QualityWatch

The Nuffield Trust is an independent health research charity overseen by a board of Trustees including a number of senior NHS clinicians, managers and academics. The Trust's vision is to help achieve a high quality health and social care system that improves the health and care of people in the UK by providing evidence-based research and policy analysis and informing and generating debate. The Nuffield Trust undertakes work for the public good and within a research governance framework. The Nuffield Trust requires access to data from NHS Digital to achieve these legitimate interests.

The Nuffield Trust wishes to use these data to continue the QualityWatch project - the objective of which is to monitor changes in the quality of care delivered by the NHS over the next few years.

QualityWatch (http://www.qualitywatch.org.uk/) is a major research programme from the Health Foundation and the Nuffield Trust that aims to provide independent scrutiny of the quality of health and social care delivered to patients and service users.

QualityWatch launched in 2013, in the wake of high-profile investigations into major failures of care, including the Mid Staffordshire NHS Foundation Trust Public Inquiry and Professor Sir Bruce Keogh’s review of high mortality rates at 14 NHS trusts. At the outset of the programme, it was anticipated that the quality of health and social care services would come under increasing pressure during a period expected to be characterised by severe spending constraint; continuing growth in demand arising from increasing levels of morbidity in an ageing population; and the implementation of the major policy reforms enacted by the coalition government.

QualityWatch was originally conceived as a five-year programme to help those working in health and social care to identify priority areas for improvement. The programme is primarily concerned with monitoring and commenting on what is happening to quality of care, with the aim of inciting action and improvement by presenting novel and dispassionate analysis, free from the constraints and potential conflicts of a policy agenda. Secondary objectives are to contribute to the development of new methods of measuring and assessing quality, and to provide a platform for a diverse range of perspectives on the quality of health and social care services.

QualityWatch was intended to provide an independent picture of the quality of care, to supplement and inform the work of other initiatives and the statutory national bodies. It has primarily focused on the NHS and social care in England, but also draws on evidence from the four countries of the UK and health systems in other comparable countries around the world. The programme now tracks over 300 indicators of health and social care quality via a public website, has provided in-depth analysis of a number of topics and has produced four annual statements on the overall state of quality.

QualityWatch has received additional funding from NIHR to continue the project, planned to run until at least 2020 and will deliver similar outputs in terms of a website, summarised quality metrics, briefings, data blogs and data visualisations to achieve its goals using evidence and data – such as that derived from HES where appropriate.

Specifically on the use of HES, analysis undertaken as part of the QualityWatch project will involve examination of patterns of hospital activity by area or by provider, developing comparative analyses and standardising for a range of episode level, or patient level variables - such as age, the presence of a long term conditions, prior patterns of use. Such analyses require complex processing for fair comparisons and to capture activity for whole populations - something that only nationally collated data can provide.

The remit of the QualityWatch programme is to provide independent, evidence based monitoring of quality. The key indicators span six domains of quality (Effectiveness, Equity, Patient experience, Capacity, Safety and Access), across all aspects of health and social care (for example, primary care, community, acute, mental health, social care).

The Nuffield Trust meet quarterly with the Health Foundation to review the programme, and draw on clinical and academic expertise on a topic by topic basis to review the indicators. The scope of indicators is under constant review and the indicators are updated to address emerging quality and safety issues, and to address gaps in the coverage. Examples of development areas are further indicators for: mental health building on previous work on disparity in use of services between patients with mental health conditions compared to physical conditions; maternity services, and improving safety indicators to include measures relating to sepsis and deterioration. As an example, for the safety domain, the Nuffield Trust consult with are the NHS Improvement Patient Safety team and the central Patient Safety Measurement Unit who support the Maternal and Neonatal Safety Programme. The Nuffield Trust also plan to review measures of quality at a system level, in response to the NHS England drive towards integrated care. In addition to development of indicators and regular updating of these, the Nuffield Trust also undertake analysis on topical issues, to produced data briefings, or provide additional analysis for topics covered in regular indicator updates. Topic issues are identified through the Nuffield Trust’s in depth knowledge of the health policy, analysis of the data monitored from the Health Foundation, and in response to issues identified by other stakeholders or academic publications. As an example, the Nuffield Trust has recently undertaken an analysis of emergency readmissions data (up to 2016/17), in response to analysis undertaken by Health Watch, and addressing issues raised by the National Audit Office.

The impact of some interventions and policy changes which impact on health outcomes and service utilisation can develop over a considerable period of time. One of the areas which the Nuffield Trust are planning to explore further in QualityWatch is equity of service provision, and how this has been impacted by decreasing access to services in this decade. There is evidence that equity in a number of aspects of care, for example elective joint replacement, improved with rising intervention rates during the previous decade. In order to assess the impact of increased waiting times, a longer historical perspective is required, and for this reason, data going back to 1999/2000 (2 additional years) is requested.

The Nuffield Trust will not share patient level NHS Digital data with The Health Foundation. Any data shared will be aggregate data with all small numbers suppressed in line with the HES analysis guide.

The Nuffield Trust analyses patterns of hospital activity by area or by provider, developing comparative analyses and standardising for a range of episode level, or patient level variables – such as age, the presence of a long terms condition, prior patterns of use. Such analyses require complex processing for fair comparisons and to capture activity for whole populations – something that only nationally collated data can provide.

Under this Data Sharing Agreement, for the purpose of QualityWatch, the Nuffield Trust is permitted to reuse appropriately minimised subsets of HES data supplied to the Nuffield Trust under a separate Data Sharing Agreement (ref: DARS-NIC-384572-J7P6Y). For the collective purposes of QualityWatch, the use of HES data from 1999/2000 through to 2020/21 is needed although the minimum amount of years and data will be used for each type of analysis on an individual basis.

The data requested and already disseminated will be accessed and processed by substantive employees of the Nuffield Trust only.

Additional note – third parties:

The Nuffield Trust are not seeking permission for any third parties to access these data, even where these third parties are study partners. The use of this data will be limited to Nuffield Trust for the purpose outlined above only. Data published or provided to third parties will be limited to aggregated data, at area, organisational or cohort-level all with small numbers suppressed in line with HES analysis guide.

The Nuffield Trust will perform statistical analysis using statistical software including SAS, R and stata. At all times, data remains on the Trust’s local IT systems, in accordance with our ISO27001 scope. The Nuffield Trust uses on premise system with licenced software for SAS. R is an open-source application. Additionally, the physical server where the Trust stores and performs analysis, does not have internet access as it is blocked at the perimeter.

Nuffield Trust uses the services of a UK based external IT Support company to provide support for its Hardware and systems. While Wavex have the ability to add/delete/modify user account, Nuffield Trust have enforced a contractual restriction to Wavex in respect of accessing the secure environment and the Nuffield Trust has applied real-time alerting system to changes within Active Directory. Any changes made by Wavex are reviewed. Additionally, Nuffield Trust has applied technical “Deny All” restriction for the account used by Wavex. This restricts them from accessing any data (including NHSD data) within the secure environment.

All organisations party to this agreement must comply with the Data Sharing Framework Contract requirements, including those regarding the use (and purposes of that use) by “Personnel” (as defined within the Data Sharing Framework Contract - i.e. employees, agents and contractors of the Data Recipient who may have access to that data).

The Data will only be used for the purposes described in this Agreement.

Planned outputs from the Qualitywatch programme include:

• Up to 8 briefings per year on various topical quality issues as described above and determined during the programme, varying from the general (such as the state of quality in mental health services) to the specific (such as the use of and access to emergency departments by children). The output briefings will be written reports made publicly available free of charge on the www.qualitywatch.org.uk/ or www.nuffieldtrust.org.uk/ websites*.

*The Trust are aiming to transfer the existing QualityWatch content onto the Nuffield Trust main website but all content will be branded under the QualityWatch banner.

• Up to 6 comment/data blogs per year focused on topical issues in quality of care

• 2/3 data visualisations of quality measures per year

• Regular monthly updates of quality indicators, creation of charts and associated commentary for the QualityWatch website

Any outputs drawing on HES data will be aggregate with small number suppressed in line with the HES Analysis Guide.

QualityWatch will continue to monitor changes in the quality of care delivered by the NHS over the next few years.

The key aims of QualityWatch continue from the original project:

• Provide an authoritative, independent and contextualised analysis on the quality of health and social care over time, while at the same time augmenting and informing other statutory and non-statutory national initiatives

• Highlight where there are clear and compelling gaps between existing standards of care and what is possible, in order to prompt action to improve quality

• Help develop the way quality of care is measured.

A review of how QualityWatch can better achieve these aims (along with a more general sense-making goal to inform the public, practitioners and policymakers of trends in quality measures) will be conducted in the first few months of 2018. Inter alia, this will include a number of measurable benefits/activities and impacts. The nature of the programme means that linking planned outputs directly to benefits to the health and social care system, its providers and patients/clients a difficult exercise. However, there are intermediate measures the Trust are likely to use – such as web traffic, downloads and citations etc. Measuring the impact of the new programme will also be an explicit part of the contract agreement with the funders, The Health Foundation.

As an indication of the impact the original QualityWatch project has achieved, the Nuffield Trust can point to the fact that there are many examples of QualityWatch work being cited in parliamentary debates and select committees as well as used by national bodies (such as NHS England), by local providers of care and receiving coverage in many national/local media outlets. The benefits of this work are seen in terms of independently providing a picture of the quality of health and social care, by providing analyses to inform decisions made by healthcare commissioners and providers, when thinking about the types of services needed to deliver benefits to patients, as well as by policy makers at a national level.

A number of research studies as part of the QualityWatch project, using NHS data, which have been widely used to inform decision making and debate in health and social care. The Nuffield Trust publishes these reports on the QualityWatch website and in peer reviewed journals where appropriate. Two examples are provided below:

The Nuffield Trust report "Focus on: Mental ill health and hospital use" published in October 2015 described how people with mental ill health used hospital services and in particular highlighted the need to better support their physical health needs.

• This report was cited in NHS England's implementing the Five Year Forward View for Mental Health. Analysis provided in the Nuffield Trust report was used to estimate possible savings in relation to physical health screenings and interventions for people with severe mental illness. https://www.england.nhs.uk/wp-content/uploads/2016/07/fyfv-mh.pdf

• The methods identified in this report have been replicated by several organisations who wish to repeat the methodology locally, in particular, the West Midlands Commissioning Support Unit reports that they have remodelled their approach to the physical care of people with mental health problems as a direct result of the QualityWatch publication on this topic.

• Results of this work were presented at an expert roundtable on mental health issues in Summer 2015 convened by the then Shadow Health Secretary Diane Abbott to brief her and the Labour frontbench health team on this area of policy.

• In addition to this there was a campaign launched calling for an increase in funding for mental health services, where the news report quoted the findings from this report (in November 2015). http://www.bbc.co.uk/news/health-34676799

• Results have also been presented a number of national and international conferences; most recently at the 16th International Conference on Integrated Care, Barcelona.

The Nuffield Trust report "Focus on: Allied Health Professionals: can we measure quality of care?" published in September 2014 emphasised the need for better data and information about Allied Health Professionals (AHP) to understand more about the quality of the care they deliver.

• This report was followed up with a round table event with key members of the AHP and health data community with the aim of forming a plan to improve data collection in this area of the workforce.

• There was a written question in parliament in response to recommendations made in this report. http://www.parliament.uk/business/publications/written-questions-answers-statements/written- question/Commons/2014-12-01/216697/

This work was taken forward and contributed to recommendations made in NHS England's "Allied Health Professions into Action Using Allied Health Professionals to transform health, care and wellbeing". https://www.england.nhs.uk/wp- content/uploads/2017/01/ahp-action-transform-hlth.pdf

Whilst it is hard to draw causality, Nuffield have also been made aware of NHS England undertaking work to drive improvements in the quality of physical health care provided by mental health providers to service users with severe and enduring mental ill health and will be developing a national clinical audit to underpin this under the National Mental Health CQUIN scheme for 2016/17.

The planned outputs of the QualityWatch project will be made freely available on the Nuffield Trust or QualityWatch websites, or published in recognised research Journals. Where the Nuffield Trust have developed any potentially useful tools for providers or commissioners these will be made freely available for use, or for further development by others.