Neurosurgical National Audit Programme (NNAP)

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Processing activities

[4 paragraphs unchanged] The data will be accessed onsite at the premises of NECSWS’ offices by authorised personnel via remote access, or via a single approved laptop. Except in the case of the laptop, the data will remain on the servers at NTT Global Data Centres at all times. [9 paragraphs unchanged]

Unchanged: Objective for processing, Expected output, Expected measurable benefits, Benefits reported.

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Objective for processing

The Neurosurgical National Audit Programme (NNAP) was established by the Society of British Neurological Surgeons (SBNS) in 2013 as part of a major quality improvement initiative. The programme aims to support neurosurgical units in the UK to improve patient care, outcomes, safety, and experience by providing high quality, robust audit data that is analysed and presented in a consistent and clinically relevant way. Currently the only data available to achieve this is Hospital Episode Statistics (HES) data linked to Civil Registration/Mortality data. The data requested covers NHS Trusts in England undertaking neurosurgical procedures, a total of thirty. It is essential that all neurosurgical centres are included in the audit. The data is minimised to include only neurosurgery patients (both adult and paediatric). SBNS - the sole data controller for this Agreement - has a responsibility to ensure that the thirty NHS trusts undertaking neurosurgery in England are doing so safely. The Society of British Neurological Surgeons (SBNS) requires access to NHS England data for the purpose of the Neurosurgical National Audit Programme (NNAP). The HES and linked Civil Registration/Mortality data are required to identify what neurosurgery has taken place, where it has taken place, and who has carried out individual procedures. Pseudonymised data (local patient ID) is required so that surgeons and clinical leads can review mortality events as part of clinical audit, ensure the accuracy of the HES record (e.g. was it an elective procedure or an emergency admission?), and ensure that it was attributed to the correct surgeon. The NNAP is an ongoing audit and it will be necessary to continue to assess changes in performance over time. It is expected that outcomes at five and ten years will be included as the programme continues. The only alternative method of achieving NNAP’s goals is to collect the data separately. This is costly in resources, especially for Trusts who would have to provide the same data twice. Requesting the HES and Civil Registration/Mortality data is the only practicable means of determining the outcomes of neurosurgery. The data being requested is assessed to be the minimum necessary for the purpose. The NNAP aims to support neurosurgical units in England to improve patient care, outcomes, safety, and experience by providing high quality, robust audit data that is analysed and presented in a consistent and clinically relevant way. SBNS has a responsibility to ensure that the thirty NHS trusts undertaking neurosurgery in England are doing so safely. The legal basis for processing the data is ‘processing is necessary for the purposes of the legitimate interests pursued by the controller or by a third party, except where such interests are overridden by the interests or fundamental rights and freedoms of the data subject which require protection of personal data, in particular where the data subject is a child’ (Article 6(1)(f) of the UK GDPR). The data is being processed to determine the outcome of specific neurosurgical procedures, using mortality as the key indicator. The processing will determine any trusts whose performance is considered to be outlying the norm (‘outlier’), enable discussion amongst clinicians and managers to improve performance where necessary, reduce variations in the outcomes of neurosurgery, enable the identification and development of other indicators of outcome. The processing is in the interest of patients, clinicians, healthcare managers, and health-related programmes, e.g. Getting It Right First Time (GIRFT). The SBNS have completed a Legitimate Interests Assessment and are satisfied that the interests of the individual patients do not override the legitimate interests of SBNS. The NNAP is a comprehensive audit programme that reflects the full range of elective and emergency neurosurgical activity. The NNAP is fully engaged with the Getting It Right First Time (GIRFT) programme, aiming to improve patient care while reducing costs in all specialities. Processing is also necessary ‘for reasons of public interest in the area of public health, such as protecting against serious cross-border threats to health or ensuring high standards of quality and safety of health care and of medicinal products or medical devices’ (Article 9(2)(i)). The purpose of processing the data is to determine the outcomes of neurosurgical procedures thereby improving patient safety and patient outcomes. The conditions of Schedule 1, Part 1, Para 3 of the DPA 2108 are met as the processing is necessary for reasons of public interest in public health, and is undertaken and supervised by health professionals (consultant neurosurgeons). Surgeons will be provided with a secure online reporting service, via the NNAP website, that will enable them to review their own clinical practice and validate the outcome data relating to the procedures they performed. SBNS have engaged NEC Software Solutions UK Limited (NEC) as a data processor. NEC undertake analyses of the data on behalf of SBNS and publish outcomes and related information on the NNAP website. NEC manage and process the data which will be held in a secure data centre provided by NTT Global Data Centres, with Iron Mountain (UK) PLC providing secure storage for back up. NTT Global Data Centres and Iron Mountain (UK) PLC are listed as data processors solely for data storage. Consultants nominated by SBNS will have access to data for the purposes of investigating potential outlier performance. The Society of British Neurological Surgeons (SBNS) has established the NNAP to promote improvements in the quality of neurosurgical services and patient care by providing neurosurgical units in England with a comprehensive audit programme that reflects the full range of elective and emergency neurosurgical activity. The NNAP is fully engaged with the Getting It Right First Time (GIRFT) programme, aiming to improve patient care while reducing costs in all specialities. High standards of professional practice are promoted through the Society's involvement in the education and the examination of Neurosurgeons and through its scientific meetings and associated activities in the continuing professional development of Neurosurgeons and Neurosurgery. Therefore the Society of British Neurosurgeons requires data from NHS Digital for the purposes of its legitimate interests to do the above. The following NHS England data will be accessed: There is evidence from other national audits that the publication of activity and audit data, when carefully analysed and interpreted, leads to improvements in patient outcomes. The SBNS supports the publication of outcome data that will promote the understanding of the range and complexity of neurosurgical services and the steps being taken to improve those services. • Hospital Episode Statistics (HES) Admitted Patient Care (APC) data – necessary to identify what neurosurgery has taken place, where it has taken place, who has carried out individual procedure, whether the records are accurate, and what the outcomes of the neurosurgery were NNAP was established to provide both patients and surgeons with information about the outcomes of neurosurgery and surgeon and hospital level information is published annually as part of the Clinical Outcomes Publication (COP). COP is an NHS England initiative designed to increase transparency within the NHS and to provide the public with information on surgical outcomes. This forms only 10% of the overall audit work. Individual consultant and unit level reports may be accessed through this website. Currently, the key indicator is 30- day mortality although additional indicators may be added in the future. The consultant code is essential to enable the publication of information at the surgeon-level. • Civil Registration Mortality data – necessary to review mortality events as part of the clinical audit, determine mortality events within 90 days of a procedure, and assess outcomes of different procedure types. Surgeons will also be provided with a secure online reporting service, via the NNAP website, that will enable them to review their own clinical practice. Whilst record-level data will be available to surgeons, it will include only that data necessary to enable them to identify the patient in local patient administration systems and/or theatre systems, i.e. date of procedure, procedure type, etc. The data will also be used for specific analyses to be undertaken at the request of SBNS. The data requested under this agreement is to enable consultants to view and validate the outcome data relating to the procedures they performed. Consultants nominated by SBNS will have access to data for the purposes of investigating potential outlier performance. Consultant neurosurgeons will have secure access to data relating to their own practice. This will enable surgeons to preview and validate the information that is intended for publication on the NNAP website. The risk-based methodology used to determine performance against the key indicator of mortality will identify potential outlier performance. That surgeon's data will be made available to the investigating surgeon to determine if there is a case to answer and to take any action necessary, i.e. patient pseudo-identifiers will be removed and dates - if required, summarised. However, it is essential that any surgeon whose data indicates outlier performance can be identified using the Consultant Code so that Trust Chief Executives can be informed and a plan for further, local audit and follow-up action can be initiated. SBNS also receive queries about surgeon and hospital level performance from NHS England and the regulator, Care Quality Commission (CQC) and the Getting it Right First Time (GIRFT) programme. Data will be used to help respond to these queries. All data that will be published on public websites will be aggregated with small number suppression applied. The level of the data will be pseudonymised. The data will be minimised as follows: • Limited to a cohort identified by NHS England as having undergone a neurosurgical procedure • Limited to data since 2013 The SBNS is the controller as the organisation responsible for ensuring that the data will only be processed for the purpose described above. The lawful basis for processing personal data under the UK GDPR is: Article 6(1)(f) - processing is necessary for the purposes of the legitimate interests pursued by the controller or by a third party. The SBNS has determined the processing is necessary for its legitimate interests in being able to determine the outcome of specific neurosurgical procedures, using mortality as the key indicator. The processing will determine any trusts whose performance is considered to be outlying the norm (‘outlier’), enable discussion amongst clinicians and managers to improve performance where necessary, reduce variations in the outcomes of neurosurgery, and enable the identification and development of other indicators of outcome. The lawful basis for processing special category data under the UK GDPR is: Article 9(2)(i) - processing is necessary for reasons of public interest in the area of public health, such as protecting against serious cross-border threats to health or ensuring high standards of quality and safety of health care and of medicinal products or medical devices. This processing is in the public interest because the purpose of processing the data is to determine the outcomes of neurosurgical procedures thereby improving patient safety and patient outcomes. [1 paragraph unchanged] The data will also be used for specific analyses to be undertaken at the request of SBNS. The results of the analysis will take the form of aggregated data, not record level data. SBNS also receive queries about surgeon and hospital level performance from NHS England and the regulator, Care Quality Commission (CQC) and the Getting it Right First Time (GIRFT) programme. The data will also be used to answer these queries. In general, these organisations will ask specific questions of NNAP, generally about specific trust-related activity. They are users of the outputs of the analysis, rather than processors of the actual data. NEC Software Solutions (UK) Ltd (NECSWS) is a processor acting under the instructions of SBNS. NECSWS’ role is limited to managing and undertaking analyses of the data on behalf of the SBNS and publishing outcomes. The head of SBNS is employed as a neurosurgeon at Leeds NHS FT however access to data will be as a substantive employee of SBNS. There is no access to data by the project team at Leeds NHS FT. NTT Global Data Centres provide IT hosting services to NECSWS and will store the data as contracted by NECSWS.

Processing activities

All organisations party to this agreement will comply with the Data Sharing Framework Contract, including requirements on the use (and purposes of that use) by “Personnel” (as defined within the Data Sharing Framework Contract i.e.: employees, agents and contractors of the Data Recipient who may have access to that data). No cohort data will flow to NHS England for the purposes of this Agreement. There will be no flow of identifiable or confidential data from any of the data controllers/processors named in this agreement into NHS Digital. NEC will provide NHS Digital with a list of OPCS4 procedural classification codes and the speciality codes for neurosurgical and paediatric neurosurgical procedures. These are just codes in the dataset, and not record level data. NHS England will provide the relevant records from the HES Admitted Patient Care and Civil Registration Deaths datasets to NEC Software Solutions (UK) Ltd (NECSWS). The data will contain no direct identifying data items. The data will be pseudonymised and individuals cannot be reidentified through linkage with other data in the possession of the recipient. NHS Digital are to use these codes to filter the HES Admitted Patient Care (APC) product from 2013/14 onwards and extract records accordingly. The data will be stored on servers at NTT Global Data Centres. NHS Digital are then to extract mortality records for people included in the HES extract. The data will not be transferred to any other location. The data will then be transferred back to NEC Software Solutions UK Limited (NEC), on an annual basis. The data will be accessed onsite at the premises of NECSWS’ offices by authorised personnel via remote access, or via a single approved laptop. Except in the case of the laptop, the data will remain on the servers at NTT Global Data Centres at all times. The data, upon receipt, will be loaded onto a dedicated, secure server in the NTT data centre which is only accessible to a limited number of users. The reduced data-set completed as a result of the cleansing and categorisation of the supplied data-set will be held on a protected database server, also hosted within the data centre. NEC staff will access the data held in the data centre either directly from an NEC office or via a secure VPN which requires two factor authentication, including the use of an RSA token. The VPN is an extension of the NEC secure network and does not provide direct access to the server. Access to the server is subject to additional controls. All processing takes place on the server and not local machines. Personnel are otherwise prohibited from downloading or copying data to local devices. NEC's Health Analysts will clean the data prior to undertaking risk adjusted mortality analyses for the purposes of producing funnel plots in order to identify potential outlier performance. The data will also be adjusted so that the multiplicity of OPCS4 procedures from the HES APC product requested are grouped into a manageable number of procedure categories. The data will not leave England at any time. Once the cleansing, mortality analysis, and grouping of data is complete, the data will be loaded onto a database server so that it can be previewed by consultants prior to publication. Surgeons will have access to record level data for only those procedures in which they are indicated as 'Consultant' - ie surgeons will only access record level data pertaining to their own patients - they will not view data on patients of other surgeons. The finalised data-set will also be uploaded to the surgeon-level reporting service. Access is restricted to employees of NECSWS and agents of the SBNS. Data will be processed by: Record-level data will be available to surgeons which will include only those procedures in which they are indicated as ‘Consultant’. Data made available to surgeons will enable them to identify the patient in local patient administration systems and/or theatre systems via i.e. date of procedure, procedure type, etc. • NEC will manage and process the data which will be held in a secure data centre provided by NTT Global Data Centres, with Iron Mountain (UK) PLC providing secure storage for back up. NEC will also undertake analyses of the data and publish outcomes and related information on the NNAP website. All personnel accessing the data have been appropriately trained in data protection and confidentiality. • SBNS. Neurosurgeons (appointed by the chair of the NNAP steering committee) and a Research Fellow appointed by SBNS will have access to the record level data for the purposes of audit and analysis. The data will not be linked with any other data. • Consultant neurosurgeons will be able to access aggregated and record level data relating to their practice. Surgeons will only be able to access record level data for those procedures attributed to them. There will be no requirement and no attempt to reidentify individuals when using the data, except where surgeons need to look up their own patients in the instance of a recorded mortality event. The data will be used for ad-hoc queries and analysis requested by the data controller, SBNS. This work will be undertaken by NEC health data analysts and, where necessary, an SBNS surgeon nominated by the data controller. Analysts from NECSWS will clean and analyse the data for the purposes of identifying potential outlier performance. All data will be processed by substantive employees of either SBNS, NEC, NTT Global Data Centres EMEA UK Limited (NTT - who act in a processing capacity as data centre host), and Iron Mountain (as off-site backup storage provider). There will be no subsequent flows of data. Neurosurgeons and a research fellow (appointed by the SBNS) will process the data for the purposes of audit and analysis. The data provided to the SBNS is limited to subsets specifically required for the analysis to be undertaken. In order to ensure that the data remains in a secure location, SBNS access to the data will be by remote desktop via NEC's VPN. A single, dedicated folder will be made available to the SBNS, and the remote desktop will include all those tools necessary to manipulate the data. Account holders will be required to sign to accept NEC's terms and conditions for access to the network and the data. It is expected that no more than two surgeons will require such access. Logging onto the VPN will not be permitted in public locations or via public, insecure WiFi connections. The Terms and Conditions that an SBNS surgeon will be required to sign will explicitly include this condition, restricting access to be either from within an office located in a hospital or using a secure home connection. Although working primarily at the CEU, the SBNS Fellow will be provided with access to the data via VPN. The Fellow will be required to sign NEC terms and conditions before being granted access. RCS CEU are not, for the purposes of this agreement, acting as a data processor: they are supporting and guiding the work of the Fellow only. With the data residing on the server, the SBNS Lead is unable to answer these questions promptly as it requires access to the NEC VPN and requires use to a secure WiFi or LAN connection to do so. It is taking up to a week to provide responses to queries which, if there was direct access to the data, the questions could be answered almost immediately. It has been agreed by NHS Digital Security Team to allow the use of the data on the SBNS surgeon’s laptop, at present the surgeon currently uses his laptop to access Trust systems via the Trust VPN and has access to Electronic Patient Records and Radiographs for patients throughout most of Yorkshire. The Trust requires all employees using IT to undertake annual e-learning modules relating to security, data protection, and information governance. The SBNS surgeon’s laptop will be appropriately specified for the task with security features including: Full disk encryption with XTS-AES 128 encryption using a 256 bit key. Two factor authentication when logging on: password and user authentication (password or retina scan) for logging onto Laptop can be remotely protected or wiped. The OS automatically updates when new versions or patches are available. The laptop is protected against viruses and malware, again automatically updated. VPN access is achieved using two factor authentication, ie. RSA Key and passcode. Data provided for processing on the laptop will not include the local patient identifier (LOPATID) or GMC codes. As part of the outlier analysis, NPS will provide the GMC code of any surgeon whose data indicates potential outlier performance directly to the SBNS lead. The data requested for NNAP includes all codes associated with Neurosurgery and the diagnosis codes for paediatric neurosurgery, this data set will be filtered to a much smaller extract following analysis and cleaning by NEC and the SBNS surgeon will be provided with data relating to a smaller set of procedure codes and episodes that did not include a surgical intervention. A recent request to amend the data supplied includes the addition of Local Patient ID (LOPATID) but it is proposed that that field is not included in the data held on the laptop. It is also proposed that an alias is provided for the Surgeon GMC code. With regards to Data Destruction, NEC will ask the SBNS Lead to complete a data destruction certificate before any new data is provided. There will be no linkage permitted to other data sets apart from what is detailed in this agreement. There will be no attempts by employees of the named data processors or controllers to re-identify participants in the audit.

Expected output

The following expected outputs of the processing will be produced. be: Website Dashboard and Reports: • Publication of dashboards on the Neurosurgical National Audit Programme (NNAP) website (www.nnap.org.uk) One output of NNAP is the COP publication, the date of which changes each year. It is expected that the COP publication will be complete in December of each year, with the data being published on Choices in the following February or March. • A portal available to surgeons to analyse the outcomes of their own procedures The publication will not contain any patient level data - it will only contain aggregated data with small number suppression applied. • Responses to ad-hoc queries from the GIRFT programme, NHS England and the Care Quality Commission Information will also be shared with the Getting it Right First Time (GiRFT) programme for publication on the GiRFT dashboard. Again, only aggregated data with small number suppression will be supplied. • Ad-hoc reports to NHS England and other NHS bodies as requested All data published on the NNAP website for the GIRFT Dashboad will be aggregated data. Despite the closure of both COP and Choices, NNAP has continued to publish information on its dedicated website (www.nnap.org.uk). This includes information about surgeons and trusts including mortality outcomes. Information about adult and paediatric elective and non-elective procedures are included. Mortality analyses does not include paediatric procedures nor non-elective surgery. • Ad-hoc presentations at professional meetings such as the SBNS Annual Meeting and other relevant conferences Surgeon Validation: • The Clinical Outcomes Publication Surgeons taking part in the audit will have access to record level data for the purpose of validating the information due to be published as part of COP. Surgeons will only have access to those procedures where they are indicated as 'Consultant' - as indicated by the CONSULT field in the HES product. The outputs will not contain NHS England data and will only contain aggregated information with small numbers suppressed as appropriate in line with the relevant disclosure rules for the dataset(s) from which the information was derived. Reports. Ad Hoc reports will be made available to NHS England, NHS Improvement and other NHS bodies as requested. These reports will be based on aggregated data and normally at Trust or Hospital Level. Most outputs are updated annually in line with the latest available data. Presentations: The outcomes of the analysis will be presented at professional meetings and conferences. These will be based on aggregated data. Bespoke reports have been produced for all Trusts undertaking neurosurgical procedures, containing outlier analyses at Trust level. All published outputs will only contain aggregated data with small number suppression applied as in line with the HES Analysis Guide. An SBNS Research Fellow has published two papers based on the data: The assessment of the clinical and coded accuracy, and comprehensiveness of HES data for the purposes of reassurance of the national neurosurgical audit (NNAP). The Clinical Effectiveness Unit (CEU) has a experience in validating HES data (for instance in abdominal aortic aneurysm surgery). NEC will use this methodology to reassure audit clinicians, hospitals and the public that the data is accurate. The HES data outputs will also be used by the CEU to construct a modified comorbidity index that relates to neurosurgery using HES data and previous admissions under other specialty departments. The CEU will also use the data outputs to explore the utility of neurosurgical HES data in defining research projects using measures such as numbers needed to treat and allowing accurate design of clinical trials. ************** Outputs achieved by spring 2022: An SBNS Research Fellow has concentrated primarily on defining indicators of outcomes for neurosurgery and working with NEC to refine the risk-adjusted method for determining outlier performance. Two papers have been published: [2 paragraphs unchanged] Despite the closure of both COP and Choices, NNAP has continued to publish information on its dedicated website (www.nnap.org.uk). This includes information about surgeons and trusts including mortality outcomes. Information about adult and paediatric elective and non-elective procedures are included. Mortality analyses does not include paediatric procedures nor non-elective surgery. The first round of outlier analyses took longer to finalise than expected, principally because the quality of the data at surgeon level led to many challenges about the attribution of procedures associated with a mortality event within 30 days. In some cases it was due to local admission processes for emergency admissions and in some it was poor quality data (e.g. large numbers of procedures recorded in 2019 being attributed to two surgeons who had retired from the trust in 2005). For the second round of outlier analyses, it was decided to undertake trust-level analyses only and bespoke reports for both adult and paediatric practice were produced for the 30 trusts. Where there were concerns about the outcomes of neurosurgery, the SBNS Lead was able to visit the trusts and use the reports as a basis for discussion about improving services. Again, this is a lengthy process as each mortality event has to be checked against local records to assess the accuracy of those records, often resulting in the analysis having to be re-run. Information about each consultant’s practice will continue to be published. The ability to download records and provide consultants with access to an enhanced, dynamic set of reports is expected to improve the quality of data available from HES The SBNS Lead is also the Neurosurgery Lead for GIRFT and the production of trust level reports has identified those trusts where GIRFT support may be required. GIRFT only have access to the outputs of the analysis, not the data itself. Reports: Responses to ad hoc queries from NHSE, CQC, and GIRFT have been provided as needed. Presentations: SBNS Annual Meetings have included NNAP sessions.

Expected measurable benefits

The expected benefits to health care are in the improvement of patient outcomes and patient safety through the ability to identify outlier performance against the key indicator of mortality mortality, and the ability for surgeons to assess the outcomes of their own clinical practice by comparing it to the outcomes of their colleagues. Outlier performance analysis is designed to ensure clinical and management review of clinical practice to identify systemic or individual issues to ensure the necessary corrective action is taken. Updated data and information will be provided to patients annually via the NNAP website. The potential number of patients affected is in the tens of thousands. Cost savings should be made by reducing the number of repeat, or revision, procedures, by identifying those procedure types with poorer outcomes; or using case-mix adjustment to improve patient and procedure selection. Patients are the intended main beneficiaries of the data processing, as clinicians will be able to monitor the outcomes of surgery and assess their own clinical practice. It is in the legitimate interest of patients that that the quality and effectiveness of their care is being monitored and assessed. The expected benefits as outlined in NNAP's legitimate interest assessment include the detection of potential outlier performance. This will ensure clinical and management review of clinical practice to identify systemic or individual issues to ensure the necessary corrective action is taken. The potential number of patients affected is in the tens of thousands. The cost savings are difficult to quantify. However, savings will be made by reducing the number of repeat, or revision, procedures. This would be achieved by the identification of those procedure types with less good outcomes or using case-mix adjustment to improve patient and procedure selection. Patients are the main beneficiaries of the data processing, as clinicians will be able to monitor the outcomes of surgery and assess their own clinical practice. The use of the data could: Outcomes will be monitored on an annual basis and, as NNAP has already been in existence for three years, the benefits of processing the data will be realised immediately. • lead to the identification or improvement of treatments or interventions, or health and care system design to improve health and care outcomes or experience. • inform planning health services and programmes, for example to improve equity of access, experience and outcomes. • provide a mechanism for checking the quality of care. This could include identifying areas of good practice to learn from, or areas of poorer practice which need to be addressed. • support knowledge creation or exploratory research (and the innovations and developments that might result from that exploratory work).

Benefits reported

[1 paragraph unchanged] Patients have access to information about the outcomes of elective adult and paediatric neurosurgery for each of the 30 trusts with neurosurgical centres. They are also provided with information about the practice of those trusts and individual neurosurgeons. Patients have access to data that can be used to determine their choice of surgeon and/or trust. The outlier analysis has identified trusts whose performance in regard to neurosurgery has been indicated as ‘outlier’. The trust level reports have provided the necessary information to NNAP and trusts to identify potential issues. Where the problem is perceived to be an organisational issue, the problem has been discussed with board-level management, and enabled the ‘Getting It Right First Time’ (GIRFT) programme to direct resources to those Trusts most in need. The legitimate interests of NNAP are being met. The outlier analysis has identified trusts whose performance in regard to neurosurgery has been indicated as ‘outlier’. The trust level reports have provided the necessary information to NNAP and trusts to identify potential issues. Where the problem is perceived to be an organisational issue, the problem has been discussed with board-level management and GIRFT support provided. Audits of local data based on NNAP analysis have also revealed potential [37 words unchanged] from undertaking specific procedures, providing additional training/supervision, encouraging the implementation of neurosurgical MDTs, multidisciplinary teams, etc. [2 paragraphs unchanged] The analysis of the data has also enabled GIRFT to direct resources to those trusts in most need. Whilst it is difficult to quantify the yielded benefits, through the identification of potential outlier performance, it has been possible to notify the trust, to identify the issues, and take remedial action or put the necessary support in place. This will have led to improvements in patient outcomes and patient safety.

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Datasets: + HES-ID to MPS-ID HES Admitted Patient Care

Objective for processing

The Neurosurgical National Audit Programme (NNAP) was established by the Society of [48 words unchanged] clinically relevant way. Currently the only data available to achieve this is HES Hospital Episode Statistics (HES) data linked to Civil Registration/Mortality data. The data requested covers NHS Trusts in England undertaking neurosurgical procedures, a total of thirty. It is essential that all neurosurgical centres are included in the audit. The data is minimised to include only neurosurgery patients (both adult and paediatric). SBNS - the sole data controller for this Agreement - has a responsibility to ensure that all twenty four the thirty NHS trusts undertaking neurosurgery in England are doing so safely. The linkage requested 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 of fundamental rights and freedoms of the data subject which require protection of personal data, in particular where the data subject is a child) - covered by Article 6 (1)(F) of the GDPR. The HES and linked Civil Registration/Mortality data are required to identify what neurosurgery has taken place, where it has taken place, and who has carried out individual procedures. Pseudonymised data (local patient ID) is required so that surgeons and clinical leads can review mortality events as part of clinical audit, ensure the accuracy of the HES record (e.g. was it an elective procedure or an emergency admission?), and ensure that it was attributed to the correct surgeon. The NNAP is an ongoing audit and it will be necessary to continue to assess changes in performance over time. It is expected that outcomes at five and ten years will be included as the programme continues. The only alternative method of achieving NNAP’s goals is to collect the data separately. This is costly in resources, especially for Trusts who would have to provide the same data twice. Requesting the HES and Civil Registration/Mortality data is the only practicable means of determining the outcomes of neurosurgery. The data being requested is assessed to be the minimum necessary for the purpose. The Society of British Neurological Surgeons (SBNS) has established the NNAP to promote improvements in the quality of neurosurgical services and patient care by providing neurosurgical units in the UK and Ireland with a comprehensive audit programme that reflects the full range of elective and emergency neurosurgical activity. The legal basis for processing the data is ‘processing is necessary for the purposes of the legitimate interests pursued by the controller or by a third party, except where such interests are overridden by the interests or fundamental rights and freedoms of the data subject which require protection of personal data, in particular where the data subject is a child’ (Article 6(1)(f) of the UK GDPR). The data is being processed to determine the outcome of specific neurosurgical procedures, using mortality as the key indicator. The processing will determine any trusts whose performance is considered to be outlying the norm (‘outlier’), enable discussion amongst clinicians and managers to improve performance where necessary, reduce variations in the outcomes of neurosurgery, enable the identification and development of other indicators of outcome. The processing is in the interest of patients, clinicians, healthcare managers, and health-related programmes, e.g. Getting It Right First Time (GIRFT). The SBNS have completed a Legitimate Interests Assessment and are satisfied that the interests of the individual patients do not override the legitimate interests of SBNS. The Society promotes safe and effective Neurosurgical treatment for patients throughout Great Britain and Ireland. The Society has developed and maintains the National Neurosurgical Audit Programme (NNAP), which produces outcome data for all neurosurgical in patients in England. It is also fully engaged with the Getting It Right First Time (GIRFT) project, aiming to improve patient care while reducing costs in all specialities. High standards of professional practice are promoted through the Society's involvement in the education and the examination of Neurosurgeons and through its scientific meetings and associated activities in the continuing professional development of Neurosurgeons and Neurosurgery. Therefore the Society of British Neurosurgeons requires data from NHS Digital the purposes of it's legitimate interests to do the above. Processing is also necessary ‘for reasons of public interest in the area of public health, such as protecting against serious cross-border threats to health or ensuring high standards of quality and safety of health care and of medicinal products or medical devices’ (Article 9(2)(i)). The purpose of processing the data is to determine the outcomes of neurosurgical procedures thereby improving patient safety and patient outcomes. The conditions of Schedule 1, Part 1, Para 3 of the DPA 2108 are met as the processing is necessary for reasons of public interest in public health, and is undertaken and supervised by health professionals (consultant neurosurgeons). SBNS have engaged NEC Software Solutions UK Limited (NEC) as a data processor. NEC undertake analyses of the data on behalf of SBNS and publish outcomes and related information on the NNAP website. NEC manage and process the data which will be held in a secure data centre provided by NTT Global Data Centres, with Iron Mountain (UK) PLC providing secure storage for back up. NTT Global Data Centres and Iron Mountain (UK) PLC are listed as data processors solely for data storage. The Society of British Neurological Surgeons (SBNS) has established the NNAP to promote improvements in the quality of neurosurgical services and patient care by providing neurosurgical units in England with a comprehensive audit programme that reflects the full range of elective and emergency neurosurgical activity. The NNAP is fully engaged with the Getting It Right First Time (GIRFT) programme, aiming to improve patient care while reducing costs in all specialities. High standards of professional practice are promoted through the Society's involvement in the education and the examination of Neurosurgeons and through its scientific meetings and associated activities in the continuing professional development of Neurosurgeons and Neurosurgery. Therefore the Society of British Neurosurgeons requires data from NHS Digital for the purposes of its legitimate interests to do the above. [2 paragraphs unchanged] Consultant neurosurgeons will have secure access to data relating to their own practice. This will enable surgeons to preview and validate the information that is intended for publication on the NNAP COP website. Surgeons will also be provided with a secure online reporting service, via the NNAP website, that will enable them to review their own clinical practice. Whilst record-level data will be available to surgeons, it will include only that data necessary to enable them to identify the patient in local patient administration systems and/or theatre systems, i.e. date of procedure, procedure type, etc. Surgeons will also be provided with a secure online reporting service, via the NNAP website, that will enable them to review their own clinical practice. Whilst record-level data will be available to surgeons, it will include only that data necessary to enable them to identify the patient in local PAS and/or theatre systems, i.e. date of procedure, procedure type, etc. The data requested under this agreement is to enable consultants to view and validate the outcome data relating to the procedures they performed. Consultants nominated by SBNS will have access to data for the purposes of investigating potential outlier performance. Consultant neurosurgeons will have secure access to data relating to their own practice. This will enable surgeons to preview and validate the information that is intended for publication on the NNAP website. The risk-based methodology used to determine performance against the key indicator of mortality will identify potential outlier performance. That surgeon's data will be made available to the investigating surgeon to determine if there is a case to answer and to take any action necessary, i.e. patient pseudo-identifiers will be removed and dates - if required, summarised. However, it is essential that any surgeon whose data indicates outlier performance can be identified using the Consultant Code so that Trust Chief Executives can be informed and a plan for further, local audit and follow-up action can be initiated. The data requested under this agreement is to enable consultants to validate the outcome data relating to the procedures they performed. Consultants nominated by SBNS will have access to data for the purposes of investigating potential outlier performance. The risk-based methodology used to determine performance against the key indicator of mortality will identify potential outlier performance. That surgeon's data will be made available to the investigating surgeon to determine if there is a case to answer and to take any action necessary, i.e. patient pseudo-identifiers will be removed and dates - if required, summarised. However, it is essential that any surgeon whose data indicates outlier performance can be identified using the Consultant Code so that Trust Chief Executives can be informed and a plan for further, local audit and follow-up action can be initiated. [1 paragraph unchanged] This audit is not commissioned by HQIP but NHS England provided the funding to HQIP to cover the COP work for all clinical audits irrespective of the data controllership. HQIP therefore are only funding the work to produce the COP for this audit. The financial support is for costs of data processing for this work only - not the other 90% of the audit. The audit is funded by a charge to all those trusts in NHS England that undertake the relevant neurosurgical procedures. The data will also be used for specific analyses to be undertaken at the request of SBNS, the data controller. SBNS. The results of the analysis will take the form of aggregated data, [14 words unchanged] from NHS England and the regulator, Care Quality Commission (CQC) and the Get Getting it Right First Time (GIRFT) programme. The data will also be used to answer these queries. In general, these organisations will ask specific questions of NNAP, generally about specific trust-related activity. They are users of the outputs of the analysis, rather than processors of the actual data. The SBNS has appointed a Research Fellow to undertake further analyses of the data with a view to publication in professional journals. The work of the Fellow will be overseen by the Director of the Clinical Effectiveness Unit (CEU) at the Royal College of Surgeons (RCS). The head of SBNS is employed as a neurosurgeon at Leeds NHS FT however access to data will be as a substantive employee of SBNS. There is no access to data by the project team at Leeds NHS FT. The head of SBNS is employed as a neurosurgeon at Leeds NHS FT however access to data will be as a substantive employee of SBNS. There is no access to data or no project team at LTH NHS FT.

Processing activities

[1 paragraph unchanged] There will be no flow of identifiable or confidential data from any of the data controllers/processors named in this agreement into NHS Digital. NPS NEC will provide NHS Digital with a list of OPCS4 procedural classification codes and the speciality codes for neurosurgical and paediatric neurosurgical procedures. These are just codes in the dataset, and not record level data. NHS Digital are to use these codes to filter the HES APC Admitted Patient Care (APC) product from 2013/14 onwards and extract records accordingly. [1 paragraph unchanged] The data will then be transferred back to Northgate Public Services (NPS), NEC Software Solutions UK Limited (NEC), on an annual basis. Upon receipt, the data requested will be held by Northgate Public Services (NPS) in its secure data centre. The data, upon receipt, will be loaded onto a dedicated, secure server in the NTT data centre which is only accessible to a limited number of users. The reduced data-set completed as a result of the cleansing and categorisation of the supplied data-set will be held on a protected database server, also hosted within the data centre. NEC staff will access the data held in the data centre either directly from an NEC office or via a secure VPN which requires two factor authentication, including the use of an RSA token. The VPN is an extension of the NEC secure network and does not provide direct access to the server. Access to the server is subject to additional controls. All processing takes place on the server and not local machines. NPS' NEC's Health Analysts will then clean the data prior to undertaking risk adjusted mortality analyses for the [28 words unchanged] APC product requested are grouped into a manageable number of procedure categories. Once the cleansing, mortality analysis, and grouping of data is complete, the [19 words unchanged] Surgeons will have access to record level data for only those procedures in which they are indicated as 'Consultant' - ie surgeons will only access [7 words unchanged] patients - they will not view data on patients of other surgeons. The finalised data-set will also be uploaded to the surgeon-level reporting service. Once the preview process is complete and any adjustments to the data (e.g reassignment of a procedure to another surgeon) the data will be published on the COP website. The finalised data-set will also be uploaded to the surgeon-level reporting service. Surgeons only have access to the data relating to their own patents. Data will be processed by: An SBNS surgeon will have access to record level data, for the purposes of undertaking outlier analyses and to respond to ad-hoc queries from organisations such as NHS England, NHS Improvement, and individual Trust Medical Directors. SBNS are the data controller for this project. • NEC will manage and process the data which will be held in a secure data centre provided by NTT Global Data Centres, with Iron Mountain (UK) PLC providing secure storage for back up. NEC will also undertake analyses of the data and publish outcomes and related information on the NNAP website. The data will also be used for ad-hoc queries and analysis requested by the data controller, SBNS. This work will be undertaken by NPS health data analysts and, where necessary, an SBNS surgeon nominated by the data controller. • SBNS. Neurosurgeons (appointed by the chair of the NNAP steering committee) and a Research Fellow appointed by SBNS will have access to the record level data for the purposes of audit and analysis. All data will be processed by substantive employees of either SBNS, NPS, Gyron Internet Ltd (who act in a processing capacity as data centre host), and Iron Mountain (as off-site backup storage provider). • Consultant neurosurgeons will be able to access aggregated and record level data relating to their practice. Surgeons will only be able to access record level data for those procedures attributed to them. The data held by NPS will be stored on a secure server in the Gyron Internet Ltd data centre which is only accessible to a limited number of users. The reduced data-set completed as a result of the cleansing and categorisation of the supplied data-set will be held on a protected database server, also hosted with NPS' data centre. The data will be used for ad-hoc queries and analysis requested by the data controller, SBNS. This work will be undertaken by NEC health data analysts and, where necessary, an SBNS surgeon nominated by the data controller. NPS staff will access the data held in the data centre either directly from an NPS office or via a secure VPN which requires two factor authentication, including the use of an RSA token. The VPN is an extension of the NPS secure network and does not provide direct access to the server. Access to the server is subject to additional controls. All data will be processed by substantive employees of either SBNS, NEC, NTT Global Data Centres EMEA UK Limited (NTT - who act in a processing capacity as data centre host), and Iron Mountain (as off-site backup storage provider). There will be no subsequent flows of data. In order to ensure that the data remains in a secure location, SBNS access to the data will be by remote desktop via NPS' NEC's VPN. A single, dedicated folder will be made available to the SBNS, [11 words unchanged] manipulate the data. Account holders will be required to sign to accept NPS' NEC's terms and conditions for access to the network and the data. It [80 words unchanged] to the data via VPN. The Fellow will be required to sign NPS NEC terms and conditions before being granted access. RCS CEU are not, for [9 words unchanged] processor: they are supporting and guiding the work of the Fellow only. With the data residing on the server, the SBNS Lead is unable to answer these questions promptly as it requires access to the Northgate NEC VPN and requires use to a secure WiFi or LAN connection to [18 words unchanged] direct access to the data, the questions could be answered almost immediately. [8 paragraphs unchanged] The data requested for NNAP includes all codes associated with Neurosurgery and [10 words unchanged] be filtered to a much smaller extract following analysis and cleaning by Northgate NEC and the SBMS SBNS surgeon will be provided with data relating to a smaller set of [46 words unchanged] also proposed that an alias is provided for the Surgeon GMC code. With regards to Data Destruction, Northgate NEC will ask the SBNS Lead to complete a data destruction certificate before any new data is provided. There will be no linkage permitted to other data sets apart from what is detailed in this agreement. [1 paragraph unchanged]

Expected output

[4 paragraphs unchanged] Information will also be shared with the Get Getting it Right First Time (GiRFT) programme for publication on the GiRFT dashboard. Again, only aggregated data with small number suppression will be supplied. All data published on the NNAP website for COP, the GiRFT Dashboad, and Choices will be aggregated data. All data published on the NNAP website for the GIRFT Dashboad will be aggregated data. Despite the closure of both COP and Choices, NNAP has continued to publish information on its dedicated website (www.nnap.org.uk). This includes information about surgeons and trusts including mortality outcomes. Information about adult and paediatric elective and non-elective procedures are included. Mortality analyses does not include paediatric procedures nor non-elective surgery. [5 paragraphs unchanged] The assessment of the clinical and coded accuracy, and comprehensiveness of HES [19 words unchanged] experience in validating HES data (for instance in abdominal aortic aneurysm surgery). Northgate NEC will use this methodology to reassure audit clinicians, hospitals and the public that the data is accurate. [2 paragraphs unchanged] ************** Outputs achieved by spring 2022: An SBNS Research Fellow has concentrated primarily on defining indicators of outcomes for neurosurgery and working with NEC to refine the risk-adjusted method for determining outlier performance. Two papers have been published: • ‘Patterns and outcomes of neurosurgery in England over a five-year period: A national retrospective cohort study’. • ‘Readmission and reoperation rates after resection of malignant primary brain tumours in England 2013 to 2017’. Despite the closure of both COP and Choices, NNAP has continued to publish information on its dedicated website (www.nnap.org.uk). This includes information about surgeons and trusts including mortality outcomes. Information about adult and paediatric elective and non-elective procedures are included. Mortality analyses does not include paediatric procedures nor non-elective surgery. The first round of outlier analyses took longer to finalise than expected, principally because the quality of the data at surgeon level led to many challenges about the attribution of procedures associated with a mortality event within 30 days. In some cases it was due to local admission processes for emergency admissions and in some it was poor quality data (e.g. large numbers of procedures recorded in 2019 being attributed to two surgeons who had retired from the trust in 2005). For the second round of outlier analyses, it was decided to undertake trust-level analyses only and bespoke reports for both adult and paediatric practice were produced for the 30 trusts. Where there were concerns about the outcomes of neurosurgery, the SBNS Lead was able to visit the trusts and use the reports as a basis for discussion about improving services. Again, this is a lengthy process as each mortality event has to be checked against local records to assess the accuracy of those records, often resulting in the analysis having to be re-run. Information about each consultant’s practice will continue to be published. The ability to download records and provide consultants with access to an enhanced, dynamic set of reports is expected to improve the quality of data available from HES The SBNS Lead is also the Neurosurgery Lead for GIRFT and the production of trust level reports has identified those trusts where GIRFT support may be required. GIRFT only have access to the outputs of the analysis, not the data itself. Reports: Responses to ad hoc queries from NHSE, CQC, and GIRFT have been provided as needed. Presentations: SBNS Annual Meetings have included NNAP sessions.

Expected measurable benefits

[1 paragraph unchanged] Updated data and information will be provided to patients annually via the NNAP COP website. Patients will be better informed on the NHS Choices website about procedures undertaken by their consultant. It is in the legitimate interest of patients that that the quality and effectiveness of their care is being monitored and assessed. The expected benefits as outlined in NNAP's legitimate interest assessment include the detection of potential outlier performance. This will ensure clinical and management review of clinical practice to identify systemic or individual issues to ensure the necessary corrective action is taken. The potential number of patients affected is in the tens of thousands. The cost savings are difficult to quantify. However, savings will be made by reducing the number of repeat, or revision, procedures. This would be achieved by the identification of those procedure types with less good outcomes or using case-mix adjustment to improve patient and procedure selection. Patients are the main beneficiaries of the data processing, as clinicians will be able to monitor the outcomes of surgery and assess their own clinical practice. It is in the legitimate interest of patients that that the quality and effectiveness of their care is being monitored and assessed. The detection of potential outlier performance will ensure clinical and management review of clinical practice to identify systemic or individual issues to ensure the necessary corrective action is taken. The potential number of patients affected is in the tens of thousands. The cost savings are difficult to quantify. However, savings will be made by reducing the number of repeat, or revision, procedures. This would be achieved by the identification of those procedure types with less good outcomes or using case-mix adjustment to improve patient and procedure selection. Patients are the main beneficiaries of the data processing, as clinicians will be able to monitor the outcomes of surgery and assess their own clinical practice. [1 paragraph unchanged]

Benefits reported

Not stated in the previous version; added here.

Patients have access to information about the outcomes of elective adult and paediatric neurosurgery for each of the 30 trusts with neurosurgical centres. They are also provided with information about the practice of those trusts and individual neurosurgeons. Patients have access to data that can be used to determine their choice of surgeon and/or trust.

Patients have access to information about the outcomes of elective adult and paediatric neurosurgery for each of the 30 trusts with neurosurgical centres. They are also provided with information about the practice of those trusts and individual neurosurgeons. Patients have access to data that can be used to determine their choice of surgeon and/or trust.

The legitimate interests of NNAP are being met. The outlier analysis has identified trusts whose performance in regard to neurosurgery has been indicated as ‘outlier’. The trust level reports have provided the necessary information to NNAP and trusts to identify potential issues. Where the problem is perceived to be an organisational issue, the problem has been discussed with board-level management and GIRFT support provided. Audits of local data based on NNAP analysis have also revealed potential outlier performance amongst a few individual surgeons. Once identified a detailed audit of patient records takes place with support being provided by those responsible for clinical governance and the appropriate action taken. This can include preventing surgeons from undertaking specific procedures, providing additional training/supervision, encouraging the implementation of neurosurgical MDTs, etc.

Healthcare Managers have access to a detailed report about the neurosurgical practice in their trusts and an indication, based on 30-day mortality, of how the trust is performing. Concerns about the data included in the reports have been addressed directly to the SBNS lead and, if there are clinical concerns, the appropriate action taken.

Individual surgeons have access to data about mortality events, enabling them to audit their own practice. Based on the publication of the data, some Clinical Directors have taken steps to improve the quality of coding.

The analysis of the data has also enabled GIRFT to direct resources to those trusts in most need.

Whilst it is difficult to quantify the yielded benefits, through the identification of potential outlier performance, it has been possible to notify the trust, to identify the issues, and take remedial action or put the necessary support in place. This will have led to improvements in patient outcomes and patient safety.

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

Objective for processing

[7 paragraphs unchanged] Surgeons will also be provided with a secure online reporting service, via [26 words unchanged] data necessary to enable them to identify the patient in local PAS (Patient Administration System) and/or theatre systems, i.e. date of procedure, procedure type, etc. [1 paragraph unchanged] The data published for COP is also required for publication via the Choices website. All data that will be published on public websites will be aggregated with small number suppression applied. [1 paragraph unchanged] The data will also be used for specific analyses to be undertaken [31 words unchanged] hospital level performance from NHS England and the regulator, Care Quality Commission (CQC). (CQC) and the Get it Right First Time (GIRFT) programme. The data will also be used to answer these queries. The SBNS has appointed a Research Fellow to undertake further analyses of the data with a view to publication in professional journals. The work of the Fellow will be overseen by the Director of the Clinical Effectiveness Unit (CEU) at the Royal College of Surgeons (RCS). [1 paragraph unchanged]

Processing activities

[11 paragraphs unchanged] All data will be processed by substantive employees of either SBNS, NPS, Sungard Gyron Internet Ltd (who act in a processing capacity as data centre host), and Iron Mountain (as off-site backup storage provider). The data held by NPS will be stored on a secure server in the SunGard Gyron Internet Ltd data centre which is only accessible to a limited number of users. [18 words unchanged] held on a protected database server, also hosted with NPS' data centre. [1 paragraph unchanged] In order to ensure that the data remains in a secure location, SBNS access to the data will be by remote desktop via NPS' VPN (Virtual Private Network). VPN. A single, dedicated folder will be made available to the SBNS, and [29 words unchanged] the network and the data. It is expected that no more than one surgeon two surgeons will require such access. Logging onto the VPN will not be permitted [34 words unchanged] an office located in a hospital or using a secure home connection. Although working primarily at the CEU, the SBNS Fellow will be provided with access to the data via VPN. The Fellow will be required to sign NPS terms and conditions before being granted access. RCS CEU are not, for the purposes of this agreement, acting as a data processor: they are supporting and guiding the work of the Fellow only. With the data residing on the server, the SBNS Lead is unable to answer these questions promptly as it requires access to the Northgate VPN and requires use to a secure WiFi or LAN connection to do so. It is taking up to a week to provide responses to queries which, if there was direct access to the data, the questions could be answered almost immediately. It has been agreed by NHS Digital Security Team to allow the use of the data on the SBNS surgeon’s laptop, at present the surgeon currently uses his laptop to access Trust systems via the Trust VPN and has access to Electronic Patient Records and Radiographs for patients throughout most of Yorkshire. The Trust requires all employees using IT to undertake annual e-learning modules relating to security, data protection, and information governance. The SBNS surgeon’s laptop will be appropriately specified for the task with security features including: Full disk encryption with XTS-AES 128 encryption using a 256 bit key. Two factor authentication when logging on: password and user authentication (password or retina scan) for logging onto Laptop can be remotely protected or wiped. The OS automatically updates when new versions or patches are available. The laptop is protected against viruses and malware, again automatically updated. VPN access is achieved using two factor authentication, ie. RSA Key and passcode. Data provided for processing on the laptop will not include the local patient identifier (LOPATID) or GMC codes. As part of the outlier analysis, NPS will provide the GMC code of any surgeon whose data indicates potential outlier performance directly to the SBNS lead. The data requested for NNAP includes all codes associated with Neurosurgery and the diagnosis codes for paediatric neurosurgery, this data set will be filtered to a much smaller extract following analysis and cleaning by Northgate and the SBMS surgeon will be provided with data relating to a smaller set of procedure codes and episodes that did not include a surgical intervention. A recent request to amend the data supplied includes the addition of Local Patient ID (LOPATID) but it is proposed that that field is not included in the data held on the laptop. It is also proposed that an alias is provided for the Surgeon GMC code. With regards to Data Destruction, Northgate will ask the SBNS Lead to complete a data destruction certificate before any new data is provided. [2 paragraphs unchanged]

Expected output

[11 paragraphs unchanged] The assessment of the clinical and coded accuracy, and comprehensiveness of HES data for the purposes of reassurance of the national neurosurgical audit (NNAP). The Clinical Effectiveness Unit (CEU) has a experience in validating HES data (for instance in abdominal aortic aneurysm surgery). Northgate will use this methodology to reassure audit clinicians, hospitals and the public that the data is accurate. The HES data outputs will also be used by the CEU to construct a modified comorbidity index that relates to neurosurgery using HES data and previous admissions under other specialty departments. The CEU will also use the data outputs to explore the utility of neurosurgical HES data in defining research projects using measures such as numbers needed to treat and allowing accurate design of clinical trials.

Unchanged: Expected measurable benefits.

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

Objective for processing

[7 paragraphs unchanged] Surgeons will also be provided with a secure online reporting service, via [26 words unchanged] data necessary to enable them to identify the patient in local PAS (Patient Administration System) and/or theatre systems, i.e. date of procedure, procedure type, etc. [5 paragraphs unchanged]

Processing activities

[14 paragraphs unchanged] In order to ensure that the data remains in a secure location, SBNS access to the data will be by remote desktop via NPS' VPN. VPN (Virtual Private Network). A single, dedicated folder will be made available to the SBNS, and [89 words unchanged] an office located in a hospital or using a secure home connection. [2 paragraphs unchanged]

Benefits reported

Stated in the previous version and removed here.

Yielded Benefits is not a requirement for new applications.

Unchanged: Expected output, Expected measurable benefits.