth episode (mothers and babies) during this period. (iii) IFS will use episode level data to compare 30-day and 365-day in-hospital mortality rates of patients treated by different consultants following admission to an NHS hospital for an AMI or stroke. Admittances for AMI and stroke are derived from ICD-10 diagnosis codes contained in HES. Consultants are assigned to patients in HES using the anonymised consultant ID (variable ‘pconsult’). Patients who die in hospital are recorded in inpatient HES (through the discharge method variable). Anonymised patient IDs will be used to examine whether patients who are discharged but then readmitted during the 30 day period following the initial admission die in a subsequent hospital spell. IFS will use the linked HES and mortality records to calculate all-mortality (in-hospital and out-hospital) 30-day and 365-day rates for AMI and stroke patients admitted to hospital. The analysis requires the construction of detailed control variables to account for differences in the underlying health of patients treated by different consultants and hospitals. Failing to account for these differences will lead to inaccurate estimates of the effects that each consultant has on patient outcomes. Detailed measures of health conditions and past hospital use are therefore essential for this analysis. IFS will derive a range of clinical indicators using the ICD-10 diagnosis codes in HES, and use these to create the Charlson Index to capture patient morbidity. The Charlson comorbidity index predicts the one-year mortality for a patient who may have a range of comorbid conditions, such as heart disease, AIDS, or cancer. Using data from 1997/98 – 2017/18, IFS will use the anonymised patient identifier to track patient inpatient admissions and outpatient attendances over time in order to construct detailed histories of patient hospital use. Using the Health Resource Group (HRG) variable in the inpatient HES dataset, IFS can allocate costs for each of these activities to summarise past hospital use. IFS will also create a variable for each year which indicates whether a patient has been treated for a heart attack or stroke in a previous year. Previous research has shown that a major determinant in survival following a heart attack is the amount of time that elapses between onset and treatment, and the distance that patients need to travel to reach a hospital for treatment. This will be addressed by examining the distance between the Lower Super Output Area of patient residence and the hospital in which they are treatment. In addition, for the period 2007/08 – 2017/18, IFS will use the Accident and Emergency data to examine whether the onset occurred at home (variable ‘aeincloctype’) and the time that elapsed between arrival at hospital and admission (variable ‘tretdur’). In order to separately estimate the impact of consultants from the hospitals in which they work, the analysis needs to control for differences in the types of patients treated by different hospitals. It also requires the observation of consultants working in different hospitals over time. IFS will address the first point by combining publicly available aggregated geographical data relating to the socio-economic status and population health to summarise the characteristics of the patient population served by each hospital. Inpatient HES data will also be used to create other indicators of patient health and quality of local primary care (e.g. the admission rates for ACS conditions in the local area), and the quality of other care provided in the hospital (e.g. hospital level readmission rates for elective hip replacements). In addition, for the period 2007/08 – 2017/18, Accident and Emergency data can be used to separately analyse the outcomes for patients who arrived at the hospital in an ambulance (contained in variable ‘aearrivalmode’). This would allow analysis on a subset of patients for which it is certain that patient did not choose the hospital in which they were treated, and therefore rules out matching of (otherwise unobservably sicker) patients to hospitals which could potentially bias results. The second point is addressed by following consultants across hospitals over time, through the use of anonymised consultant team variable (‘pconsult’). This allows a comparison of patient outcomes when treated by the same consultant but in a different setting. DATA: Inpatient data from 01/04/2003, A&E records from 01/04/2007, and mortality records. These data apply to all patients with a diagnosis of AMI (ICD10 code I21 or I22) or stroke (code I63). New Projects (Version 5.3) a) IFS will examine how the use of NHS hospitals between 1997/98 and 2017/18 varies across birth cohorts with different levels of education. IFS will use A&E, inpatient and outpatient records for as many years as possible during this period to calculate the quantity (e.g. how many inpatient admissions take place each year) and the type (e.g. is treatment emergency or elective?) of care received by patients. These measures will be used to implement a regression discontinuity design. In 1947, the minimum school leaving age increased from 14 to 15 for all individuals born after 1 April 1933. Previous research (e.g. Royer and Clark, 2013) has shown that individuals born just after this date therefore have more years of education than individuals born before. However, these groups of people should otherwise be identical. IFS will therefore calculate utilisation measures for different groups of patients based upon their month and year of birth, and compare these measures across groups. Differences in hospital use can then be explained by the differences in education. The analysis requires data on all hospital use among these groups in order to fully capture the effects of the reform. It also requires data for as long a time period as possible in order to understand the effect of the reform over time. For example, inpatient data from 1997/98 to 2017/18 will provide almost 20 years of data following the same patients to understand whether their pattern of hospital use is systematically different over a long period. DATA: Inpatient data from 01/04/1997 onwards, outpatient data from 01/04/2004, and A&E data from 01/04/2007, for patients born between 1918 and 1948. b) To examine the impact of the experience composition of medical teams on patient, IFS will compare patient outcomes in each NHS hospital during periods of time when the average experience of doctors on wards were likely to differ substantially. This uses quasi-experimental variation in the composition of teams following four days of industrial action by some junior doctors between January and April 2016. On affected days the ratio of senior to junior doctors increased substantially. IFS will therefore compare outcomes of patients treated on affected and non-affected days to isolate the impact of these compositional changes in teams on patient outcomes. Outcomes include length of stay, A&E visits, inpatient readmissions and in-hospital mortality of patients following admission to hospital. Outcomes for patients of patients who were already present in hospital on affected days will be analysed separately from those who arrive on those specific dates to address issues of case mix driven by patient choices. Concerns over potential changes in patient severity due to anticipation of the industrial action will further be addressed by examining outcomes of emergency patients only (as these patients have limited choice about when they attend hospital) and by controlling for observed changes in patient morbidity (using ICD-10 codes) and demographic characteristics. Variation in patient outcomes will then be compared to staffing data obtained by FOI requests from each hospital trust, which measures the number and grade of all doctors and nurses present in A&E and inpatient departments on different days. This will allow changes in patient outcomes to be related to changes in the composition and seniority of medical teams on duty in different departments, in order to isolate the impact of changes in seniority in teams on patient outcomes. DATA: Inpatient, outpatient and A&E data from 01/04/2010 to 31/03/2018. c) IFS will calculate waiting times for inpatient treatment at the GP practice level for each month between March 2010 and March 2018. IFS will use the outpatient data to count the monthly number of outpatient appointments in each specialty for patients registered at each GP practice. IFS will combine this GP practice level dataset (merged using the GP practice code) with monthly information on GP prescriptions for opioids and other medication. These data will be derived by IFS researchers from publicly available data (‘Practice Level Prescribing Data’ made available by NHS Digital) on the prescription activities of all GP practices (available from August 2010). IFS will use inpatient and outpatient data from 2010/11 to 2017/18 to maximise sample size (and therefore statistical power) for the period of time for which the prescribing data are available. DATA: Inpatient, outpatient and A&E data from 01/04/2010 to 31/03/2018. d) Data at the patient episode level (HES) on NHS funded elective procedures will be used to estimate a model of patient level hospital choice, when the patient is guided by GP advice. It is expected that the hospital site data will be augmented by publicly available hospital characteristics, and GP practice level data will be merged with practice characteristics (both from NHS Digital). DATA: Inpatient, outpatient and A&E data from 01/04/2015 to 31/03/2018. Backup storage is located on an IFS server stored by IDNet. IFS's data manager has confirmed that this server is held in a locked cabinet physically restricted to named IFS technical support staff and IDNet staff, and that only IFS staff can access the data held within the server. IDNet are therefore not considered to be acting as a data processor, and are listed as a storage location only.

Expected output

(1) There will be three written outputs: (i) an IFS working paper was published in August 2017, and is be available on the IFS website (https://www.ifs.org.uk/publications/9683) for those who use the website including government departments and academics; (ii) an academic economics journal article, which has been submitted to the Journal for Health Economics, an international peer-reviewed Economics journal with an impact factor of 3.250. The principal audience is economics academics who will read and cite the paper; (iii) a non-technical research summary which will receive a press-release and target policy makers from the Department of Health, Monitor, NHS England and the CQC in the next year. The aims are to produce written outputs that are widely cited in the academic literature and encourage more academic work on the NHS, and non-technical summaries that will provide information for policy makers that would otherwise be unavailable or very costly for the Department of Health or Monitor to acquire. IFS has presented the work at the Royal Economic Society and European Economic Association conferences, and discussed finding with the Competition and Markets Authority. Project 0.3: The principal outputs are (i) a working paper, which was published under the IFS working paper series (see project 1) in August 2015 (https://www.ifs.org.uk/uploads/publications/wps/WP201521.pdf), (ii) an academic conference presentation in March 2015, (iii) a peer-reviewed journal article in the economics journal Fiscal Studies, which was published as part of a special issue of Fiscal Studies on cross-country comparisons of health spending across the lifecycle in November 2016 (http://onlinelibrary.wiley.com/doi/10.1111/j.1475-5890.2016.12101/full), and a non-technical, policy summary (https://www.ifs.org.uk/publications/8737). Fiscal Studies is a peer-reviewed economics general with all articles explicitly aimed at bridging the gap between academic research and policy, with a reputation for publishing timely high-quality articles that are easily accessible to policymakers. A workshop to discuss preliminary findings took place in March 2015. This workshop was attended by representatives from the Department of Health, who subsequently invited IFS to present the findings at the Department. IFS have spoken to the OECD about this work, who believes it could help inform their highly influential work on cross-country comparisons of health systems. Update (June 2021): A paper has recently been published in Health Economics (https://onlinelibrary.wiley.com/doi/full/10.1002/hec.4223). The non-technical summary will be published and disseminated shortly. The project resulted in a publication in a special issue of Health Affairs on end of life care, although the IFS analysis with HES was not used directly for this publication. In 2018, The IFS-Health Foundation report "Securing the Future" (https://www.ifs.org.uk/publications/12994) included updated patterns of utilisation. The report had 757 print and digital mentions, and 775 broadcast mentions. In the 7 days after launch, the report had 343 downloads. (2) Some of these outputs from this project, including several conference presentations, a policy presentation and a non-technical policy summary, have already been produced under the previous license Agreement. Previous conference presentations included a workshop attended by representatives from the Department of Health, Monitor, the Nuffield Trust, the Office for Health Economics, and the Kings Fund, and economics academic conferences including the Royal Economic Society conference. IFS understand that the report was highly influential in the NHS funding debates both within and outside government that surrounded the 70th anniversary. Update (June 2021): A non-technical summary of the use of private providers in the NHS was published in November 2019 (https://www.ifs.org.uk/publications/14593). A paper was published in the Journal of Health Economics in September 2020 (https://www.ifs.org.uk/publications/15249). UPDATE: A second working paper was published in June 2018 on the IFS website, and received extensive national news coverage (BBC 6pm and 10pm news, BBC local radio network). As noted above, the submission of the second paper has been delayed due to a lack of recent outpatient data (and will be submitted soon after this is obtained). A third working paper– on end-of-life medical spending – is currently under review at Health Economics. (3) The principal outputs are (i) a working paper, which was published under the IFS working paper series (see project 1) in August 2015 (https://www.ifs.org.uk/uploads/publications/wps/WP201521.pdf), (ii) an academic conference presentation in March 2015, (iii) a peer-reviewed journal article in the economics journal Fiscal Studies, which was published as part of a special issue of Fiscal Studies on cross-country comparisons of health spending across the lifecycle in November 2016 (http://onlinelibrary.wiley.com/doi/10.1111/j.1475-5890.2016.12101/full), and a non-technical, policy summary (https://www.ifs.org.uk/publications/8737). The work was also been presented at the Department of Health (to DHSC and NHS England analysts) in November 2018, and IFS will follow up with DHSC in early 2020 to present updated results when they are available. Fiscal Studies is a peer-reviewed economics general with all articles explicitly aimed at bridging the gap between academic research and policy, with a reputation for publishing timely high-quality articles that are easily accessible to policymakers. A workshop to discuss preliminary findings took place in March 2015. This workshop was attended by representatives from the Department of Health, who subsequently invited IFS to present the findings at the Department. IFS have spoken to the OECD about this work, who believes it could help inform their highly influential work on cross-country comparisons of health systems. The project resulted in a publication in a special issue of Health Affairs on end of life care, although the IFS analysis with HES was not used directly for this publication. In 2018, The IFS-Health Foundation report "Securing the Future" (https://www.ifs.org.uk/publications/12994) included updated patterns of utilisation. The report had 757 print and digital mentions, and 775 broadcast mentions. In the 7 days after launch, the report had 343 downloads. IFS understand that the report was highly influential in the NHS funding debates both within and outside government that surrounded the 70th anniversary. UPDATE: A second working paper was published in June 2018 on the IFS website, and received extensive national news coverage (BBC 6pm and 10pm news, BBC local radio network). As noted above, the submission of the second paper has been delayed due to a lack of recent outpatient data (and will be submitted soon after this is obtained). A third working paper– on end-of-life medical spending – is currently under review at Health Economics. The work was also been presented at the Department of Health (to DHSC and NHS England analysts) in November 2018, and IFS will follow up with DHSC in early 2020 to present updated results when they are available. [1 paragraph unchanged] (4) The principal outputs are (i) academic conference presentation at the European Economists Association (EEA) Annual Conference in August 2015, the Royal Economic Society (RES) Annual Conference in March 2016, the International Institute for Public Finance (IIPF) in August 2016, and the European Association of Labour Economists (EALE) Annual Conference in September 2016, (ii) a working paper, published under the IFS working paper series, and (iii) the submission of a peer-reviewed journal article to the Economic Journal. The benefits of these outputs are discussed above. Output (i) has already been realised. The EEA, RES, IIPF and EALE Conferences are attended by the leading economists in Europe and the USA, and in light of comments received at the conferences, the work on this project has been extended. Update (December 2023): Work on the third paper is ongoing, and is being prepared for submission to the Journal of Public Economics. This is expected to be submitted in Spring 2024. A final output will be published in a peer-reviewed journal at the end of the peer-review process. As a result, the original target date for the publication of the working paper and journal submission was pushed back from Spring 2016. Work is still ongoing, and IFS expect to publish output (ii) in late Winter 2019. IFS have also produced a non-technical policy summary for policymakers, which will be sent to representatives of Department of Health, Monitor and NHS England after output (iii) has been published. Project 0.5: The outputs from this project have been delayed by difficulties in accessing the non-HES data sets required. The paper has been presented at the European Economic Association Congress and other internal workshops. Update (June 2021): This work has been delayed by reduced staffing during the COVID pandemic, but work is expected to resume soon. Three outputs are expected in early 2019: (1) a the final report, to be submitted to the Nuffield Foundation; (2) an IFS working paper (see above), and (3) a related academic paper. Both report and paper will be available on the IFS website. (5) The outputs from this project have been delayed by difficulties in accessing the non-HES data sets required. The paper has been presented at the European Economic Association Congress and other internal workshops. Three outputs are expected in early 2019: (1) a the final report, to be submitted to the Nuffield Foundation; (2) an IFS working paper (see above), and (3) a related academic paper. Both report and paper will be available on the IFS website. [2 paragraphs unchanged] (6) The analysis will be used to produce a range of outputs. Three types of written output are expected: (i) a working paper, which was published in March 2018 as part of the National Bureau for Economic Research (NBER) working paper series (https://www.nber.org/papers/w24445), (ii) a peer-reviewed journal article (this was submitted to the Review of Economic Studies, a leading peer-reviewed economics journal, in March 2018, and a revised manuscript (first publication step) was requested from the journal in June 2018); (iii) a non-technical research summary which will be press-released, and shared directly with NHS Improvement and the Department of Health. Update (December 2023): IFS published an IFS Working Paper (most recent version October 2022) and a revised manuscript has been requested at the Journal of Human Resources (in December 2023). This is an encouraging step towards publication. The results of this research have been extensively disseminated via IFS reports, comment pieces and media interviews along with more than 20 academic conferences in Europe and North America. Among many others, IFS have discussed this research on the Today programme; written an article for The Conversation; delivered an invited keynote address at a Sure Start Northern Ireland conference held in Belfast (November 2023); and discussed the implications of our work for DfE’s new programme of Family Hubs with the relevant civil servants within DfE. This work led to an ‘urgent parliamentary question’ in the House of Commons the day after it was released, and it was cited to justify policy proposals in Labour’s manifesto for the 2019 General Election. This work has already been discussed with economists at NHS Improvement who are also working on projects to examine the quality of care in A&E departments, and a presentation was given to NHS Improvement economists in September 2017. Other outputs will include presentations at academic conferences and to government departments. Revised projects (Added in v4) This paper underwent 3 rounds of revisions at the Review of Economic Studies but was ultimately rejected by the journal. It has subsequently been submitted to the American Economic review and the Journal of the European Economic Association. It is currently under review at the Review of Economics and Statistics (submitted in Autumn 2019). Project 4.3: The project is expected to produce a range of outputs, including ((i) multiple academic conference presentations to general economics (e.g. the Annual Royal Economics Society conference) and health economics audiences (e.g. the annual meeting of the UK Health Economists Study Group); (ii) an IFS working paper (see above); (iii) the submission of a journal article to a leading peer-review economics journal, such as the Review of Economic Studies (Impact Factor: 4.038) or the Journal of Health Economics (IF: 2.579); (iv) a non-technical policy summary, which will be press released and sent to contacts at the Department of Health and NHS England. Update: The paper was submitted to the Review of Economic Studies in March 2018, and is currently undergoing a second round of revisions. IFS will published a non-technical summary upon publication, but have engaged directly with NHS Improvement and NHS England to disseminate findings ahead of NHS England’s Review of the 4-hour target in Spring 2019. Update (June 2021): The paper has been accepted for publication, and is forthcoming in the Review of Economics and Statistics. IFS have directly engaged with NHS England and Improvement, and spoken to them during the review of 4-hour NHS targets that is ongoing. The proposed new targets are consistent with the main findings of the paper: that regulation forcing quicker treatment for those with particularly time-sensitive conditions saves patient lives. (9) There will be three written outputs: an IFS working paper (this will update a previous version that did not include HES data), (ii) a resubmission to a leading economics journal (a previous version, without HES data, was submitted in September 2015. IFS have been invited to resubmit a new version), and (iii) a non-technical report discussing the results of the work in order to benefit policymakers, and other entities interested in breastfeeding, such as UNICEF and the National Childbirth Trust. Update: After initial publication, IFS submitted a working paper to the American Economic Journal: Applied Economics. Part of the revisions requested by the referees required the use of hospital data to examine readmissions rates. Using HES, IFS have attempted to answer the referee queries, and have resubmitted the paper to the journal. IFS are waiting for a decision (publication, further revisions or rejection). IFS will then publish a non-technical summary after it is accepted at a journal. In the meantime, IFS have engaged directly with DHSC, presenting the preliminary results of the work at the department. Update (June 2021): The paper has been resubmitted to the journal after further revisions and are currently awaiting a decision on the paper. (10) This research project, which was previously under another data Agreement, has already produced a number of outputs. This has included presentations at the Royal Economic Society, University of Manchester, University College London and Northwestern University, as well as a series of discussions with NHS Improvement and a range of NHS employees (managers, physiotherapists and nurses). These existing outputs relate to sub-objective (i), and the work will now be extended to sub-objectives (ii) and (iii). Results were presented at a half day conference in September 2017 aimed at policy makers (https://www.ifs.org.uk/events/1515), with a 10 minute discussion from a member of NHS Improvement. A draft working paper was published in November 2017 (https://drive.google.com/file/d/0B-aAQJWf8MpDblJXdlI4WWhzRjg/view) and results were presented at various conferences and universities between November 2017 and March 2018. The paper will be submitted for publication to an academic economics journal in late-2018. Update: The paper was submitted to the American Economic Journal: Economic Policy in November 2018, and received a response from the editor in May 2019 and was granted a revise and resubmit. The paper was resubmitted on 31 July 2019 and IFS are waiting to hear back. Update (June 2021): The paper has been conditionally accepted at the American Economic Journal: Economic Policy and is awaiting publication. Revised projects (November 2019) (i) Outputs will include a working paper, submission to a peer-reviewed economics journal, such as the Journal of Health Economics, and an IFS briefing note and press release (as above). These outputs require linked ONS-mortality data in order to be completed. Results have been presented at the Wennberg Collaborative Conference on variation in Health care (2017) and the European Economics Association Congress (2018). A working paper should be available in 2020. Given the direct policy-relevance of this analysis, IFS will contact Department of Health, NHS England, and NICE in order to present and discuss the findings, to ensure that they are aware of the results and to check the validity of any assumptions that have been made. Update: Publication is now expected in late 2019/early 2020 after her return and after the results are updated using out-of-hospital mortality data. Update (April 2021): Progress on this paper was delayed due to unavailability of staff during the COVID pandemic and is expected to be completed by the end of 2021. (ii) Outputs will include a working paper, submission to a peer-reviewed economics journal, and an IFS briefing note and press release following submission to a journal. The staff member responsible for this project has been on maternity leave since early 2019. As a result, the project has been delayed. Existing outputs under the previous research Agreement included presentations at academic conferences such as the European Economists Association (EEA) Conference, which focused on receiving comments from economists on how to improve the analysis, and presentations to policy makers involved in the planning and delivery of NHS care. Staffing constraints have meant that progress was slower than anticipated. However, the work has been discussed with the Royal College of Midwives and the North East London Sustainability and Transformation Planning Team. Descriptive results were presented in a half day event in September 2017, aimed at policy-makers (https://www.ifs.org.uk/events/1515). The event featured a presentation from IFS and a policy response from the Royal College of Midwives. Alongside the event, the IFS published a briefing note for policy makers "Under Pressure? NHS maternity services in England". Update: Publication is expected in early 2020. Update (June 2021): Progress on this paper was delayed due to unavailability of staff during the COVID pandemic and is expected to be completed by the end of 2021. (iii) The project is expected to produce a range of outputs, including ((i) multiple academic conference presentations to general economics (e.g. the Annual Royal Economics Society conference) and health economics audiences (e.g. the annual meeting of the UK Health Economists Study Group); (ii) an IFS working paper (see above); (iii) the submission of a journal article to a leading peer-review economics journal, such as the Review of Economic Studies (Impact Factor: 4.038) or the Journal of Health Economics (IF: 2.579); (iv) a non-technical policy summary, which will be press released and sent to contacts at the Department of Health and NHS England. [1 paragraph unchanged] Outputs (ii) – (iv) require access to linked mortality data for completion. These outputs required the same data as project (i) 4.1 – now that IFS has received the data publication and submission of [25 words unchanged] presented at the 2019 European Economics Association Annual Conference in August 2019. [1 paragraph unchanged] New projects Update (December 2023): An IFS working paper was published in August 2022, along with a press release describing the findings of the work. The paper was subsequently submitted to several leading economics journals (including the Quarterly Journal of Economics and the American Economics Review), where referee reports were received and used to edit the paper. Following submission to the Journal of Political Economy: Microeconomics, a revised manuscript has been requested (December 2023). A revised version of the paper will be submitted in early 2024, and will hopefully be accepted later that year. a) There will be four principle outputs: (i) academic presentations at leading economics conferences (including the RES, EEA etc); (ii) a working paper, published under the IFS working paper series; (iii) a peer-reviewed journal article in a leading general purpose economics journal and (iv) a non-technical summary for policymakers. Projects added in v5: Work on this project has been delayed due to a lack of outpatient data for the final years. Upon receipt of the data IFS will begin analysis. IFS would therefore expect to present results in Autumn 2020, and publish a working paper and submit to a journal in 2021. Project 5.1: There will be four principle outputs: (i) academic presentations at leading economics conferences (including the RES, EEA etc); (ii) a working paper, published under the IFS working paper series; (iii) a peer-reviewed journal article in a leading general purpose economics journal and (iv) a non-technical summary for policymakers. Work on this project has been delayed due to a lack of outpatient data for the final years. Upon receipt of the data IFS will begin analysis. IFS would therefore expect to present results in Autumn 2020, and publish a working paper and submit to a journal in 2021. Output (iv) will be published following publication of the working paper. Dissemination [12 words unchanged] Department of Health and NHS England about the project design and results. [1 paragraph unchanged] b) There will be four principle outputs (presentations, a working paper, at least one peer-reviewed journal article submitted to a leading economics journal, and a non-technical summary) similar in nature to those outlined above. IFS would expect to present the work in late 2020 and early 2021, and publish outputs (ii) – (iv) in 2021. Update (December 2023): Progress on this paper continued to be delayed throughout 2021 and early 2022 due to staffing constraints. Progress is still ongoing, with a IFS working paper and submission to the Journal of Health Economics (or a similarly ranked economics journal) expected in Summer 2024. Update (June 2021): Progress on this paper was delayed due to unavailability of staff during the COVID pandemic. We would now expect to publish a working paper in Spring 2022. Project 5.4: Over the next two to three years, IFS envisage at least one or two IFS working papers. These papers are read by IFS affiliated researchers, other academic researchers and policy practitioners who follow IFS outputs. IFS expect also one or two more technical research papers that involve in-depth discussion of methodological issues. These papers are aimed at a journal in empirical industrial organization, applied econometrics or health economics; IFS anticipate submission to the Economic Journal (impact factor 2.370 in 2015) or the RAND Journal of Economics (impact factor 1.465 in 2016). The research will be presented at university research seminars and international conferences, e.g. the annual conference of the Royal Economic Society; and, as was done with earlier work on related topics, IFS expect to interact with NHS Improvement and health charities such as the Health Foundation. c) There will be four principle outputs (presentations, a working paper, at least one peer-reviewed journal article submitted to a leading medical or economics journal, and a non-technical summary). IFS would expect these outputs to be delivered in 2020. Update (June 2021): Progress on this paper was delayed due to unavailability of staff during the COVID pandemic and has pushed the timeline on the project back by around a year. d) Over the next two to three years, IFS envisage at least one or two IFS working papers. These papers are read by IFS affiliated researchers, other academic researchers and policy practitioners who follow IFS outputs. IFS expect also one or two more technical research papers that involve in-depth discussion of methodological issues. These papers are aimed at a journal in empirical industrial organization, applied econometrics or health economics; IFS anticipate submission to the Economic Journal (impact factor 2.370 in 2015) or the RAND Journal of Economics (impact factor 1.465 in 2016). The research will be presented at university research seminars and international conferences, e.g. the annual conference of the Royal Economic Society; and, as was done with earlier work on related topics, IFS expect to interact with NHS Improvement and health charities such as the Health Foundation. [1 paragraph unchanged] All outputs will be aggregated with small numbers suppressed in line with the HES Analysis Guide. STATUS (December 2023): Work on this project is ongoing, with working papers and conference presentations expected in 2024. New projects (Added in v7) Project 7.1: The analysis will produce a wider range of outputs in different form. This includes (i) presentations to analysts and policy teams at the Department of Health and Social Care and NHS England (arranged through the NIHR Health and Social Care Workforce PRU), (ii) presentations at economics and health economics conferences, (iii) working papers published as part of the IFS working paper series and made available on the IFS website, (iv) peer-reviewed open access journal articles at economics and/or health research services journals and (v) non-technical research summaries published on the IFS website and shared with relevant stakeholders (including those listed above in relation to outputs (i)). IFS work expect to present work and publish outputs (ii) – (v) throughout the duration of the data agreement (up to November 2026). Project 7.2: The analysis will produce a range of outputs: (i) presentations at economics and health economics conferences (including the Health Economics Study Group), (ii) a working paper published as part of the IFS working paper series and available on the IFS website, (iii) a peer-reviewed open access journal article at an economics journal, and (iv) a non-technical research summary published on the IFS website and shared with relevant stakeholders. IFS would expect to present the work in late 2024 and early 2025, and publish outputs (ii) – (iv) in 2025 (final publication may extend beyond this depending on how long the peer review process takes) . Project 7.3: The analysis will produce a range of outputs: (i) presentations at economics and health economics conferences, (ii) a working paper published as part of the IFS working paper series and available on the IFS website, (iii) a peer-reviewed open access journal article at an economics journal. IFS would expect to present the work in 2024 and early 2025, and publish outputs (ii) – (iv) in 2025 (final publication may extend beyond this depending on how long the peer review process takes). Project 7.4: The analysis will produce several outputs in different formats: (i) presentations at international economics and environmental economics conferences, (ii) two working papers published on the IFS website, (iii) two peer-reviewed open-access journal article at economics journals, (iv) non-technical research summaries shared with relevant stakeholders. IFS expects to start presenting the work in late 2024 and submit outputs for publication in 2025-early 2026. Project 7.5: The analysis will produce a range of outputs: (i) presentations at economics and health economics conferences (including the Health Economics Study Group), (ii) a working paper published as part of the IFS working paper series and available on the IFS website, (iii) a peer-reviewed open access journal article at an economics journal, and (iv) a non-technical research summary published on the IFS website and shared with relevant stakeholders. IFS would expect to present the work in 2025 and 2026, and publish outputs (ii) – (iv) in 2026 (final publication may extend beyond this depending on how long the peer review process takes). Research using HES data under this agreement has already yielded a number of academic publications (all of which have been accompanied by non-technical summaries and are open-access). These academic articles are examples of the papers that IFS aim to produce in future for the projects stated above. Examples of these completed publications include: 1) E. Kelly, G. Stoye and M. Vera-Hernandez (2016), ‘Public hospital spending in England: Evidence from National Health Service administrative records’, Fiscal Studies, Vol 37(3-4). 2) E. Kelly and G. Stoye (2020), ‘The impacts of private provider entry on the public market for elective care in England’, Journal of Health Economics, Vol 73. 3) W. Beckert and E. Kelly (2021), ‘Divided by choice? For-profit providers, patient choice and mechanisms of patient sorting in the English National Health Service’, Health Economics, 30(4):820-839 4) R. Crawford, G. Stoye and B. Zaranko (2021), ‘Long-term care spending and hospital use among the older population in England’, Journal of Health Economics, Vol 78. 5) E. Fitzsimons and M. Vera-Hernandez (2022), ‘Breastfeeding and Child Development’, American Economic Journal: Applied Economics, Vol 14(3):329-66. 6) T. Hoe (2022), ‘Does hospital crowding matter? Evidence from Trauma and Orthopedics in England’, American Economic Journal: Economic Policy, Vol 14(2):231-62. 7) J. Gruber, T. Hoe and G. Stoye (2023), ‘Saving lives by tying hands: the unexpected effects of constraining health care providers’, Review of Economics and Statistics, 105(1). 8) G. Stoye and M. Warner (2023), ‘The effects of doctor strikes on patient outcomes: evidence from the English NHS’, Journal of Economic Behavior and Organization, 212(2023):698-707. All outputs will be aggregated with small numbers suppressed in line with the HES Analysis Guide

Expected measurable benefits

[1 paragraph unchanged] (1) The model of hospital choice can be used to model how patients respond to potential policies, such as the reorganization of hospital services, or hospital mergers. The focus on equity is in line with NHS England principles of promoting equality and equity in provision, and the objectives of the Department of Health and Social Care (DHSC). IFS will liaise with the DHSC to understand how the model could be more useful to them, and following publication in an economics journal, IFS will communicate key findings with DHSC. Project 0.3: Demographic pressures are set to continue to be a pressing concern for the NHS over the coming years, with various forecasts indicating cost and demand pressures of around 4% on the NHS budget over the next 15 years (Charlesworth et al., 2018; OBR, 2018). Understanding how health spending changes with age, how this relationship has changed over time, and which factors influence this (e.g. availability of social care for older people, broader changes in life expectancy etc) is a key input in forecasting and meeting future demand for NHS care. The work is also extremely relevant for NHS Improvement in their role in promoting hospital quality, and the work on the impact of competition on patient outcomes by the Competition Markets Authority (CMA) (see Whitehouse and Shiraldi (2019) for a recent summary of this work). Understanding to what extent patients exercise choice in choosing hospitals, and which characteristics of the hospitals are most important to them, is fundamental in evaluating the extent to which competition drives hospital behaviour, and ultimately what this means for patients. The model will therefore be used to inform these regulators in their work on competition. The results of the work will be disseminated directly through existing contracts o the relevant teams at NHS-I and the CMA when the results are finalised (with preliminary results already presented to NHS-I), and further benefits are expected to accrue after this time. (2) Policies of the previous two parliaments have increased the role of the private sector in delivering NHS funded care, yet there is very little evidence on the impact of these providers on the impact for NHS funded care. This research will help inform policy makers of the potential effects on patient demand, health care supply, the financial implications for NHS providers, and the equity of provision if the role of these providers is expanded in the future. These issues are of importance to the Department of Health, Monitor, the Cabinet Office and NHS England. Thus far, this has been demonstrated by both the Cabinet Office and NHS England requesting updates to this work, indicating that this work has the potential to feed into policy-making in the short to medium term. A working paper version of this research was warmly received by a number of representatives from Monitor, including the Economics Director, Cooperation and Competition at Monitor, when presented in September 2013. The role of the private sector in providing NHS care has once again become an important policy and political issue: the 2017 Labour election manifesto announced an intention to remove all private provider involvement from the NHS (while the Conservative manifesto announced that this role – and the internal market in general - could be reviewed). Given the large role that the private sector is now playing in providing some forms of elective care, such a move would have serious consequences for the capacity of the NHS to deliver certain types of care. IFS’s work – using the most up to date data - would show how the role of the private sector role in providing NHS orthopaedic care has evolved over 15 years, and demonstrate how this has impacted both overall capacity and the distribution of care e.g. where have hip replacements most increased, and what type of populations have this most benefitted). This will be disseminated directly to NHS England, and would be submitted as evidence in any public reviews on private sector involvement in the NHS. (Update June 2021): This issue has become even more important in the wake of the COVID pandemic and discussions about how to meet the large backlog in elective activity. More private sector involvement is one potential way to increase the capacity of publicly funded activity. The evidence from IFS' work could provide important lessons about the potential impacts of a further expansion of the use of the private sector by the NHS in this context, and IFS will reach out to NHS England and DHSC to directly disseminate the findings of their research to maximise the impact of this evidence. The research can therefore directly benefit patients by improving NHS England/DHSC's knowledge of the impacts of private sector involvement, and help them to balance the benefits to patients that come from expanding NHS-funded services (and therefore cutting waiting times) with the potential for increasing health inequalities if private hospital are typically located near to wealthier patients. (3) Demographic pressures are set to continue to be a pressing concern for the NHS over the coming years, with various forecasts indicating cost and demand pressures of around 4% on the NHS budget over the next 15 years (Charlesworth et al., 2018; OBR, 2018). Understanding how health spending changes with age, how this relationship has changed over time, and which factors influence this (e.g. availability of social care for older people, broader changes in life expectancy etc) is a key input in forecasting and meeting future demand for NHS care. [1 paragraph unchanged] (4) Changes in the volume and composition of the population have important implications for the quantity and type of health services demanded by patients. This work will show how rapid population change can affect demand for services, what this means for staffing ratios in these specialties, and therefore help national policymakers (e.g. DHSC), CCGs and Acute Trusts plan for the future. This could be in terms of how to organise primary and secondary care services or how to determine future staffing levels. Project 0.5: The analysis of Sure Start will provide a detailed and thorough cost-benefit analysis of the programme. Sure Start was funded at £1.8 billion in 2010-11 and accounted for a third of government expenditure on early years programmes. Funding per eligible child fluctuated over time but averaged about £6,500 per year. This reflects a considerable government investment in early years interventions, and it is important to understand whether this intervention provided value for money by improving subsequent outcomes. Benefits will accrue after the results are published and disseminated to policymakers. In particular, IFS will communicate findings directly to the team responsible for workforce planning at DHSC. IFS have direct links with this team – working on them with a number of workforce issues (see below) – and therefore have a direct route to dissemination through this relationship. IFS will also reach out to providers to disseminate findings of the work to them and help them to understand the impact of low staff-patient ratios in maternity care. This work was funded by the Health Foundation, who have a close relationship with a large network of Trusts and CCGs, and who will help IFS to speak to these interested parties. IFS have already discussed findings with the North East London Sustainability and Transformation Planning Team (NELST), and hospital managers at St Guys and Thomas. These discussions (also relating to project ii) helped NELST to internally review their provision of maternity care (underway in December 2016) following large increases in the number of mothers seeking care at their hospitals. IFS will continue this dissemination further following publication of the results. (5) The analysis of Sure Start will provide a detailed and thorough cost-benefit analysis of the programme. Sure Start was funded at £1.8 billion in 2010-11 and accounted for a third of government expenditure on early years programmes. Funding per eligible child fluctuated over time but averaged about £6,500 per year. This reflects a considerable government investment in early years interventions, and it is important to understand whether this intervention provided value for money by improving subsequent outcomes. [1 paragraph unchanged] Poor child health generates substantial costs for children, their families and the [75 words unchanged] 8). Potential long-run costs could be in excess of £2 billion (ibid). Using HES to understand whether Sure Start is an effective way to reduce the rate of these hospitalisations is a concrete example of how IFS hope to add value to the health and social care system. Understanding the role of community based health services is vital in designing new models of care that both deliver better value to the patient and their families, and help the NHS to continue to deliver high quality care with constrained resources. Using HES to understand whether Sure Start is an effective way to reduce the rate of these hospitalisations is a concrete example of how IFS hope to add value to the health and social care system. Understanding the role of community based health services is vital in designing new models of care that both deliver better value to the patient and their families, and help the NHS to continue to deliver high quality care with constrained resources. [4 paragraphs unchanged] (6) The analysis has already delived benefits through our interaction with NHS Improvement and NHS England, with the results showing that the policy improved patient outcomes and the main mechanism through which these health improvements were achieved (i.e. quicker treatment time for those with acute and time-sensitive conditions such as stroke) are consistent with at least some of the newly proposed A&E standards (e.g. Critical Time Standards). Future analysis will examine these channel further to improve knowledge about which patients are most affected by the target and how a stricter target would affect patients with different diagnoses. This will enable policymakers (in particular, NHS Improvement and the Department of Health) to evaluate which target level they wish to implement and which diagnoses to include in the Critical Time Standards definition, by clearly setting out whether the potential benefits of a stricter policy target (through reduced waiting times) are outweighed by increased distortions to treatment decisions (through excessive or insufficient admissions) and/or unfavourable patient outcomes. The work has previousloy been discussed with NHS Improvement’s Emergency Care Improvement team, and the NHS Improvement Economics team. IFS will hold further discussions with NHS Improvement and NHS England to ensure that the findings are presented in a way that enables practical implementation. Benefits to commissioning (and eventually to patient care), will therefore be achieved through increasing NHS Improvement/England’s knowledge of the effects of the target on patient health and hospital decision-making. (9) This work will increase knowledge of the effects of breastfeeding on child health, particularly for low socio-economic status patients. This knowledge will enable national commissioners (particularly NICE) to make clearer recommendations for breastfeeding practices. This will benefit the system by improving child health and cognitive development, and potentially reducing future healthcare and education costs. IFS will communicate this knowledge to commissioners and practitioners through press-releasing the research findings, and seeking meetings with contacts at NICE. This project informs on the benefits measured using children’s cognitive development as well as health measures which are independent of health care use (anthropometric measures). The potential benefits of this work in helping to inform about best practices in breastfeeding will be realised by directly communicating the findings to the relevant policymakers. This process has already begun, with a presentation of preliminary results of project given to DHSC in February 2019. IFS will continue this engagement with DHSC following results being finalised, and with UNICEF. IFS will also ask their existing contacts at DHSC to help IFS to communicate the results with other important stakeholders, including NICE and the Nursing and Midwifery Council. (10) Hospital crowding has a well established potential to negatively impact patient outcomes (Hoot and Aronsky, 2008). However, hospitals must also trade off levels of crowding against waiting times for treatment (i.e. reducing crowding leads to fewer patients being treated, and therefore extending waiting times). These waits in themselves may negatively impact patients, and performance against NHS elective waiting time targets have recently fallen to 10 year lows. The aim is to inform and influence policy making relating to emergency admissions in England in a way that improves patient care. By demonstrating how emergency admissions can negatively affect patient care (through increasing crowding), and evaluating the role of past and future policies on this, the research will enable policymakers (e.g. Department of Health, NHS Improvement) to examine the existing reaction of hospitals to crowding, and to consider options that mitigate the effects of emergency admissions on patient care. This would provide knowledge and evidence that speaks directly to immediate policy concerns about shortages of capacity in the NHS. Progress has already begun in engaging policymakers on this issue through a public presentation of the work (see existing outputs in the "outputs" section, purpose 15) and a presentation at NHS Improvement. After results are finalised (after the paper is accepted for publication at a journal) IFS will continue to directly disseminate results to NHS Improvement, and to the Department of Health. This research is timely given recent increases in crowding, as widely noted by the media and poor performance against waiting time targets, and will provide these policymakers with rigorous evidence on the trade-offs between decreasing crowding and increasing waiting times, and what this ultimately means for patient health. [1 paragraph unchanged] i) The NHS invested heavily in establishing 24/7 PCI centres following the 2008 National Infarct Angioplasty Project (NIAP) review and updating of the NICE guidance with respect to the treatment of heart attack patients. Heart attacks are a serious but common condition, with other 60,000 cases treated in NHS hospitals each year. Project 4.3: Consultants play a crucial role in the delivery of NHS healthcare. However, little is understood about the extent to which patient outcomes depend on the individual consultant who is responsible for their care. This project will provide evidence on the distribution of consultant effects. IFS will meet with NHS England and the Department of Health to discuss the results of their analysis and how the model could be used to guide policy to benefit the health and social care system (DHSC are already aware of this work through their involvement in the DHSC Policy Research Unit programme, and this offers a direct route for dissemination of results and subsequent policy influence). The rollout of the PCI centres was a high profile and expensive policy, based on the findings of medical trials that indicated that substantial reductions in mortality following a heart attack could be achieved by changing treatment (Stukel et al., 2007). However, work in the US previously showed that the real-world benefits of implementing a similar policy did not achieve the health benefits for patients that were suggested by the previous medical trials (Cutler, 2007; McClellan et al., 1994), This research therefore examines the impact of establishing the PCI centres on patient care and outcomes following heart attacks in England. The preliminary results suggest that the changes had little effect on mortality (in contrast to what was hoped for based on the medical trials), but out-of-hospital data are required to fully quantify these effects. These results are important for health care in England, suggesting that the treatment is not as effective as expected or hoped for. The work should also shed light on why the treatment was less effective: possibly due to delays in treatments for patients or geographical variation in the quality of the treatment delivered. IFS will disseminate the results directly to NICE in order to increase their evidence base on the effectiveness of heart attack treatment, which in turn should have positive benefits for patients with these conditions. These benefits are expected to accrue after dissemination, and should have lasting impacts on patient care going forward. ii) Results from this project will show how patient volumes and crowding affect the quality of maternity care. Existing work (from other countries) has shown that crowding in maternity units has significant negative impacts on patients who are admitted on days of the week where wards are crowded (Macfarlane, 1978; Palmer et al., 2015). This project will extend this work to examine the impacts of crowding in the context of the NHS. The project also examines a more extensive set of outcomes for patients and the types of treatment undergone. Preliminary results show that the number of mothers waiting for discharge in the maternity unit is strongly correlated with the incidence of critical incidents and emergency readmissions. Crowding also leads to significantly higher costs as use of emergency C-sections and spell length all increase considerably. The rising use of C-sections is an unexplained and important policy issue (Lancet, 2018; WHO, 2018) among policymakers, and this research will provide clear evidence of a relationship between crowding and the incidence of this procedure. These results are important in planning hospital responses to crowding in their maternity wards, and potentially provide information about how patient care could be changed in the face of rising demand. This could benefit patients in the longer term if hospitals modify their behaviour (either through increasing staff, or organising wards differently to ease crowding). IFS will disseminate the results to stakeholders, including the Royal College of Midwives and DHSC. IFS have existing links with the RCM through which to communicate the findings. Preliminary results were presented to a RCM policy officer, and she reported that she would speak to Head of Midwifery units about them. Further dissemination among these groups will take place after publication of the results, with benefits to the health care system realised after this. (iii) Consultants play a crucial role in the delivery of NHS healthcare. However, little is understood about the extent to which patient outcomes depend on the individual consultant who is responsible for their care. This project will provide evidence on the distribution of consultant effects. IFS will meet with NHS England and the Department of Health to discuss the results of their analysis and how the model could be used to guide policy to benefit the health and social care system (DHSC are already aware of this work through their involvement in the DHSC Policy Research Unit programme, and this offers a direct route for dissemination of results and subsequent policy influence). [1 paragraph unchanged] Similar work has been carried out in the past in the United [25 words unchanged] states used similar models to produce publicly available ‘report cards’ for hospitals. Economic evaluations of the adoption of these hospital performance measures have indicated substantial improvements in the quality of care received by patients at previously poorly-performing providers. For example, researchers found a reduction of a third in the mortality rate of patients undergoing coronary artery bypass graft surgery in New York State between 1991 and 1997 in hospitals which had received a ‘high-mortality’ flag in the previous year (Cutler, Huckman and Landrum, 2004). Similarly, surgeon-specific report cards in Pennsylvania led to significant improvements in risk-adjusted mortality rates in the following years (Kolstad, 2013). New projects Economic evaluations of the adoption of these hospital performance measures have indicated substantial improvements in the quality of care received by patients at previously poorly-performing providers. For example, researchers found a reduction of a third in the mortality rate of patients undergoing coronary artery bypass graft surgery in New York State between 1991 and 1997 in hospitals which had received a ‘high-mortality’ flag in the previous year (Cutler, Huckman and Landrum, 2004). Similarly, surgeon-specific report cards in Pennsylvania led to significant improvements in risk-adjusted mortality rates in the following years (Kolstad, 2013). a) Equity - the equal availability of healthcare services to all citizens on the basis of need – was a founding principle of the NHS and continues to be a priority for policymakers. The project will increase understanding of the role played by education in driving differences in healthcare use across different socio-economic groups, and help policymakers design policy to reduce such inequalities. IFS will meet with representatives from the Department of Health, NHS England NHS Improvement to discuss the design of the project and disseminate results. These organizations are already aware of IFS work on healthcare inequalities, and are all members of the advisory group for the Health Foundation funded project on this topic (see Section 8b for funding details), allowing direct dissemination through existing contacts. Projects Added in v5: b) This research will provide much-needed evidence on how different mixes of staff (both in terms of seniority and in occupations) impact patient outcomes. Understanding of these issues to date has been limited both by a lack of available data on patient outcomes and staffing, and a lack of experimental variation to study (provided by the industrial action in this case). Project 5.1: Equity - the equal availability of healthcare services to all citizens on the basis of need – was a founding principle of the NHS and continues to be a priority for policymakers. The project will increase understanding of the role played by education in driving differences in healthcare use across different socio-economic groups, and help policymakers design policy to reduce such inequalities. IFS will meet with representatives from the Department of Health, NHS England NHS Improvement to discuss the design of the project and disseminate results. These organizations are already aware of IFS work on healthcare inequalities, and are all members of the advisory group for the Health Foundation funded project on this topic (see Section 8b for funding details), allowing direct dissemination through existing contacts. The challenges faced by the NHS in finding sufficient staff numbers to meet increasing demographic pressures is broadly recognised (Buchan et al., 2017). Meanwhile there have been very large compositional changes within the medical workforce, with large increases in consultant numbers but much smaller increases in junior doctors and nursing staff (Buchan et al., 2017; Lee and Stoye, 2018). This means that the composition of teams providing healthcare have undergone large changes in recent years. Understanding how these changes in the ratio of senior and junior doctors may have impacted patient outcomes is important in understanding where recruitment and training efforts should be targeted in future, and how hospitals should rota staff together. Project 5.4: Reforms of the English NHS over the last two decades have turned on the premise that in a system of regulated national tariffs the introduction of competition can induce health care providers to compete on quality and thereby incentivize them to invest in quality enhancement. This mechanism relies on patient choice in response to differential provider quality whereby choice is exercised through mandated GP advice and referral. Therefore, a proper and robust understanding of the incentives and relative contributions of GPs and patients in the choice process is essential to maximize the extent to which patient choice benefits patients and acts as a lever of competition in the English health care sector. IFS will liaise with NHS Improvement and the Competition and Markets Authority to ascertain that IFS's analysis can contribute to, and ideally enhance, their work. The research therefore has the potential to make important contributions to the understanding of how teams produce healthcare and what this means for patient outcomes. This in turn has the potential to produce benefits for NHS patients by feeding into NHS workforce planning. These benefits will be achieved by working directly with the DHSC teams responsible for the analysis and long-term planning of the hospital workforce. More generally, IFS are working directly with DHSC on NHS workforce issues as part of the DHSC Policy Research Unity (runs January 2019 to December 2023, and renewed to December 2028 in late 2023). Through this relationship the department is aware of all IFS projects that relate to NHS staff (in terms of staff-patient ratios, and in staff behaviour) and productivity. This is particularly relevant to projects 0.4, 0.6, 4.2, 4.3 and b. This relationship provides a direct dissemination route for the findings in the DHSC team responsible for NHS workforce planning and analytics, and connected teams within DHSC and other policy bodies (e.g. NHS England, Health Education England and NHS Improvement), and increases the potential for findings to benefit patients within the health and social care system by informing and influencing policy. IFS have strong existing links with these teams, both through current work that IFS are doing with the workforce team at DHSC on the factors related to recruitment and retention of NHS staff, and as a member of the DHSC Workforce Policy Research Unity (2019 – 2023). Results can therefore be disseminated easily to the relevant national policymaker working in this area. IFS would discuss the project as it progresses with DHSC, and then disseminate final results when the paper is published. Benefits would therefore be expected to start during this dissemination progress and last into the future through the research’s impact on long-term planning for NHS workforce. New Projects (Added in v7) c) Worldwide, the use of opioids has increased dramatically over the last two decades. In the UK the number of opioid prescriptions doubled between 2000 and 2012, raising fears about the misuse of these drugs (https://www.pharmaceutical-journal.com/news-and-analysis/a-crisis-hidden-in-plain-sight-prescription-opioid-misuse-in-the-uk/20203928.article). Project 7.1: How to recruit, retain and motivate NHS and social care staff is possibly the biggest issue faced by the health and social care system at present. Recent policy initiatives (such as the Nurse 50k programme) have aimed to boost staff numbers in the NHS, and the recent Long-Term Workforce Plan sets out plans to hire thousands of additional staff over the next decade (NHS England, 2023). The social care sector is also facing a huge challenge in recruiting and retaining staff, with an estimated 152,000 vacancies in 2022/23 (Skills for Care, 2023). However, the evidence base on the factors that affect retention, recruitment and performance of staff in these sectors – and ultimately what this means for the health outcomes of people using these services – is extremely limited. This makes designing effective staffing policies extremely difficult. However, little is known about how use varies across the country, or what drives the use of opioids (and therefore any subsequent negative consequences). This project will expand knowledge of where opioids are most frequently prescribed, and help to inform policymakers and practitioners about the extent to which opioid use has been driven by rationing of other forms of NHS care. IFS will use existing contacts at Public Health England to disseminate this work among policymakers. IFS are also collaborating with UCL Department of Primary Care and Population Health, who will use their links with primary care practitioners to disseminate findings directly to GPs. This work will generate crucial new evidence on the factors that affect retention, recruitment and performance by staff in the NHS and social care sector, and what this means for health outcomes of NHS patients and adult social care users. Studying how policy changes and economic shocks have affected labour supply in these sectors will provide new information to policymakers setting wages (directly in the case of the NHS, and indirectly through local government financial settlements in the case of the social care sector) and setting policies that affect working wider conditions for staff. This will directly feed into policy decisions that affect staff, and in turn, their patients. d) Reforms of the English NHS over the last two decades have turned on the premise that in a system of regulated national tariffs the introduction of competition can induce health care providers to compete on quality and thereby incentivize them to invest in quality enhancement. This mechanism relies on patient choice in response to differential provider quality whereby choice is exercised through mandated GP advice and referral. Therefore, a proper and robust understanding of the incentives and relative contributions of GPs and patients in the choice process is essential to maximize the extent to which patient choice benefits patients and acts as a lever of competition in the English health care sector. IFS will liaise with NHS Improvement and the Competition and Markets Authority to ascertain that IFS's analysis can contribute to, and ideally enhance, their work. IFS will maximise the potential impact and benefits of this research by working closely with the Department of Health and Social Care and NHS England. As part of the NIHR Health and Social Care Workforce Policy Research Unit, IFS researchers will have discussions with DHSC and NHS England analysts to understand which shocks and which staff groups are policy priorities, and this will guide IFS to focus on groups where the research can have the biggest impact and where there is currently a shortfall in evidence. These connections will make sure that the work is disseminated directly to analysts and policy teams making decisions within DHSC and the NHS, again maximising the impact of the work. Wider dissemination to other researchers, other stakeholders and through the media will ensure that the lessons learnt from the research will feed into the wider debate about staffing policies. More generally, IFS are working directly with DHSC on NHS workforce issues as part of the DHSC Policy Research Unity (runs January 2019 to December 2023). Through this relationship the department is aware of all IFS projects that relate to NHS staff (in terms of staff-patient ratios, and in staff behaviour) and productivity. This is particularly relevant to projects 4, 6, ii, iii and b. This relationship provides a direct dissemination route for the findings in the DHSC team responsible for NHS workforce planning and analytics, and connected teams within DHSC and other policy bodies (e.g. NHS England, Health Education England and NHS Improvement), and increases the potential for findings to benefit patients within the health and social care system by informing and influencing policy. Project 7.2: A&E departments are currently facing many pressures, with very high waiting times relative to targets, delayed ambulance handovers, and challenges admitting patients when bed occupancy is very high. Even pre-pandemic, it was a stated aim of NHS England to reduce pressure on A&E departments, in part by reducing attendances (NHS Long Term Plan, 2019). This aim has been re-iterated in NHS England’s Delivery Plan for Recovering Urgent and Emergency Care Services, alongside objectives to reduce A&E waiting times, improve capacity and improve processes. This work will help improve understanding of the determinants of A&E performance. Because A&E departments are complex systems, this makes it hard to understand how changes in factors may change performance. The structural economic model will therefore be used to understand and predict how changes in i) patient demand ii) hospital capacity and bed occupancy iii) staffing will affect A&E waiting times and other outcomes. This will help policy makers and practitioners understand how they can improve and forecast A&E performance. Ultimately, improvements in A&E performance will help improve the speed and quality of care that patients receive. IFS will present and discuss the work with relevant stakeholders, including NHS England, DHSC and hospital trusts. Another major focus of NHS England is healthcare inequalities. By examining differences in the responsiveness to A&E waiting times by characteristics like ethnicity and local area income deprivation, the work will be able to quantify the extent to which A&E waiting times create unequal access to emergency healthcare. If there are large differences for particular groups, IFS will present and discuss the findings with health inequalities experts to better understand how the NHS might be able to mitigate the factors driving these differences. Project 7.3: The UK government has pledged £2.4bn to implement AI and robotics into the NHS. This followed surgeons urging the NHS to embrace new technologies to tackle future crises and global challenges. However, evidence that robots improve surgeons' performance is scarce, and doubt persists on whether this expensive technology is worth the enthusiasm of practitioners. The role of this study is to explore the transformative potential of new technologies and in particular surgical robots. In particular, two benefits will accrue. First, the study will provide evidence on the effect of robots on the outcomes of patients in the English NHS, therefore offering a first piece of evidence on the actual potential of this machine to deliver on its promises. Second, the study will evaluate the potential of robots to address long-standing inequalities in the delivery of high-quality services. The study attempts to reveal that robots can significantly reduce hospital stays and decrease adverse events from surgery. However, it also plans to highlight the role of surgical expertise in realising these benefits. The advent of robots in healthcare, as proposed by this research, may represent a pivotal step towards enhancing patient experiences and safety, but also an important tool to reduce disparities in the quality of care. Project 7.4: The analysis will shed light on the air quality and health benefits of recently implemented green policies. The health and social care costs of air pollution in England reached £43 million in 2017 according to a 2018 report (Public Health England, 2018), due to air pollution’s association with increased coronary heart disease, stroke, lung cancer and child asthma. The report warned that these costs could reach £5.3 billion by 2035 in the absence of further reduction in air pollution. IFS will examine how successful recent policies were at reducing air pollution’s health costs. This analysis can shed light on relevant policy directions to continue decreasing these costs for the healthcare system by 2035. Part of the policies that IFS will consider have air quality improvements and related health improvement as their main policy objective (e.g, the London Low-Emission Zone), while others primarily aim at decarbonizing the UK economy in line with the government’s net zero strategy (e.g, the Carbon Price Support). Both types of policies have in common to generate salient costs to well-identified groups of the population, such as car commuters (in the case of the London LEZ) or energy-intensive industries (in the case of the Carbon price Support), with a risk of policy backlash. Low-emission zones and subsidy schemes for cleaner transport also represent a significant amount of public money for local councils and the central government. For example, between 2010 and 2015 £500 million were invested to support the ultra low-emission vehicle industry, including funding for low emission zones and cleaner buses. In light of the costs imposed by these policies to individuals, firms and taxpayers in general, it is crucial to understand the extent to which they deliver benefits in terms of improved health and reduced healthcare costs, and to whom these benefits accrue. Using HES data is crucial in answering these questions for two reasons. First, having individual-level data allows to control for many unobserved individual characteristics correlated with pollution exposure, such as socio-economic status or awareness of air pollution levels. Having rich demographic characteristics on individuals also makes it possible to identify the subgroups of individuals more vulnerable to pollution, who also benefit the most from policy-driven air quality improvements. Second, IFS will be able to quantify any monetary benefits of the policies in terms of avoided treatment costs using information on the HRG of the spells. This is in contrast to many other studies analysing the effect of air pollution in the UK, or to studies evaluating the benefits of green transport policies in other countries (Margaryan, 2021, Pestel and Wozny, 2021). IFS are strongly committed to reaching out to policymakers to disseminate the findings. Dissemination will involve writing up non-technical reports and publishing them on IFS website, communicating the results through press releases, and reaching out directly to health and environmental policy-makers at the NHS, the UK Health Security Agency, and DEFRA. Project 7.5: The discharge of sewage into rivers and around the UK coast has become increasingly common in recent years, and has often been highlighted by media reports. With climate change exacerbating these events (which are currently legally permissible during heavy periods of high rainfall), current regulations may provide inadequate in preventing harms to population health. Despite this pressing issue, there is little evidence on the health effects experienced by local residents exposed to compromised water quality. This study will provide new evidence on the impacts on population health of sewage spills and poor water quality. Moreover, it will quantify the financial burden on the NHS of treating patients suffering from water-pollution related illnesses. This will provide policymakers with evidence on the costs of sewage spills to population health, feeding into a comprehensive cost-benefit analysis of revisions to water quality regulation.

Benefits reported

Previous and ongoing IFS work with data provided by NHS Digital England has formed the basis of discussions with a wide range of policymakers (e.g. Department of Health, DHSC, NHS England, NHS Improvement, Cabinet Office, representatives from PCTs and CCGs, PCTs/CCGs, Royal Colleges etc) within the health and social care system. As previously noted by the DHSC, in a letter to accompany this our application, the work and subsequent discussions help to build knowledge about specific policies or broader policy areas. It is hoped that the evidence produced by the work can then feed into policy decisions in future. In particular, IFS researchers work closely teams at DHSC and NHS England in their role within the NIHR Health and Social Care Workforce Policy Research Unit (active from 2019 to 2023, and recently renewed to 2028). This provides a direct dissemination route for the research to the national policymakers setting policy in the health and social care space. Particular benefits include: The agreement covers multiple projects, all of which aim to generate new evidence that feeds into policymaking decisions. Several of these projects are ongoing, and their benefits have not been realised yet. - Two research reports related to project 2 were published in 2012 (‘Choosing the place of care’) and in 2013 (‘Public pay and private provision’) respectively, and widely disseminated among relevant policymakers. This included discussions with Monitor, DH, NHS England and the Cabinet Office Economics Team. The results were also presented at the Nuffield Trust’s Competition for Care conference in May 2013, alongside speakers and delegates from the Competition and Cooperation Panel, Monitor, NHS England, and the NHS Confederation. These findings provided evidence of the growth of the private sector that was discussed by this set of policymakers as part of their policy making process Particular realised benefits include: - Two research reports related to projects 0.1 and 0.2 (studying the impact of private providers and patient choice in the NHS) were published in 2012 and 2013, and widely disseminated among relevant policymakers. This included discussions with Monitor, DH, NHS England and the Cabinet Office Economics Team. The results were presented at the Competition for Care conference in May 2013, alongside delegates from the Competition and Cooperation Panel, Monitor, NHS England, and NHS Confederation. The work provided evidence of the growth of the private sector that was discussed by this set of policymakers as part of their policy making process (Update June 2021): Building upon this, a A non-technical summary of the use of private providers in the NHS was released in November 2019, an article was and articles were published in the Journal of Health Economics in September 2020 (the Journal of Health Economics is the top health economics journal, with an impact factor of 2.8), and an article was published in Health Economics in February 2021 (see project 1). 2021. These publications provided detailed evidence of the use of private providers in [10 words unchanged] on health inequalities as a result of private provider entry to NHS markets and the expansion of choice. markets. The lessons learned from this research - namely that private provider entry lead to expansions in publicly funded healthcare capacity with limited impacts on inequality but with no observed improvements in care quality - will be especially important over the coming years as policymakers seek ways to meet the huge post-covid backlogs in NHS elective care that have formed as a result of the pandemic, care, including extending use of private providers for routine operations. - Results from project 3 have been 0.3 (studying inequalities in healthcare) were presented to the DHSC on three separate occasions (June 2016, October 2018, March 2019), with updates on the work (or newly requested extensions) work/extensions requested by DHSC each time. These presentations have been requested by DHSC as part of their evidence gathering on how demand for NHS care is changing (and how it and is likely to change in the future). In particular, future (e.g the March 2019 presentation talk was requested by the Social Care analysis team as part of their preparations for the 2019 Spending Review. Review). The research will therefore potentially influence the future provision of health and social care in England through increasing the evidence based used by DHSC in their decision making processes. In December 2020, we met with the NHS Confederation and the Health for Care Coalition to discuss findings. They have drawn on our research in their subsequent discussions with other NHS stakeholders and policymakers over the financial settlement for, and integration of, health and social care. The findings of the research were also discussed with the National Audit Office in May 2021 in the context of their work on Efficiency in Government, where our work demonstrates the importance of considering the interface between local and central government, and provides robust evidence of spillovers between the two. (Update June 2021): We will shortly approach NHS England and DHSC with updated results, following the publication of the results in the Journal of Health Economics in July 2021 (https://www.sciencedirect.com/science/article/pii/S016762962100062X). - In September 2017, IFS hosted an event attended by a range of policymakers entitled "NHS services in the face of increasing demand - what does it mean for patients?". This included presentations on a range of projects (0.7, 0.10 and 4.2 in this agreement). The event was attended by a wide array of representatives from the Department of Health and Arms Length Bodies (ALBs), the Cabinet Office, health think tanks, several Royal Colleges, charities and patient representatives, and helped to build awareness of the findings of the research among these groups. In December 2020, we met with representatives of NHS Confederation and the Health for Care Coalition to discuss the findings of this project. They have drawn on our research in their subsequent discussions with other NHS stakeholders and policymakers over the financial settlement for, and integration of, health and social care. - In May 2018, IFS published a comprehensive report on NHS and social care funding. This included analysis using HES to examine how NHS activity had evolved over the past 20 years (project 0.3), and how this related to changes in NHS funding over time. The report had 757 print and digital mentions, and 775 broadcast mentions (including BBC 6 and 10 o clock news, BBC national and local radio, Sky News, ITV etc). This report has been influential in the wider debate over NHS funding, widely discussed by MPs of various departments and helping to stimulate public debate over how to fund the NHS, and it was disseminated widely within the Department of Health and NHS England immediately prior to the government announcement of a five-year settlement for NHS funding in June 2018. The findings of the research were also discussed with the National Audit Office in May 2021 in the context of their work on Efficiency in Government, where our work demonstrates the importance of considering the interface between local and central government, and provides robust evidence of spillovers between the two. - The work on the impact of the 4-hour target on patient care in NHS A&E departments (project 0.6) has been widely disseminated among NHS Improvement, the main policymaker responsible for implementing/maintaining the target in NHS hospitals, and discussed with NHS England. During the design of the work, IFS discussed the project at a preliminary stage with the NHS Improvement Emergency Care Improvement Programme to maximise the usefulness of the work. The results of the work were subsequently discussed with the ECIP team and presented to the NHS-I Economics team. The final results of the work (published in the Review of Economics and Statistics, a leading economics journal) showed that the 4-hour target has meaningful impacts for the standard of care provided to patients at a time when hospitals are struggling to meet the target. In particular, health benefits are delivered for patients with time-sensitive conditions. Suggested changes to the 4-hourt target in 2021 included the introduction of ‘critical time standards’ for acute and time-sensitive conditions. IFS researchers shared the work with NHS England, highlighting how effective the original 4-hour target had been when it was routinely being met, and offering suggestions for how any new targets could be implemented to maximise benefits for patients. The research is regularly cited among researchers studying wait time delays and patient outcomes, helping to amplify the knowledge gained from the work. The Royal College of Emergency Medicine cited the work in their written evidence to the Health and Social Care Committee’s inquiry into the situation in accident and emergency departments in January 2023. - In September 2017, IFS hosted an event attended by a range of policymakers entitled "NHS services in the face of increasing demand - what does it mean for patients?". This included presentations on a range of projects (7,10 and ii in this application). The event was attended by a wide array of representatives from the Department of Health and Arms Length Bodies (ALBs), the Cabinet Office, health think tanks, several Royal Colleges, charities and patient representatives, and helped to build awareness of the findings of the research among these groups. - The report produced in 2019 from project 0.5, examining the impacts of Sure Start on childhood health, has been highly cited and influential in debates on how best to support families with young children. The central findings were reflected in the key priority areas of the Leadsom Review (published in March 2021). They have also been cited in prominent reviews of the health care system, including the LSE-Lancet Commission on the Future of the NHS and the Marmot Review 10 Years On, providing evidence on the importance of early-years intervention for promoting better population health (and therefore reducing future demands on the health and social care system). This research has also been influential in other UK nations, with a recent invited keynote at a major Sure Start conference in Northern Ireland. Senior policymakers in Northern Ireland fed back to us that our research was instrumental in the decision this year to continue funding for Sure Start services in the absence of an Executive decision otherwise. - In May 2018, IFS (joint with the Health Foundation) published a comprehensive report on NHS and social care funding. This included analysis using HES to examine how NHS activity had evolved over the past 20 years (under project 3 in this application), and how this related to changes in NHS funding over time. The report had 757 print and digital mentions, and 775 broadcast mentions (including BBC 6 and 10 o clock news, BBC national and local radio, Sky News, ITV etc). In the 7 days after launch, the report had 343 downloads. This report has been influential in the wider debate over NHS funding, widely discussed by MPs of various departments and helping to stimulate public debate over how to fund the NHS, and it was disseminated widely within the Department of Health and NHS England immediately prior to the government announcement of a five-year settlement for NHS funding in June 2018. - Preliminary and final results of the work on the 2016 doctor strikes (published Summer 2023) were discussed with DHSC (5.2). This work was disseminated directly to teams working on workforce planning through the IFS role in the NIHR Health and Social Care Workforce Policy Research Unit (which ran from 2019 to 2023, and has been renewed for a further 5 years starting in January 2024). This provided evidence of the causal impact of past junior doctor strikes on patient outcomes in light of ongoing industrial action (previous evidence on these effects were very scarce and descriptive in nature). These results highlighted that while the strikes had no aggregate effect on patient outcomes, there were negative impacts on some ethnic minority groups, and that both national policymakers and managers in trusts need to carefully plan short-term measures during staff shortages in order to avoid negative consequences for all patients. IFS researchers disseminated these results to hospital managers by writing an op-ed to accompany the publication of the journal article in the Health Services Journal, also discussing why industrial action by doctors in 2023 (and in the future) may differ from the impacts of past strikes. - The work on the impact of the 4-hour target on patient care in NHS A&E departments (project 6) has been widely disseminated among NHS Improvement, the main policymaker responsible for implementing and maintaining the target in NHS hospitals, and discussed with NHS England. During the design of the work, IFS discussed the project with the NHS Improvement Emergency Care Improvement Programme to maximise the usefulness of the work. The results of the work have been subsequently discussed with the ECIP team and presented to the NHS-I Economics team in detail. - Estimates of the benefits of breastfeeding were used in the cost-benefit analysis conducted by DHSC in their business case for the 2020 Spending Review, justifying that the breastfeeding support part of the ‘Early Start’ programme was good value for money. IFS research was critical to quantify the benefits, and was the only evidence showing cognitive effects. In the absence of this work, several of the possible benefits of breastfeeding would not have been valued, and the business case would have undervalued the benefits of breastfeeding interventions. Results have also been disseminated to DHSC in order to estimate how breastfeeding impacts earnings. The Early Start programme will come to an end in 2025, and DHSC have indicated they expect to use these estimated impacts on earnings in the renewal of the funding of the programme, when they will need to submit a new Business Case. (Update June 2021) The work (about to be published in the Review of Economics and Statistics, a leading economics journal) has shown that the 4-hour target has meaningful impacts for the standard of care provided to patients at a time when hospitals are struggling to meet the target. In particular, health benefits are delivered for patients with time-sensitive conditions. Recent changes to the 4-hourt target (confirmed in May 2021) include the introduction of ‘critical time standards’ for acute and time-sensitive conditions. IFS research shows that such a policy would be consistent with improved outcomes for patients, with quicker treatment for these conditions reducing mortality. - (Update June 2021) The report produced in 2019 from project 5, examining the impacts of the Sure Start programme on childhood health, has been highly cited and influential in debates on how best to support families with young children. The central findings around the positive health impacts of joined-up early years services, and the need for ongoing evaluation, were reflected in the key priority areas of the Leadsom Review (published in March 2021). They have also been cited in prominent reviews of the health care system, including the LSE-Lancet Commission on the Future of the NHS (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00232-4/fulltext), and the Marmot Review 10 Years On (https://www.health.org.uk/publications/reports/the-marmot-review-10-years-on), providing evidence on the importance of early-years intervention for promoting better population health (and therefore reducing future demands on the health and social care system).

Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.

Objective for processing

The Institute of Fiscal Studies (IFS) conducts independent research into the effects of economics on health and the health system with the aim to better inform policy makers, practitioners and the general public. The IFS process data in accordance with their legitimate interests under GDPR (Article 6(1)(f) and Article 9(2)(j)), as summarised below: The Institute for Fiscal Studies was founded as an independent research institute, with the principal aim of better informing public debate on economics in order to promote the development of effective fiscal policy. Its research impacts policy makers, think tanks and practitioners and is communicated widely on a national and international scale. On healthcare, IFS focuses on the increased use of market mechanisms within the NHS. They examine the responses of patients, GPs and other healthcare workers to market incentives, and the impacts upon recorded NHS activity and hospital outcomes. The Institute for Fiscal Studies is the sole Data Controller and Data Processor for this application and all work programmes are funded by the Economic and Social Research Council (ESRC) Institute for Public Policy at the IFS. In addition, project (5) is funded by the Nuffield Foundation, and Project B and iii are funded by an ESRC grant ‘The impact of medical labour on variation in patient outcomes: evidence from English public hospitals’. IFS confirm that none of the funders exert any influence over the projects and outputs. This Agreement covers data from 1997/98 to 2017/18. It is important to have data that covers this period for three key reasons. First, a number of the research aims are to investigate the impact associated with different policy changes that have taken place during this period. In each case, IFS need data from before and after the policy change. For example, project (2) studies the impact of introducing private providers into the NHS market for elective care, which took place as part of a set of reforms throughout the 2000s. Having data from before, during and after this period is essential in understanding the changes that took place as a result of these reforms. Second, data from 1997/98 to 2017/18 will provide the longest time series possible. This will allow IFS to better understand trends in NHS activity over time (e.g. in project (a) this allows IFS to examine how NHS activity has developed across birth cohorts, and in project (1) to examine whether the impact of competition has changed over this period. Finally, using data from multiple years helps to maximise sample size. This is crucial in boosting the statistical power of the research, helping to accurately identify and estimate effects. As a result, these data requirements are essential in allowing IFS to carry out the proposed research. The IFS process data in accordance with their legitimate interests under GDPR (Article 6(1)(f) and Article 9(2)(j)), as summarised below: [3 paragraphs unchanged] IFS have a number of research projects being conducted at once. IFS requires has received data from NHS Digital to complete these projects. This agreement Agreement numbers and describes each project aim, processing, outputs and benefits individually individually. Each project will only make use of the data necessary for that particular purpose. IFS are requesting two more supplementary years of hospital episode statistics admitted patient care data (HES APC) to continue working on their projects. Projects from the prior agreement: Original Projects: [1 paragraph unchanged] STATUS: A working paper was produced in August 2017 (published on the IFS website here: https://www.ifs.org.uk/uploads/publications/wps/WP201715.pdf) and was then submitted to a peer-reviewed economics journal. It was initially submitted to the Economic Journal in August 2017 and rejected a few months later. It was then submitted to the Journal of Health Economics in August 2018, and was rejected. The staff member responsible for this project is on maternity leave and will be returning in January 2020. Progress on the project will resume after this. STATUS (June 2021): A working paper was produced in August 2017 (published on the IFS website here: https://www.ifs.org.uk/uploads/publications/wps/WP201715.pdf). A paper has recently been published in Health Economics (https://onlinelibrary.wiley.com/doi/full/10.1002/hec.4223). A non-technical review is currently being written and will be published and disseminated shortly. No new data are requested for this project. No new data are requested for this project, but existing data are required to answer queries that arise as part of the peer-review process. A non-technical review will be published and disseminated after the paper is accepted for publication at a journal (as results may vary slightly following the peer review process). [3 paragraphs unchanged] STATUS: A working paper was initially published on the IFS website in August 2015, and an updated version published in August 2016 (https://www.ifs.org.uk/publications/8451). The paper was initially submitted to the American Economic Journal: Economic Policy in August 2015, and rejected in October 2015. The paper then underwent editing, and was submitted to the Economic Journal in March 2016, and rejected in October 2016. It was then submitted to the Journal of Public Economics in April 2017 and rejected in October 2017. A new version of this was submitted to the Journal of Health Economics in Autumn 2019. This includes updating the paper to cover events over the past few years (the current paper only analyses data up to 2012/13) and therefore requires both the initial data used in the earlier drafts and data that covers the most recent years (up to 2017/18). Dissemination activities would then resume after updating the work and being accepted for publication at a journal. STATUS (June 2021): A working paper was initially published on the IFS website in August 2015, and an updated version published in August 2016 (https://www.ifs.org.uk/publications/8451). The paper was submitted to several economics journal but was not published. A separate, but related, second working paper was published on the IFS website in January 2020 (https://ifs.org.uk/publications/14667) and published in the Journal of Health Economics in September 2020 (https://ifs.org.uk/publications/15249). A non-technical summary of the use of private providers in the NHS was published in November 2019 (https://ifs.org.uk/publications/14593). [2 paragraphs unchanged] STATUS: STATUS (June 2021): These data were initially have been used to publish a working paper and a produce two peer-reviewed article articles, published in Fiscal Studies in 2016 (https://www.ifs.org.uk/publications/8759), (https://www.ifs.org.uk/publications/8759) and a second working paper in Summer 2018 (https://www.ifs.org.uk/publications/13070). IFS are editing this second paper for submission to the Journal of Health Economics. IFS have been waiting for more recent outpatient data from NHS Digital to complete this draft. The working paper is almost complete and should be submitted to the Journal of Health Economics within a month of receiving the final two years of outpatient data from NHS Digital. The data are also being used for a paper on end-of-life medical spending. This paper was submitted to the Journal of Health Economics in Autumn 2021 (https://www.sciencedirect.com/science/article/pii/S016762962100062X). Work is ongoing on a third paper: the first is a working paper was published in September 2019 (https://ifs.org.uk/publications/14326) and was rejected. It is now under review at Health Economics (submitted in October 2019). currently undergoing revisions before being submitted to a journal (Social Science and Medicine). During the research process IFS have liaised with the Department of Health [16 words unchanged] paper in November 2018, and have been invited back for more discussions). [2 paragraphs unchanged] STATUS: STATUS (June 2021): Work began on this project in late 2014, and a draft working [74 words unchanged] to changes in staffing at IFS, and subsequent progress has been slow. However, IFS are now preparing This was further delayed by reduced staffing during the draft for submission COVID pandemic, but work is expected to the Journal of Health Economics. The current draft only uses data up to 2013, and more up-to-date data are required to make the paper more current for submission. resume soon. [2 paragraphs unchanged] STATUS: STATUS (June 2021): This report was launched in June 2019 (available here: https://www.ifs.org.uk/publications/14139). The academic [17 words unchanged] well received, and IFS have received many comments from other academics. IFS expect received additional supplementary funding from the Nuffield Foundation to continue the work going forward. IFS expects to complete a working paper (with submission by the end of 2021, and will submit to a top econ journal) in mid to late 2020. economics journal as well as carrying out further non-technical policy dissemination. . [5 paragraphs unchanged] STATUS: STATUS (June 2021): A working paper was published in March 2018, 2018 and the a revised paper submitted to was accepted for publication in the Review of Economic Studies. The paper is currently Economics and Statistics in its second round of invited revisions at this journal. The data are required to be held to finish all subsequent revisions, and to publish a non-technical summary. February 2021 (https://direct.mit.edu/rest/article/doi/10.1162/rest_a_01044/100991/Saving-Lives-by-Tying-Hands-The-Unexpected-Effects). IFS have also engaged in a number of dissemination activities, which are [9 words unchanged] with the teams responsible for reviewing the 4-hour target at NHS England. The analysis now being extended to examine the potential consequences of changing the 4-hour target in A&E targets in England (as has recently been announced) and a second paper is expected over the next two years. [2 paragraphs unchanged] STATUS: A working paper – which did not use HES data – was first published in 2015, and submitted to an economics journal. The paper was invited to make revisions and resubmit to the American Economic Journal: Applied Economics. Part of the revisions requested by the referees required HES data to check readmission rates across different day of admission. The work using these data has been completed, and the paper has been resubmitted to the journal (decision pending). The data are therefore only required to complete further revisions requested by referees, and to publish a non-technical summary following publication in the journal. STATUS (June 2021): A working paper was published in March 2018 and a revised paper was accepted for publication in the Review of Economics and Statistics in February 2021 (https://direct.mit.edu/rest/article/doi/10.1162/rest_a_01044/100991/Saving-Lives-by-Tying-Hands-The-Unexpected-Effects). IFS have also engaged in a number of dissemination activities, which are ongoing, including presenting at NHS Improvement and holding discussions with the teams responsible for reviewing the 4-hour target at NHS England. The analysis now being extended to examine the potential consequences of changing the 4-hour target in A&E targets in England (as has recently been announced) and a second paper is expected over the next two years. [2 paragraphs unchanged] STATUS: STATUS (June 2021): A draft paper was submitted to the American Economic Journal: Economic Policy. [20 words unchanged] a revise and resubmit. The paper was resubmitted on 31 July 2019 and IFS are waiting to hear back. the paper has now been conditionally accepted. The data are required to make any changes required during the last part of the peer review process. No additional data have been requested for this purpose. [2 paragraphs unchanged] (i) The objective is to examine the impact of percutaneous coronary intervention [93 words unchanged] and many deaths after the first 30 days will occur outside hospital. This is a revised version of a previously listed project that that compared the use of PCI in AMI patients in England and the US. The revision is necessary due to difficulties in obtaining US data. STATUS: A draft paper has been completed and presented previously at conferences. The feedback from these presentations indicated that out-of-hospital data are required to fully capture the impacts of the PCI centres. IFS have therefore applied for these data as part of this request. These data will be used to complete the project. Work on this project has been delayed due to a delay in receiving the correct mortality data. This has now been received, and researchers are now updating the results with these data. IFS expect to publish a working paper in late 2020 and then submit to a journal. This is a revised version of a previously listed project that that compared the use of PCI in AMI patients in England and the US. The revision is necessary due to difficulties in obtaining US data. STATUS (June 2021): A draft paper has been completed and presented previously at conferences. The feedback from these presentations indicated that out-of-hospital data are required to fully capture the impacts of the PCI centres. IFS therefore applied for these data as part of this request (previous request) but work was delayed after receiving incorrect mortality data. This has now been received, but work was further delayed due to unavailability of staff during the COVID pandemic. IFS researchers are now updating the results and expect to publish a working paper in late 2021 and then submit to a journal. [2 paragraphs unchanged] STATUS: STATUS (June 2021): This project initially looked at choice in maternity care. After the beginning [51 words unchanged] outcomes of mothers and babies. Much of this work has been completed, although but was delayed when the lead author is currently was on maternity leave. Upon leave, and then further during the lead author’s return, COVID pandemic. IFS would expect to finish the project and publish a working paper in early 2020. [2 paragraphs unchanged] STATUS: STATUS (June 2021): A paper has been drafted, and presented at a number of academic economics conferences. To complete Progress on the paper, out-of-hospital death data are required (as requested). A paper would then be was delayed due to unavailability of staff during the COVID pandemic and is now expected to be submitted to a top economics journal completed by the end of the year, although 2021 (with data would be need to be held throughout the peer-review process to answer referee queries. queries). [1 paragraph unchanged] New Projects: New Projects highlighted in v5.3 of this Agreement: [1 paragraph unchanged] STATUS (June 2021): Progress on this paper was delayed due to unavailability of staff during the COVID pandemic. This has pushed the timeline back on this project by around 12-18 months. [2 paragraphs unchanged] STATUS (June 2021): Progress on this paper was delayed due to unavailability of staff during the COVID pandemic. We would now expect to publish a working paper in Spring 2022. [2 paragraphs unchanged] STATUS (June 2021): Progress on this paper was delayed due to unavailability of staff during the COVID pandemic and has pushed the timeline on the project back by around a year. [2 paragraphs unchanged] STATUS (June 2021): Progress on this work is progressing as expected, with working papers expected to be published in the next 1-2 years. [1 paragraph unchanged] All projects are underwritten by the Economic and Social Research Council (ESRC) Centre for Public Policy at the IFS. In addition, there are some additional funding streams. i is funded by an ESRC funded grant on Health Network 5 is funded by the Nuffield Foundation Project B and iii are funded by an ESRC grant ‘The impact of medical labour on variation in patient outcomes: evidence from English public hospitals” IFS confirm that none of the funders exert any influence over the projects and outputs.

Processing activities

[1 paragraph unchanged] Only substantive employees of IFS will have access to the data and only for the purposes described in this document. There will be no data linkage undertaken with NHS Digital data provided under this Agreement that is not already noted in the Agreement. All outputs will be aggregated with small numbers suppressed in line with the HES analysis guide or other applicable NHS Digital guidance. Data will only be accessed and processed by substantive employees of the Institute for Fiscal Studies and will not be accessed or processed by any other third parties not mentioned in this Agreement. All projects are underwritten by the Economic and Social Research Council (ESRC) Centre for Public Policy at the IFS. In addition, there are some additional funding streams. The data are processed and stored at the Institute for Fiscal Studies on a BitLocker encrypted drive using AES 256 bit encryption. This drive is on the SAN (Storage Area Network) located at the Institute for Fiscal Studies. i is funded by an ESRC funded grant on Health Network No data (other than aggregated data with small numbers suppressed) will flow outside the UK or be shared with third parties. 5 is funded by the Nuffield Foundation Project B and iii are funded by an ESRC grant ‘The impact of medical labour on variation in patient outcomes: evidence from English public hospitals” IFS confirm that none of the funders exert any influence over the projects and outputs. No data (other than aggregated data with small numbers suppressed) will flow outside the UK or be shared with third parties. This is particularly in relation to projects i and 8, but also applies to all the other projects described. [3 paragraphs unchanged] As it is expected that clinical need will be a crucial input [26 words unchanged] into account and therefore provide more accurate analysis and predictions. PROMs data are also required over this period will be analysed in order to understand how the clinical benefits following joint replacement surgery has changed over time, particularly in light of the independent sector reforms. This is essential for an analysis which estimates the implications for population health following the huge increases in the volume of joint replacements observed in the ten years prior (i.e. IFS can examine whether the clinical benefit for patients has increased or decreased as a result of greater availability of hip and knee replacements. This will help to analyse whether the independent sector reforms have increased the welfare of NHS patients). This is essential for an analysis which estimates the implications for population health following the huge increases in the volume of joint replacements observed in the ten years prior (i.e. IFS can examine whether the clinical benefit for patients has increased or decreased as a result of greater availability of hip and knee replacements. This will help to analyse whether the independent sector reforms have increased the welfare of NHS patients). [4 paragraphs unchanged] (2) IFS will model the relationship between the total number of NHS [41 words unchanged] offering hip replacements, relative to the nearest Acute Trust providing hip replacements. Data will be combined with publicly available area level and GP practice characteristics, in order to examine variation in outcomes or behaviour, or to control for potentially confounding factors at the area level. Publicly available area level data includes measures of population size and levels of deprivation. These variables are used in area-level regressions as control variables. This includes population data (available from the Office for National Statistics and local deprivation scores made available for public use by the Department for Communities and Local Government). IFS require data back until at least 2000, as the policy to increase and formalise the role of the Independent Sector began in 2003, and the ability to study a comparison group is essential to accurately identify the impact of the policy. Data will be combined with publicly available area level and GP practice characteristics, in order to examine variation in outcomes or behaviour, or to control for potentially confounding factors at the area level. Publicly available area level data includes measures of population size and levels of deprivation. These variables are used in area-level regressions as control variables. This includes population data (available from the Office for National Statistics and local deprivation scores made available for public use by the Department for Communities and Local Government). IFS require data back until at least 2000, as the policy to increase and formalise the role of the Independent Sector began in 2003, and the ability to study a comparison group is essential to accurately identify the impact of the policy. [1 paragraph unchanged] (3) IFS will examine the age profile of English hospital spending across [38 words unchanged] the average spending per individuals of a given age can be derived. IFS will then examine how this develops over time, providing evidence on whether average spending for individuals of a given age has changed over time (i.e. is the average spend for a 70 year old male in 1997/98 different to a 70 year old male in 2017/18). IFS will then examine how this develops over time, providing evidence on whether average spending for individuals of a given age has changed over time (i.e. is the average spend for a 70 year old male in 1997/98 different to a 70 year old male in 2017/18). [2 paragraphs unchanged] IFS require hold data back to 1997/98 to provide the longest time series possible over [62 words unchanged] in 2017/18 uses more healthcare than a 70 year old in 1997/98). [1 paragraph unchanged] (4) IFS will model the impact of rapid immigration on the demand [35 words unchanged] the number of birth episodes recorded by inpatient HES across these regions. IFS will then also examine the number of 30 day readmissions for new-born children across these areas, using the pseudonymised HES identifier, to examine whether the quality of maternity care has deteriorated in an observable way in areas where the population has rapidly grown. This will provide evidence on whether NHS trusts adapts quickly to changes in the size and the characteristics of the population which they treat. HES A&E data is required for the most recent period of time in order to understand the use of the service during a period which has witnessed significant changes in the size, and composition, of the English population. This provides sufficient variation in the data to attempt to estimate causal impacts of population change on demand for, and quality of, A&E services. IFS will then also examine the number of 30 day readmissions for new-born children across these areas, using the pseudonymised HES identifier, to examine whether the quality of maternity care has deteriorated in an observable way in areas where the population has rapidly grown. This will provide evidence on whether NHS trusts adapts quickly to changes in the size and the characteristics of the population which they treat. HES A&E data is held in order to understand the use of the service during a period which has witnessed significant changes in the size, and composition, of the English population. This provides sufficient variation in the data to attempt to estimate causal impacts of population change on demand for, and quality of, A&E services. [5 paragraphs unchanged] (6) IFS will use the A&E HES data from 2010/11 - 2017/18 [32 words unchanged] computing the counterfactual probability of admission in the absence of the target. IFS will calculate this counterfactual by estimating a polynomial regression (regressing admission on the period of admission) for all patients who are feasibly not affected by the target (e.g. all patients admitted/discharged from A&E between 0 – 180 minutes, and after 240 minutes). IFS will use data on patient characteristics and investigations/symptoms contained in the A&E data, along with diagnosis codes for admitted patients (in their APC HES records) to examine how the characteristics of patients vary with time. IFS will calculate this counterfactual by estimating a polynomial regression (regressing admission on the period of admission) for all patients who are feasibly not affected by the target (e.g. all patients admitted/discharged from A&E between 0 – 180 minutes, and after 240 minutes). IFS will use data on patient characteristics and investigations/symptoms contained in the A&E data, along with diagnosis codes for admitted patients (in their APC HES records) to examine how the characteristics of patients vary with time. [1 paragraph unchanged] IFS will use the linked HES and mortality data (at patient record [43 words unchanged] the mortality data would therefore allow all-location mortality outcomes to be examined. IFS will also examine the underlying cause of death, to investigate whether cause of death is the same as the major diagnoses when patients recently visited hospital. IFS will also examine the underlying cause of death, to investigate whether cause of death is the same as the major diagnoses when patients recently visited hospital. [3 paragraphs unchanged] (10) The project will use inpatient data for the years 1997 to [38 words unchanged] of emergency admissions at each hospital with patient outcomes at that hospital. Sub-objective (ii) will assess how this statistical relationship has changed over different time periods and hospitals, for example before and after the introduction of Payment by Results in 2004. Sub-objective (iii) will involve linking the inpatient and A&E data to establish which patients at trauma and orthopaedic departments arrived by ambulance. Statistical models will then be used to evaluate how the number of emergency admissions, and the associated impact on patient outcomes, would change if ambulances were to assign patients to hospitals differently or if certain A&E departments were to close. Sub-objective (ii) will assess how this statistical relationship has changed over different time periods and hospitals, for example before and after the introduction of Payment by Results in 2004. Sub-objective (iii) will involve linking the inpatient and A&E data to establish which patients at trauma and orthopaedic departments arrived by ambulance. Statistical models will then be used to evaluate how the number of emergency admissions, and the associated impact on patient outcomes, would change if ambulances were to assign patients to hospitals differently or if certain A&E departments were to close. [2 paragraphs unchanged] i) This project will use the inpatient data of all those admitted [92 words unchanged] to estimate the impact of the PCI roll out on patient health. It will be necessary to calculate rates back to 2000 to understand whether the countries have been converging or diverging overtime as the treatment became more widespread in the early 2000s. IFS require the most recent data as the preferred journal requires data from the past 5 years to be included. IFS will identify the impact of receiving a PCI by using variation in access to a hospital with a PCI centre over time and space, as 24/7 PCI centres were rolled out. IFS will therefore merge information on when 24/7 centres opened, obtained through FOI requests, and calculate the distance between the centroid of each AMI patients LSOA and their nearest PCI centre, on the date that they had the AMI. It will be necessary to calculate rates back to 2000 to understand whether the countries have been converging or diverging overtime as the treatment became more widespread in the early 2000s. IFS require the most recent data as the preferred journal requires data from the past 5 years to be included. IFS will identify the impact of receiving a PCI by using variation in access to a hospital with a PCI centre over time and space, as 24/7 PCI centres were rolled out. IFS will therefore merge information on when 24/7 centres opened, obtained through FOI requests, and calculate the distance between the centroid of each AMI patients LSOA and their nearest PCI centre, on the date that they had the AMI. [3 paragraphs unchanged] (iii) IFS will use episode level data to compare 30-day and 365-day [22 words unchanged] AMI and stroke are derived from ICD-10 diagnosis codes contained in HES. Consultants are assigned to patients in HES using the anonymised consultant ID (variable ‘pconsult’). Patients who die in hospital are recorded in inpatient HES (through the discharge method variable). Anonymised patient IDs will be used to examine whether patients who are discharged but then readmitted during the 30 day period following the initial admission die in a subsequent hospital spell. IFS will use the linked HES and mortality records to calculate all-mortality (in-hospital and out-hospital) 30-day and 365-day rates for AMI and stroke patients admitted to hospital. The analysis requires the construction of detailed control variables to account for differences in the underlying health of patients treated by different consultants and hospitals. Failing to account for these differences will lead to inaccurate estimates of the effects that each consultant has on patient outcomes. Detailed measures of health conditions and past hospital use are therefore essential for this analysis. IFS will derive a range of clinical indicators using the ICD-10 diagnosis codes in HES, and use these to create the Charlson Index to capture patient morbidity. The Charlson comorbidity index predicts the one-year mortality for a patient who may have a range of comorbid conditions, such as heart disease, AIDS, or cancer. Using data from 1997/98 – 2017/18, IFS will use the anonymised patient identifier to track patient inpatient admissions and outpatient attendances over time in order to construct detailed histories of patient hospital use. Using the Health Resource Group (HRG) variable in the inpatient HES dataset, IFS can allocate costs for each of these activities to summarise past hospital use. IFS will also create a variable for each year which indicates whether a patient has been treated for a heart attack or stroke in a previous year. Previous research has shown that a major determinant in survival following a heart attack is the amount of time that elapses between onset and treatment, and the distance that patients need to travel to reach a hospital for treatment. This will be addressed by examining the distance between the Lower Super Output Area of patient residence and the hospital in which they are treatment. In addition, for the period 2007/08 – 2017/18, IFS will use the Accident and Emergency data to examine whether the onset occurred at home (variable ‘aeincloctype’) and the time that elapsed between arrival at hospital and admission (variable ‘tretdur’). Consultants are assigned to patients in HES using the anonymised consultant ID (variable ‘pconsult’). Patients who die in hospital are recorded in inpatient HES (through the discharge method variable). Anonymised patient IDs will be used to examine whether patients who are discharged but then readmitted during the 30 day period following the initial admission die in a subsequent hospital spell. IFS will use the linked HES and mortality records to calculate all-mortality (in-hospital and out-hospital) 30-day and 365-day rates for AMI and stroke patients admitted to hospital. In order to separately estimate the impact of consultants from the hospitals in which they work, the analysis needs to control for differences in the types of patients treated by different hospitals. It also requires the observation of consultants working in different hospitals over time. IFS will address the first point by combining publicly available aggregated geographical data relating to the socio-economic status and population health to summarise the characteristics of the patient population served by each hospital. Inpatient HES data will also be used to create other indicators of patient health and quality of local primary care (e.g. the admission rates for ACS conditions in the local area), and the quality of other care provided in the hospital (e.g. hospital level readmission rates for elective hip replacements). In addition, for the period 2007/08 – 2017/18, Accident and Emergency data can be used to separately analyse the outcomes for patients who arrived at the hospital in an ambulance (contained in variable ‘aearrivalmode’). This would allow analysis on a subset of patients for which it is certain that patient did not choose the hospital in which they were treated, and therefore rules out matching of (otherwise unobservably sicker) patients to hospitals which could potentially bias results. The analysis requires the construction of detailed control variables to account for differences in the underlying health of patients treated by different consultants and hospitals. Failing to account for these differences will lead to inaccurate estimates of the effects that each consultant has on patient outcomes. Detailed measures of health conditions and past hospital use are therefore essential for this analysis. IFS will derive a range of clinical indicators using the ICD-10 diagnosis codes in HES, and use these to create the Charlson Index to capture patient morbidity. The Charlson comorbidity index predicts the one-year mortality for a patient who may have a range of comorbid conditions, such as heart disease, AIDS, or cancer. Using data from 1997/98 – 2017/18, IFS will use the anonymised patient identifier to track patient inpatient admissions and outpatient attendances over time in order to construct detailed histories of patient hospital use. Using the Health Resource Group (HRG) variable in the inpatient HES dataset, IFS can allocate costs for each of these activities to summarise past hospital use. IFS will also create a variable for each year which indicates whether a patient has been treated for a heart attack or stroke in a previous year. Previous research has shown that a major determinant in survival following a heart attack is the amount of time that elapses between onset and treatment, and the distance that patients need to travel to reach a hospital for treatment. This will be addressed by examining the distance between the Lower Super Output Area of patient residence and the hospital in which they are treatment. In addition, for the period 2007/08 – 2017/18, IFS will use the Accident and Emergency data to examine whether the onset occurred at home (variable ‘aeincloctype’) and the time that elapsed between arrival at hospital and admission (variable ‘tretdur’). In order to separately estimate the impact of consultants from the hospitals in which they work, the analysis needs to control for differences in the types of patients treated by different hospitals. It also requires the observation of consultants working in different hospitals over time. IFS will address the first point by combining publicly available aggregated geographical data relating to the socio-economic status and population health to summarise the characteristics of the patient population served by each hospital. Inpatient HES data will also be used to create other indicators of patient health and quality of local primary care (e.g. the admission rates for ACS conditions in the local area), and the quality of other care provided in the hospital (e.g. hospital level readmission rates for elective hip replacements). In addition, for the period 2007/08 – 2017/18, Accident and Emergency data can be used to separately analyse the outcomes for patients who arrived at the hospital in an ambulance (contained in variable ‘aearrivalmode’). This would allow analysis on a subset of patients for which it is certain that patient did not choose the hospital in which they were treated, and therefore rules out matching of (otherwise unobservably sicker) patients to hospitals which could potentially bias results. [2 paragraphs unchanged] New Projects (Version 5.3) [5 paragraphs unchanged] Outcomes include length of stay, A&E visits, inpatient readmissions and in-hospital mortality [30 words unchanged] specific dates to address issues of case mix driven by patient choices. Concerns over potential changes in patient severity due to anticipation of the industrial action will further be addressed by examining outcomes of emergency patients only (as these patients have limited choice about when they attend hospital) and by controlling for observed changes in patient morbidity (using ICD-10 codes) and demographic characteristics. Concerns over potential changes in patient severity due to anticipation of the industrial action will further be addressed by examining outcomes of emergency patients only (as these patients have limited choice about when they attend hospital) and by controlling for observed changes in patient morbidity (using ICD-10 codes) and demographic characteristics. [8 paragraphs unchanged] This agreement covers data from 1997/98 to 2017/18. It is important to have data that covers this period for three key reasons. First, a number of the research aims are to investigate the impact associated with different policy changes that have taken place during this period. In each case, IFS need data from before and after the policy change. For example, project (2) studies the impact of introducing private providers into the NHS market for elective care, which took place as part of a set of reforms throughout the 2000s. Having data from before, during and after this period is essential in understanding the changes that took place as a result of these reforms. Second, data from 1997/98 to 2017/18 will provide the longest time series possible. This will allow IFS to better understand trends in NHS activity over time (e.g. in project (a) this allows IFS to examine how NHS activity has developed across birth cohorts, and in project (1) to examine whether the impact of competition has changed over this period. Finally, using data from multiple years helps to maximise sample size. This is crucial in boosting the statistical power of the research, helping to accurately identify and estimate effects. As a result, these data requirements are essential in allowing IFS to carry out the proposed research. Backup storage is located on an IFS server stored by IDNet. IFS's data manager has confirmed that this server is held in a locked cabinet physically restricted to named IFS technical support staff and IDNet staff, and that only IFS staff can access the data held within the server. IDNet are therefore not considered to be acting as a data processor, and are listed as a storage location only.

Expected output

[1 paragraph unchanged] Update: Update (June 2021): A submitted paper is currently under review at the American Journal of has recently been published in Health Economics. Economics (https://onlinelibrary.wiley.com/doi/full/10.1002/hec.4223). The non-technical summary will be published and disseminated after the paper is accepted at a journal. shortly. (2) Some of these outputs from this project, including several conference presentations, a policy presentation and a non-technical policy summary, have already been produced under the previous license agreement. Agreement. Previous conference presentations included a workshop attended by representatives from the Department [13 words unchanged] Kings Fund, and economics academic conferences including the Royal Economic Society conference. At the time of the last application (2017) IFS had submitted to the Journal for Public Economics. This submission was unsuccessful, and IFS are now preparing for a submission to the Journal for Health Economics. This was submitted to the Journal of Health Economics in Autumn 2019. (3) The principal outputs are (i) a working paper, which was published under the IFS working paper series (see project 1) in August 2015 (https://www.ifs.org.uk/uploads/publications/wps/WP201521.pdf), (ii) an academic conference presentation in March 2015, (iii) a peer-reviewed journal article in the economics journal Fiscal Studies, which was published as part of a special issue of Fiscal Studies on cross-country comparisons of health spending across the lifecycle in November 2016 (http://onlinelibrary.wiley.com/doi/10.1111/j.1475-5890.2016.12101/full), and a non-technical, policy summary (https://www.ifs.org.uk/publications/8737). Fiscal Studies is a peer-reviewed economics general with all articles explicitly aimed at bridging the gap between academic research and policy, with a reputation for publishing timely high-quality articles that are easily accessible to policymakers. A workshop to discuss preliminary findings took place in March 2015. This workshop was attended by representatives from the Department of Health, who subsequently invited IFS to present the findings at the Department. IFS have spoken to the OECD about this work, who believes it could help inform their highly influential work on cross-country comparisons of health systems. The project resulted in a publication in a special issue of Health Affairs on end of life care, although the IFS analysis with HES was not used directly for this publication. In 2018, The IFS-Health Foundation report "Securing the Future" (https://www.ifs.org.uk/publications/12994) included updated patterns of utilisation. The report had 757 print and digital mentions, and 775 broadcast mentions. In the 7 days after launch, the report had 343 downloads. IFS understand that the report was highly influential in the NHS funding debates both within and outside government that surrounded the 70th anniversary. Update (June 2021): A non-technical summary of the use of private providers in the NHS was published in November 2019 (https://www.ifs.org.uk/publications/14593). A paper was published in the Journal of Health Economics in September 2020 (https://www.ifs.org.uk/publications/15249). (3) The principal outputs are (i) a working paper, which was published under the IFS working paper series (see project 1) in August 2015 (https://www.ifs.org.uk/uploads/publications/wps/WP201521.pdf), (ii) an academic conference presentation in March 2015, (iii) a peer-reviewed journal article in the economics journal Fiscal Studies, which was published as part of a special issue of Fiscal Studies on cross-country comparisons of health spending across the lifecycle in November 2016 (http://onlinelibrary.wiley.com/doi/10.1111/j.1475-5890.2016.12101/full), and a non-technical, policy summary (https://www.ifs.org.uk/publications/8737). Fiscal Studies is a peer-reviewed economics general with all articles explicitly aimed at bridging the gap between academic research and policy, with a reputation for publishing timely high-quality articles that are easily accessible to policymakers. A workshop to discuss preliminary findings took place in March 2015. This workshop was attended by representatives from the Department of Health, who subsequently invited IFS to present the findings at the Department. IFS have spoken to the OECD about this work, who believes it could help inform their highly influential work on cross-country comparisons of health systems. The project resulted in a publication in a special issue of Health Affairs on end of life care, although the IFS analysis with HES was not used directly for this publication. In 2018, The IFS-Health Foundation report "Securing the Future" (https://www.ifs.org.uk/publications/12994) included updated patterns of utilisation. The report had 757 print and digital mentions, and 775 broadcast mentions. In the 7 days after launch, the report had 343 downloads. IFS understand that the report was highly influential in the NHS funding debates both within and outside government that surrounded the 70th anniversary. [1 paragraph unchanged] (4) The principal outputs are (i) academic conference presentation at the European Economists Association (EEA) Annual Conference in August 2015, the Royal Economic Society (RES) Annual Conference in March 2016, the International Institute for Public Finance (IIPF) in August 2016, and the European Association of Labour Economists (EALE) Annual Conference in September 2016, (ii) a working paper, published under the IFS working paper series, and (iii) the submission of a peer-reviewed journal article to the Economic Journal. The benefits of these outputs are discussed above. Output (i) has already been realised. The EEA, RES, IIPF and EALE Conferences are attended by the leading economists in Europe and the USA, and in light of comments received at the conferences, the work on this project has been extended. As a result, the original target date for the publication of the working paper and journal submission was pushed back from Spring 2016. Work is still ongoing, and IFS expect to publish output (ii) in late Winter 2019. IFS have also produced a non-technical policy summary for policymakers, which will be sent to representatives of Department of Health, Monitor and NHS England after output (iii) has been published. Update (June 2021): The second paper (previous work delayed) has recently been published by the Journal of Health Economics (https://www.sciencedirect.com/science/article/pii/S016762962100062X). The third paper was rejected by Health Economics and is currently being prepared for submission to Social Science and Medicine. (5) The outputs from this project have been delayed by difficulties in accessing the non-HES data sets required. The paper has been presented at the European Economic Association Congress and other internal workshops. Three outputs are expected in early 2019: (1) a the final report, to be submitted to the Nuffield Foundation; (2) an IFS working paper (see above), and (3) a related academic paper. Both report and paper will be available on the IFS website. The academic paper will be targeted to a top economic journal, such as the Economic Journal (see above). The findings of the report will be disseminated by press release and an IFS policy observation (on the IFS website) in order to reach target audiences in the media and general public. A launch event will be organised at IFS, where the results will be presented and academics will be invited (experts in early years policy) and policy makers (MPs working on early years policy of the All Party Parliamentary Group) to discuss their implications. (4) The principal outputs are (i) academic conference presentation at the European Economists Association (EEA) Annual Conference in August 2015, the Royal Economic Society (RES) Annual Conference in March 2016, the International Institute for Public Finance (IIPF) in August 2016, and the European Association of Labour Economists (EALE) Annual Conference in September 2016, (ii) a working paper, published under the IFS working paper series, and (iii) the submission of a peer-reviewed journal article to the Economic Journal. The benefits of these outputs are discussed above. Output (i) has already been realised. The EEA, RES, IIPF and EALE Conferences are attended by the leading economists in Europe and the USA, and in light of comments received at the conferences, the work on this project has been extended. Update: The additional datasets have now been secured, and as noted above, the report was launched in June 2019. A paper for journal submission is expected to be completed in the second half of 2020. As a result, the original target date for the publication of the working paper and journal submission was pushed back from Spring 2016. Work is still ongoing, and IFS expect to publish output (ii) in late Winter 2019. IFS have also produced a non-technical policy summary for policymakers, which will be sent to representatives of Department of Health, Monitor and NHS England after output (iii) has been published. (6) The analysis will be used to produce a range of outputs. Three types of written output are expected: (i) a working paper, which was published in March 2018 as part of the National Bureau for Economic Research (NBER) working paper series (https://www.nber.org/papers/w24445), (ii) a peer-reviewed journal article (this was submitted to the Review of Economic Studies, a leading peer-reviewed economics journal, in March 2018, and a revised manuscript (first publication step) was requested from the journal in June 2018); (iii) a non-technical research summary which will be press-released, and shared directly with NHS Improvement and the Department of Health. This work has already been discussed with economists at NHS Improvement who are also working on projects to examine the quality of care in A&E departments, and a presentation was given to NHS Improvement economists in September 2017. Other outputs will include presentations at academic conferences and to government departments. Update (June 2021): This work has been delayed by reduced staffing during the COVID pandemic, but work is expected to resume soon. (5) The outputs from this project have been delayed by difficulties in accessing the non-HES data sets required. The paper has been presented at the European Economic Association Congress and other internal workshops. Three outputs are expected in early 2019: (1) a the final report, to be submitted to the Nuffield Foundation; (2) an IFS working paper (see above), and (3) a related academic paper. Both report and paper will be available on the IFS website. The academic paper will be targeted to a top economic journal, such as the Economic Journal (see above). The findings of the report will be disseminated by press release and an IFS policy observation (on the IFS website) in order to reach target audiences in the media and general public. A launch event will be organised at IFS, where the results will be presented and academics will be invited (experts in early years policy) and policy makers (MPs working on early years policy of the All Party Parliamentary Group) to discuss their implications. Update (June 2021): Submission of this paper was delayed during the COVID pandemic, and IFS received additional supplementary funding from the Nuffield Foundation to continue carrying out the work over 2021. An updated working paper is expected to be published by the end of 2021, and will be submitted to a top economics journal and disseminated shortly afterwards. (6) The analysis will be used to produce a range of outputs. Three types of written output are expected: (i) a working paper, which was published in March 2018 as part of the National Bureau for Economic Research (NBER) working paper series (https://www.nber.org/papers/w24445), (ii) a peer-reviewed journal article (this was submitted to the Review of Economic Studies, a leading peer-reviewed economics journal, in March 2018, and a revised manuscript (first publication step) was requested from the journal in June 2018); (iii) a non-technical research summary which will be press-released, and shared directly with NHS Improvement and the Department of Health. This work has already been discussed with economists at NHS Improvement who are also working on projects to examine the quality of care in A&E departments, and a presentation was given to NHS Improvement economists in September 2017. Other outputs will include presentations at academic conferences and to government departments. [2 paragraphs unchanged] Update (June 2021): The paper has been accepted for publication, and is forthcoming in the Review of Economics and Statistics. IFS have directly engaged with NHS England and Improvement, and spoken to them during the review of 4-hour NHS targets that is ongoing. The proposed new targets are consistent with the main findings of the paper: that regulation forcing quicker treatment for those with particularly time-sensitive conditions saves patient lives. [2 paragraphs unchanged] (10) This research project, which was previously under another data agreement, has already produced a number of outputs. This has included presentations at the Royal Economic Society, University of Manchester, University College London and Northwestern University, as well as a series of discussions with NHS Improvement and a range of NHS employees (managers, physiotherapists and nurses). These existing outputs relate to sub-objective (i), and the work will now be extended to sub-objectives (ii) and (iii). Results were presented at a half day conference in September 2017 aimed at policy makers (https://www.ifs.org.uk/events/1515), with a 10 minute discussion from a member of NHS Improvement. A draft working paper was published in November 2017 (https://drive.google.com/file/d/0B-aAQJWf8MpDblJXdlI4WWhzRjg/view) and results were presented at various conferences and universities between November 2017 and March 2018. The paper will be submitted for publication to an academic economics journal in late-2018. Update (June 2021): The paper has been resubmitted to the journal after further revisions and are currently awaiting a decision on the paper. (10) This research project, which was previously under another data Agreement, has already produced a number of outputs. This has included presentations at the Royal Economic Society, University of Manchester, University College London and Northwestern University, as well as a series of discussions with NHS Improvement and a range of NHS employees (managers, physiotherapists and nurses). These existing outputs relate to sub-objective (i), and the work will now be extended to sub-objectives (ii) and (iii). Results were presented at a half day conference in September 2017 aimed at policy makers (https://www.ifs.org.uk/events/1515), with a 10 minute discussion from a member of NHS Improvement. A draft working paper was published in November 2017 (https://drive.google.com/file/d/0B-aAQJWf8MpDblJXdlI4WWhzRjg/view) and results were presented at various conferences and universities between November 2017 and March 2018. The paper will be submitted for publication to an academic economics journal in late-2018. [1 paragraph unchanged] Revised projects Update (June 2021): The paper has been conditionally accepted at the American Economic Journal: Economic Policy and is awaiting publication. Revised projects (November 2019) [2 paragraphs unchanged] (ii) Outputs will include a working paper, submission to a peer-reviewed economics journal, and an IFS briefing note and press release following submission to a journal. The staff member responsible for this project has been on maternity leave since early 2019. As a result, the project has been delayed. The staff member is returning in January 2020, and a working paper is expected to be published in 2020. Existing outputs under the previous research agreement included presentations at academic conferences such as the European Economists Association (EEA) Conference, which focused on receiving comments from economists on how to improve the analysis, and presentations to policy makers involved in the planning and delivery of NHS care. Staffing constraints have meant that progress was slower than anticipated. However, the work has been discussed with the Royal College of Midwives and the North East London Sustainability and Transformation Planning Team. Descriptive results were presented in a half day event in September 2017, aimed at policy-makers (https://www.ifs.org.uk/events/1515). The event featured a presentation from IFS and a policy response from the Royal College of Midwives. Alongside the event, the IFS published a briefing note for policy makers "Under Pressure? NHS maternity services in England". Update (April 2021): Progress on this paper was delayed due to unavailability of staff during the COVID pandemic and is expected to be completed by the end of 2021. (ii) Outputs will include a working paper, submission to a peer-reviewed economics journal, and an IFS briefing note and press release following submission to a journal. The staff member responsible for this project has been on maternity leave since early 2019. As a result, the project has been delayed. Existing outputs under the previous research Agreement included presentations at academic conferences such as the European Economists Association (EEA) Conference, which focused on receiving comments from economists on how to improve the analysis, and presentations to policy makers involved in the planning and delivery of NHS care. Staffing constraints have meant that progress was slower than anticipated. However, the work has been discussed with the Royal College of Midwives and the North East London Sustainability and Transformation Planning Team. Descriptive results were presented in a half day event in September 2017, aimed at policy-makers (https://www.ifs.org.uk/events/1515). The event featured a presentation from IFS and a policy response from the Royal College of Midwives. Alongside the event, the IFS published a briefing note for policy makers "Under Pressure? NHS maternity services in England". [1 paragraph unchanged] (iii) The project is expected to produce a range of outputs, including ((i) multiple academic conference presentations to general economics (e.g. the Annual Royal Economics Society conference) and health economics audiences (e.g. the annual meeting of the UK Health Economists Study Group); (ii) an IFS working paper (see above); (iii) the submission of a journal article to a leading peer-review economics journal, such as the Review of Economic Studies (Impact Factor: 4.038) or the Journal of Health Economics (IF: 2.579); (iv) a non-technical policy summary, which will be press released and sent to contacts at the Department of Health and NHS England. The Health Economists Study Group is a work-in-progress conference attended by the leading health economists in England, and representatives from NHS England, the Department of Health and leading health policy organisations such as the Health Foundation and the Kings Fund. Their comments will give the researchers the chance to improve the analysis and focus the findings in the most informative way for policy. Output (i) has been realised in 2016 - 2018, with a number of presentations at leading UK universities (UCL, King’s College London, Oxford) and conference presentation at the International Institute for Public Finance (IIPF) Annual Conference in August 2017 and the Royal Economic Society (RES) conference in March 2018. Outputs (ii) – (iv) require access to linked mortality data for completion. These outputs required the same data as project (i) – now that IFS has received the data publication and submission of a working paper is to a journal is expected in the first half of 2020. An early draft (not using the linked mortality data) was presented at the 2019 European Economics Association Annual Conference in August 2019. Update (June 2021): Progress on this paper was delayed due to unavailability of staff during the COVID pandemic and is expected to be completed by the end of 2021. (iii) The project is expected to produce a range of outputs, including ((i) multiple academic conference presentations to general economics (e.g. the Annual Royal Economics Society conference) and health economics audiences (e.g. the annual meeting of the UK Health Economists Study Group); (ii) an IFS working paper (see above); (iii) the submission of a journal article to a leading peer-review economics journal, such as the Review of Economic Studies (Impact Factor: 4.038) or the Journal of Health Economics (IF: 2.579); (iv) a non-technical policy summary, which will be press released and sent to contacts at the Department of Health and NHS England. The Health Economists Study Group is a work-in-progress conference attended by the leading health economists in England, and representatives from NHS England, the Department of Health and leading health policy organisations such as the Health Foundation and the Kings Fund. Their comments will give the researchers the chance to improve the analysis and focus the findings in the most informative way for policy. Output (i) has been realised in 2016 - 2018, with a number of presentations at leading UK universities (UCL, King’s College London, Oxford) and conference presentation at the International Institute for Public Finance (IIPF) Annual Conference in August 2017 and the Royal Economic Society (RES) conference in March 2018. Outputs (ii) – (iv) require access to linked mortality data for completion. These outputs required the same data as project (i) – now that IFS has received the data publication and submission of a working paper is to a journal is expected in the first half of 2020. An early draft (not using the linked mortality data) was presented at the 2019 European Economics Association Annual Conference in August 2019. Update (June 2021): Progress on this paper was delayed due to unavailability of staff during the COVID pandemic. The publication of a working paper (and subsequent submission to a journal) is expected in the next 6 months. [1 paragraph unchanged] a) There will be four principle outputs: (i) academic presentations at leading [25 words unchanged] leading general purpose economics journal and (iv) a non-technical summary for policymakers. Work on this project has been delayed due to a lack of outpatient data for the final years. Upon receipt of the data IFS will begin analysis. IFS would therefore expect to present results in Autumn 2020, and publish a working paper and submit to a journal in 2021. Output (iv) will be published following publication of the working paper. Dissemination activities will take place throughout the project, talking to contacts at the Department of Health and NHS England about the project design and results. Work on this project has been delayed due to a lack of outpatient data for the final years. Upon receipt of the data IFS will begin analysis. IFS would therefore expect to present results in Autumn 2020, and publish a working paper and submit to a journal in 2021. Output (iv) will be published following publication of the working paper. Dissemination activities will take place throughout the project, talking to contacts at the Department of Health and NHS England about the project design and results. Update (June 2021): Progress on this paper was delayed due to unavailability of staff during the COVID pandemic. This has pushed the timeline back on this project by around 12-18 months. [1 paragraph unchanged] Update (June 2021): Progress on this paper was delayed due to unavailability of staff during the COVID pandemic. We would now expect to publish a working paper in Spring 2022. [1 paragraph unchanged] Update (June 2021): Progress on this paper was delayed due to unavailability of staff during the COVID pandemic and has pushed the timeline on the project back by around a year. [1 paragraph unchanged] Update (June 2021): Progress on this work is progressing as expected, with working papers expected to be published in the next 1-2 years. [1 paragraph unchanged]

Expected measurable benefits

[2 paragraphs unchanged] The work is also extremely relevant for NHS Improvement in their role [61 words unchanged] which competition drives hospital behaviour, and ultimately what this means for patients. The model will therefore be used to inform these regulators in their work on competition. The results of the work will be disseminated directly through existing contracts o the relevant teams at NHS-I and the CMA when the results are finalised (with preliminary results already presented to NHS-I), and further benefits are expected to accrue after this time. (2) Policies of the previous two parliaments have increased the role of the private sector in delivering NHS funded care, yet there is very little evidence on the impact of these providers on the impact for NHS funded care. This research will help inform policy makers of the potential effects on patient demand, health care supply, the financial implications for NHS providers, and the equity of provision if the role of these providers is expanded in the future. These issues are of importance to the Department of Health, Monitor, the Cabinet Office and NHS England. Thus far, this has been demonstrated by both the Cabinet Office and NHS England requesting updates to this work, indicating that this work has the potential to feed into policy-making in the short to medium term. A working paper version of this research was warmly received by a number of representatives from Monitor, including the Economics Director, Cooperation and Competition at Monitor, when presented in September 2013. The model will therefore be used to inform these regulators in their work on competition. The results of the work will be disseminated directly through existing contracts o the relevant teams at NHS-I and the CMA when the results are finalised (with preliminary results already presented to NHS-I), and further benefits are expected to accrue after this time. The role of the private sector in providing NHS care has once again become an important policy and political issue: the 2017 Labour election manifesto announced an intention to remove all private provider involvement from the NHS (while the Conservative manifesto announced that this role – and the internal market in general - could be reviewed). Given the large role that the private sector is now playing in providing some forms of elective care, such a move would have serious consequences for the capacity of the NHS to deliver certain types of care. IFS’s work – using the most up to date data - would show how the role of the private sector role in providing NHS orthopaedic care has evolved over 15 years, and demonstrate how this has impacted both overall capacity and the distribution of care e.g. where have hip replacements most increased, and what type of populations have this most benefitted). This will be disseminated directly to NHS England, and would be submitted as evidence in any public reviews on private sector involvement in the NHS. (2) Policies of the previous two parliaments have increased the role of the private sector in delivering NHS funded care, yet there is very little evidence on the impact of these providers on the impact for NHS funded care. This research will help inform policy makers of the potential effects on patient demand, health care supply, the financial implications for NHS providers, and the equity of provision if the role of these providers is expanded in the future. These issues are of importance to the Department of Health, Monitor, the Cabinet Office and NHS England. Thus far, this has been demonstrated by both the Cabinet Office and NHS England requesting updates to this work, indicating that this work has the potential to feed into policy-making in the short to medium term. A working paper version of this research was warmly received by a number of representatives from Monitor, including the Economics Director, Cooperation and Competition at Monitor, when presented in September 2013. The role of the private sector in providing NHS care has once again become an important policy and political issue: the 2017 Labour election manifesto announced an intention to remove all private provider involvement from the NHS (while the Conservative manifesto announced that this role – and the internal market in general - could be reviewed). Given the large role that the private sector is now playing in providing some forms of elective care, such a move would have serious consequences for the capacity of the NHS to deliver certain types of care. IFS’s work – using the most up to date data - would show how the role of the private sector role in providing NHS orthopaedic care has evolved over 15 years, and demonstrate how this has impacted both overall capacity and the distribution of care e.g. where have hip replacements most increased, and what type of populations have this most benefitted). This will be disseminated directly to NHS England, and would be submitted as evidence in any public reviews on private sector involvement in the NHS. (Update June 2021): This issue has become even more important in the wake of the COVID pandemic and discussions about how to meet the large backlog in elective activity. More private sector involvement is one potential way to increase the capacity of publicly funded activity. The evidence from IFS' work could provide important lessons about the potential impacts of a further expansion of the use of the private sector by the NHS in this context, and IFS will reach out to NHS England and DHSC to directly disseminate the findings of their research to maximise the impact of this evidence. The research can therefore directly benefit patients by improving NHS England/DHSC's knowledge of the impacts of private sector involvement, and help them to balance the benefits to patients that come from expanding NHS-funded services (and therefore cutting waiting times) with the potential for increasing health inequalities if private hospital are typically located near to wealthier patients. [12 paragraphs unchanged] (6) This The analysis has already delived benefits through our interaction with NHS Improvement and NHS England, with the results showing that the policy improved patient outcomes and the main mechanism through which these health improvements were achieved (i.e. quicker treatment time for those with acute and time-sensitive conditions such as stroke) are consistent with at least some of the newly proposed A&E standards (e.g. Critical Time Standards). Future analysis will examine these channel further to improve knowledge of about which patients are most affected by the target and how the four-hour a stricter target influences patient treatments and outcomes. would affect patients with different diagnoses. This will enable policymakers (in particular, NHS Improvement and the Department of Health) to evaluate whether they want to continue to enforce this target, and to choose which target level they wish to implement, implement and which diagnoses to include in the Critical Time Standards definition, by clearly setting out whether the potential benefits of a stricter policy [10 words unchanged] to treatment decisions (through excessive or insufficient admissions) and/or unfavourable patient outcomes. This is particularly important given the recent announcement (July 2016) that 53 trusts are temporarily exempt from the target. The work has previousloy been discussed with NHS Improvement’s Emergency Care Improvement team, and the NHS Improvement Economics team. IFS will hold further discussions with NHS Improvement and NHS England to ensure that the findings are presented in a way that enables [5 words unchanged] (and eventually to patient care), will therefore be achieved through increasing NHS Improvement’s Improvement/England’s knowledge of the effects of the target on patient health and hospital decision-making. [15 paragraphs unchanged] (iii) Consultants play a crucial role in the delivery of NHS healthcare. [88 words unchanged] offers a direct route for dissemination of results and subsequent policy influence). The model be used for policy experiments such as “what is the impact of patient survival rates if the 5% of worst performing consultants were replaced by median-performance consultants?”. DHSC, NHS England or Acute Trusts may use this as a basis for deciding whether some consultants require more training, additional support from the Acute Trust, or should be moved to other positions. The model be used for policy experiments such as “what is the impact of patient survival rates if the 5% of worst performing consultants were replaced by median-performance consultants?”. DHSC, NHS England or Acute Trusts may use this as a basis for deciding whether some consultants require more training, additional support from the Acute Trust, or should be moved to other positions. [5 paragraphs unchanged] The research therefore has the potential to make important contributions to the [42 words unchanged] teams responsible for the analysis and long-term planning of the hospital workforce. IFS have strong existing links with these teams, both through current work that IFS are doing with the workforce team at DHSC on the factors related to recruitment and retention of NHS staff, and as a member of the DHSC Workforce Policy Research Unity (2019 – 2023). Results can therefore be disseminated easily to the relevant national policymaker working in this area. IFS would discuss the project as it progresses with DHSC, and then disseminate final results when the paper is published. Benefits would therefore be expected to start during this dissemination progress and last into the future through the research’s impact on long-term planning for NHS workforce. c) Worldwide, the use of opioids has increased dramatically over the last two decades. In the UK the number of opioid prescriptions doubled between 2000 and 2012, raising fears about the misuse of these drugs (https://www.pharmaceutical-journal.com/news-and-analysis/a-crisis-hidden-in-plain-sight-prescription-opioid-misuse-in-the-uk/20203928.article). However, little is known about how use varies across the country, or what drives the use of opioids (and therefore any subsequent negative consequences). This project will expand knowledge of where opioids are most frequently prescribed, and help to inform policymakers and practitioners about the extent to which opioid use has been driven by rationing of other forms of NHS care. IFS will use existing contacts at Public Health England to disseminate this work among policymakers. IFS are also collaborating with UCL Department of Primary Care and Population Health, who will use their links with primary care practitioners to disseminate findings directly to GPs. IFS have strong existing links with these teams, both through current work that IFS are doing with the workforce team at DHSC on the factors related to recruitment and retention of NHS staff, and as a member of the DHSC Workforce Policy Research Unity (2019 – 2023). Results can therefore be disseminated easily to the relevant national policymaker working in this area. IFS would discuss the project as it progresses with DHSC, and then disseminate final results when the paper is published. Benefits would therefore be expected to start during this dissemination progress and last into the future through the research’s impact on long-term planning for NHS workforce. c) Worldwide, the use of opioids has increased dramatically over the last two decades. In the UK the number of opioid prescriptions doubled between 2000 and 2012, raising fears about the misuse of these drugs (https://www.pharmaceutical-journal.com/news-and-analysis/a-crisis-hidden-in-plain-sight-prescription-opioid-misuse-in-the-uk/20203928.article). However, little is known about how use varies across the country, or what drives the use of opioids (and therefore any subsequent negative consequences). This project will expand knowledge of where opioids are most frequently prescribed, and help to inform policymakers and practitioners about the extent to which opioid use has been driven by rationing of other forms of NHS care. IFS will use existing contacts at Public Health England to disseminate this work among policymakers. IFS are also collaborating with UCL Department of Primary Care and Population Health, who will use their links with primary care practitioners to disseminate findings directly to GPs. [2 paragraphs unchanged]

Benefits reported

Previous and ongoing IFS work with data provided by NHS Digital has [35 words unchanged] system. As previously noted by the DHSC, in a letter to accompany our this application, our the work and subsequent discussions help to build knowledge about specific policies or broader policy areas. The It is hoped that the evidence produced by the work can then feed into policy decisions in future. [2 paragraphs unchanged] - Results from project 3 have been presented to the DHSC on three separate occasions (June 2016, October 2018, March 2019), with updates on the work (or newly requested extensions) requested by DHSC each time. These presentations have been requested by DHSC as part of their evidence gathering on how demand for NHS care is changing (and how it is likely to change in the future). In particular, the March 2019 presentation was requested by the Social Care analysis team as part of their preparations for the 2019 Spending Review. The research will therefore potentially influence the future provision of health and social care in England through increasing the evidence based used by DHSC in their decision making processes.. (Update June 2021): Building upon this, a non-technical summary of the use of private providers in the NHS was released in November 2019, an article was published in the Journal of Health Economics in September 2020 (the Journal of Health Economics is the top health economics journal, with an impact factor of 2.8), and an article was published in Health Economics in February 2021 (see project 1). These publications provided detailed evidence of the use of private providers in the NHS prior to the COVID-19 pandemic, and the impact on health inequalities as a result of private provider entry to NHS markets and the expansion of choice. The lessons learned from this research - namely that private provider entry lead to expansions in publicly funded healthcare capacity with limited impacts on inequality but with no observed improvements in care quality - will be especially important over the coming years as policymakers seek ways to meet the huge backlogs in NHS elective care that have formed as a result of the pandemic, including extending use of private providers for routine operations. - Results from project 3 have been presented to the DHSC on three separate occasions (June 2016, October 2018, March 2019), with updates on the work (or newly requested extensions) requested by DHSC each time. These presentations have been requested by DHSC as part of their evidence gathering on how demand for NHS care is changing (and how it is likely to change in the future). In particular, the March 2019 presentation was requested by the Social Care analysis team as part of their preparations for the 2019 Spending Review. The research will therefore potentially influence the future provision of health and social care in England through increasing the evidence based used by DHSC in their decision making processes. (Update June 2021): We will shortly approach NHS England and DHSC with updated results, following the publication of the results in the Journal of Health Economics in July 2021 (https://www.sciencedirect.com/science/article/pii/S016762962100062X). In December 2020, we met with representatives of NHS Confederation and the Health for Care Coalition to discuss the findings of this project. They have drawn on our research in their subsequent discussions with other NHS stakeholders and policymakers over the financial settlement for, and integration of, health and social care. The findings of the research were also discussed with the National Audit Office in May 2021 in the context of their work on Efficiency in Government, where our work demonstrates the importance of considering the interface between local and central government, and provides robust evidence of spillovers between the two. [2 paragraphs unchanged] - The work on the impact of the 4-hour target on patient [14 words unchanged] the main policymaker responsible for implementing and maintaining the target in NHS hospitals. hospitals, and discussed with NHS England. During the design of the work, IFS discussed the project with the [23 words unchanged] the ECIP team and presented to the NHS-I Economics team in detail. The work shows that the 4-hour target has meaningful impacts for the standard of care provided to patients at a time when hospitals are struggling to meet the target, and is expected to yield further benefits by providing evidence of the impact of the target in future discussions over the future of the policy (e.g. a consultation on the 4-hour target has been publicly mooted in recent months). (Update June 2021) The work (about to be published in the Review of Economics and Statistics, a leading economics journal) has shown that the 4-hour target has meaningful impacts for the standard of care provided to patients at a time when hospitals are struggling to meet the target. In particular, health benefits are delivered for patients with time-sensitive conditions. Recent changes to the 4-hourt target (confirmed in May 2021) include the introduction of ‘critical time standards’ for acute and time-sensitive conditions. IFS research shows that such a policy would be consistent with improved outcomes for patients, with quicker treatment for these conditions reducing mortality. - (Update June 2021) The report produced in 2019 from project 5, examining the impacts of the Sure Start programme on childhood health, has been highly cited and influential in debates on how best to support families with young children. The central findings around the positive health impacts of joined-up early years services, and the need for ongoing evaluation, were reflected in the key priority areas of the Leadsom Review (published in March 2021). They have also been cited in prominent reviews of the health care system, including the LSE-Lancet Commission on the Future of the NHS (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00232-4/fulltext), and the Marmot Review 10 Years On (https://www.health.org.uk/publications/reports/the-marmot-review-10-years-on), providing evidence on the importance of early-years intervention for promoting better population health (and therefore reducing future demands on the health and social care system).