Prisoner health: Understanding prisoners’ healthcare needs, their use of healthcare services and quality of care received - Use of Secondary Care Services

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

Datasets: + Emergency Care Data Set (ECDS)

Objective for processing

[3 paragraphs unchanged] • rigorous, robust and evidence-based in the work we undertake; undertaken; [5 paragraphs unchanged] For the purpose of these legitimate interests, the Nuffield Trust, as data controller, is undertaking the following study: Prisoner health: Understanding prisoners' healthcare needs, their use of healthcare services and quality of care received. Prisoner health: Understanding prisoners’ healthcare needs, their use of healthcare services and quality of care received. Delivery of healthcare in prisons and other secure settings presents unique challenges and it is acknowledged that there is a lack of quantitative evidence regarding healthcare quality in these environments. Data driven evidence is vital to inform ongoing debates regarding conditions in prisons and to shape future policy. Ultimately, this research aims to use routine hospital data to better understand the healthcare needs of prisoners, their use of hospital services and how the quality of care for prisoners compares to the non-prisoner population. Delivery of healthcare in prisons and other secure settings presents unique challenges and it is acknowledged that there is a lack of quantitative evidence regarding healthcare quality in these environments. Ultimately, this research aims to use routine hospital data to better understand the healthcare needs of prisoners, their use of hospital services and how the quality of care for prisoners compares to the non-prisoner population. [1 paragraph unchanged] The Nuffield Trust has previously used the data under this Agreement to identify a longstanding work programme exploring health service use and quality of care for people in penal establishments who access secondary healthcare services. establishments. This firstly included investigating how penal establishment relates to other demographic information [38 words unchanged] about the health of prisoners based on the use of hospital services. The Nuffield Trust then went on to investigate how prisoners’ use of secondary care services has changed over time (2016/17 - 2020/21) using Hospital Episode Statistics (HES) data. This work was important in order to monitor the change in use of hospital services year on year as a sign of the impact of conditions in the prison estate on the health needs of prisoners, as well as the impact of policy and practice changes on prisoner health care usage. These areas of the analysis have been completed. The Nuffield Trust wish to continue their prisoner health work to do two things. Firstly, the Nuffield Trust wish to use hospital data (Hospital Episode Statistics) to conduct targeted analysis describing the hospital service use of specific groups of prisoners, including older prisoners aged 50+, younger prisoners aged 25 and under and women prisoners – all of which are areas which have been the focus of current or recent select committee inquiries. The Nuffield Trust then went on to investigate how prisoners’ use of secondary care services has changed over time (2016/17 - 2020/21) using Hospital Episode Statistics (HES) data. This work was important in order to monitor the change in use of hospital services year on year as a sign of the impact of conditions in the prison estate on the health needs of prisoners, as well as the impact of policy and practice changes on prisoner health care usage. Secondly, The work then progressed to describe the hospital service use of specific groups of prisoners, including older prisoners aged 50+, younger prisoners aged 25 and under and women prisoners’, all of which were areas which have been the focus of select committee inquiries. The Nuffield Trust will also looked at use of hospital services in the first year of the Covid-19 pandemic (2020/21). The Nuffield Trust also undertook analysis to compare the use of services of to a matched sample in the general population. The Nuffield Trust will undertake analysis of matched samples to compare prisoners’ use of secondary care to the general population. In the original study, simple age-sex standardised comparisons were conducted, but going forward, the Nuffield Trust will continue to match samples for prisoners from the general population based on demographic characteristics and prior hospital use. The Nuffield Trust will compare hospital service use between the two groups to estimate what the level of health care need for prisoners would be if they had the same access to healthcare as the general population. The Nuffield Trust will be able This work was important because prison health services need a basis on which to answer questions such as: in more accurately predict the follow up period (minimum 3 months) how many people in the matched control sample were admitted for key clinical reasons, for example, for cancer treatment. The Nuffield Trust can then compare these figures to the prison population sample upon which the matched sample is based to look at the difference in numbers. NHS Digital will not create a specific control group but the Nuffield Trust will match prisoners' use of secondary healthcare with that needs of the general public using HES data from prisoner population and therefore what sorts of services they should be offering, and the applicant’s underlying separate Data Sharing Agreement (DARS-NIC-226261-M2T0Q). quantity. These areas of the analysis have been completed The Nuffield Trust wish to continue their prisoner health work to explore what can be learned from the Emergency Care Data Set (ECDS), about prisoners’ use of secondary care services in an emergency. The Nuffield Trust will carry out descriptive analysis using Hospital Episode Statistics (HES) data (ECDS) to describe prisoners’ use of emergency hospital services in 2023/24. This will provide an opportunity to apply our existing methodology (postcode matching) to ECDS data. In the very first prison health project The Nuffield Trust looked at A&E data (superseded by ECDS), but the quality of coding was poor with a large amount of missing diagnostic information, so the work instead focused on inpatient and outpatient data in our published work. Now that ECDS is well established, The Nuffield Trust can extent our work to address prisoners use of urgent care services. The Nuffield Trust will also contextualise the descriptive findings relative to the non-prison population. This could include age-sex standardised comparisons of specific diagnosis recorded. In addition to descriptive analysis, The Nuffield Trust will explore ECDS data fields and document the quality of information they provide about use of A&E services linked to prison (cross referencing versus figures drawn from postcode approach and publicly available data). The purpose of this work is providing objective data driven evidence as to how prisoners use urgent care services (A&E). The Nuffield Trust already holds ECDS data, and therefore the only additional data required is a list of the Nuffield Token Person ids, associated study IDs and RECORD_IDENTIFIER of individuals from the postcode list provided to NHS England who are present in 2023/24 ECDS data. RECORD_IDENTIFIER is a record identifier created by the HES system. Access to this record identifier will enable identification of where individuals have multiple admissions whilst in the same location. There is a moral argument in favour of disseminating information regarding use of urgent care services by prisoners, as reducing health inequalities experienced by inclusion health groups - which includes people in contact with the justice system - is an NHS England priority. Core20PLUS5 is a national NHS England approach to inform action to reduce healthcare inequalities at both national and system level. The Nuffield Trust work can provide data to support targeted action to reduce health inequalities experienced by people in prison. The Nuffield Trust can identify urgent hospital care that falls under the five clinical areas which the Core20PLUS5 approach aims to target. This includes mental illness, which is a significant issue within prisons. A recent report commissioned by NHS England highlighted than nine in ten prisoners have at least one mental health or substance misuse problem. There are no risks to the public of dissemination of this work. Small numbers will be suppressed, and no individual prisoner (or prison) will be identifiable in reporting. The data requested will achieve the aim identified as it will enable the Nuffield Trust to identify urgent hospital activity linked to prison estate locations in England. This data is required in order to identify urgent care activity linked to a prison estate postcode within national ECDS data. This is currently no other way to reliably identify hospital activity linked to a prison estate location from routinely collected data. The Nuffield Trust have had recent conversations with NHS North East London Commissioning Support Unit to discuss our approach and are aware that the Office of National Statistics has also used this approach in recent work to explore use of NHS talking therapies by prisoners. Data minimisation is not required as this application pertains to a bridging file. [1 paragraph unchanged] This analysis will produce specific outputs focused on older, younger and women prisoners as well as specific outputs reporting on the findings from the matched sample control work. Whilst exploration of Covid-19 related hospital admissions is not a primary objective of the work, the data period will cover 2019 and 2020, and therefore there will be descriptive analysis of hospital admissions where Covid-19 is recorded as an admission diagnosis. The Nuffield Trust will work with an established expert panel supporting the project to identify key clinical outcomes amenable to identification in hospital data which will provide useful information regarding unmet need. The expert panel, which acts in an advisory capacity, currently includes representatives from NHS England, CareUK, the RCGP Secure environments group, an Independent Monitoring Board rep, the Howard League, a head of prison healthcare, and academics working in prisoner health research. The expert panel do not provide any governing role. The Nuffield Trust already holds the HES data files under agreement DARS-NIC-226261-M2T0Q-v0.5, and therefore the only additional data required is a list of the Nuffield HES ID’s, associated study IDs and EPIKEY/ATTENDKEY/AEKEY of individuals from the postcode list provided to NHS Digital who are present in HES Inpatient, Outpatient or A&E data. This previously covered the data periods 2016/17, 2017/18, 2018/19 and 2019/20 respectively. EPIKEY/ATTENDKEY/AEKEY are record identifiers created by the HES system. Access to these record identifiers will enable identification of where individuals have multiple admissions whilst in the same location. The Nuffield Trust now wish to also access 2020/21 Inpatient and Outpatient data, 2019/20 A&E data. The Nuffield Trust also intend to request linkable ECDS data for 2019/20 and 2020/21 in the future. This extended data period (2019/20 – 2020/21 across inpatient, outpatient, A&E) is in part to cover the most up-to-date data periods available for these data sets, but also to have as long a period of data as possible for looking at prior history of hospital use as well as follow-up activity when undertaking matched sample analysis. All other objectives for processing remain the same. These datasets are important to allow the analysis to be carried out in as rigorous a way as possible. This means having access to enough data in order to look at prior history of hospital use and follow-up activity. With less data sample size declines which impacts the quality of the analysis. [1 paragraph unchanged] This project extension is being funded by the Health Foundation, an independent charity committed to bringing about better health and health care for people in the UK. This funding is currently set to run until June 2024. The Health Foundation do not make any decisions regarding the collection or analysis of data under this Agreement. [1 paragraph unchanged] Summary of data access requested: While there are no other organisations involved directly in the work, the Nuffield Trust engages widely with stakeholders to discuss the work and ensure that relevant context is reflected in how the findings are reported. For instance, current challenges around overcrowding and staffing challenges are important when considering impact on prisoners’ use of urgent care services. * For Inpatient (HES APC) and outpatient (HES Outpatients) data this will cover the data period 2016/17 - 2020/21. Summary of data access already requested under a previous iteration of the agreement: * • For A&E Inpatient (HES APC) and outpatient (HES Outpatients) data this will cover the data period 2016/17 - 2019/20. 2020/21. • For A&E data this will cover the data period 2016/17 – 2019/20 Under v3.2 of the agreement: • ECDS 2023/24 annual data.

Processing activities

[2 paragraphs unchanged] 1. The data controller will provide a list of the prison postcodes and an associated study ID for every prison in England to NHS Digital. England. 2. NHS Digital England to extract HESIDs, EPIKEY/ATTENDKEY/AEKEY* token person ID, RECORD_IDENTIFIER and STUDY_ID for individuals present in HES data where HOMEADD is in the postcode list supplied for 2019/20 and 2020/21 (* depending on data set) 2023/24. 3. NHS Digital England to disseminate data to The Nuffield Trust. 4. The data is disseminated by NHS Digital England and imported into SAS. The server is held on-site, and access is restricted to named individuals according to The Nuffield Trust's Information Security Management System (ISMS). [1 paragraph unchanged] 6. Remote access to the database is permitted, but only through Citrix via secure token (so processing is still carried out on site), and with local printing and downloading disabled. 6. Remote access to the data is only permitted using RDP and Multi Factor Authentication. [2 paragraphs unchanged] 9. Once held in SAS, the researcher will view the data and undertake descriptive analysis – analysis, such as demographic characteristics and reasons for admission, length of stay and associated co-morbidities. attendance. Informed by discussion with stakeholders regarding key healthcare issues and indicators of quality of care, urgent care issues, focused analysis will be undertaken relating to specific cohorts of prisoners (older women (such as attendances linked to violence or young offenders) self-harm) or looking at specific chronic conditions. The researchers will use routinely available [6 words unchanged] amend these based on the nature of the study's group of interest. 10. Comparisons will be made based on the standardised national rates for age and sex bands. E.g. national rates of emergency admissions would be used to construct expected rates of emergency admissions within the prison cohort. The Trust is able to then compare the prison cohort against national standardised rates. 10. The Nuffield Trust will also contextualise the descriptive findings relative to the non-prison population within ECDS. This could include age-sex standardised comparisons of specific diagnosis recorded. 11. The individual researcher then analyses the data, before applying the relevant disclosure controls to any output. Software used will be SAS, R and stata. Typically, this will involve analysis on several outcome measures, risk adjustment and the construction of control groups. Software used will be SAS, R and stata. Typically, this will involve analysis on several outcome measures, risk adjustment and the construction of control groups. [1 paragraph unchanged] For the postcode-based aspect of the analysis, the Nuffield Trust will provide NHS Digital England with a list of addresses (including postcode) of all prison establishments in England (n=118) in addition to a study identifier for each location. In return, NHS Digital England will provide a list of the Nuffield HES ID’s, token person IDs, associated study IDs and EPIKEY/ATTENDKEY/AEKEY RECORD_IDENTIFIER of individuals from the postcode list provided who are present in HES Inpatient, Outpatient, or A&E ECDS data in the period 2019/20 and 2020/21. The Nuffield Trust already holds all relevant information relating to data covering 2016/17 – 2019/20 (dependent on the datasets). 2023/24. Please note: No local datasets will be sent to NHS Digital – purely a list of the prison addresses. The Nuffield Trust already holds all relevant information relating to data covering 2023/24. In early phases of this work (now completed) the Nuffield Trust used 2005/6 – 2017/18 APC data to explore the reliability of ADMISORC (Source of Admission; identifies where a patient was immediately prior to admission) and DISDEST (Destination on Discharge; identifies where a patient was due to go on leaving hospital). 2017/18 APC, OP, A&E, HES Data was also used by the Nuffield Trust to carry out descriptive analysis of prisoners’ use of hospital services. Please note: No local datasets will be sent to NHS England - purely a list of the prison addresses. [1 paragraph unchanged] 1. Descriptive analysis: 2016/17, 2017/18, 2018/19 and 2019/20 2019/20, 2020/21 APC, OP & A&E HES Data. Data (A&E up to 2019/20). [1 paragraph unchanged] The Nuffield Trust already holds the HES data files as described above and is therefore requesting permission purely to conduct analysis to identify the matched control group and report on differences in the subsequent use of hospitals. This will involve identifying people who were in prison in 2018 and 2019, but who either earlier in 2018, 2019 or in 2016, 2017, 2018 used hospital services when they were not in prison. The general population comparator group will be matched on the basis of: No specific control group has been created for this study and the matched patient group will come from the applicant 's underlying separate Data Sharing Agreement (DARS-NIC-226261-M2T0Q). • Demographic characteristics at point of most recent community-based admission including Index of Multiple Deprivation. Date required in V3.2 of the agreement: • Prior history of hospital use over a minimum of the last 18-months as well as diagnostic history as part of hospital data. The processing activities remain the same but will incorporate the latest year of ECDS data. Additional data required for analysis: • People linked to a prison postcode at any point between April 2016 and March 2020 will be excluded. 1. 2023/24 ECDS data. No specific control group has been created for this study and the matched patient group will come from the applicant’s underlying separate Data Sharing Agreement (DARS-NIC-226261-M2T0Q). Please note: The Nuffield Trust already holds the HES data files, and therefore the only additional data required is a list of the Nuffield HES IDs, associated study IDs and RECORD_IDENTIFIERS of individuals from the postcode list provided to NHS England who are present in HES ECDS data in the periods of interest. Date required going forward: * For ECDS data, this will cover the period 2023/24 The processing activities remain the same but will incorporate additional year(s) of data. Additional data required for both the descriptive analysis and matched control sample work: 1. 2020/21 APC & OP Data, and 2019/20 A&E data. Please note: The Nuffield Trust already holds the HES data files, and therefore the only additional data required is a list of the Nuffield HES IDs, associated study IDs and EPIKEY/ATTENDKEY/AEKEY of individuals from the postcode list provided to NHS Digital who are present in HES APC, Outpatient, or A&E data in the periods of interest. * For Inpatient and outpatient data this will cover the data period 2020/21. * For A&E data this will cover the data period 2019/20. A separate list of Nuffield HES id’s, associated study IDs and EPIKEY/ATTENDKEY/AEKEY of individuals from the postcode list will be required for each year. Access to A&E data for 19/20 will provide the benefit of a longer follow-up period comparable to historical A&E data. [2 paragraphs unchanged] 1. The use of the prison postcode is an initial safeguard, as [65 words unchanged] Justice Programme manager to ensure consistency with the official postcodes in use. In terms of checks, the Nuffield Trust have used the online Post Office postcode checking service to review the postcode used for each site, as well as checking online address details for each prison where possible. 2. If a prison officer has an injury which requires them to go to Hospital, they are identifiable only by their home postcode within HES, which the Nuffield Trust will not have access to, and as their home postcode will not be the prison, their data will not be captured using the prison postcode methodology. 2. In terms of checks, the Nuffield Trust have used the online Post Office postcode checking service to review the postcode used for each site, as well as checking online address details for each prison where possible. ONS also have a postcode directory look-up, which enables detailed visual review of specific postcode locations. 3. If a prison officer has an injury which requires them to go to Hospital, they are identifiable only by their home postcode within HES, which the Nuffield Trust will not have access to, and as their home postcode will not be the prison, their data will not be captured using the prison postcode methodology. [1 paragraph unchanged] 1. Sensible cross-checks will be undertaken such as making sure HESIDs linked to [24 words unchanged] include HESIDs for individuals above the age range threshold for such establishments. 2. 1. A small number of prisons have accommodation for staff onsite. It is unlikely that such accommodation would be staff members’ members' full-time permanent residence but to minimise the likelihood of any prison staff [6 words unchanged] codes will be examined to look for reference to admissions related to ‘Problems 'Problems related to employment and unemployment’, unemployment', as well as the sorts of checks identified under point 1. 3. 2. An additional safeguard has been put in place to ensure that cases [21 words unchanged] up to 18-months of age) cannot be identified in the data extraction. [3 paragraphs unchanged] Wavex Technology provide Nuffield Trust with services of managed IT services. They [11 words unchanged] with their accounts. They do not process or store data including NHS Digital England data. Wavex have signed an updated contract with Nuffield stating: “Recipient "Recipient undertakes, not to access sensitive research data residing on Nuffield Trust’s Trust's Research hardware. Any attempt by recipient’s recipient's employee to access the data, either through bypass of the security features, [12 words unchanged] breach of the contract and could result in immediate termination to their contract.” contract." Data Protect UK provide Nuffield Trust with services of storing encrypting backup [9 words unchanged] disaster recovery. Data Protect UK do not have access to the NHS Digital England data on the tapes. The Nuffield Trust shall ensure access to data disseminated by NHS Digital England is strictly prohibited and must not be accessed by the Trust’s Trust's IT Managed Services Provider.

Expected output

All outputs for this study project will be aggregated with small number suppressed in line with the HES Analysis Guide. The study output and anticipated publication date is listed below. All outputs may also include presentational web material (for example slideshows and blog posts), in addition to presentations given in person at relevant research or policy conferences, etc. A summary of completed recent outputs: The main anticipated output of the project is a data report describing use of urgent care services by prisoners in 2023/24. This is scheduled for publication in Autumn 2025. 1. A data report describing secondary health care services used by prisoners between 2016/17 and 2019/20, and how the pattern of service use has changed over this period, as well as a policy review setting out how healthcare is provided to prisoners and key commissioning/provider/independent body involvement were made publicly available on the Nuffield Trust website in October 2021. Throughout the project there will also blogs and briefings to publicise the research and promote key findings. 2. Progress report to funders. A progress report to the funders, The Health Foundation was delivered in June 2021, outlining the success of the matched control sampling methodology and plans for the cohort analysis of specific groups including women prisoners, older prisoners and younger prisoners in the second stage research submission. Anticipated dates of study reports are listed below. All may also include presentational web material (for example slideshows and blog posts), in addition to presentations given in person at relevant research or policy conferences, etc. October 2021 – June 2023: * Three smaller topic-based reports focused on women prisoners (Spring 2022), older prisoners (Autumn 2022), younger prisoners (Spring 2023) * Matched control analysis report (Spring 2023) * June 2023: End-of-award report to funders Throughout the projects there will also be blogs and briefings to publicise the research and promote key findings. [1 paragraph unchanged] The Nuffield Trust has published multiple magazine articles (including for the BMJ, the Howard League and the Independent Monitor Magazine) as well as a journal article in Cardiology in Focus, discussing the cardiac health care needs of people in prison. There are many examples of The Nuffield Trust's work being cited in parliamentary debates and select committees as well as used by national bodies including the Department of Health and NHS England, CQC and Monitor. Many of the projects have been funded by the Department of Health and NHS, and the Nuffield Trust work in partnership with NHS and other care organisations and with universities. The Nuffield Trust has also provided examples of their studies for NHS England to use as evidence to the health select committee. There are many examples of The Nuffield Trust's work being cited in parliamentary debates and select committees as well as used by national bodies including the Department of Health and NHS England, CQC and Monitor. Many of the projects have been funded by the Department of Health and NHS, and the Nuffield Trust work in partnership with NHS and other care organisations and with universities. The Nuffield Trust has also provided examples of their studies for NHS Digital to use as evidence to the health select committee. In June 2018, the BMA referenced the prisoner health project in their submission to the Health Select Committee inquiry into prison health care, saying that they "particularly welcome the Nuffield Trust’s ongoing project to look at the health trends of the prison population and hope that government will consider carefully their findings once they are published, particularly how government can produce data which would allow better understanding of prisoner health.” In May 2019 , the Nuffield Trust were asked to sit on the advisory group for a project submission to the 'UKRI Future Leaders Fellowship Grants Committee' entitled Prison Regulation for Safer Societies. This is important because this work aims to improve regulation in prison in order to improve safety, and by definition health. In September 2019, the Nuffield Trust prepared evidence for submission to the Justice Committees inquiry into the ageing prisoner population. This is important to healthcare in order to add quantitative knowledge to the evidence base in this area, which has been identified is limited. It also brings the healthcare needs of prisoners to the attention of key policy makers. In March 2021, the Nuffield Trust prisoner health work was referenced in a paper by the EMG Transmission Group on Covid-19 transmission in prison settings. It was considered at SAGE 84 on 25 March 2021. This is important to healthcare as the group was meeting to consider whether prisoners should be prioritised for COVID-19 vaccinations.

Expected measurable benefits

[6 paragraphs unchanged] It is also expected that the work has and will continue to [60 words unchanged] this change (this was also one of the Nuffield Trust report recommendations). https://www.gov.uk/government/publications/review-of-operational-policy-on-pregnancy-mother-and-baby-units-and-maternal-separation https://www.gov.uk/government/publications/review-of- operational-policy-on-pregnancy-mother-and-baby-units-and-maternal-separation [2 paragraphs unchanged]

Benefits reported

The benefits realised from the analysis of data under this Agreement so far include: Selected example of benefits: 1. November 2021: An MP raised multiple questions about the Nuffield Trust prisoner health report published in October 2021, as written House of Commons questions. This is important to healthcare as it raises the healthcare needs of prisoners (a group who face multiple health inequalities) with key government stakeholders for whom prisoner health falls under their remit. October 2024: The Nuffield Trust met with Chair of the Brook House Inquiry, to share learning from our Nuffield Trust prisoner health research to inform an upcoming piece of work to explore the implementation of a peer support service in prisons in America. This is beneficial to share learning which can be used shape work to improve healthcare for incarcerated prisoners in America. 2. October 2021: Ran a workshop at the RCGP Secure Environments Group 8th Health & Justice Summit: Communities of Practice in Secure Care. This is beneficial to healthcare because it provided information to commissioners of prison health services about the challenges prisoners face accessing hospital care. October 2024: The Nuffield Trust was asked to sit on the advisory group for a research proposal which if successful will explore the use of technological solutions to support monitoring of vital signs in prison as well as changes in mental health. This is beneficial to healthcare to help share knowledge from different research areas to improve the health of people in prison and shape future policy to address key healthcare challenges. 3. The Nuffield Trust was asked to contribute evidence to inform the COVID-19 pandemic recovery plan for NHSE Health & Justice. This is beneficial to healthcare because prisons face a backlog of unmet healthcare need as a result of the pandemic and the work of the Nuffield Trust provides up-to-date evidence of the baseline challenges around access to services and the fact that services were predominantly absorbed by managing injury and self-harm. October 2024: The Nuffield Trust met with the Chief Medical Officers team to discuss an upcoming short report focused on prisoners healthcare needs and healthcare provision in prison. This is important to healthcare in order to add quantitative knowledge to the evidence base in this area, which has been identified is limited. 4. September 2021: Asked to meet with the lead independent clinical reviewer of the Prisons and Probation Ombudsman report into the death of a baby at HMP Bronzefield to discuss how this research may be used to improve understanding of maternity services for women in prison and contribute to improvement. This has led to improvements to maternity services to prevent babies from dying in prison. September 2024: The Nuffield Trust co-authored a BMJ Commissioned analysis entitled, Maternity Provision for Incarcerated Women in the UK: Bridging Gaps in Clinical Care. This is beneficial to healthcare because it provided information to a broad clinical audience regarding the challenges prisoners faced by pregnant women in prison accessing healthcare. 5. September 2021: The Nuffield Trust were able to inform the investigators of ongoing challenges regarding women given birth outside of hospitals (in a prison cell or en-route to hospital), stemming from the Nuffield Trust's work being referenced in the Prisons and Probation Ombudsman’s report into the death of a baby at HMP Bronzefield. This was beneficial to healthcare as it saw the systemic challenges of caring for pregnant women in prison so that suitable support can be put in place to avoid babies dying in prison. August 2024: The Nuffield Trust was asked to write a book chapter for the next edition of the Handbook on Prisons, focused on the needs of older people in prison. This is beneficial to healthcare as it provides information to people interested in the issues affecting prisoners as to the challenges facing older people. This is important given that there is growing awareness of the challenges of managing increasing numbers of older people in prison, and how services will need to adapt. 6. August 2021: Submitted evidence to July 2024: The Nuffield Trust provided expert review of the APPG on Women Healthcare Services Safety Investigations Body (HSSIB) report, Management of Chronic Healthcare Conditions in the Penal System inquiry into women’s health and wellbeing in prisons. Prison. This is important to healthcare in order to share research learning and to add quantitative knowledge to the evidence base in this area, which has been identified is limited. 7. June 2021: Asked to speak about the Nuffield Trust prisoner health work at the quarterly meeting of the RCGP Secure Environments Group. This is important to healthcare in order to add quantitative knowledge to the evidence base in this area, which has been identified is limited. June 2024: The Nuffield Trust provided external review of a PhD focused on improving healthcare for women post incarceration in Australia, via care coordinators. This is beneficial to share learning which can be used shape work to improve healthcare for incarcerated prisoners in Australia. 8. May 2021: Was asked to contribute to the Health Foundation Covid-19 Impact Inquiry focused on prisons. This is important to healthcare as part of building a body of evidence as to the challenges prisons faced during the COVID-19 pandemic, and what recovery needs they might be. May 2024: The Nuffield Trust attended afternoon tea at the House of Lords at the launch of a report regarding healthcare for prisoners with cancer. This was beneficial to share learning from our Nuffield Trust research with a broad audience regarding the healthcare needs of people in prison. 9. From August 2020: Legacy prison health work is now being used at HMP Wandsworth to enable Advice and Guidance for clinical needs for patients. This is important to healthcare as it provides a practical example of the results being used to inform care. March 2024: The Nuffield Trust presented at the cancer and exclusion series at the Christie School of Oncology, Manchester, on the topic of, Inequality and inaction. The challenges prisoners face accessing hospital care. This was important to share quantitative evidence with practitioners from a range of healthcare disciplines regarding the challenges prisoners face accessing hospital care. 10. In March 2020: Study findings featured in a short film released on Mother’s day 2020, calling for pregnant women in prison to be released due to the risks of Covid-19 (https://shonaminson.com/). This is important to healthcare as many people do not realise there are pregnant women in prison so it is hoped that this has raised awareness of the presence of these women and their needs. October 2022: The Nuffield Trust was interviewed by the Director of a theatre company, Lung, to inform understanding of the key healthcare needs of people in prison as part of the background development of a stage production (Woodhill). This was important to share learning from quantitative evidence regarding the challenges prisoners face accessing hospital care. 11. January 2020 - Attended a roundtable meeting on Prison Health Research organised by the Royal College of General Physicians Secure Environment Group due to identification as a key stakeholder in the field. This is important because the group was meeting to consider gaps in knowledge regarding prisoner health information which the work of the Nuffield Trust could inform. November 2021: An MP raised multiple questions about the Nuffield Trust prisoner health report published in October 2021, as written House of Commons questions. This is important to healthcare as it raises the healthcare needs of prisoners (a group who face multiple health inequalities) with key government stakeholders for whom prisoner health falls under their remit. October 2021: The Nuffield Trust ran a workshop at the RCGP Secure Environments Group 8th Health & Justice Summit: Communities of Practice in Secure Care. This is beneficial to healthcare because it provided information to commissioners of prison health services about the challenges prisoners face accessing hospital care. The Nuffield Trust was asked to contribute evidence to inform the COVID-19 pandemic recovery plan for NHSE Health & Justice. This is beneficial to healthcare because prisons face a backlog of unmet healthcare need as a result of the pandemic and the work of the Nuffield Trust provides up-to-date evidence of the baseline challenges around access to services and the fact that services were predominantly absorbed by managing injury and self-harm. September 2021: The Nuffield Trust was asked to meet with the lead independent clinical reviewer of the Prisons and Probation Ombudsman report into the death of a baby at HMP Bronzefield to discuss how this research may be used to improve understanding of maternity services for women in prison and contribute to improvement. This has led to improvements to maternity services to prevent babies from dying in prison. September 2021: The Nuffield Trust were able to inform the investigators of ongoing challenges regarding women given birth outside of hospitals (in a prison cell or en-route to hospital), stemming from the Nuffield Trust's work being referenced in the Prisons and Probation Ombudsmans report into the death of a baby at HMP Bronzefield. This was beneficial to healthcare as it saw the systemic challenges of caring for pregnant women in prison so that suitable support can be put in place to avoid babies dying in prison. August 2021: Submitted evidence to the APPG on Women in the Penal System inquiry into womens health and wellbeing in prisons. This is important to healthcare in order to add quantitative knowledge to the evidence base in this area, which has been identified is limited. June 2021: Asked to speak about the Nuffield Trust prisoner health work at the quarterly meeting of the RCGP Secure Environments Group. This is important to healthcare in order to add quantitative knowledge to the evidence base in this area, which has been identified is limited. May 2021: Was asked to contribute to the Health Foundation Covid-19 Impact Inquiry focused on prisons. This is important to healthcare as part of building a body of evidence as to the challenges prisons faced during the COVID-19 pandemic, and what recovery needs they might be. From August 2020: Legacy prison health work is now being used at HMP Wandsworth to enable Advice and Guidance for clinical needs for patients. This is important to healthcare as it provides a practical example of the results being used to inform care. In March 2020: Study findings featured in a short film released on Mother͛s day 2020, calling for pregnant women in prison to be released due to the risks of Covid-19 (https://shonaminson.com/). This is important to healthcare as many people do not realise there are pregnant women in prison so it is hoped that this has raised awareness of the presence of these women and their needs. January 2020 - Attended a roundtable meeting on Prison Health Research organised by the Royal College of General Physicians Secure Environment Group due to identification as a key stakeholder in the field. This is important because the group was meeting to consider gaps in knowledge regarding prisoner health information which the work of the Nuffield Trust could inform.

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

Datasets: + 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

[13 paragraphs unchanged] The following analysis is complete but explains the The Nuffield Trust has previously used the data under this Agreement to identify people in penal establishments who access secondary healthcare services. This firstly included investigating how penal establishment relates to other demographic information such as information about the location of the health care provider and area of residence (LSOA), as well as using prison postcode as a proxy to identify patients from a penal establishment and investigating what can be learned about the health of prisoners based on the use of hospital services. The Nuffield Trust then went on to investigate how prisoners’ use of secondary care services has changed over time (2016/17 - 2020/21) using Hospital Episode Statistics (HES) data. This work was important in order to monitor the change in use of hospital services year on year as a sign of the impact of conditions in the prison estate on the health needs of prisoners, as well as the impact of policy and practice changes on prisoner health care usage. These areas of the analysis have been completed. two aspects of the analysis already undertaken under the previous iteration of this Agreement: The Nuffield Trust wish to continue their prisoner health work to do two things. Firstly, the Nuffield Trust wish to use hospital data (Hospital Episode Statistics) to conduct targeted analysis describing the hospital service use of specific groups of prisoners, including older prisoners aged 50+, younger prisoners aged 25 and under and women prisoners – all of which are areas which have been the focus of current or recent select committee inquiries. 1. The Nuffield Trust will explore the potential of two specific HES data fields; ADMISORC (where the patient was before they were admitted to hospital, with options ranging from usual place of residence (home) or other options, such as penal establishment and DISDEST (where the patient was due to go when they leave hospital, with options ranging from usual place of residence (home) to other options such as penal establishment) to reliably identify people in penal establishments who access secondary healthcare services. The Nuffield Trust will look at how many people are recorded as either being admitted to, or returning to a penal establishment from hospital, as well as how this relates to other demographic information such as information about the location of the health care provider (Procode3) as well as LSOA, which is area of residence. This phase of analysis is necessary to assess the accuracy with which these fields are completed, any specific anomalies which may impact on how they are interpreted and therefore the extent to which they can be used to validate the methodology to be applied in the work described under point 2. Secondly, the Nuffield Trust will compare the use of services of a matched sample in the general population. The Nuffield Trust will undertake analysis of matched samples to compare prisoners’ use of secondary care to the general population. In the original study, simple age-sex standardised comparisons were conducted, but going forward, the Nuffield Trust will continue to match samples for prisoners from the general population based on demographic characteristics and prior hospital use. The Nuffield Trust will compare hospital service use between the two groups to estimate what the level of health care need for prisoners would be if they had the same access to healthcare as the general population. The Nuffield Trust will be able to answer questions such as: in the follow up period (minimum 3 months) how many people in the matched control sample were admitted for key clinical reasons, for example, for cancer treatment. The Nuffield Trust can then compare these figures to the prison population sample upon which the matched sample is based to look at the difference in numbers. NHS Digital will not create a specific control group but the Nuffield Trust will match prisoners' use of secondary healthcare with that of the general public using HES data from the applicant’s underlying separate Data Sharing Agreement (DARS-NIC-226261-M2T0Q). Data to be analysed will cover the period 2005/2006 to 2017/18, as 2006 marks the point at which commissioning of healthcare services in prisons in England became the responsibility of the NHS; representing a significant change in commissioning responsibilities. As well as describing existing potential gaps in care, this work will provide vital information for prison health services to allow for better future planning. Prison health services need a basis on which to more accurately predict the healthcare needs of the prisoner population and therefore what sorts of services they should be offering, and the quantity. Please note: This is existing data the Nuffield Trust already holds for separate purposes under a separate Data Sharing Agreement. This Agreement will permit the re-use of a subset of that data and therefore no additional data is required for this aspect of the analysis. This analysis will produce specific outputs focused on older, younger and women prisoners as well as specific outputs reporting on the findings from the matched sample control work. 2. Analysis will be undertaken by the Nuffield Trust using prison postcode as a proxy to identify patients from a penal establishment; a methodology which the Nuffield Trust has successfully applied in the context of care home residents in past research. A prison postcode will usually include only the prison population and not those working in the prison or residential properties in close proximity. Whilst exploration of Covid-19 related hospital admissions is not a primary objective of the work, the data period will cover 2019 and 2020, and therefore there will be descriptive analysis of hospital admissions where Covid-19 is recorded as an admission diagnosis. Based on the findings from a prior phase of analysis which will not involve HES data (consisting of a literature review and conversations with experts in the field), analysis will be undertaken to determine what can be learned about the health of prisoners based on the use of hospital services. This may include analysis relating to specific cohorts of prisoners (for instance, women or young offenders) or looking at specific chronic conditions. The Nuffield Trust will work with an established expert panel supporting the project to identify key clinical outcomes amenable to identification in hospital data which will provide useful information regarding unmet need. The expert panel, which acts in an advisory capacity, currently includes representatives from NHS England, CareUK, the RCGP Secure environments group, an Independent Monitoring Board rep, the Howard League, a head of prison healthcare, and academics working in prisoner health research. The expert panel do not provide any governing role. Data to be analysed will cover the period 2017/18. The Nuffield Trust already holds the HES data files under agreement DARS-NIC-226261-M2T0Q-v0.5, and therefore the only additional data required is a list of the Nuffield HES ID’s, associated study IDs and EPIKEY/ATTENDKEY/AEKEY of individuals from the postcode list provided to NHS Digital who are present in HES Inpatient, Outpatient or A&E data. This previously covered the data periods 2016/17, 2017/18, 2018/19 and 2019/20 respectively. EPIKEY/ATTENDKEY/AEKEY are record identifiers created by the HES system. Access to these record identifiers will enable identification of where individuals have multiple admissions whilst in the same location. Please note: The Nuffield Trust already holds the HES data file (disseminated under separate Agreement DARS-NIC-384572-J7P6Y and later superseded by DARS-NIC-226261-M2T0Q), and therefore the only additional data required is a list of the Nuffield HES ID’s, associated study IDs and EPIKEY/ATTENDKEY/AEKEY* of individuals from the postcode list provided to NHS Digital who are present in HES Inpatient, Outpatient or A&E data in the period 2017/18 respectively. *EPIKEY/ATTENDKEY/AEKEY are record identifiers created by the HES system. Access to these record identifiers will enable identification of where individuals have multiple admissions whilst in the same location. The Nuffield Trust now wish to also access 2020/21 Inpatient and Outpatient data, 2019/20 A&E data. The Nuffield Trust also intend to request linkable ECDS data for 2019/20 and 2020/21 in the future. This extended data period (2019/20 – 2020/21 across inpatient, outpatient, A&E) is in part to cover the most up-to-date data periods available for these data sets, but also to have as long a period of data as possible for looking at prior history of hospital use as well as follow-up activity when undertaking matched sample analysis. All other objectives for processing remain the same. These datasets are important to allow the analysis to be carried out in as rigorous a way as possible. This means having access to enough data in order to look at prior history of hospital use and follow-up activity. With less data sample size declines which impacts the quality of the analysis. This research will provide valuable information on the quality of data collected regarding prisoners in routine datasets, as well as the potential for postcode methodology, to accurately identify individuals from prison postcodes accessing secondary care services. It has been acknowledged that there is at best limited quantitative evidence regarding the healthcare needs of prisoners; something this research will provide. If successful, the approach would provide a means of assessing how the healthcare needs of prisoners are changing over time, and the impact of any targeted interventions. Analysis to explore the potential of two specific HES data fields; ADMISORC (where the patient was before they were admitted to hospital) and DISDEST(where the patient was due to go when they leave hospital) to reliably identify people in penal establishments who access secondary healthcare services has been completed. The Nuffield Trust concluded that at present, the coding of source of admission and destination of discharge in hospital data is not sufficiently reliable to identify prisoners’ use of hospital services. The Nuffield Trust holds no derived data files in relation to this analysis. Update 2020: Study extension The Nuffield Trust wish to extend their prisoner health work in order to use hospital data (Hospital Episode Statistics) to determine how prisoners’ use of secondary care services has changed over time as well as to compare the use of services of a matched sample in the general population. This work is important in order to monitor the change in use of hospital services year on year as a sign of the impact of conditions in the prison estate on the health needs of prisoners, as well as the impact of policy and practice changes on prisoner health care usage. This analysis will also enable identification of changing levels of healthcare use in a population with complex needs and an ageing profile. The Nuffield Trust will explore how prisoners’ use of secondary care services has changed over the last four years (2016/17 - 2019/20) using Hospital Episode Statistics (HES) data. Prison postcode will be used as a proxy to identify patients from a prison estate establishment within hospital data. This is the same methodology which the Nuffield Trust successfully applied in the context of patients using hospital services from a prison estate establishment in the original study using 2017/18 data. The selection of the data period (2016/17 – 2019/20) is in part to cover the most up-to-date data period available, but also to have as long a period of data as possible for looking at prior history of hospital use as well as follow-up activity when undertaking matched sample analysis. The Nuffield Trust will undertake analysis of matched samples to compare prisoners’ use of secondary care to the general population. In the original study simple age-sex standardised comparisons were conducted, but in this extension the Nuffield Trust will match samples for prisoners from the general population based on demographic characteristics and prior hospital use. The Nuffield Trust will compare hospital service use between the two groups to estimate what the level of health care need for prisoners would be if they had the same access to healthcare as the general population. The Nuffield Trust will be able to answer questions such as: in the follow up period (min 3 months) how many people in the matched control sample were admitted for key clinical reasons, for example for cancer treatment. The Nuffield Trust can then compare these figures to the prison population sample upon which the matched sample is based to look at the difference in numbers. NHS Digital will not create a specific control group but the Nuffield Trust will match prisoners' use of secondary healthcare with that of the general public using HES data from the applicant’s underlying separate Data Sharing Agreement (DARS-NIC-226261-M2T0Q). As well as describing existing potential gaps in care, this work will provide vital information for prison health services to allow for better future planning. Prison health services need a basis on which to more accurately predict the healthcare needs of the prisoner population and therefore what sorts of services they should be offering, and the quantity. The Nuffield Trust will work with an expert panel supporting the project to identify key clinical outcomes amenable to identification in hospital data which will provide useful information regarding unmet need. The expert panel, which acts in an advisory capacity, currently includes representatives from NHS England, CareUK, the RCGP Secure environments group, an Independent Monitoring Board rep, the Howard League, a head of prison healthcare, and academics working in prisoner health research. The expert panel do not provide any governing role. Subject to the next stage of funding being obtained, similar to the original prisoner health study there will be targeted analysis describing the hospital service use of specific groups of prisoners which will produce specific outputs as well as specific outputs reporting on the findings from the matched sample control work. Specific groups of prisoners of interest include older prisoners aged 50+, younger prisoners aged 25 and under and women prisoners – all of which are areas which have been the focus of current or recent select committee inquiries. Whilst exploration of Covid-19 related hospital admissions is not a primary objective of the work, the data period will cover 2019 and 2020, and therefore there will be descriptive analysis of hospital admissions where Covid-19 is recorded as an admission diagnosis The Nuffield Trust already holds the HES data files under agreement DARS-NIC-226261-M2T0Q-v0.5, and therefore the only additional data required is a list of the Nuffield HES ID’s, associated study IDs and EPIKEY/ATTENDKEY/AEKEY of individuals from the postcode list provided to NHS Digital who are present in HES Inpatient, Outpatient or A&E data. This will cover the data periods 2016/17, 2017/18, 2018/19 and 2019/20 respectively. EPIKEY/ATTENDKEY/AEKEY are record identifiers created by the HES system. Access to these record identifiers will enable identification of where individuals have multiple admissions whilst in the same location. [1 paragraph unchanged] This project extension is being funded by the Health Foundation, an independent charity committed to bringing about better health and health care for people in the UK. This funding is currently set to run until June 2024. The Health Foundation do not make any decisions regarding the collection or analysis of data under this Agreement. [1 paragraph unchanged] Summary of data access requested: * For Inpatient (HES APC) and outpatient (HES Outpatients) data this will cover the data period 2016/17 - 2020/21. * For A&E data this will cover the data period 2016/17 - 2019/20.

Processing activities

[1 paragraph unchanged] Whilst the nature of detailed analysis varies, the following describes the broad context of processing undertaken in the previous iteration of this Agreement:: Agreement: [1 paragraph unchanged] 2. NHS Digital to extract HESIDs, EPIKEY/ATTENDKEY/AEKEY* and STUDY_ID for individuals present in HES data where HOMEADD is in the postcode list supplied for 2017/18 2019/20 and 2020/21 (* depending on data set) [6 paragraphs unchanged] 9. Once held in SAS, the researcher will view the data and undertake descriptive analysis – such as reasons for admission, length of stay and associated co-morbidities. Based on the findings Informed by discussion with stakeholders regarding key healthcare issues and indicators of the Phase I literature review, quality of care, focused analysis will be undertaken relating to specific cohorts of prisoners (for instance, (older women or young offenders) or looking at specific chronic conditions. The researchers [10 words unchanged] amend these based on the nature of the study's group of interest. [1 paragraph unchanged] 11. The individual researcher then analyses the data, before applying the relevant disclosure controls to any output. Software used will be SAS, R and stata. Typically Typically, this will involve analysis on several outcome measures, risk adjustment and the construction of control groups. 12. No record level data would be linked to this dataset, but locally sourced Escort and Bedwatch (E&B) data from a sample of prison establishments will be used as a means of validating the volume of cases emerging from the HES postcode-based analysis. E&B data is based at an individual prison level and is essentially a record of prisoners moved to or from hospitals whether for urgent or unplanned care and the associated cost. 12. Outputs are thus produced which consist of aggregate data (or indicator/statistical data) only. Please note: E&B data contains no individual information about prisoners (such as their name, prisoner number or age). It is purely a record of the number of transfers and reasons for transfers. The Nuffield Trust will not be attempting to link this to HES data – it is purely being used to determine if the volume of cases emerging from the HES data reflects the volume of cases recorded for financial monitoring. This is important cross validation which will strengthen the HES based analysis. For the postcode-based aspect of the analysis, the Nuffield Trust will provide NHS Digital with a list of addresses (including postcode) of all prison establishments in England (n=118) in addition to a study identifier for each location. In return, NHS Digital will provide a list of the Nuffield HES ID’s, associated study IDs and EPIKEY/ATTENDKEY/AEKEY of individuals from the postcode list provided who are present in HES Inpatient, Outpatient, or A&E data in the period 2019/20 and 2020/21. The Nuffield Trust already holds all relevant information relating to data covering 2016/17 – 2019/20 (dependent on the datasets). 13. Outputs are thus produced which consist of aggregate data (or indicator/statistical data) only. For the postcode-based aspect of the analysis, the Nuffield Trust will provide NHS Digital with a list of addresses (including postcode) of all prison establishments in England (n=118) in addition to a study identifier for each location. In return, NHS Digital will provide a list of the Nuffield HES ID’s, associated study IDs and EPIKEY/ATTENDKEY/AEKEY of individuals from the postcode list provided who are present in HES Inpatient, Outpatient or A&E data in the period 2017/18. [1 paragraph unchanged] The datasets necessary for the study are listed below: In early phases of this work (now completed) the Nuffield Trust used 2005/6 – 2017/18 APC data to explore the reliability of ADMISORC (Source of Admission; identifies where a patient was immediately prior to admission) and DISDEST (Destination on Discharge; identifies where a patient was due to go on leaving hospital). 2017/18 APC, OP, A&E, HES Data was also used by the Nuffield Trust to carry out descriptive analysis of prisoners’ use of hospital services. Data required for analysis: Data in use: 1. 2005/2006 – 2017/18 APC Using a subset of data held by the Nuffield Trust under Agreement DARS-NIC-384572-J7P6Y, the Trust will explore the reliability of ADMISORC and DISDEST in a preliminary phase of analysis. The Nuffield Trust has undertaken some preliminary tests and has confidence that the outcome will be the identification of prisoners only. As with using any data set, there are risks involved, but a number of controls are in place to confirm that only prisoners are identified. See below for a summary of the controls. Factors which minimise the risk: 1. The use of the prison postcode is an initial safeguard, as prison postcodes relate just to individual prisons and therefore people in nearby residential accommodation will not be included based on having a shared postcode. 2. If a prison officer has an injury which requires them to go to Hospital, they are identifiable only by their home postcode within HES, which the Nuffield Trust will not have access to, and as their home postcode will not be the prison, their data will not be captured using the prison postcode methodology. Additional steps: 1. Sensible cross-checks will be undertaken such as making sure HESIDs linked to male prisons do not include details for females, and vice versa. Similarly, Young Offender Institutions or Secure Training Centres would not be expected to include HESIDs for individuals above the age range threshold for such establishments. 2. A small number of prisons have accommodation for staff onsite. It is unlikely that such accommodation would be staff members’ full time permanent residence but to minimise the likelihood of any prison staff being included within the dataset diagnostic codes will be examined to look for reference to admissions related to ‘Problems related to employment and unemployment’, as well as the sorts of checks identified under point 1. Finally, as with all reporting, small numbers will be suppressed and so no individual officers (or prisoners for that matter) will be identifiable in reporting. 2. 2017/18 APC, OP, A&E, HES Data. Please note: The only additional data required is a list of the Nuffield HES ID’s, associated study IDs and EPIKEY/ATTENDKEY/AEKEY of individuals from the postcode list provided to NHS Digital who are present in HES Inpatient, Outpatient or A&E data in the period 2017/18. Additional note - third parties: The Nuffield Trust will not provide access to record level data for any unnamed third parties, even where these third parties are study partners. The use of this data will be limited to the Nuffield Trust for the purpose outlined above only. Data published or provided to third parties will be limited to aggregated data, at area, organisational or cohort-level all subject to small number suppression in line with the HES Analysis Guide. Wavex Technology provide Nuffield Trust with services of managed IT services. They currently have domain level credentials but not access to the data with their accounts. They do not process or store data including NHS Digital data. Wavex have signed an updated contract with Nuffield stating: “Recipient undertakes, not to access sensitive research data residing on Nuffield Trust’s Research hardware. Any attempt by recipient’s employee to access the data, either through bypass of the security features, or amendments to the security settings would be seen as a material breach of the contract and could result in immediate termination to their contract.” Data Protect UK provide Nuffield Trust with services of storing encrypting backup tapes at their storage facility for the purposes of disaster recovery. Data Protect UK do not have access to the NHS Digital data on the tapes. The Nuffield Trust shall ensure access to data disseminated by NHS Digital is strictly prohibited and must not be accessed by the Trust’s IT Managed Services Provider. Update 2020 Study Extension: The datasets necessary for the study are listed below: Data required: [1 paragraph unchanged] Please note: The Nuffield Trust already holds the HES data files, and therefore the only additional data required is a list of the Nuffield HES IDs, associated study IDs and EPIKEY/ATTENDKEY/AEKEY of individuals from the postcode list provided to NHS Digital who are present in HES APC, Outpatient or A&E data in the periods of interest. The data periods are 2016/17, 2017/18, 2018/19 and 2019/20 respectively. A separate list of Nuffield HES id’s, associated study IDs and EPIKEY/ATTENDKEY/AEKEY of individuals from the postcode list will be required for each year. Personal Demographics Service (PDS) has now been rolled out across the prison estate which means that prison addresses are recorded in a standardised way, including postcode. The Nuffield Trust have been provided with the PDS address list by the Health & Justice Programme manager to ensure consistency with the official postcodes in use. In terms of checks, the Nuffield Trust have used the online Post Office postcode checking service to review the postcode used for each site, as well as checking online address details for each prison where possible. The Nuffield Trust also carry out checks of the data itself as an additional safeguard. For instance, ensuring there is no data for women linked to men’s prisons (and vice versa) as well as ensuring the broad age categories are appropriate for specific prison categories. The Nuffield Trust would not for instance expect to see older adults in a youth estate location. [6 paragraphs unchanged] An additional safeguard has been put in place to ensure that cases will be filtered to exclude any babies born in prison or living in Mother and Baby Units (which only hold children up to 18-months of age) can not be identified in the data extraction. Date required going forward: There will be no requirement nor attempt to re-identify individuals. The processing activities remain the same but will incorporate additional year(s) of data. Additional data required for both the descriptive analysis and matched control sample work: 1. 2020/21 APC & OP Data, and 2019/20 A&E data. Please note: The Nuffield Trust already holds the HES data files, and therefore the only additional data required is a list of the Nuffield HES IDs, associated study IDs and EPIKEY/ATTENDKEY/AEKEY of individuals from the postcode list provided to NHS Digital who are present in HES APC, Outpatient, or A&E data in the periods of interest. * For Inpatient and outpatient data this will cover the data period 2020/21. * For A&E data this will cover the data period 2019/20. A separate list of Nuffield HES id’s, associated study IDs and EPIKEY/ATTENDKEY/AEKEY of individuals from the postcode list will be required for each year. Access to A&E data for 19/20 will provide the benefit of a longer follow-up period comparable to historical A&E data. As with using any data set, there are risks involved, but a number of controls are in place to confirm that only prisoners are identified. See below for a summary of the controls. Factors which minimise the risk: 1. The use of the prison postcode is an initial safeguard, as prison postcodes relate just to individual prisons and therefore people in nearby residential accommodation will not be included based on having a shared postcode. Personal Demographics Service (PDS) has now been rolled out across the prison estate which means that prison addresses are recorded in a standardised way, including postcode. The Nuffield Trust have been provided with the PDS address list by the Health & Justice Programme manager to ensure consistency with the official postcodes in use. In terms of checks, the Nuffield Trust have used the online Post Office postcode checking service to review the postcode used for each site, as well as checking online address details for each prison where possible. 2. If a prison officer has an injury which requires them to go to Hospital, they are identifiable only by their home postcode within HES, which the Nuffield Trust will not have access to, and as their home postcode will not be the prison, their data will not be captured using the prison postcode methodology. Additional steps: 1. Sensible cross-checks will be undertaken such as making sure HESIDs linked to male prisons do not include details for females, and vice versa. Similarly, Young Offender Institutions or Secure Training Centres would not be expected to include HESIDs for individuals above the age range threshold for such establishments. 2. A small number of prisons have accommodation for staff onsite. It is unlikely that such accommodation would be staff members’ full-time permanent residence but to minimise the likelihood of any prison staff being included within the dataset diagnostic codes will be examined to look for reference to admissions related to ‘Problems related to employment and unemployment’, as well as the sorts of checks identified under point 1. 3. An additional safeguard has been put in place to ensure that cases will be filtered to exclude any babies born in prison or living in Mother and Baby Units (which only hold children up to 18-months of age) cannot be identified in the data extraction. There will be no requirement nor attempt to re-identify individuals. Finally, as with all reporting, small numbers will be suppressed and so no individual officers (or prisoners for that matter) will be identifiable in reporting. Additional note - third parties: The Nuffield Trust will not provide access to record level data for any unnamed third parties, even where these third parties are study partners. The use of this data will be limited to the Nuffield Trust for the purpose outlined above only. Data published or provided to third parties will be limited to aggregated data, at area, organisational or cohort-level all subject to small number suppression in line with the HES Analysis Guide. Wavex Technology provide Nuffield Trust with services of managed IT services. They currently have domain level credentials but not access to the data with their accounts. They do not process or store data including NHS Digital data. Wavex have signed an updated contract with Nuffield stating: “Recipient undertakes, not to access sensitive research data residing on Nuffield Trust’s Research hardware. Any attempt by recipient’s employee to access the data, either through bypass of the security features, or amendments to the security settings would be seen as a material breach of the contract and could result in immediate termination to their contract.” Data Protect UK provide Nuffield Trust with services of storing encrypting backup tapes at their storage facility for the purposes of disaster recovery. Data Protect UK do not have access to the NHS Digital data on the tapes. The Nuffield Trust shall ensure access to data disseminated by NHS Digital is strictly prohibited and must not be accessed by the Trust’s IT Managed Services Provider.

Expected output

[1 paragraph unchanged] Since the start of the study, the following publications have been produced: A summary of completed recent outputs: Davies (In press). Cardiovascular health within the UK prison population. Heart. 1. A data report describing secondary health care services used by prisoners between 2016/17 and 2019/20, and how the pattern of service use has changed over this period, as well as a policy review setting out how healthcare is provided to prisoners and key commissioning/provider/independent body involvement were made publicly available on the Nuffield Trust website in October 2021. Davies (In press). Prisoners’ access to secondary care and the impact of Covid-19. Howard League ECAN Bulletin. Howard League. 2. Progress report to funders. A progress report to the funders, The Health Foundation was delivered in June 2021, outlining the success of the matched control sampling methodology and plans for the cohort analysis of specific groups including women prisoners, older prisoners and younger prisoners in the second stage research submission. Davies M and Keeble E (2020) “Covid-19 in prisons: fewer cases than feared but it’s not the whole story”, Nuffield Trust comment. - Davies M (2020 "Covid-19: how is it impacting on prisoners health?" -Davies M, Rolewicz L, Schlepper L and Fagunwa F (2020) Locked out? Prisoners' use of hospital care. Research report, Nuffield Trust. - Davies M (2020 "Prisoner health: Dr Miranda Davies Q&A" - Davies M (2020 "Miranda Davies: Why we should worry about prisoners missing hospital appointments."The BMJ Opinion. -Nuffield Trust (2020 "Prisoners missing out on hospital treatment, new research reveals" Nuffield Trust press release - Davies M (2019) Prisoners' use of hospital services. RCGP's 7th Health and Justice Summit: Journeys Through Justice - Leadership and Transformation - Davies M (2019 "Pregnancy and childbirth in prison: what do we know?" Nuffield Trust - Davies M (2019) "Prisoner health and homeless health: understanding the links between them." https://www.nuffieldtrust.org.uk/news-item/prisoner-health-and-homeless-health-understanding-thelinks-between-them - Davies, M. (2019) Prisoners' physical healthcare needs and quality of care. February 2019. The Monitor. Issue 126. -Davies M (2019). Understanding prisoners' healthcare needs and their use of hospital services using routine healthcare data. 31st January 2019. 6th Health & Justice Summit: Safety through Continuity. - Davies M (2018) "Understanding prisoners' experience of health care to improve our research" https://www.nuffieldtrust.org.uk/news-item/understanding-prisoners-experience-of-health-care-toimprove-our-research - Davies M (2018) "What to expect when you're expecting in prison?", Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/what-to-expect-when-you-re-expecting-in-prison - Davies M (2018) "Us and them: the impact of prejudice on prisoners' health care" https://www.nuffieldtrust.org.uk/news-item/us-and-them-the-impact-of-prejudice-on-prisoners-health-care - Davies M (2018) "Numbers matter in prison", Nuffield Trust comment. https://www.nuffieldtrust.org.uk/newsitem/ numbers-matter-in-prison [1 paragraph unchanged] January 2021 - April 2021: October 2021 – June 2023: 1. Data briefing. This report will describe the secondary health care services used by prisoners between 2016/17 and 2019/20, and how the pattern of service use has changed over this period. The report will be available on the Nuffield Trust website. * Three smaller topic-based reports focused on women prisoners (Spring 2022), older prisoners (Autumn 2022), younger prisoners (Spring 2023) 2. Policy review. This briefing document will set out how healthcare is provided to prisoners and key * Matched control analysis report (Spring 2023) commissioning/provider/independent body involvement. It will be publicly available on The Nuffield Trust website. * June 2023: End-of-award report to funders April 2021: 3. Progress report to funders. A progress report to the funders, The Health Foundation, outlining the success of the matched control sampling methodology and plans for the cohort analysis of specific groups including women prisoners, older prisoners and younger prisoners in the second stage research submission. January 2021 - April 2021: Meeting of the expert panel. June 2021 - June 2020: Estimated stage 2 output dates: Subject to receiving the funding for stage 2 of the work outlined, the following reports will be produced: * Three smaller topic-based reports focused on younger prisoners, older prisoners and women prisoners. * Matched control analysis report [1 paragraph unchanged] Please note: The listed output dates are specific to the year one funded activity. This will include targeted outputs focused on the hospital service use of specific groups of prisoners (older prisoners, younger prisoners, and women prisoners) in greater detail as well as reporting on the findings from the matched sample control work. Since 2009 the Nuffield Trust's research studies, using NHS data, have been widely used to inform decision making and debate in health care. The Trust has held agreements with the NHS to receive patient datasets since. The Nuffield Trust publishes their reports on the Nuffield website and in peer reviewed journals where appropriate. The Nuffield Trust has published multiple magazine articles (including for the BMJ, the Howard League and the Independent Monitor Magazine) as well as a journal article in Cardiology in Focus, discussing the cardiac health care needs of people in prison. There are many examples of The Nuffield Trust's work being cited in parliamentary debates and select committees as well as used by national bodies including the Department of Health and NHS England, CQC and Monitor. Many of the projects have been funded by the Department of Health and NHS, and the Nuffield Trust work in partnership with NHS and other care organisations and with universities. The Nuffield Trust has also provided examples of their studies for NHS Digital to use as evidence to the health select committee. In June 2018, the BMA referenced the prisoner health project in their submission to the Health Select Committee inquiry into prison health care, saying that they "particularly welcome the Nuffield Trust’s ongoing project to look at the health trends of the prison population and hope that government will consider carefully their findings once they are published, particularly how government can produce data which would allow better understanding of prisoner health.” In May 2019 , the Nuffield Trust were asked to sit on the advisory group for a project submission to the 'UKRI Future Leaders Fellowship Grants Committee' entitled Prison Regulation for Safer Societies. This is important because this work aims to improve regulation in prison in order to improve safety, and by definition health. In September 2019, the Nuffield Trust prepared evidence for submission to the Justice Committees inquiry into the ageing prisoner population. This is important to healthcare in order to add quantitative knowledge to the evidence base in this area, which has been identified is limited. It also brings the healthcare needs of prisoners to the attention of key policy makers. In March 2021, the Nuffield Trust prisoner health work was referenced in a paper by the EMG Transmission Group on Covid-19 transmission in prison settings. It was considered at SAGE 84 on 25 March 2021. This is important to healthcare as the group was meeting to consider whether prisoners should be prioritised for COVID-19 vaccinations.

Expected measurable benefits

Since 2009 the Nuffield Trust's research studies, using NHS data, have been widely used to inform decision making and debate in health care. The Trust has held agreements with the NHS to receive patient datasets since. The Nuffield Trust publishes their reports on the Nuffield website and in peer reviewed journals where appropriate. There are many examples of The Nuffield Trust's work being cited in parliamentary debates and select committees as well as used by national bodies including the Department of Health and NHS England, CQC and Monitor. Many of the projects have been funded by the Department of Health and NHS, and the Nuffield Trust work in partnership with NHS and other care organisations and with universities. The Nuffield Trust has also provided examples of their studies for NHS Digital to use as evidence to the health select committee. [3 paragraphs unchanged] The Nuffield Trust will widely disseminate the research findings to policy makers, [51 words unchanged] the Nuffield Trust has built in a six-month window to the project time-line timeline to allow for development of these types of relationships. An There is a well-established expert panel is being established to supporting the project who provide advice and spread the benefits within their respective organisations. The expert panel do not provide any governing role. Members already include representatives from NHS England, CareUK, England/Improvement, UKHSA, the RCGP Secure environments group, an Independent Monitoring Board rep, Birth Companions, HMPPS, the Howard League, a head of prison healthcare, the Prison Reform Trust, personnel working in prisons, and academics working in prisoner health research. Engagement with the expert panel and other experts will ensure that the project findings can feed into the development of national strategies regarding prisoners’ healthcare needs. For instance, in November 2021, the Nuffield Trust has already been approached by a clinician developing guidelines for the care of prisoners requiring dialysis so that the presented project findings to the Offender Health Core20PLUS5 group. This engagement is beneficial to health care because people in prison are a targeted inclusion health group in the CORE20 strategy. The work of the Nuffield Trust can inform guideline development provide pertinent information regarding inequalities in this area (expected timeline late 2018/ mid 2019). access to healthcare services which the group is required to identify and attempt to address It is also expected that the work has and will continue to be used as an evidence source by advocacy groups to highlight healthcare issues faced by prisoners. As an example, in August 2020, The Ministry of Justice committed to publishing for the first-time regular figures regarding the number of pregnant women in custody and births in prison and the Nuffield Trust has already been approached by prisoner health work was referenced in the Queen’s Nursing Institute (the QNI Support health professionals review leading to provide better healthcare for people in prison) Homeless health programme to include a link to this change (this was also one of the project introductory blog in their News update which is shared with 1500 contacts nationally (due to be released May/June 2018). Nuffield Trust report recommendations). https://www.gov.uk/government/publications/review-of-operational-policy-on-pregnancy-mother-and-baby-units-and-maternal-separation The Nuffield Trust will also submit articles for publication in peer review journals (Mid 2019) so that the approach adopted can be replicated in future by others to continue to assess quality in prison healthcare. The additional year(s) of data requested will increase the likelihood of the work having measurable impact on the basis that the data is more timely and complete. Update 2020 Study Extension: It is expected that this work will be used to inform key policy documents in the coming months. For instance, the Nuffield Trust have already provided content for the COVID-19 pandemic recovery plan for NHSE Health & Justice. The Nuffield Trust has also submitted evidence to the Prisons Strategy White Paper Consultation. An active expert panel was formed as part of the first Nuffield Trust prison health research project, and this therefore provides a basis for inviting relevant attendees to join the advisory group as appropriate. The study team have already approached the Royal College of General Physicians Secure Environment Group, The Howard League, a prison service user involvement manager, Birth Companions and the BMA who have expressed their agreement for future involvement. Further invitations will be extended to represent the following groups: prisoner advocacy groups, prison services, government bodies, commissioners and providers, academic researchers and individuals with specific experience working with older, younger and women prisoners. Engagement with the expert panel and other experts will ensure that the project findings can feed into the development of national strategies regarding prisoners’ healthcare needs. It is also expected that the work will be used as an evidence source by advocacy groups to highlight healthcare issues faced by prisoners. As an example, in March 2020, findings from the first prison health project featured in a short film released on Mother’s Day 2020, calling for pregnant women in prison to be released due to the risks of Covid-19 (https://shonaminson.com/). It is expected that the new analysis work will continue to be used as an evidence source by advocacy groups and more widely to highlight healthcare issues faced by prisoners and to promote where changes in policy and practice are needed. The findings regarding how health care usage by prisoners compares to the general population will also be of use to prison healthcare commissioners when considering areas of unmet need and service specification requirements. The Nuffield Trust will also submit articles for publication in peer review journals (Early 2021) so that the approach adopted can be replicated in future by others to continue to assess quality in prison healthcare.

Benefits reported

[1 paragraph unchanged] 1) In August 2020 The Ministry of Justice committed to publishing for the first time regular figures regarding the number of pregnant women in custody and births in prison and the Nuffield Trust prisoner health work was referenced in the review leading to this change (this was also one of the Nuffield Trust report recommendations). https://www.gov.uk/government/publications/review-of-operational-policy-on-pregnancy-mother-and-baby-units-and-maternal-separation 1. November 2021: An MP raised multiple questions about the Nuffield Trust prisoner health report published in October 2021, as written House of Commons questions. This is important to healthcare as it raises the healthcare needs of prisoners (a group who face multiple health inequalities) with key government stakeholders for whom prisoner health falls under their remit. 2) From August 2020: Legacy prison health work is now being used at HMP Wandsworth to enable Advice and Guidance for clinical needs for patients. 2. October 2021: Ran a workshop at the RCGP Secure Environments Group 8th Health & Justice Summit: Communities of Practice in Secure Care. This is beneficial to healthcare because it provided information to commissioners of prison health services about the challenges prisoners face accessing hospital care. 3) August 2020: the study team have been invited to write an article for Cardiology in Focus to advise regarding the cardiac health of people in prison. 3. The Nuffield Trust was asked to contribute evidence to inform the COVID-19 pandemic recovery plan for NHSE Health & Justice. This is beneficial to healthcare because prisons face a backlog of unmet healthcare need as a result of the pandemic and the work of the Nuffield Trust provides up-to-date evidence of the baseline challenges around access to services and the fact that services were predominantly absorbed by managing injury and self-harm. 4) August 2020: Invited to write an article for the Howard Leagues ECAN Bulletin regarding the Nuffield Trust’s prison health research and the impact of Covid-19 on people in prison and access to healthcare. 4. September 2021: Asked to meet with the lead independent clinical reviewer of the Prisons and Probation Ombudsman report into the death of a baby at HMP Bronzefield to discuss how this research may be used to improve understanding of maternity services for women in prison and contribute to improvement. This has led to improvements to maternity services to prevent babies from dying in prison. 5) In March 2020: Study findings featured in a short film released on Mother’s day 2020, calling for pregnant women in prison to be released due to the risks of Covid-19 (https://shonaminson.com/). 5. September 2021: The Nuffield Trust were able to inform the investigators of ongoing challenges regarding women given birth outside of hospitals (in a prison cell or en-route to hospital), stemming from the Nuffield Trust's work being referenced in the Prisons and Probation Ombudsman’s report into the death of a baby at HMP Bronzefield. This was beneficial to healthcare as it saw the systemic challenges of caring for pregnant women in prison so that suitable support can be put in place to avoid babies dying in prison. 6) January 2020 - Attended a roundtable meeting on Prison Health Research organised by the Royal College of General Physicians Secure Environment Group due to identification as a key stakeholder in the field. 6. August 2021: Submitted evidence to the APPG on Women in the Penal System inquiry into women’s health and wellbeing in prisons. This is important to healthcare in order to add quantitative knowledge to the evidence base in this area, which has been identified is limited. 7) September 2019 -Prepared evidence for submission to the Justice Committees inquiry into the ageing prisoner population 7. June 2021: Asked to speak about the Nuffield Trust prisoner health work at the quarterly meeting of the RCGP Secure Environments Group. This is important to healthcare in order to add quantitative knowledge to the evidence base in this area, which has been identified is limited. 8) May 2019 – Asked to provide advice to a welsh GP who is due to talk about the needs of prisoners with chronic renal failure at the Welsh National Renal Meeting in June. 8. May 2021: Was asked to contribute to the Health Foundation Covid-19 Impact Inquiry focused on prisons. This is important to healthcare as part of building a body of evidence as to the challenges prisons faced during the COVID-19 pandemic, and what recovery needs they might be. 9) May 2019 – Asked to sit on the advisory group for a project submission to the 'UKRI Future Leaders Fellowship Grants Committee' entitled Prison Regulation for Safer Societies. 9. From August 2020: Legacy prison health work is now being used at HMP Wandsworth to enable Advice and Guidance for clinical needs for patients. This is important to healthcare as it provides a practical example of the results being used to inform care. 10) March 2019 – Asked to provide advice to Penal Reform International in relation to their Global Prison Trends 2019 report. 10. In March 2020: Study findings featured in a short film released on Mother’s day 2020, calling for pregnant women in prison to be released due to the risks of Covid-19 (https://shonaminson.com/). This is important to healthcare as many people do not realise there are pregnant women in prison so it is hoped that this has raised awareness of the presence of these women and their needs. 11) March 2019 – Hosted David Parker-Radford from the Queens Nursing Institute at the Nuffield Trust as part of a two day visit under the Clore programme. 11. January 2020 - Attended a roundtable meeting on Prison Health Research organised by the Royal College of General Physicians Secure Environment Group due to identification as a key stakeholder in the field. This is important because the group was meeting to consider gaps in knowledge regarding prisoner health information which the work of the Nuffield Trust could inform. 12) December 2018: Phase I progress report. This was an interim report to the funders, the Health Foundation – reflecting the key findings from Phase I (non-HES based analysis) and confirming the approach to be adopted in Phase II, the HES based analysis. It will outline the selection of the outcome measures of prison healthcare quality selected for examination in the Phase II quantitative analysis. This will include background literature on measures of healthcare quality in prisons as well as feedback from the expert panel. The expert panel includes individuals working within prison and prison health who are supporting the project. 13) June 2018 - The BMA referenced the prisoner health project in their submission to the Health Select Committee inquiry into prison health care: “We particularly welcome the Nuffield Trust’s ongoing project to look at the health trends of the prison population and hope that government will consider carefully their findings once they are published, particularly how government can produce data which would allow better understanding of prisoner health.” https://www.parliament.uk/business/committees/committees-a-z/commons-select/health-and-social-care-committee/inquiries/parliament-2017/prison-healthcare-inquiry-17-19/

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

Objective for processing

[4 paragraphs unchanged] • relevant, supportive but also challenging when we need to be; needed; • open and engaging with all those we the organisation come into contact with; [1 paragraph unchanged] For the purpose of these legitimate interests, the Nuffield Trust is undertaking the following study: Under the HRA’s GDPR Operational Guidance the Nuffield Trust therefore relies on Article 6 (1) (f) “processing is necessary for the purposes of the legitimate interests pursued by the controller or by a third party, except where such interests are overridden by the interests or fundamental rights and freedoms of the data subject”. The Nuffield Trust’s legitimate interest is carrying out healthcare research in the wider public interest of improved healthcare outcomes for NHS patients. The Trust relies on Article 9 Condition 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) as the condition for processing “Special” categories of personal data. For the purpose of these legitimate interests, the Nuffield Trust, as data controller, is undertaking the following study: [1 paragraph unchanged] Delivery of healthcare in prisons and other secure settings presents unique challenges [40 words unchanged] and how the quality of care for prisoners compares to the non-prisoner population (no specific control cohort will be created for this study). population. There are two aspects of the proposed analysis: The aims of this research are aligned to the Trust’s legitimate interests (as described above) “to improve the quality of health care that improves the health of people in the UK by providing evidence-based research and policy analysis and informing and generating debate.” The following analysis is complete but explains the two aspects of the analysis already undertaken under the previous iteration of this Agreement: [2 paragraphs unchanged] Please note: This is existing data the Nuffield Trust already holds for separate purposes under a separate Data Sharing Agreement. This Agreement will permit the reuse re-use of a subset of that data and therefore no additional data is required for this aspect of the analysis. 2. Analysis will be undertaken by the Nuffield Trust using prison postcode [17 words unchanged] successfully applied in the context of care home residents in past research. A prison postcode will usually include only the prison population and not those working in the prison or residential properties in close proximity. [2 paragraphs unchanged] Please note: The Nuffield Trust already holds the HES data file (disseminated under separate Agreement DARS-NIC-84572-J7P6Y), DARS-NIC-384572-J7P6Y and later superseded by DARS-NIC-226261-M2T0Q), and therefore the only additional data required is a list of the [49 words unchanged] identification of where individuals have multiple admissions whilst in the same location. [1 paragraph unchanged] Please note: There are no partner organisations involved in this project; therefore, the data under this Agreement will not be accessed by anyone other than the Nuffield Trust project team. Analysis to explore the potential of two specific HES data fields; ADMISORC (where the patient was before they were admitted to hospital) and DISDEST(where the patient was due to go when they leave hospital) to reliably identify people in penal establishments who access secondary healthcare services has been completed. The Nuffield Trust concluded that at present, the coding of source of admission and destination of discharge in hospital data is not sufficiently reliable to identify prisoners’ use of hospital services. The Nuffield Trust holds no derived data files in relation to this analysis. The project is funded by The Health Foundation, an independent charity committed to bringing about better health and health care for people in the UK. Update 2020: Study extension The Nuffield Trust wish to extend their prisoner health work in order to use hospital data (Hospital Episode Statistics) to determine how prisoners’ use of secondary care services has changed over time as well as to compare the use of services of a matched sample in the general population. This work is important in order to monitor the change in use of hospital services year on year as a sign of the impact of conditions in the prison estate on the health needs of prisoners, as well as the impact of policy and practice changes on prisoner health care usage. This analysis will also enable identification of changing levels of healthcare use in a population with complex needs and an ageing profile. The Nuffield Trust will explore how prisoners’ use of secondary care services has changed over the last four years (2016/17 - 2019/20) using Hospital Episode Statistics (HES) data. Prison postcode will be used as a proxy to identify patients from a prison estate establishment within hospital data. This is the same methodology which the Nuffield Trust successfully applied in the context of patients using hospital services from a prison estate establishment in the original study using 2017/18 data. The selection of the data period (2016/17 – 2019/20) is in part to cover the most up-to-date data period available, but also to have as long a period of data as possible for looking at prior history of hospital use as well as follow-up activity when undertaking matched sample analysis. The Nuffield Trust will undertake analysis of matched samples to compare prisoners’ use of secondary care to the general population. In the original study simple age-sex standardised comparisons were conducted, but in this extension the Nuffield Trust will match samples for prisoners from the general population based on demographic characteristics and prior hospital use. The Nuffield Trust will compare hospital service use between the two groups to estimate what the level of health care need for prisoners would be if they had the same access to healthcare as the general population. The Nuffield Trust will be able to answer questions such as: in the follow up period (min 3 months) how many people in the matched control sample were admitted for key clinical reasons, for example for cancer treatment. The Nuffield Trust can then compare these figures to the prison population sample upon which the matched sample is based to look at the difference in numbers. NHS Digital will not create a specific control group but the Nuffield Trust will match prisoners' use of secondary healthcare with that of the general public using HES data from the applicant’s underlying separate Data Sharing Agreement (DARS-NIC-226261-M2T0Q). As well as describing existing potential gaps in care, this work will provide vital information for prison health services to allow for better future planning. Prison health services need a basis on which to more accurately predict the healthcare needs of the prisoner population and therefore what sorts of services they should be offering, and the quantity. The Nuffield Trust will work with an expert panel supporting the project to identify key clinical outcomes amenable to identification in hospital data which will provide useful information regarding unmet need. The expert panel, which acts in an advisory capacity, currently includes representatives from NHS England, CareUK, the RCGP Secure environments group, an Independent Monitoring Board rep, the Howard League, a head of prison healthcare, and academics working in prisoner health research. The expert panel do not provide any governing role. Subject to the next stage of funding being obtained, similar to the original prisoner health study there will be targeted analysis describing the hospital service use of specific groups of prisoners which will produce specific outputs as well as specific outputs reporting on the findings from the matched sample control work. Specific groups of prisoners of interest include older prisoners aged 50+, younger prisoners aged 25 and under and women prisoners – all of which are areas which have been the focus of current or recent select committee inquiries. Whilst exploration of Covid-19 related hospital admissions is not a primary objective of the work, the data period will cover 2019 and 2020, and therefore there will be descriptive analysis of hospital admissions where Covid-19 is recorded as an admission diagnosis The Nuffield Trust already holds the HES data files under agreement DARS-NIC-226261-M2T0Q-v0.5, and therefore the only additional data required is a list of the Nuffield HES ID’s, associated study IDs and EPIKEY/ATTENDKEY/AEKEY of individuals from the postcode list provided to NHS Digital who are present in HES Inpatient, Outpatient or A&E data. This will cover the data periods 2016/17, 2017/18, 2018/19 and 2019/20 respectively. EPIKEY/ATTENDKEY/AEKEY are record identifiers created by the HES system. Access to these record identifiers will enable identification of where individuals have multiple admissions whilst in the same location. There are no partner organisations involved in this project; therefore, the data under this Agreement will not be accessed by anyone other than substantive employees of The Nuffield Trust project team. The Nuffield Trust are sole data controller for the purposes of this Agreement. This project extension is being funded by the Health Foundation, an independent charity committed to bringing about better health and health care for people in the UK. The Health Foundation do not make any decisions regarding the collection or analysis of data under this Agreement. The data requested under this Agreement will only be processed by The Nuffield Trust.

Processing activities

The data will only be accessed and processed by “Personnel” (as defined [10 words unchanged] contractors of the Data Recipient who may have access to that data) and of the Nuffield Trust. The data will only be processed for the purposes described in this application. Agreement. Whilst the nature of detailed analysis varies, the following describes the broad context of processing is undertaken in summary:- the previous iteration of this Agreement:: 1. The data is downloaded from NHS Digital and imported into SAS. The server is held on-site, and access is restricted to named individuals according to The Nuffield Trust's Information Security Management System (ISMS). 1. The data controller will provide a list of the prison postcodes and an associated study ID for every prison in England to NHS Digital. 2. The data is held within separate folders on a dedicated research server. 2. NHS Digital to extract HESIDs, EPIKEY/ATTENDKEY/AEKEY* and STUDY_ID for individuals present in HES data where HOMEADD is in the postcode list supplied for 2017/18 (* depending on data set) 3. Remote access to the database is permitted, but only through Citrix via secure token (so processing is still carried out on site), and with local printing and downloading disabled. 3. NHS Digital to disseminate data to Nuffield Trust. 4. Only individuals who have signed a confidentiality agreement and have received Information Governance training are permitted access. 4. The data is disseminated by NHS Digital and imported into SAS. The server is held on-site, and access is restricted to named individuals according to The Nuffield Trust's Information Security Management System (ISMS). 5. All access to individual files is recorded, and a sample audited to investigate the existence of any adverse incidents and ensure that appropriate access has been maintained. 5. The data is held within separate folders on a dedicated research server. 6. Once held in SAS, the researcher will view the data and undertake descriptive analysis – such as reasons for admission, length of stay and associated co-morbidities. Based on the findings of the Phase I literature review, focused analysis will be undertaken relating to specific cohorts of prisoners (for instance, women or young offenders) or looking at specific chronic conditions. The researchers will use routinely available filter definitions where possible but may amend these based on the nature of the study's group of interest. 6. Remote access to the database is permitted, but only through Citrix via secure token (so processing is still carried out on site), and with local printing and downloading disabled. 7. Comparisons will be made based on the standardised national rates for age and sex bands. E.g. national rates of emergency admissions would be used to construct expected rates of emergency admissions within the prison cohort. The Trust is able to then compare the prison cohort against national standardised rates. 7. Only individuals who have signed a confidentiality agreement and have received Information Governance training are permitted access. 8. The individual researcher then analyses the data, before applying the relevant disclosure controls to any output. Software used will be SAS, R and stata. Typically this will involve analysis on several outcome measures, risk adjustment and the construction of control groups. 8. All access to individual files is recorded, and a sample audited to investigate the existence of any adverse incidents and ensure that appropriate access has been maintained. 9. No record level data would be linked to this dataset, but Locally sourced Escort and Bedwatch (E&B) data from a sample of prison establishments will be used as a means of validating the volume of cases emerging from the HES postcode-based analysis. E&B data is based at an individual prison level and is essentially a record of prisoners moved to or from hospitals whether for urgent or unplanned care and the associated cost. 9. Once held in SAS, the researcher will view the data and undertake descriptive analysis – such as reasons for admission, length of stay and associated co-morbidities. Based on the findings of the Phase I literature review, focused analysis will be undertaken relating to specific cohorts of prisoners (for instance, women or young offenders) or looking at specific chronic conditions. The researchers will use routinely available filter definitions where possible but may amend these based on the nature of the study's group of interest. 10. Comparisons will be made based on the standardised national rates for age and sex bands. E.g. national rates of emergency admissions would be used to construct expected rates of emergency admissions within the prison cohort. The Trust is able to then compare the prison cohort against national standardised rates. 11. The individual researcher then analyses the data, before applying the relevant disclosure controls to any output. Software used will be SAS, R and stata. Typically this will involve analysis on several outcome measures, risk adjustment and the construction of control groups. 12. No record level data would be linked to this dataset, but locally sourced Escort and Bedwatch (E&B) data from a sample of prison establishments will be used as a means of validating the volume of cases emerging from the HES postcode-based analysis. E&B data is based at an individual prison level and is essentially a record of prisoners moved to or from hospitals whether for urgent or unplanned care and the associated cost. [1 paragraph unchanged] 10. 13. Outputs are thus produced which consist of aggregate data (or indicator/statistical data) only. [3 paragraphs unchanged] Data required: Data required for analysis: [1 paragraph unchanged] Using a subset of data held by the Nuffield Trust under Agreement DARS-NIC-84572-J7P6Y, DARS-NIC-384572-J7P6Y, the Trust will explore the reliability of ADMISORC and DISDEST in a preliminary phase of analysis. The Nuffield Trust has undertaken some preliminary tests and has confidence that [22 words unchanged] of controls are in place to confirm that only prisoners are identified. The Nuffield Trust intends to feedback to NHS Digital in a meaningful way on whether the initial postcode approach fails at a secondary control. See below for a summary of the controls. [1 paragraph unchanged] 1. The use of the prison postcode is an initial safeguard, as [12 words unchanged] residential accommodation will not be included based on having a shared postcode. Examples of this that have been checked include: - HMP Belmarsh (SE28 0EB); HMP Thameside (SE28 0DF); and HMP/YOI Isis (SE28 0FB) are all located on the same site (Western Way, London) but have different postcodes - HMP Wandsworth (SW18 3HU) postcode is separate to those of neighbouring houses on Heathfield Square. - HMP Bronzefield (TW15 3JZ) – nearest road is Ruggles-Brise Road, which has a postcode of TW15 3LD / 3LF. - HMP/YOI Feltham (TW13 4ND) – this is on Bedfont Road, and even the visitors centre has a different postcode (TW13 4NP). [4 paragraphs unchanged] Finally, as with all our reporting, small numbers will be suppressed and so no individual officers (or prisoners for that matter) will be identifiable in reporting. [7 paragraphs unchanged] Update 2020 Study Extension: The datasets necessary for the study are listed below: Data required: 1. Descriptive analysis: 2016/17, 2017/18, 2018/19 and 2019/20 APC, OP & A&E HES Data. Please note: The Nuffield Trust already holds the HES data files, and therefore the only additional data required is a list of the Nuffield HES IDs, associated study IDs and EPIKEY/ATTENDKEY/AEKEY of individuals from the postcode list provided to NHS Digital who are present in HES APC, Outpatient or A&E data in the periods of interest. The data periods are 2016/17, 2017/18, 2018/19 and 2019/20 respectively. A separate list of Nuffield HES id’s, associated study IDs and EPIKEY/ATTENDKEY/AEKEY of individuals from the postcode list will be required for each year. Personal Demographics Service (PDS) has now been rolled out across the prison estate which means that prison addresses are recorded in a standardised way, including postcode. The Nuffield Trust have been provided with the PDS address list by the Health & Justice Programme manager to ensure consistency with the official postcodes in use. In terms of checks, the Nuffield Trust have used the online Post Office postcode checking service to review the postcode used for each site, as well as checking online address details for each prison where possible. The Nuffield Trust also carry out checks of the data itself as an additional safeguard. For instance, ensuring there is no data for women linked to men’s prisons (and vice versa) as well as ensuring the broad age categories are appropriate for specific prison categories. The Nuffield Trust would not for instance expect to see older adults in a youth estate location. 2. Matched control samples: 2016/17, 2017/18, 2018/19 and 2019/20 APC, OP & A&E HES Data. The Nuffield Trust already holds the HES data files as described above and is therefore requesting permission purely to conduct analysis to identify the matched control group and report on differences in the subsequent use of hospitals. This will involve identifying people who were in prison in 2018 and 2019, but who either earlier in 2018, 2019 or in 2016, 2017, 2018 used hospital services when they were not in prison. The general population comparator group will be matched on the basis of: • Demographic characteristics at point of most recent community-based admission including Index of Multiple Deprivation. • Prior history of hospital use over a minimum of the last 18-months as well as diagnostic history as part of hospital data. • People linked to a prison postcode at any point between April 2016 and March 2020 will be excluded. No specific control group has been created for this study and the matched patient group will come from the applicant’s underlying separate Data Sharing Agreement (DARS-NIC-226261-M2T0Q). An additional safeguard has been put in place to ensure that cases will be filtered to exclude any babies born in prison or living in Mother and Baby Units (which only hold children up to 18-months of age) can not be identified in the data extraction. There will be no requirement nor attempt to re-identify individuals.

Expected output

All outputs for this study will be aggregate aggregated with small number suppressed in line with the HES Analysis Guide. Anticipated dates of study reports are listed. All may also include presentational web material (for example slideshows and blog posts), in addition to presentations given in person at relevant research or policy conferences, etc. Since the start of the study, the following publications have been produced: December 2018: Phase I progress report Davies (In press). Cardiovascular health within the UK prison population. Heart. This will be an interim report to the funders, the Health Foundation – reflecting the key findings from Phase I (non-HES based analysis) and confirming the approach to be adopted in Phase II, the HES based analysis. It will outline the selection of the outcome measures of prison healthcare quality selected for examination in the Phase II quantitative analysis. This will include background literature on measures of healthcare quality in prisons as well as feedback from the expert panel. The expert panel includes individuals working within prison and prison health who are supporting the project. Davies (In press). Prisoners’ access to secondary care and the impact of Covid-19. Howard League ECAN Bulletin. Howard League. July 2019: Final report and summary Davies M and Keeble E (2020) “Covid-19 in prisons: fewer cases than feared but it’s not the whole story”, Nuffield Trust comment. This will be the final report to the funders, the Health Foundation. It will provide details of the findings emerging from the phase II HES based analysis. - Davies M (2020 "Covid-19: how is it impacting on prisoners health?" July 2018, December 2018 and July 2019: Meetings of the expert panel. -Davies M, Rolewicz L, Schlepper L and Fagunwa F (2020) Locked out? Prisoners' use of hospital care. Research report, Nuffield Trust. Throughout the projects there will also be blogs and briefings to publicise the research and promote key findings. Two introductory blogs for the project have already been published: - Davies M (2020 "Prisoner health: Dr Miranda Davies Q&A" Davies M (2018) "Numbers matter in prison", Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/numbers-matter-in-prison - Davies M (2020 "Miranda Davies: Why we should worry about prisoners missing hospital appointments."The BMJ Opinion. Davies M (2018) "Us and them: the impact of prejudice on prisoners’ health care", Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/us-and-them-the-impact-of-prejudice-on-prisoners-health-care -Nuffield Trust (2020 "Prisoners missing out on hospital treatment, new research reveals" Nuffield Trust press release Papers will be submitted for peer reviewed journal publication in the summer 2019. - Davies M (2019) Prisoners' use of hospital services. RCGP's 7th Health and Justice Summit: Journeys Through Justice - Leadership and Transformation - Davies M (2019 "Pregnancy and childbirth in prison: what do we know?" Nuffield Trust - Davies M (2019) "Prisoner health and homeless health: understanding the links between them." https://www.nuffieldtrust.org.uk/news-item/prisoner-health-and-homeless-health-understanding-thelinks-between-them - Davies, M. (2019) Prisoners' physical healthcare needs and quality of care. February 2019. The Monitor. Issue 126. -Davies M (2019). Understanding prisoners' healthcare needs and their use of hospital services using routine healthcare data. 31st January 2019. 6th Health & Justice Summit: Safety through Continuity. - Davies M (2018) "Understanding prisoners' experience of health care to improve our research" https://www.nuffieldtrust.org.uk/news-item/understanding-prisoners-experience-of-health-care-toimprove-our-research - Davies M (2018) "What to expect when you're expecting in prison?", Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/what-to-expect-when-you-re-expecting-in-prison - Davies M (2018) "Us and them: the impact of prejudice on prisoners' health care" https://www.nuffieldtrust.org.uk/news-item/us-and-them-the-impact-of-prejudice-on-prisoners-health-care - Davies M (2018) "Numbers matter in prison", Nuffield Trust comment. https://www.nuffieldtrust.org.uk/newsitem/ numbers-matter-in-prison Anticipated dates of study reports are listed below. All may also include presentational web material (for example slideshows and blog posts), in addition to presentations given in person at relevant research or policy conferences, etc. January 2021 - April 2021: 1. Data briefing. This report will describe the secondary health care services used by prisoners between 2016/17 and 2019/20, and how the pattern of service use has changed over this period. The report will be available on the Nuffield Trust website. 2. Policy review. This briefing document will set out how healthcare is provided to prisoners and key commissioning/provider/independent body involvement. It will be publicly available on The Nuffield Trust website. April 2021: 3. Progress report to funders. A progress report to the funders, The Health Foundation, outlining the success of the matched control sampling methodology and plans for the cohort analysis of specific groups including women prisoners, older prisoners and younger prisoners in the second stage research submission. January 2021 - April 2021: Meeting of the expert panel. June 2021 - June 2020: Estimated stage 2 output dates: Subject to receiving the funding for stage 2 of the work outlined, the following reports will be produced: * Three smaller topic-based reports focused on younger prisoners, older prisoners and women prisoners. * Matched control analysis report Throughout the projects there will also be blogs and briefings to publicise the research and promote key findings. Please note: The listed output dates are specific to the year one funded activity. This will include targeted outputs focused on the hospital service use of specific groups of prisoners (older prisoners, younger prisoners, and women prisoners) in greater detail as well as reporting on the findings from the matched sample control work.

Expected measurable benefits

[6 paragraphs unchanged] An expert panel is being established to provide advice and spread the benefits within their respective organisations. The expert panel do not provide any governing role. Members already include representatives from NHS England, CareUK, the RCGP Secure environments [9 words unchanged] a head of prison healthcare, and academics working in prisoner health research. [3 paragraphs unchanged] Update 2020 Study Extension: An active expert panel was formed as part of the first Nuffield Trust prison health research project, and this therefore provides a basis for inviting relevant attendees to join the advisory group as appropriate. The study team have already approached the Royal College of General Physicians Secure Environment Group, The Howard League, a prison service user involvement manager, Birth Companions and the BMA who have expressed their agreement for future involvement. Further invitations will be extended to represent the following groups: prisoner advocacy groups, prison services, government bodies, commissioners and providers, academic researchers and individuals with specific experience working with older, younger and women prisoners. Engagement with the expert panel and other experts will ensure that the project findings can feed into the development of national strategies regarding prisoners’ healthcare needs. It is also expected that the work will be used as an evidence source by advocacy groups to highlight healthcare issues faced by prisoners. As an example, in March 2020, findings from the first prison health project featured in a short film released on Mother’s Day 2020, calling for pregnant women in prison to be released due to the risks of Covid-19 (https://shonaminson.com/). It is expected that the new analysis work will continue to be used as an evidence source by advocacy groups and more widely to highlight healthcare issues faced by prisoners and to promote where changes in policy and practice are needed. The findings regarding how health care usage by prisoners compares to the general population will also be of use to prison healthcare commissioners when considering areas of unmet need and service specification requirements. The Nuffield Trust will also submit articles for publication in peer review journals (Early 2021) so that the approach adopted can be replicated in future by others to continue to assess quality in prison healthcare.

Benefits reported

Yielded Benefits is not a requirement for new applications. The benefits realised from the analysis of data under this Agreement so far include: 1) In August 2020 The Ministry of Justice committed to publishing for the first time regular figures regarding the number of pregnant women in custody and births in prison and the Nuffield Trust prisoner health work was referenced in the review leading to this change (this was also one of the Nuffield Trust report recommendations). https://www.gov.uk/government/publications/review-of-operational-policy-on-pregnancy-mother-and-baby-units-and-maternal-separation 2) From August 2020: Legacy prison health work is now being used at HMP Wandsworth to enable Advice and Guidance for clinical needs for patients. 3) August 2020: the study team have been invited to write an article for Cardiology in Focus to advise regarding the cardiac health of people in prison. 4) August 2020: Invited to write an article for the Howard Leagues ECAN Bulletin regarding the Nuffield Trust’s prison health research and the impact of Covid-19 on people in prison and access to healthcare. 5) In March 2020: Study findings featured in a short film released on Mother’s day 2020, calling for pregnant women in prison to be released due to the risks of Covid-19 (https://shonaminson.com/). 6) January 2020 - Attended a roundtable meeting on Prison Health Research organised by the Royal College of General Physicians Secure Environment Group due to identification as a key stakeholder in the field. 7) September 2019 -Prepared evidence for submission to the Justice Committees inquiry into the ageing prisoner population 8) May 2019 – Asked to provide advice to a welsh GP who is due to talk about the needs of prisoners with chronic renal failure at the Welsh National Renal Meeting in June. 9) May 2019 – Asked to sit on the advisory group for a project submission to the 'UKRI Future Leaders Fellowship Grants Committee' entitled Prison Regulation for Safer Societies. 10) March 2019 – Asked to provide advice to Penal Reform International in relation to their Global Prison Trends 2019 report. 11) March 2019 – Hosted David Parker-Radford from the Queens Nursing Institute at the Nuffield Trust as part of a two day visit under the Clore programme. 12) December 2018: Phase I progress report. This was an interim report to the funders, the Health Foundation – reflecting the key findings from Phase I (non-HES based analysis) and confirming the approach to be adopted in Phase II, the HES based analysis. It will outline the selection of the outcome measures of prison healthcare quality selected for examination in the Phase II quantitative analysis. This will include background literature on measures of healthcare quality in prisons as well as feedback from the expert panel. The expert panel includes individuals working within prison and prison health who are supporting the project. 13) June 2018 - The BMA referenced the prisoner health project in their submission to the Health Select Committee inquiry into prison health care: “We particularly welcome the Nuffield Trust’s ongoing project to look at the health trends of the prison population and hope that government will consider carefully their findings once they are published, particularly how government can produce data which would allow better understanding of prisoner health.” https://www.parliament.uk/business/committees/committees-a-z/commons-select/health-and-social-care-committee/inquiries/parliament-2017/prison-healthcare-inquiry-17-19/