Monitoring the quality of healthcare in England

The Health Foundation is an independent charity working to improve health and the quality of healthcare in the United Kingdom. As part of this strategy, the Health Foundation Research and Analysis team analyses data on the quality of health and care.

The Health Foundation is the data controller and also processes the data for this study.

The Research and Analysis team requires access to person-level data for an in-house programme of analyses to be completed over the course of the next 5 years.

The aim of this programme is to:

•produce new insights into quality of patient care,

•investigate how the quality of care can be improved

•understand the demand for health care in the UK using linked HES data and innovative analytical methods.

The overall purpose and benefit of this work is to inform the NHS and policy makers about changes in the characteristics and health needs of patients, factors that drive health care utilisation and health outcomes, and variation in health need, and quality of care. The work of The Health Foundation is designed to help the NHS understand the rising demand for health care and to plan for the future. The work packages within this programme will cover a number of thematic areas. These were identified as priorities for care quality and outcomes improvement in the recently published NHS Long Term Plan.

The Health Foundation are processing the data in line with their charitable goals as part of their legitimate interests. This is covered under the GDPR Article 6(1)(f) - This work is necessary for the purposes of the legitimate interests pursued by the controller or by a third party except where such interests are overridden by the interests or fundamental rights and freedoms of the data subject which require protection of personal data, in particular where the data subject is a child.

As set out in the legitimate interest assessment that The Health Foundation have undertaken - the Data is to help achieve the following:

• To improve health service delivery (by evaluating policies and reporting feedback to the NHS and policy makers)

• To make health policy making more effective (the work packages look at specific policy implementation and how this has been effective and feedback will be given to policy makers)

• test innovations and spread what works

• build skills and knowledge (data access will help to evaluate and understand the rising demand for healthcare and plan for the future)

• develop and share evidence on what works and why (through conferences, presentations, and journal articles that will explain outcomes and results that have been generated using the NHS England Data.

The data is also required for service evaluation purposes - meeting the conditions outlined as per Article 9 (2)(I) of the GDPR. 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, on the basis of Union or Member State law which provides for suitable and specific measures to safeguard the rights and freedoms of the data subject, in particular professional secrecy. The Health Foundation are carrying out service evaluation work as described in this agreement to investigate how the quality of care can be improved.

Amazon Web Services (AWS) is a processor acting under the instructions of The Health Foundation. The role of AWS is limited to cloud storage of the Data only. The Health Foundation expects to transfer all Data from AWS to a Secure eResearch Platform (SeRP) at Swansea University by 31st July 2025.

Swansea University is a processor acting under the instructions of The Health Foundation. NHSE data linked to study data will be stored and analysed in Swansea University's Secure eResearch Platform (SeRP - https://popdatasci.swan.ac.uk/products-services/secure-e-research-platform/). NHS England will provide the relevant records from the HES and deaths datasets to The Health Foundation, then subsequently to Swansea University upon transfer to (SeRP).

The Data will contain no direct identifying data items but will contain a unique person ID which can be used to link the Data with other record level data already held by the recipient.

Following the transfer of all Data from The Health Foundation/AWS to Swansea University/SeRP, all NHS England Data will be stored and analysed on Swansea University's SeRP. Off-site storage of data for disaster recovery is provided via AWS region Europe (London) under SeRP AWS account. Data will not be transferred to any other location.

The overall purpose and benefit of this work is to inform the NHS and policy makers about changes in the characteristics and health needs of patients, factors that drive health care utilisation and health outcomes, and variation in health need, and quality of care. The work of The Health Foundation is designed to help the NHS understand the rising demand for health care and to plan for the future. The work packages within this programme will cover a number of thematic areas. These were identified as priorities for care quality and outcomes improvement in the recently published NHS Long Term Plan.

The Data Analytics team within The Health Foundation wish to undertake the following work streams:

Work stream 1: Monitoring trends

The Health Foundation will use patient-level data to summarise national contexts and to monitor local and national trends in secondary care in order to improve understanding of the drivers of demand and quality of patient care. Examples of trends that The Health Foundation wish to monitor include changes in disease (all diseases) prevalence and complexity over time, healthcare take-up and demand for distinct patient groups (e.g. patients with long-term conditions), as well as variations or changes in the characteristics of patients accessing secondary care. Key areas of focus within this theme will be:

• Multimorbidity: understanding the changing profiles and needs of patients with multiple long-term health conditions, following on from previous Health Foundation publications, which found that over half of hospital admissions and outpatient visits are for people living with 2 or more conditions. The Health Foundation aims to understand more about trends in combinations of conditions that patients present with in different parts of secondary care. Another goal of this workstream is to investigate the levels on under-recording of co-morbidities in electronic health records when they are not the primary reason for admission. This will be done by comparing HES-based prevalence estimates to estimates from other data sources, e.g. CPRD (Clinical Practice Research Datalink). The results from these analyses will help the NHS understand the rising demand for health care and to offer insight for policy makers and commissioners to design better quality patient care.

• Health and care inequality: unmet need and unexplained local variation in health care access and health outcomes. This analysis will help to raise awareness about existing and developing health inequalities and support the NHS and policy makers in finding solutions to address them.

• International comparison of quality metrics. Analysts at The Health Foundation will also analyse the data to provide aggregate statistics for international comparative analysis of health care quality, utilisation, cost and outcomes. This will be a contribution to an ongoing collaboration between the Health Foundation and partners from 11 other countries, including Germany, France, Australia and the USA. The aim is to compare how healthcare spending and demand for high-cost patients differs between countries. Understanding the differences between countries and their approaches will help to inform better management of these patient groups in the NHS. Note that for this project, only aggregate statistics with small numbers suppressed in line with NHS England guidance will be shared with colleagues overseas. These will be checked to ensure that no patient can be identified, and that the statistics contain no confidential information. No individual patient data will be shared. The collaborators do not have any influence on the means by which the data at the Health Foundation are being analysed.

• Patterns in healthcare demand and utilisation. Work will analyse the dataset to examine trends in demand for emergency and elective care over time and impact on patient outcomes (such as 30-day and 1-year mortality and 30-day readmission). This will also examine the impact of changing performance of hospital providers for example; changes to bed occupancy rates, A&E performance and waiting times.

Work-stream 1 will require linked patient-level Accident & Emergency/Emergency Care Data Set, Admitted Patient Care, Critical Care, Outpatient and Civil Registration Data for years 2008/2009 to current and future data up to 2023, for the whole population. To assess historical trends, access to a long time-series of data is required. To assess the health of children and young people, which is of particular interest in the mental health trends and examining trends in healthcare utilisation over time, a whole population sample is required. To assess outcomes, will need linked mortality data, including date of death to calculate 30-day all-cause mortality rates following a hospital admission.

Work stream 2: Seasonal variations

As part of the Health Foundation’s ongoing monitoring of winter pressures and the knock-on effect in care quality, analysts from the Data Analytics Team will investigate seasonal variations in A&E attendance and emergency admissions. This will include investigating patient profiles, including a focus on respiratory conditions due to their prevalence during the winter months, and a focus on long-stay patients.

The Health Foundation will undertake analyses that also aims to understand the consequences of winter pressures for other NHS services throughout the rest of the year, particularly on elective care such as outpatient appointments and elective hospital treatments. Key areas within this will be:

• Seasonal analysis of the volume of elective care and outpatient appointments with respect to geographical variation. This analysis will support policymakers and commissioners in planning for winter, as it will provide insight into areas that will require additional support.

• Cancellation of elective care in winter and their effect on demand and waiting times during other times of the year.

• Seasonal variation of length of stay for elective admissions and association with patient outcomes, such as emergency readmission and mortality.

This analysis will require linked patient-level inpatient and outpatient as well as mortality data, including date of death to calculate 30-day all-cause mortality rates following a hospital admission. This analysis will require data for years 2008/2009 to current and future data up to 2023, because it is important for this work to see whether changes in health service performance over time is affected by seasonal demand and variation. For example, were Health Foundation analysts to use the data from the recent years to see whether demand for health services increased in winter or summer, it would be useful to know whether these are recent phenomenon or whether such seasonal variations existed previously. This is important as The Health Foundation wouldn’t wish to make policy recommendations based on one-off ‘chance’ events, and therefore this justifies why it is necessary to look at seasonal variations within a fairly long-time frame - so that informed proposals can be made.

Work stream 3: Emergency hospital admissions and same-day emergency care

As part of the NHS Long Term Plan, NHS England is aiming to reduce pressure on emergency hospital services by reducing overall emergency admissions and by increasing the proportion of ‘zero-day admissions’ by providing Same Day Emergency Care (SDEC), which is also known as ambulatory emergency care.

The analysis for this workstream will investigate patient and provider characteristics associated with zero-day and 1+ day emergency admissions. Analysts will assess the effect on health outcomes, including 30-day readmission rates and mortality, compared to patients with longer hospital admissions. In addition, the effect of zero-day admissions at provider level will be analysed to explore geographical variation. This will be done using performance measures including A&E waiting times, inpatient bed days, bed occupancy, stranded patients and delayed transfers of care. This analysis will inform policymakers about progress in the implementation of the service changes set out in the NHS Long Term Plan and will provide insight into their effect on quality of patient care.

This analysis will require linked patient-level Accident & Emergency/Emergency Care Data Set, Admitted Patient Care, Critical Care, Outpatient for years 2008/2009 to current and future data up to 2023. so that progress of the implementation of this new care model can be monitored. The NHS Long-Term plan introduces a number of policy initiatives. In order to see how these initiatives will impact hospital emergency admissions, it is important to analyse emergency admissions data over time. For example, if between 2008 and 2018, The Health Foundation analyse a trend which then changes because of the implementation of a new policy, then the true effects of the policy can be determined. If The Health Foundation only used a short time period for analysis, then the significance of the impact of the change in policy would be more difficult to ascertain. Therefore, analysts require a fairly good run of years of data to be able to undertake a robust policy analysis.

Workstream 4: Outpatient care

Over the last decade the number of hospital outpatient appointments in England has almost doubled from 54 to 94 million yearly attendances. Outpatient care currently represents the largest proportion of NHS contact with patients in a hospital setting and accounts for around £8 billion in yearly healthcare expenditure.

The analysis for this workstream aims to provide new insight into quality of outpatient care by descriptively characterising outpatient journeys, focusing on patient characteristics and complexity, provider and appointment characteristics. Trends will be monitored over time, and an assessment of how these factors relate to case-mix in outpatient clinics and analyse geographical variation and variation associated with socioeconomic deprivation. This will provide commissioners, national and local healthcare leaders with better evidence on the patient need and current quality of outpatient care, in order to support them in finding solutions to meet these needs.

After a decade of substantial yearly growth, the number of outpatient appointments has remained constant since 2016/17. In the NHS Long Term Plan, this was attributed to the fact that GP referrals had been successfully constrained in recent years. The Health Foundation will dedicate part of the analysis to investigating the effect of this recent policy change by analysing the characteristics of patients that were not referred as a result and what the effect on outcomes was. This will include the effect on utilisation of other services as well as patient outcomes, such as emergency admissions and mortality.

One in five outpatient appointments in England are reported as cancelled by the patient or the hospital or as ‘did not attend’ (DNA). Missed or cancelled appointments have financial and operational implications for the NHS but can also have negative effects on quality of care and patient outcomes. This analysis will use patient-level data to investigate appointments that are frequently cancelled or missed, as well as geographical variation in cancellations and non-attendances and any links to socioeconomic deprivation. Included in this analysis will be an investigation as to whether the frequency of outpatient appointments, as well as the number of cancelled and missed appointments, is associated with patient outcomes, such as emergency re-admissions and mortality. This will also include comparisons between conventional and novel statistical approaches. This analysis will support policymakers and practitioners in understanding and avoiding non-attendances in outpatient care, which help to improve the efficiency of outpatient clinics and the quality of patient care.

This work stream will require linked patient-level inpatient and outpatient data, as well mortality data, including variables on date and cause of death.

As above, as the Health Foundation are (as part of this Work Stream) looking into policy change. A longer time span of data is required so that the full effect from the implementation of the policy can be analysed, so the true effects can be determined.

The Health Foundation wishes to process these data in order to describe and assess local and national trends in demand for secondary health care. This includes examining patterns and trends pertaining to individuals and their healthcare demands and take-up of healthcare services, in particular, those individuals with multiple health conditions, inequalities in healthcare demand. Furthermore, processing will be undertaken so that these trends can be compared with trends from other countries. In addition, data will be processed to examine seasonal variation in healthcare demand, the characteristics of patients demanding A&E services, and the demand for outpatient services.

By processing these data to generate these trends, The Health Foundation will be able to inform the health service about the situation of healthcare demand, take-up and treatment for the NHS in England. This will provide policymakers with a picture of the state of the health service demand, particularly for individuals with more than one health condition, as well as the extent to which inequalities exist. This information obtained from processing the data will provide the evidence-base for which policymakers can act to make improvements to patient healthcare. This fits with the remit of The Health Foundation, which is to bring about better health and healthcare for people living in the UK. This is essential work as demand for healthcare services continues to increase, due to an aging population, and healthcare providers continue to operate in a tight financial environment.

If the data were unavailable, The Health Foundation would not be able to undertake the work described above, and the benefits stated could not be realised. The Health Foundation has considered using aggregate sources of data for this work, but these have limitations: they have been created in a way which does not enable The Health Foundation to undertake the specific trends in healthcare that the organisation believe is important to contribute to public understanding about the health service.

The Health Foundation will be complying with UK GDPR, in particular, that data will be used for a legitimate interest, and safeguards will protect the special categories of data used for this workstream.

As mentioned previously, processing the data will enable The Health Foundation to produce analysis relating to national trends of health service utilisation. Patient-level data are required to control for several characteristics to prevent biased statistical results from being produced. The Health Foundation seeks to avoid producing misleading analyses, and therefore it is important to use patient-level data to correctly build an accurate picture of healthcare demand and utilisation in England.

In doing so, The Health Foundation believes that the data processing is proportionate to the purpose for which it seeks to use data. There is a relatively low risk that patient data could be exposed, because of the security measures in place for protecting the data, and there is much benefit that will be realised from undertaking this analysis.

Despite the fact that the Data will be pseudonymised, the Data may contain information about children and other vulnerable people owing to the fact that The Health Foundation has not restricted the Data on the basis of age, disability etc. for the analysis. Trends pertaining to all patients and their use of the health service will be generated, although broken down by age group.

The Health Foundation is an independent charity that exists to further progress and improve the health care of the nation. As a charity independent of government funding, and any other interests, it endeavours to make the public aware that the use of patients’ data is solely for the purpose of improving the health service and treatments that patients receive.

There will be no impact on the data subjects (patients) whose data will be included in the extract received by The Health Foundation. Safeguards are in place to ensure that no individual data will be released from it’s accredited secure data environment in which the data will be processed; further checks will be applied to ensure that no statistical results published could reveal the identity, and/or confidential information, about any individual. Processing such data in a secure data environment is typical for organisations such as The Health Foundation, and guidance on security accreditation is sought and applied from a number of organisations including NHS England, Office for National Statistics, UK Data Service and HMRC (His Majesty's Revenue and Customs) Data lab. Information about the use of patient data is available on The Health Foundation website.

Statistical outputs produced from all projects listed previously will be assessed against best practice guidelines on statistical disclosure control and privacy protection to ensure the confidentiality of the data is maintained. All outputs will contain only data that is aggregated with small numbers suppressed in line with the HES Analysis Guide.

Several publications will be produced from each of the work streams listed under the Purpose section. These publications typically take the form of:

- Reports aimed at policy makers, disseminated through the Foundation’s website. The Health Foundation Communications Team advertises these reports through social media channels, and in addition, senior The Health Foundation staff highlight these reports to contacts throughout the health and social care system (such as at NHS England).

- Peer-reviewed journal articles

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

- Conferences and presentations

The Health Foundation’s approach to dissemination includes not only publications but also engagement with national policy makers, practitioners and researchers. The Health Foundation’s Communications team will lead on the dissemination of findings. The Health Foundation’s staff regularly speak to senior NHS leaders. For example, The Health Foundation’s report on multiple conditions (https://www.health.org.uk/publications/understanding-the-health-care-needs-of-people-with-multiple-health-conditions) featured in national media in Autumn 2018, in addition to staff at NHS England charged with designing and delivering national policy on integration and personalised care. Furthermore, The Health Foundation regularly liaises with local providers: for example, results of analysis into social isolation, were relayed to Barking and Dagenham in London. This instigated the establishment of a range of projects aimed to tackle social isolation across different age groups.

Wider dissemination of findings takes place via the media, and through social media and direct e-communication with key stakeholders. For example, a previous publication using HES data, on emergency admissions received extensive coverage in the trade media, support via social media from relevant royal colleges and other stakeholders, and exclusive national press coverage in The Times. Other publications from the team have received similar or greater coverage from media, and strong engagement on social media.

Planned publications:

• Health foundation briefing on trends in emergency admissions since the last Health Foundation analysis published in 2021

• Health Foundation briefing on the effects of implementation of same-day emergency care (planned for 2021, once data for the financial year 2019/20 is available)

• Health Foundation publication on elective care investigating seasonal demand and demand management practices 2021 and 2023.

• Health Foundation report on outpatient appointments

• Peer-reviewed publication(s) on outpatient journeys and the effect of missed/cancelled appointments to be published in BMJ, PloS Medicine, BMJ quality and safety or similar.

• Health Foundation publication on mental health (national trends analysis), 2021

• Peer-reviewed publication(s) on international comparisons of care quality to be published in BMJ, PloS Medicine, BMJ Quality and Safety or similar (ongoing 2021, 2022, 2023).

• Health Foundation publication on trends in care quality, and impact of major system changes, 2021 and 2023

This Agreement mentions 4 Workstreams (1-4), and in addition, Workstream A in the Processing Activities section.

Workstream A is about cleaning and tidying up the data, making the data ready for analysis (for Workstreams 1-4). This is what The Health Foundation calls the HES Data Pipeline.

This work has been successfully completed. The work began when the data was originally received, and the Pipeline was completed in February 2020.

A large amount of work was undertaken to organise the data, clean, check for errors and quality issues, and could sensibly incorporate updates (quarterly updates of HES). A number of checks and tests were put in place to make sure The Health Foundation would be able to use consistent and sensible data for workstreams 1-4.

During 2020/21 analysis under Workstream 1 ‘Monitoring Trends’ was directed towards looking specifically at trends in demand for A&E services. This work analysed historical trends (workstream 1) and seasonal variation (workstream 2) of elective and emergency admissions, and outputs (tabulated data, with small numbers suppressed) from the data under this Agreement, were used to collaborate with Imperial College London to develop a modelling approach for optimal allocation of elective care capacity during the COVID-19 pandemic. The benefits from this modelling have helped the NHS policy makers make decisions regarding allocation of resources in order to reduce the waiting list of non-COVID related hospital treatments.

During 2021/2022 the focus was examining hospital length of stay and how it varies across hospital trusts, discharge destinations, and re-admission rates (workstream 3). The initial approach involved identifying key patient personas (e.g., hip fracture surgery) to facilitate comparability between trusts. The exploratory phase will focus on assessing feasibility, particularly the completeness and quality of discharge destination data, while also testing different patient personas. The full benefits are yet to be realised as analysis is ongoing.

During 2022/2023 Additionally, the analysis contributed to the evaluation of a risk stratification tool for managing elective waiting lists (workstream 4), aiming to prioritise patients based on clinical urgency and resource availability. Furthermore, the work included an evaluation of GP payment methods, assessing their impact on service delivery and patient outcomes. Insights from this research have informed NHS policymakers in resource allocation decisions to help address the backlog of non-COVID hospital treatments. As analysis continues, further benefits are expected to emerge.

The Health Foundation is an independent charity working to improve health and the quality of healthcare in the United Kingdom. As part of this strategy, the Health Foundation Data Analytics team analyses data on the quality of health and care.

The Health Foundation is the data controller and also processes the data for this study.

The Data Analytics team is requesting access to person-level data for an in-house programme of analyses to be completed over the course of the next 5 years.

The aim of this programme is to:

•produce new insights into quality of patient care,

•investigate how the quality of care can be improved

•understand the demand for health care in the UK using linked HES data and innovative analytical methods.

The overall purpose and benefit of this work is to inform the NHS and policy makers about changes in the characteristics and health needs of patients, factors that drive health care utilisation and health outcomes, and variation in health need, and quality of care. The work of The Health Foundation is designed to help the NHS understand the rising demand for health care and to plan for the future. The work packages within this programme will cover a number of thematic areas. These were identified as priorities for care quality and outcomes improvement in the recently published NHS Long Term Plan.

The Health Foundation are processing the data in line with their charitable goals as part of their legitimate interests. This is covered under the GDPR Article 6(1)(f) - This work is necessary for the purposes of the legitimate interests pursued by the controller or by a third party except where such interests are overridden by the interests or fundamental rights and freedoms of the data subject which require protection of personal data, in particular where the data subject is a child.

As set out in the legitimate interest assessment that The Health Foundation have undertaken - the data requested is to help achieve the following:

• To improve health service delivery (by evaluating policies and reporting feedback to the NHS and policy makers)

• To make health policy making more effective (the work packages look at specific policy implementation and how this has been effective and feedback will be given to policy makers)

• test innovations and spread what works

• build skills and knowledge (data access will help to evaluate and understand the rising demand for healthcare and plan for the future)

• develop and share evidence on what works and why (through conferences, presentations, and journal articles that will explain outcomes and results that have been generated using the NHS Digital Data.

The data is also required for service evaluation purposes - meeting the conditions outlined as per Article 9 (2)(I) of the GDPR. 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, on the basis of Union or Member State law which provides for suitable and specific measures to safeguard the rights and freedoms of the data subject, in particular professional secrecy. The Health Foundation are carrying out service evaluation work as described in this agreement to investigate how the quality of care can be improved.

The overall purpose and benefit of this work is to inform the NHS and policy makers about changes in the characteristics and health needs of patients, factors that drive health care utilisation and health outcomes, and variation in health need, and quality of care. The work of The Health Foundation is designed to help the NHS understand the rising demand for health care and to plan for the future. The work packages within this programme will cover a number of thematic areas. These were identified as priorities for care quality and outcomes improvement in the recently published NHS Long Term Plan.

The Data Analytics team within The Health Foundation wish to undertake the following work streams:

Work stream 1: Monitoring trends

The Health Foundation will use patient-level data to summarise national contexts and to monitor local and national trends in secondary care in order to improve understanding of the drivers of demand and quality of patient care. Examples of trends that The Health Foundation wish to monitor include changes in disease (all diseases) prevalence and complexity over time, healthcare take-up and demand for distinct patient groups (e.g. patients with long-term conditions), as well as variations or changes in the characteristics of patients accessing secondary care. Key areas of focus within this theme will be:

• Multimorbidity: understanding the changing profiles and needs of patients with multiple long-term health conditions, following on from previous Health Foundation publications, which found that over half of hospital admissions and outpatient visits are for people living with 2 or more conditions. The Health Foundation aims to understand more about trends in combinations of conditions that patients present with in different parts of secondary care. Another goal of this workstream is to investigate the levels on under-recording of co-morbidities in electronic health records when they are not the primary reason for admission. This will be done by comparing HES-based prevalence estimates to estimates from other data sources, e.g. CPRD (Clinical Practice Research Datalink). The results from these analyses will help the NHS understand the rising demand for health care and to offer insight for policy makers and commissioners to design better quality patient care.

• Health and care inequality: unmet need and unexplained local variation in health care access and health outcomes. This analysis will help to raise awareness about existing and developing health inequalities and support the NHS and policy makers in finding solutions to address them.

• International comparison of quality metrics. Analysts at The Health Foundation will also analyse the data to provide aggregate statistics for international comparative analysis of health care quality, utilisation, cost and outcomes. This will be a contribution to an ongoing collaboration between the Health Foundation and partners from 11 other countries, including Germany, France, Australia and the USA. The aim is to compare how healthcare spending and demand for high-cost patients differs between countries. Understanding the differences between countries and their approaches will help to inform better management of these patient groups in the NHS. Note that for this project, only aggregate statistics with small numbers suppressed in line with NHS Digital guidance will be shared with colleagues overseas. These will be checked to ensure that no patient can be identified, and that the statistics contain no confidential information. No individual patient data will be shared. The collaborators do not have any influence on the means by which the data at the Health Foundation are being analysed.

• Patterns in healthcare demand and utilisation. Work will analyse the dataset to examine trends in demand for emergency and elective care over time and impact on patient outcomes (such as 30-day and 1-year mortality and 30-day readmission). This will also examine the impact of changing performance of hospital providers for example; changes to bed occupancy rates, A&E performance and waiting times.

Work-stream 1 will require linked patient-level Accident & Emergency/Emergency Care Data Set, Admitted Patient Care, Critical Care, Outpatient and Civil Registration Data for years 2008/2009 to current and future data up to 2023, for the whole population. To assess historical trends, access to a long time-series of data is required. To assess the health of children and young people, which is of particular interest in the mental health trends and examining trends in healthcare utilisation over time, a whole population sample is required. To assess outcomes, will need linked mortality data, including date of death to calculate 30-day all-cause mortality rates following a hospital admission.

Work stream 2: Seasonal variations

As part of the Health Foundation’s ongoing monitoring of winter pressures and the knock-on effect in care quality, analysts from the Data Analytics Team will investigate seasonal variations in A&E attendance and emergency admissions. This will include investigating patient profiles, including a focus on respiratory conditions due to their prevalence during the winter months, and a focus on long-stay patients.

The Health Foundation will undertake analyses that also aims to understand the consequences of winter pressures for other NHS services throughout the rest of the year, particularly on elective care such as outpatient appointments and elective hospital treatments. Key areas within this will be:

• Seasonal analysis of the volume of elective care and outpatient appointments with respect to geographical variation. This analysis will support policymakers and commissioners in planning for winter, as it will provide insight into areas that will require additional support.

• Cancellation of elective care in winter and their effect on demand and waiting times during other times of the year.

• Seasonal variation of length of stay for elective admissions and association with patient outcomes, such as emergency readmission and mortality.

This analysis will require linked patient-level inpatient and outpatient as well as mortality data, including date of death to calculate 30-day all-cause mortality rates following a hospital admission. This analysis will require data for years 2008/2009 to current and future data up to 2023, because it is important for this work to see whether changes in health service performance over time is affected by seasonal demand and variation. For example, were Health Foundation analysts to use the data from the recent years to see whether demand for health services increased in winter or summer, it would be useful to know whether these are recent phenomenon or whether such seasonal variations existed previously. This is important as The Health Foundation wouldn’t wish to make policy recommendations based on one-off ‘chance’ events, and therefore this justifies why it is necessary to look at seasonal variations within a fairly long-time frame - so that informed proposals can be made.

Work stream 3: Emergency hospital admissions and same-day emergency care

As part of the NHS Long Term Plan, NHS England is aiming to reduce pressure on emergency hospital services by reducing overall emergency admissions and by increasing the proportion of ‘zero-day admissions’ by providing Same Day Emergency Care (SDEC), which is also known as ambulatory emergency care.

The analysis for this workstream will investigate patient and provider characteristics associated with zero-day and 1+ day emergency admissions. Analysts will assess the effect on health outcomes, including 30-day readmission rates and mortality, compared to patients with longer hospital admissions. In addition, the effect of zero-day admissions at provider level will be analysed to explore geographical variation. This will be done using performance measures including A&E waiting times, inpatient bed days, bed occupancy, stranded patients and delayed transfers of care. This analysis will inform policymakers about progress in the implementation of the service changes set out in the NHS Long Term Plan and will provide insight into their effect on quality of patient care.

This analysis will require linked patient-level Accident & Emergency/Emergency Care Data Set, Admitted Patient Care, Critical Care, Outpatient for years 2008/2009 to current and future data up to 2023. so that progress of the implementation of this new care model can be monitored. The NHS Long-Term plan introduces a number of policy initiatives. In order to see how these initiatives will impact hospital emergency admissions, it is important to analyse emergency admissions data over time. For example, if between 2008 and 2018, The Health Foundation analyse a trend which then changes because of the implementation of a new policy, then the true effects of the policy can be determined. If The Health Foundation only used a short time period for analysis, then the significance of the impact of the change in policy would be more difficult to ascertain. Therefore, analysts require a fairly good run of years of data to be able to undertake a robust policy analysis.

Workstream 4: Outpatient care

Over the last decade the number of hospital outpatient appointments in England has almost doubled from 54 to 94 million yearly attendances. Outpatient care currently represents the largest proportion of NHS contact with patients in a hospital setting and accounts for around £8 billion in yearly healthcare expenditure.

The analysis for this workstream aims to provide new insight into quality of outpatient care by descriptively characterising outpatient journeys, focusing on patient characteristics and complexity, provider and appointment characteristics. Trends will be monitored over time, and an assessment of how these factors relate to case-mix in outpatient clinics and analyse geographical variation and variation associated with socioeconomic deprivation. This will provide commissioners, national and local healthcare leaders with better evidence on the patient need and current quality of outpatient care, in order to support them in finding solutions to meet these needs.

After a decade of substantial yearly growth, the number of outpatient appointments has remained constant since 2016/17. In the NHS Long Term Plan, this was attributed to the fact that GP referrals had been successfully constrained in recent years. The Health Foundation will dedicate part of the analysis to investigating the effect of this recent policy change by analysing the characteristics of patients that were not referred as a result and what the effect on outcomes was. This will include the effect on utilisation of other services as well as patient outcomes, such as emergency admissions and mortality.

One in five outpatient appointments in England are reported as cancelled by the patient or the hospital or as ‘did not attend’ (DNA). Missed or cancelled appointments have financial and operational implications for the NHS but can also have negative effects on quality of care and patient outcomes. This analysis will use patient-level data to investigate appointments that are frequently cancelled or missed, as well as geographical variation in cancellations and non-attendances and any links to socioeconomic deprivation. Included in this analysis will be an investigation as to whether the frequency of outpatient appointments, as well as the number of cancelled and missed appointments, is associated with patient outcomes, such as emergency re-admissions and mortality. This will also include comparisons between conventional and novel statistical approaches. This analysis will support policymakers and practitioners in understanding and avoiding non-attendances in outpatient care, which help to improve the efficiency of outpatient clinics and the quality of patient care.

This work stream will require linked patient-level inpatient and outpatient data, as well mortality data, including variables on date and cause of death.

As above, as the Health Foundation are (as part of this Work Stream) looking into policy change. A longer time span of data is required so that the full effect from the implementation of the policy can be analysed, so the true effects can be determined.

The Health Foundation wishes to process these data in order to describe and assess local and national trends in demand for secondary health care. This includes examining patterns and trends pertaining to individuals and their healthcare demands and take-up of healthcare services, in particular, those individuals with multiple health conditions, inequalities in healthcare demand. Furthermore, processing will be undertaken so that these trends can be compared with trends from other countries. In addition, data will be processed to examine seasonal variation in healthcare demand, the characteristics of patients demanding A&E services, and the demand for outpatient services.

By processing these data to generate these trends, The Health Foundation will be able to inform the health service about the situation of healthcare demand, take-up and treatment for the NHS in England. This will provide policymakers with a picture of the state of the health service demand, particularly for individuals with more than one health condition, as well as the extent to which inequalities exist. This information obtained from processing the data will provide the evidence-base for which policymakers can act to make improvements to patient healthcare. This fits with the remit of The Health Foundation, which is to bring about better health and healthcare for people living in the UK. This is essential work as demand for healthcare services continues to increase, due to an aging population, and healthcare providers continue to operate in a tight financial environment.

If the data were unavailable, The Health Foundation would not be able to undertake the work described above, and the benefits stated could not be realised. The Health Foundation has considered using aggregate sources of data for this work, but these have limitations: they have been created in a way which does not enable The Health Foundation to undertake the specific trends in healthcare that the organisation believe is important to contribute to public understanding about the health service.

In requesting to use the data, The Health Foundation will be complying with GDPR, in particular, that data will be used for a legitimate interest, and safeguards will protect the special categories of data used for this workstream.

As mentioned previously, processing the data will enable The Health Foundation to produce analysis relating to national trends of health service utilisation. Patient-level data are required to control for several characteristics to prevent biased statistical results from being produced. The Health Foundation seeks to avoid producing misleading analyses, and therefore it is important to use patient-level data to correctly build an accurate picture of healthcare demand and utilisation in England.

In doing so, The Health Foundation believes that the data processing is proportionate to the purpose for which it seeks to use data. There is a relatively low risk that patient data could be exposed, because of the security measures in place for protecting the data, and there is much benefit that will be realised from undertaking this analysis.

The data requested constitute special categories of data under the GDPR, since The Health Foundation has requested medical records pertaining to individuals, albeit in a pseudonymised format. Despite the fact that the data will be pseudonymised, the data may contain information about children and other vulnerable people owing to the fact that The Health Foundation has not restricted the data requested on the basis of age, disability etc. for the analysis. Trends pertaining to all patients and their use of the health service will be generated, although broken down by age group.

The Health Foundation is an independent charity that exists to further progress and improve the health care of the nation. As a charity independent of government funding, and any other interests, it endeavours to make the public aware that the use of patients’ data is solely for the purpose of improving the health service and treatments that patients receive.

There will be no impact on the data subjects (patients) whose data will be included in the extract received by The Health Foundation. Safeguards are in place to ensure that no individual data will be released from it’s accredited secure data environment in which the data will be processed; further checks will be applied to ensure that no statistical results published could reveal the identity, and/or confidential information, about any individual. Processing such data in a secure data environment is typical for organisations such as The Health Foundation, and guidance on security accreditation is sought and applied from a number of organisations including NHS Digital, Office for National Statistics, UK Data Service and HMRC (Her Majesty's Revenue and Customs) Data lab. Information about the use of patient data is available on The Health Foundation website.

Statistical outputs produced from all projects listed previously will be assessed against best practice guidelines on statistical disclosure control and privacy protection to ensure the confidentiality of the data is maintained. All outputs will contain only data that is aggregated with small numbers suppressed in line with the HES Analysis Guide.

Several publications will be produced from each of the work streams listed under the Purpose section. These publications typically take the form of:

- Reports aimed at policy makers, disseminated through the Foundation’s website. The Health Foundation Communications Team advertises these reports through social media channels, and in addition, senior The Health Foundation staff highlight these reports to contacts throughout the health and social care system (such as at NHS England).

- Peer-reviewed journal articles

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

- Conferences and presentations

The Health Foundation’s approach to dissemination includes not only publications but also engagement with national policy makers, practitioners and researchers. The Health Foundation’s Communications team will lead on the dissemination of findings. The Health Foundation’s staff regularly speak to senior NHS leaders. For example, The Health Foundation’s report on multiple conditions (https://www.health.org.uk/publications/understanding-the-health-care-needs-of-people-with-multiple-health-conditions) featured in national media in Autumn 2018, in addition to staff at NHS England charged with designing and delivering national policy on integration and personalised care. Furthermore, The Health Foundation regularly liaises with local providers: for example, results of analysis into social isolation, were relayed to Barking and Dagenham in London. This instigated the establishment of a range of projects aimed to tackle social isolation across different age groups.

Wider dissemination of findings takes place via the media, and through social media and direct e-communication with key stakeholders. For example, a previous publication using HES data, on emergency admissions received extensive coverage in the trade media, support via social media from relevant royal colleges and other stakeholders, and exclusive national press coverage in The Times. Other publications from the team have received similar or greater coverage from media, and strong engagement on social media.

Planned publications:

• Health foundation briefing on trends in emergency admissions since the last Health Foundation analysis published in 2021

• Health Foundation briefing on the effects of implementation of same-day emergency care (planned for 2021, once data for the financial year 2019/20 is available)

• Health Foundation publication on elective care investigating seasonal demand and demand management practices 2021 and 2023.

• Health Foundation report on outpatient appointments

• Peer-reviewed publication(s) on outpatient journeys and the effect of missed/cancelled appointments to be published in BMJ, PloS Medicine, BMJ quality and safety or similar.

• Health Foundation publication on mental health (national trends analysis), 2021

• Peer-reviewed publication(s) on international comparisons of care quality to be published in BMJ, PloS Medicine, BMJ Quality and Safety or similar (ongoing 2021, 2022, 2023).

• Health Foundation publication on trends in care quality, and impact of major system changes, 2021 and 2023

This Agreement mentions 4 Workstreams (1-4), and in addition, Workstream A in the Processing Activities section.

Workstream A is about cleaning and tidying up the data, making the data ready for analysis (for Workstreams 1-4). This is what The Health Foundation calls the HES Data Pipeline.

This work has been successfully completed. The work began when the data was originally received, and the Pipeline was completed in February 2020.

A large amount of work was undertaken to organise the data, clean, check for errors and quality issues, and could sensibly incorporate updates (quarterly updates of HES). A number of checks and tests were put in place to make sure The Health Foundation would be able to use consistent and sensible data for workstreams 1-4.

During 2020/21 analysis under Workstream 1 ‘Monitoring Trends’ was directed towards looking specifically at trends in demand for A&E services. This work analysed historical trends (workstream 1) and seasonal variation (workstream 2) of elective and emergency admissions, and outputs (tabulated data, with small numbers suppressed) from the data under this Agreement, were used to collaborate with Imperial College London to develop a modelling approach for optimal allocation of elective care capacity during the COVID-19 pandemic. The benefits from this modelling have helped the NHS policy makers make decisions regarding allocation of resources in order to reduce the waiting list of non-COVID related hospital treatments. The full benefits are yet to be realised as analysis is ongoing.

The Health Foundation is an independent charity working to improve health and the quality of health care in the United Kingdom. As part of this strategy, the Health Foundation Data Analytics team analyses data on the quality of health and care. The Health Foundation is the sole data controller and data processor of the data supplied by NHS Digital under this Agreement.

The Data Analytics team is requesting access to person-level data for an in-house programme of analyses to be completed over the course of the next 5 years.

The aim of this programme is to:

•produce new insights into quality of patient care,

•investigate how the quality of care can be improved

•understand the demand for health care in the UK using linked HES data and innovative analytical methods.

The overall purpose and benefit of this work is to inform the NHS and policy makers about changes in the characteristics and health needs of patients, factors that drive health care utilisation and health outcomes, and variation in health need, and quality of care. The work of The Health Foundation is designed to help the NHS understand the rising demand for health care and to plan for the future. The work packages within this programme will cover a number of thematic areas. These were identified as priorities for care quality and outcomes improvement in the recently published NHS Long Term Plan.

The Health Foundation are processing the data in line with their charitable goals as part of their legitimate interests. This is covered under the GDPR Article 6(1)(f) - This work is necessary for the purposes of the legitimate interests pursued by the controller or by a third party except where such interests are overridden by the interests or fundamental rights and freedoms of the data subject which require protection of personal data, in particular where the data subject is a child. As set out in the legitimate interest assessment that The Health Foundation have undertaken - the data requested is to help achieve the following:

• To improve health service delivery (by evaluating policies and reporting feedback to the NHS and policy makers)

• To make health policymaking more effective (the work packages look at specific policy implementation and how this has been effective and feedback will be given to policy makers)

• test innovations and spread what works

• build skills and knowledge (data access will help to evaluate and understand the rising demand for healthcare and plan for the future)

• develop and share evidence on what works and why (through conferences, presentations, and journal articles that will explain outcomes and results that have been generated using the NHS Digital Data.

The data is also required for service evaluation purposes - meeting the conditions outlined as per Article 9 (2)(I) of the GDPR. 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, on the basis of Union or Member State law which provides for suitable and specific measures to safeguard the rights and freedoms of the data subject, in particular professional secrecy. The Health Foundation are carrying out service evaluation work as described in this agreement to investigate how the quality of care can be improved.

The overall purpose and benefit of this work is to inform the NHS and policy makers about changes in the characteristics and health needs of patients, factors that drive health care utilisation and health outcomes, and variation in health need, and quality of care. The work of The Health Foundation is designed to help the NHS understand the rising demand for health care and to plan for the future. The work packages within this programme will cover a number of thematic areas. These were identified as priorities for care quality and outcomes improvement in the recently published NHS Long Term Plan.

How will The Health Foundation achieve this work?

The Data Analytics team within The Health Foundation wish to undertake the following work streams:

Work stream 1: Monitoring trends

The Health Foundation will use patient-level data to summarise national contexts and to monitor local and national trends in secondary care in order to improve understanding of the drivers of demand and quality of patient care. Examples of trends that The Health Foundation wish to monitor include changes in disease (all diseases) prevalence and complexity over time, healthcare take-up and demand for distinct patient groups (e.g. patients with long-term conditions), as well as variations or changes in the characteristics of patients accessing secondary care. Key areas of focus within this theme will be:

• Multimorbidity: understanding the changing profiles and needs of patients with multiple long-term health conditions, following on from previous Health Foundation publications, which found that over half of hospital admissions and outpatient visits are for people living with 2 or more conditions. The Health Foundation aims to understand more about trends in combinations of conditions that patients present with in different parts of secondary care. Another goal of this workstream is to investigate the levels on under-recording of co-morbidities in electronic health records when they are not the primary reason for admission. This will be done by comparing HES-based prevalence estimates to estimates from other data sources, e.g. CPRD (Clinical Practice Research Datalink). The results from these analyses will help the NHS understand the rising demand for health care and to offer insight for policy makers and commissioners to design better quality patient care.

• Health and care inequality: unmet need and unexplained local variation in health care access and health outcomes. This analysis will help to raise awareness about existing and developing health inequalities and support the NHS and policy makers in finding solutions to address them.

• International comparison of quality metrics. Analysts at The Health Foundation will also analyse the data to provide aggregate statistics for international comparative analysis of health care quality, utilisation, cost and outcomes. This will be a contribution to an ongoing collaboration between the Health Foundation and partners from 11 other countries, including Germany, France, Australia and the USA. The aim is to compare how healthcare spending and demand for high-cost patients differs between countries. Understanding the differences between countries and their approaches will help to inform better management of these patient groups in the NHS. Note that for this project, only aggregate statistics with small numbers suppressed in line with NHS Digital guidance will be shared with colleagues overseas. These will be checked to ensure that no patient can be identified, and that the statistics contain no confidential information. No individual patient data will be shared. The collaborators do not have any influence on the means by which the data at the Health Foundation are being analysed.

• Patterns in healthcare demand and utilisation. Work will analyse the dataset to examine trends in demand for emergency and elective care over time and impact on patient outcomes (such as 30-day and 1-year mortality and 30-day readmission). This will also examine the impact of changing performance of hospital providers for example; changes to bed occupancy rates, A&E performance and waiting times.

Work-stream 1 will require linked patient-level A&E, inpatient, critical care, outpatient and mortality data for the last 10 years (2008/2009 to 2018/2019) for the whole population. To assess historical trends, access to a long time-series of data is required. To assess the health of children and young people, which is of particular interest in the mental health trends and examining trends in healthcare utilisation over time, a whole population sample is required. To assess outcomes, will need linked mortality data, including date of death to calculate 30-day all-cause mortality rates following a hospital admission.

Work stream 2: Seasonal variations

As part of the Health Foundation’s ongoing monitoring of winter pressures and the knock-on effect in care quality, analysts from the Data Analytics Team will investigate seasonal variations in A&E attendance and emergency admissions. This will include investigating patient profiles, including a focus on respiratory conditions due to their prevalence during the winter months, and a focus on long-stay patients.

The Health Foundation will undertake analyses that also aims to understand the consequences of winter pressures for other NHS services throughout the rest of the year, particularly on elective care such as outpatient appointments and elective hospital treatments. Key areas within this will be:

• Seasonal analysis of the volume of elective care and outpatient appointments with respect to geographical variation. This analysis will support policymakers and commissioners in planning for winter, as it will provide insight into areas that will require additional support.

• Cancellation of elective care in winter and their effect on demand and waiting times during other times of the year.

• Seasonal variation of length of stay for elective admissions and association with patient outcomes, such as emergency readmission and mortality.

This analysis will require linked patient-level inpatient and outpatient as well as mortality data, including date of death to calculate 30-day all-cause mortality rates following a hospital admission. This analysis will require data from the last 10 years, because it is important for this work to see whether changes in health service performance over time is affected by seasonal demand and variation. For example, were Health Foundation analysts to use the data from the recent years to see whether demand for health services increased in winter or summer, it would be useful to know whether these are recent phenomenon or whether such seasonal variations existed previously. This is important as The Health Foundation wouldn’t wish to make policy recommendations based on one-off ‘chance’ events, and therefore this justifies why it is necessary to look at seasonal variations within a fairly long-time frame - so that informed proposals can be made.

Work stream 3: Emergency hospital admissions and same-day emergency care

As part of the NHS Long Term Plan, NHS England is aiming to reduce pressure on emergency hospital services by reducing overall emergency admissions and by increasing the proportion of ‘zero-day admissions’ by providing Same Day Emergency Care (SDEC), which is also known as ambulatory emergency care.

The analysis for this workstream will investigate patient and provider characteristics associated with zero-day and 1+ day emergency admissions. Analysts will assess the effect on health outcomes, including 30-day readmission rates and mortality, compared to patients with longer hospital admissions. In addition, the effect of zero-day admissions at provider level will be analysed to explore geographical variation. This will be done using performance measures including A&E waiting times, inpatient bed days, bed occupancy, stranded patients and delayed transfers of care. This analysis will inform policymakers about progress in the implementation of the service changes set out in the NHS Long Term Plan and will provide insight into their effect on quality of patient care.

This analysis will require linked A&E, critical care and inpatient data with quarterly data updates when new data becomes available, so that progress of the implementation of this new care model can be monitored. The NHS Long-Term plan introduces a number of policy initiatives. In order to see how these initiatives will impact hospital emergency admissions, it is important to analyse emergency admissions data over time. For example, if between 2008 and 2018, The Health Foundation analyse a trend which then changes because of the implementation of a new policy, then the true effects of the policy can be determined. If The Health Foundation only used a short time period for analysis, then the significance of the impact of the change in policy would be more difficult to ascertain. Therefore, analysts require a fairly good run of years of data to be able to undertake a robust policy analysis.

Workstream 4: Outpatient care

Over the last decade the number of hospital outpatient appointments in England has almost doubled from 54 to 94 million yearly attendances. Outpatient care currently represents the largest proportion of NHS contact with patients in a hospital setting and accounts for around £8 billion in yearly healthcare expenditure.

The analysis for this workstream aims to provide new insight into quality of outpatient care by descriptively characterising outpatient journeys, focusing on patient characteristics and complexity, provider and appointment characteristics. Trends will be monitored over time, and an assessment of how these factors relate to case-mix in outpatient clinics and analyse geographical variation and variation associated with socioeconomic deprivation. This will provide commissioners, national and local healthcare leaders with better evidence on the patient need and current quality of outpatient care, in order to support them in finding solutions to meet these needs.

After a decade of substantial yearly growth, the number of outpatient appointments has remained constant since 2016/17. In the NHS Long Term Plan, this was attributed to the fact that GP referrals had been successfully constrained in recent years. The Health Foundation will dedicate part of the analysis to investigating the effect of this recent policy change by analysing the characteristics of patients that were not referred as a result and what the effect on outcomes was. This will include the effect on utilisation of other services as well as patient outcomes, such as emergency admissions and mortality.

One in five outpatient appointments in England are reported as cancelled by the patient or the hospital or as ‘did not attend’ (DNA). Missed or cancelled appointments have financial and operational implications for the NHS but can also have negative effects on quality of care and patient outcomes. This analysis will use patient-level data to investigate appointments that are frequently cancelled or missed, as well as geographical variation in cancellations and non-attendances and any links to socioeconomic deprivation. Included in this analysis will be an investigation as to whether the frequency of outpatient appointments, as well as the number of cancelled and missed appointments, is associated with patient outcomes, such as emergency re-admissions and mortality. This will also include comparisons between conventional and novel statistical approaches. This analysis will support policymakers and practitioners in understanding and avoiding non-attendances in outpatient care, which help to improve the efficiency of outpatient clinics and the quality of patient care.

This work stream will require linked patient-level inpatient and outpatient data, as well mortality data, including variables on date and cause of death.

As above, as the Health Foundation are (as part of this Work Stream) looking into policy change. A longer time span of data is required so that the full effect from the implentation of the policy can be analysed, so the true effects can be determined.

The Health Foundation wishes to process these data in order to describe and assess local and national trends in demand for secondary health care. This includes examining patterns and trends pertaining to individuals and their healthcare demands and take-up of healthcare services, in particular, those individuals with multiple health conditions; inequalities in healthcare demand. Furthermore, processing will be undertaken so that these trends can be compared with trends from other countries. In addition, data will be processed to examine seasonal variation in healthcare demand, the characteristics of patients demanding A&E services, and the demand for outpatient services.

By processing these data to generate these trends, The Health Foundation will be able to inform the health service about the situation of healthcare demand, take-up and treatment for the NHS in England. This will provide policymakers with a picture of the state of the health service demand, particularly for individuals with more than one health condition, as well as the extent to which inequalities exist. This information obtained from processing the data will provide the evidence-base for which policymakers can act to make improvements to patient healthcare. This fits with the remit of The Health Foundation, which is to bring about better health and healthcare for people living in the UK. This is essential work as demand for healthcare services continues to increase, due to an aging population, and healthcare providers continue to operate in a tight financial environment.

The Health Foundation will undertake this work by itself, and this will not involve participation of third parties.

If these data were unavailable, then The Health Foundation wouldn’t be able to undertake the work described above, and the benefits stated could not be realised. The Health Foundation has considered using aggregate sources of data for this work, but these have limitations: they have been created in a way which does not enable The Health Foundation to undertake the specific trends in healthcare that the organisation believe is important to contribute to public understanding about the health service.

In requesting to use these data, The Health Foundation will be complying with GDPR, in particular, that data will be used for a legitimate interest, and safeguards will protect the special categories of data used for this workstream.

As mentioned previously, processing the data will enable The Health Foundation to produce analysis relating to national trends of health service utilisation. Patient-level data are required to control for a number of characteristics to prevent biased statistical results from being produced. The Health Foundation seeks to avoid producing misleading analyses, and therefore it is important to use patient-level data to correctly build an accurate picture of healthcare demand and utilisation in England.

In doing so, The Health Foundation believes that the data processing is proportionate to the purpose for which it seeks to use data. There is a relatively low risk that patient data could be exposed, because of the security measures in place for protecting the data, and there is much benefit that will be realised from undertaking this analysis.

The data requested constitute special categories of data under the GDPR, since The Health Foundation has requested medical records pertaining to individuals, albeit in a pseudonymised format. Despite the fact that the data will be pseudonymised, the data may contain information about children and other vulnerable people owing to the fact that The Health Foundation has not restricted the data requested on the basis of age, disability etc. for the analysis. Trends pertaining to all patients and their use of the health service will be generated, although broken down by age group.

The Health Foundation is an independent charity that exists to further progress and improve the health care of the nation. As a charity independent of government funding , and any other interests, it endeavors to make the public aware that the use of patients’ data is solely for the purpose of improving the health service and treatments that patients receive.

There will be no impact on the data subjects (patients) whose data will be included in the extract received by The Health Foundation. Safeguards are in place to ensure that no individual data will be released from it’s accredited secure data environment in which the data will be processed; further checks will be applied to ensure that no statistical results published could reveal the identity, and/or confidential information, about any individual. Processing such data in a secure data environment is typical for organisations such as The Health Foundation, and guidance on security accreditation is sought and applied from a number of organisations including NHS Digital, Office for National Statistics, UK Data Service and HMRC (Her Majesty's Revenue and Customs) Datalab. Information about the use of patient data is available on The Health Foundation website.

Statistical outputs produced from all projects listed previously will be assessed against best practice guidelines on statistical disclosure control and privacy protection to ensure the confidentiality of the data is maintained. All outputs will contain only data that is aggregated with small numbers suppressed in line with the HES Analysis Guide.

Several publications will be produced from each of the work streams listed under the Purpose section. These publications typically take the form of:

- Reports aimed at policy makers, disseminated through the Foundation’s website. The Health Foundation Communications Team advertises these reports through social media channels, and in addition, senior The Health Foundation staff highlight these reports to contacts throughout the health and social care system (such as at NHS England).

- Peer-reviewed journal articles

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

- Conferences and presentations

The Health Foundation’s approach to dissemination includes not only publications but also engagement with national policy makers, practitioners and researchers. The Health Foundation’s Communications team will lead on the dissemination of findings. The Health Foundation’s staff regularly speak to senior NHS leaders. For example, The Health Foundation’s report on multiple conditions (https://www.health.org.uk/publications/understanding-the-health-care-needs-of-people-with-multiple-health-conditions) featured in national media in Autumn 2018, in addition to staff at NHS England charged with designing and delivering national policy on integration and personalised care. Furthermore, The Health Foundation regularly liaises with local providers: for example, results of analysis into social isolation, were relayed to Barking and Dagenham in London. This instigated the establishment of a range of projects aimed to tackle social isolation across different age groups.

Wider dissemination of findings takes place via the media, and through social media and direct e-communication with key stakeholders. For example, a previous publication using HES data, on emergency admissions received extensive coverage in the trade media, support via social media from relevant royal colleges and other stakeholders, and exclusive national press coverage in The Times. Other publications from the team have received similar or greater coverage from media, and strong engagement on social media.

Planned publications:

• Health foundation briefing on trends in emergency admissions since the last Health Foundation analysis published in 2018, 2021

• Health Foundation briefing on the effects of implementation of same-day emergency care (planned for 2021, once data for the financial year 2019/20 is available)

• Health Foundation publication on elective care investigating seasonal demand and demand management practices 2021 and 2023.

• Health Foundation report on outpatient appointments, 2019

• Peer-reviewed publication(s) on outpatient journeys and the effect of missed/cancelled appointments to be published in BMJ, PloS Medicine, BMJ quality and safety or similar.

• Health Foundation publication on mental health (national trends analysis), 2019 and 2021

• Peer-reviewed publication(s) on international comparisons of care quality to be published in BMJ, PloS Medicine, BMJ Quality and Safety or similar (ongoing 2021, 2022, 2023).

• Health Foundation publication on health and care inequalities, 2020

• Health Foundation publication on trends in care quality, and impact of major system changes, 2021 and 2023

The Health Foundation is an independent charity working to improve health and the quality of health care in the United Kingdom. As part of this strategy, the Health Foundation Data Analytics team analyses data on the quality of health and care. The Health Foundation is the sole data controller and data processor of the data supplied by NHS Digital under this Agreement.

The Data Analytics team is requesting access to person-level data for an in-house programme of analyses to be completed over the course of the next 5 years.

The aim of this programme is to:

•produce new insights into quality of patient care,

•investigate how the quality of care can be improved

•understand the demand for health care in the UK using linked HES data and innovative analytical methods.

The overall purpose and benefit of this work is to inform the NHS and policy makers about changes in the characteristics and health needs of patients, factors that drive health care utilisation and health outcomes, and variation in health need, and quality of care. The work of The Health Foundation is designed to help the NHS understand the rising demand for health care and to plan for the future. The work packages within this programme will cover a number of thematic areas. These were identified as priorities for care quality and outcomes improvement in the recently published NHS Long Term Plan.

The Health Foundation are processing the data in line with their charitable goals as part of their legitimate interests. This is covered under the GDPR Article 6(1)(f) - This work is necessary for the purposes of the legitimate interests pursued by the controller or by a third party except where such interests are overridden by the interests or fundamental rights and freedoms of the data subject which require protection of personal data, in particular where the data subject is a child. As set out in the legitimate interest assessment that The Health Foundation have undertaken - the data requested is to help achieve the following:

• To improve health service delivery (by evaluating policies and reporting feedback to the NHS and policy makers)

• To make health policymaking more effective (the work packages look at specific policy implementation and how this has been effective and feedback will be given to policy makers)

• test innovations and spread what works

• build skills and knowledge (data access will help to evaluate and understand the rising demand for healthcare and plan for the future)

• develop and share evidence on what works and why (through conferences, presentations, and journal articles that will explain outcomes and results that have been generated using the NHS Digital Data.

The data is also required for service evaluation purposes - meeting the conditions outlined as per Article 9 (2)(I) of the GDPR. 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, on the basis of Union or Member State law which provides for suitable and specific measures to safeguard the rights and freedoms of the data subject, in particular professional secrecy. The Health Foundation are carrying out service evaluation work as described in this agreement to investigate how the quality of care can be improved.

The overall purpose and benefit of this work is to inform the NHS and policy makers about changes in the characteristics and health needs of patients, factors that drive health care utilisation and health outcomes, and variation in health need, and quality of care. The work of The Health Foundation is designed to help the NHS understand the rising demand for health care and to plan for the future. The work packages within this programme will cover a number of thematic areas. These were identified as priorities for care quality and outcomes improvement in the recently published NHS Long Term Plan.

How will The Health Foundation achieve this work?

The Data Analytics team within The Health Foundation wish to undertake the following work streams:

Work stream 1: Monitoring trends

The Health Foundation will use patient-level data to summarise national contexts and to monitor local and national trends in secondary care in order to improve understanding of the drivers of demand and quality of patient care. Examples of trends that The Health Foundation wish to monitor include changes in disease (all diseases) prevalence and complexity over time, healthcare take-up and demand for distinct patient groups (e.g. patients with long-term conditions), as well as variations or changes in the characteristics of patients accessing secondary care. Key areas of focus within this theme will be:

• Multimorbidity: understanding the changing profiles and needs of patients with multiple long-term health conditions, following on from previous Health Foundation publications, which found that over half of hospital admissions and outpatient visits are for people living with 2 or more conditions. The Health Foundation aims to understand more about trends in combinations of conditions that patients present with in different parts of secondary care. Another goal of this workstream is to investigate the levels on under-recording of co-morbidities in electronic health records when they are not the primary reason for admission. This will be done by comparing HES-based prevalence estimates to estimates from other data sources, e.g. CPRD (Clinical Practice Research Datalink). The results from these analyses will help the NHS understand the rising demand for health care and to offer insight for policy makers and commissioners to design better quality patient care.

• Health and care inequality: unmet need and unexplained local variation in health care access and health outcomes. This analysis will help to raise awareness about existing and developing health inequalities and support the NHS and policy makers in finding solutions to address them.

• International comparison of quality metrics. Analysts at The Health Foundation will also analyse the data to provide aggregate statistics for international comparative analysis of health care quality, utilisation, cost and outcomes. This will be a contribution to an ongoing collaboration between the Health Foundation and partners from 11 other countries, including Germany, France, Australia and the USA. The aim is to compare how healthcare spending and demand for high-cost patients differs between countries. Understanding the differences between countries and their approaches will help to inform better management of these patient groups in the NHS. Note that for this project, only aggregate statistics with small numbers suppressed in line with NHS Digital guidance will be shared with colleagues overseas. These will be checked to ensure that no patient can be identified, and that the statistics contain no confidential information. No individual patient data will be shared. The collaborators do not have any influence on the means by which the data at the Health Foundation are being analysed.

• Patterns in healthcare demand and utilisation. Work will analyse the dataset to examine trends in demand for emergency and elective care over time and impact on patient outcomes (such as 30-day and 1-year mortality and 30-day readmission). This will also examine the impact of changing performance of hospital providers for example; changes to bed occupancy rates, A&E performance and waiting times.

Work-stream 1 will require linked patient-level A&E, inpatient, critical care, outpatient and mortality data for the last 10 years (2008/2009 to 2018/2019) for the whole population. To assess historical trends, access to a long time-series of data is required. To assess the health of children and young people, which is of particular interest in the mental health trends and examining trends in healthcare utilisation over time, a whole population sample is required. To assess outcomes, will need linked mortality data, including date of death to calculate 30-day all-cause mortality rates following a hospital admission.

Work stream 2: Seasonal variations

As part of the Health Foundation’s ongoing monitoring of winter pressures and the knock-on effect in care quality, analysts from the Data Analytics Team will investigate seasonal variations in A&E attendance and emergency admissions. This will include investigating patient profiles, including a focus on respiratory conditions due to their prevalence during the winter months, and a focus on long-stay patients.

The Health Foundation will undertake analyses that also aims to understand the consequences of winter pressures for other NHS services throughout the rest of the year, particularly on elective care such as outpatient appointments and elective hospital treatments. Key areas within this will be:

• Seasonal analysis of the volume of elective care and outpatient appointments with respect to geographical variation. This analysis will support policymakers and commissioners in planning for winter, as it will provide insight into areas that will require additional support.

• Cancellation of elective care in winter and their effect on demand and waiting times during other times of the year.

• Seasonal variation of length of stay for elective admissions and association with patient outcomes, such as emergency readmission and mortality.

This analysis will require linked patient-level inpatient and outpatient as well as mortality data, including date of death to calculate 30-day all-cause mortality rates following a hospital admission. This analysis will require data from the last 10 years, because it is important for this work to see whether changes in health service performance over time is affected by seasonal demand and variation. For example, were Health Foundation analysts to use the data from the recent years to see whether demand for health services increased in winter or summer, it would be useful to know whether these are recent phenomenon or whether such seasonal variations existed previously. This is important as The Health Foundation wouldn’t wish to make policy recommendations based on one-off ‘chance’ events, and therefore this justifies why it is necessary to look at seasonal variations within a fairly long-time frame - so that informed proposals can be made.

Work stream 3: Emergency hospital admissions and same-day emergency care

As part of the NHS Long Term Plan, NHS England is aiming to reduce pressure on emergency hospital services by reducing overall emergency admissions and by increasing the proportion of ‘zero-day admissions’ by providing Same Day Emergency Care (SDEC), which is also known as ambulatory emergency care.

The analysis for this workstream will investigate patient and provider characteristics associated with zero-day and 1+ day emergency admissions. Analysts will assess the effect on health outcomes, including 30-day readmission rates and mortality, compared to patients with longer hospital admissions. In addition, the effect of zero-day admissions at provider level will be analysed to explore geographical variation. This will be done using performance measures including A&E waiting times, inpatient bed days, bed occupancy, stranded patients and delayed transfers of care. This analysis will inform policymakers about progress in the implementation of the service changes set out in the NHS Long Term Plan and will provide insight into their effect on quality of patient care.

This analysis will require linked A&E, critical care and inpatient data with quarterly data updates when new data becomes available, so that progress of the implementation of this new care model can be monitored. The NHS Long-Term plan introduces a number of policy initiatives. In order to see how these initiatives will impact hospital emergency admissions, it is important to analyse emergency admissions data over time. For example, if between 2008 and 2018, The Health Foundation analyse a trend which then changes because of the implementation of a new policy, then the true effects of the policy can be determined. If The Health Foundation only used a short time period for analysis, then the significance of the impact of the change in policy would be more difficult to ascertain. Therefore, analysts require a fairly good run of years of data to be able to undertake a robust policy analysis.

Workstream 4: Outpatient care

Over the last decade the number of hospital outpatient appointments in England has almost doubled from 54 to 94 million yearly attendances. Outpatient care currently represents the largest proportion of NHS contact with patients in a hospital setting and accounts for around £8 billion in yearly healthcare expenditure.

The analysis for this workstream aims to provide new insight into quality of outpatient care by descriptively characterising outpatient journeys, focusing on patient characteristics and complexity, provider and appointment characteristics. Trends will be monitored over time, and an assessment of how these factors relate to case-mix in outpatient clinics and analyse geographical variation and variation associated with socioeconomic deprivation. This will provide commissioners, national and local healthcare leaders with better evidence on the patient need and current quality of outpatient care, in order to support them in finding solutions to meet these needs.

After a decade of substantial yearly growth, the number of outpatient appointments has remained constant since 2016/17. In the NHS Long Term Plan, this was attributed to the fact that GP referrals had been successfully constrained in recent years. The Health Foundation will dedicate part of the analysis to investigating the effect of this recent policy change by analysing the characteristics of patients that were not referred as a result and what the effect on outcomes was. This will include the effect on utilisation of other services as well as patient outcomes, such as emergency admissions and mortality.

One in five outpatient appointments in England are reported as cancelled by the patient or the hospital or as ‘did not attend’ (DNA). Missed or cancelled appointments have financial and operational implications for the NHS but can also have negative effects on quality of care and patient outcomes. This analysis will use patient-level data to investigate appointments that are frequently cancelled or missed, as well as geographical variation in cancellations and non-attendances and any links to socioeconomic deprivation. Included in this analysis will be an investigation as to whether the frequency of outpatient appointments, as well as the number of cancelled and missed appointments, is associated with patient outcomes, such as emergency re-admissions and mortality. This will also include comparisons between conventional and novel statistical approaches. This analysis will support policymakers and practitioners in understanding and avoiding non-attendances in outpatient care, which help to improve the efficiency of outpatient clinics and the quality of patient care.

This work stream will require linked patient-level inpatient and outpatient data, as well mortality data, including variables on date and cause of death.

As above, as the Health Foundation are (as part of this Work Stream) looking into policy change. A longer time span of data is required so that the full effect from the implentation of the policy can be analysed, so the true effects can be determined.

The Health Foundation wishes to process these data in order to describe and assess local and national trends in demand for secondary health care. This includes examining patterns and trends pertaining to individuals and their healthcare demands and take-up of healthcare services, in particular, those individuals with multiple health conditions; inequalities in healthcare demand. Furthermore, processing will be undertaken so that these trends can be compared with trends from other countries. In addition, data will be processed to examine seasonal variation in healthcare demand, the characteristics of patients demanding A&E services, and the demand for outpatient services.

By processing these data to generate these trends, The Health Foundation will be able to inform the health service about the situation of healthcare demand, take-up and treatment for the NHS in England. This will provide policymakers with a picture of the state of the health service demand, particularly for individuals with more than one health condition, as well as the extent to which inequalities exist. This information obtained from processing the data will provide the evidence-base for which policymakers can act to make improvements to patient healthcare. This fits with the remit of The Health Foundation, which is to bring about better health and healthcare for people living in the UK. This is essential work as demand for healthcare services continues to increase, due to an aging population, and healthcare providers continue to operate in a tight financial environment.

The Health Foundation will undertake this work by itself, and this will not involve participation of third parties.

If these data were unavailable, then The Health Foundation wouldn’t be able to undertake the work described above, and the benefits stated could not be realised. The Health Foundation has considered using aggregate sources of data for this work, but these have limitations: they have been created in a way which does not enable The Health Foundation to undertake the specific trends in healthcare that the organisation believe is important to contribute to public understanding about the health service.

In requesting to use these data, The Health Foundation will be complying with GDPR, in particular, that data will be used for a legitimate interest, and safeguards will protect the special categories of data used for this workstream.

As mentioned previously, processing the data will enable The Health Foundation to produce analysis relating to national trends of health service utilisation. Patient-level data are required to control for a number of characteristics to prevent biased statistical results from being produced. The Health Foundation seeks to avoid producing misleading analyses, and therefore it is important to use patient-level data to correctly build an accurate picture of healthcare demand and utilisation in England.

In doing so, The Health Foundation believes that the data processing is proportionate to the purpose for which it seeks to use data. There is a relatively low risk that patient data could be exposed, because of the security measures in place for protecting the data, and there is much benefit that will be realised from undertaking this analysis.

The data requested constitute special categories of data under the GDPR, since The Health Foundation has requested medical records pertaining to individuals, albeit in a pseudonymised format. Despite the fact that the data will be pseudonymised, the data may contain information about children and other vulnerable people owing to the fact that The Health Foundation has not restricted the data requested on the basis of age, disability etc. for the analysis. Trends pertaining to all patients and their use of the health service will be generated, although broken down by age group.

The Health Foundation is an independent charity that exists to further progress and improve the health care of the nation. As a charity independent of government funding , and any other interests, it endeavors to make the public aware that the use of patients’ data is solely for the purpose of improving the health service and treatments that patients receive.

There will be no impact on the data subjects (patients) whose data will be included in the extract received by The Health Foundation. Safeguards are in place to ensure that no individual data will be released from it’s accredited secure data environment in which the data will be processed; further checks will be applied to ensure that no statistical results published could reveal the identity, and/or confidential information, about any individual. Processing such data in a secure data environment is typical for organisations such as The Health Foundation, and guidance on security accreditation is sought and applied from a number of organisations including NHS Digital, Office for National Statistics, UK Data Service and HMRC (Her Majesty's Revenue and Customs) Datalab. Information about the use of patient data is available on The Health Foundation website.

Statistical outputs produced from all projects listed previously will be assessed against best practice guidelines on statistical disclosure control and privacy protection to ensure the confidentiality of the data is maintained. All outputs will contain only data that is aggregated with small numbers suppressed in line with the HES Analysis Guide.

Several publications will be produced from each of the work streams listed under the Purpose section. These publications typically take the form of:

- Reports aimed at policy makers, disseminated through the Foundation’s website. The Health Foundation Communications Team advertises these reports through social media channels, and in addition, senior The Health Foundation staff highlight these reports to contacts throughout the health and social care system (such as at NHS England).

- Peer-reviewed journal articles

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

- Conferences and presentations

The Health Foundation’s approach to dissemination includes not only publications but also engagement with national policy makers, practitioners and researchers. The Health Foundation’s Communications team will lead on the dissemination of findings. The Health Foundation’s staff regularly speak to senior NHS leaders. For example, The Health Foundation’s report on multiple conditions (https://www.health.org.uk/publications/understanding-the-health-care-needs-of-people-with-multiple-health-conditions) featured in national media in Autumn 2018, in addition to staff at NHS England charged with designing and delivering national policy on integration and personalised care. Furthermore, The Health Foundation regularly liaises with local providers: for example, results of analysis into social isolation, were relayed to Barking and Dagenham in London. This instigated the establishment of a range of projects aimed to tackle social isolation across different age groups.

Wider dissemination of findings takes place via the media, and through social media and direct e-communication with key stakeholders. For example, a previous publication using HES data, on emergency admissions received extensive coverage in the trade media, support via social media from relevant royal colleges and other stakeholders, and exclusive national press coverage in The Times. Other publications from the team have received similar or greater coverage from media, and strong engagement on social media.

Planned publications:

• Health foundation briefing on trends in emergency admissions since the last Health Foundation analysis published in 2018, 2021

• Health Foundation briefing on the effects of implementation of same-day emergency care (planned for 2021, once data for the financial year 2019/20 is available)

• Health Foundation publication on elective care investigating seasonal demand and demand management practices 2021 and 2023.

• Health Foundation report on outpatient appointments, 2019

• Peer-reviewed publication(s) on outpatient journeys and the effect of missed/cancelled appointments to be published in BMJ, PloS Medicine, BMJ quality and safety or similar.

• Health Foundation publication on mental health (national trends analysis), 2019 and 2021

• Peer-reviewed publication(s) on international comparisons of care quality to be published in BMJ, PloS Medicine, BMJ Quality and Safety or similar (ongoing 2021, 2022, 2023).

• Health Foundation publication on health and care inequalities, 2020

• Health Foundation publication on trends in care quality, and impact of major system changes, 2021 and 2023

Yielded Benefits is not a requirement for new applications.