Imperial College London research into UK Health Policy Reform

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Objective for processing

The purpose of this agreement is to support ongoing research into the impact for patients and health service users of UK health policy reforms begun in the 2000s. The research is being undertaken by members of the Centre for Health Economics & Policy Innovation (formerly the Healthcare Management Group) at Imperial College Business School based in Imperial College London. Imperial College London requires access to NHS England Data for the purpose of the following research project: From 2000 onwards, there have been reforms to the NHS in England which have been some of the most radical in the Organisations for Economic Cooperation and Development (OECD). These reforms consisted of a series of policy initiatives, beginning in the early part of the 2000s and carried out for the next 10 years, which were intended to improve care for patients. The broad remit of these reforms was to promote choice for patients and greater competition between providers of care, greater freedom for well managed organisations within the NHS within a tightly regulated system of publicly available standards and central guidance, and improvements in the patients’ experience in the form of enhanced quality of care and reduced waiting times. These reforms thus instigated changes to the (a) organisational and management structure for health care providers and (b) delivery arrangements, mandated or facilitated at the overall health system level, for specific services or specific treatments. “Research into UK Health Policy Reform”. These reforms were expensive and their effects were, and still are, highly contested, both in terms of patient benefits and benefits to tax-payer. Understanding the impact of these reforms on the efficiency of service provision, the quality of care experienced by patients, and their wider impact on the society is vital. The Data under this Data Sharing Agreement (DSA) has been used to undertake all of the projects below, Projects (4) to (7) are now complete and having delivered the expected outputs (see section '5c. Specific Outputs Expected…' for details). Under this DSA, the Data will be used for projects (1) to (3) only. The research programme examines the impact of these wide changing reforms on the delivery of the NHS of the quantity and quality of patient care. The focus of this present amended application is to examine how resilient these structures are to exogenous shocks. The data requested will allow the research team at Imperial College London to assess how the effects of these external shocks impacted these reforms and whether the system was able to adapt, measured in terms of quantity and quality of care delivered to NHS patients. The following is a summary of the aims of the research project provided by Imperial College London: The specific shocks the research team wish to examine are climate-related weather shocks and, building on their past work on infectious diseases, the new unprecedented shocks such as the Covid-19 pandemic. "The purpose of this research is to understand the implications for the NHS, and for the quality and volume of patient care, of major policy changes which affect either the funding and/or the delivery side of the NHS. Weather related shocks since the early 2000s have led to large increases in deaths due to both extreme heat, pollution levels, and conditions which encourage infectious diseases to spread more rapidly. The Covid-19 pandemic is an example of an enormous shock to the NHS in England. The research methodology developed in previous versions of this application on the resilience of the NHS to external shocks is well placed to study the impact of this pandemic on our healthcare system. The methodology allows Imperial College London to look at the direct gains — in terms of lives saved — and the costs — in terms of deferred emergency treatments and cancelled elective treatments — as well as the impact on demand of longer term health problems that are a consequence of the economic recessions that are accompanying and will follow global social distancing measures. The policy changes that the research examines are: The Covid-19 epidemic has direct effects on the ability of the NHS to deliver care, with many staff being brought back from retirement along with newly qualified graduates entering the nursing labour force early. This allows the NHS to increase staffing capacity to meet urgent needs; but, to the detriment of other activities, thereby decreasing the quantity of care for patients and causing disruptions to existing teams, which has been shown in research to decrease the quality of care that patients receive (Banks et al. 2020 — https://www.ifs.org.uk/publications/14799). (1) Policy changes which affect the level of staffing in the NHS and social care, in particular changes to NHS pay and pensions arrangements and changes to wider economic opportunities, and how these contribute to staffing shortages in the NHS The pandemic will also have wider effects on the economy which will spill over into demand for healthcare. With the economic shutdown predicting GDP to fall by around 25% in the next year, if not by more, the incomes of those in the most precarious economic positions will be hit hardest. Government policy may mitigate this to some degree, but the nationwide lockdown is already impacting both the demand for goods, and also the ability of companies to supply, which will have on going effects beyond the current year; although the scale of this impact is not yet known. Research on the relationships between the economic downturn of the late 2000s suggest that this will translate into increased prevalence of chronic conditions and therefore demand for health care (Janke et al. 2020 — https://voxeu.org/article/impact-covid-19-chronic-health-uk). (2) The impact of changes to funding at the local purchaser level Imperial College London will continue to use HES APC, A&E (and subsequently ECDS) and OP data already provided for the same purposes as before. The research team have additionally requested Civil Registration data to match the corresponding HES years and HES Critical Care data. Critical Care data will allow Imperial to specifically quantify the Covid-19 shock on the demand of care as critical care was hit hardest in the early months of the pandemic; while, APC, ECDS, OP and PROMS data will allow for an assessment of the impact of Covid-19 on all other types of care. (3) The use of pathways as a policy as it relates to cancer care The research team at Imperial College Business School will use the new data requested, together with the data they already hold, to examine the impacts of Covid-19 and weather-related shocks on patient care. The research team will examine both short-term and longer-term impacts, the distribution of these impacts across individuals of different ages and Social-Economic Status (SES), and the impacts across different locations in the UK. Recently completed research (2019-2023) under this Data Sharing Agreement has examined large external events and shocks which put pressure on the NHS and care delivery and to which policy makers have to respond. These were: DATA MINIMISATION (4) The impact of weather change, temperature and pollution exposure resulting from climate change on NHS and social care costs Imperial has minimised all data being requested where possible and has given special consideration to the following points: (5) The impact of COVID on delivery and equity in patient care - Imperial College London aim to provide a comprehensive assessment of shocks on the healthcare sector and as the extent of the shocks is unknown, Imperial College London have to consider possible direct and indirect effects across all healthcare services. It is not possible to further reduce the number of data sets requested as this could bias analyses. All data requested is pseudonymised in order to be less intrusive. (6) The effect of economic recessions on chronic health conditions - The Covid-19 pandemic is expected to last until a proven vaccine has been deployed globally, which is not expected until the end of 2021. As a result, Imperial College London are requesting data until 2021/2022 (June) to assess how the direct impact on the healthcare system and its subsequent recovery. The number of years requested cannot be reduced further as these data will also be used to assess the impact of the other healthcare shocks (e.g. weather extremes) occurring at different time points. A period with limited shocks is also required to act as a baseline. Research completed prior to 2018 under this Data Sharing Agreement has examined the following policy shocks - Imperial College London require data from across England in order to understand the heterogeneity of any impacts on healthcare and to identify regions most affected to inform policy decisions. Imperial College London Cannot narrow the data by demographics as it would potentially bias the study analysis and any narrowing of clinical factors would prevent Imperial College London from identifying the indirect effects of healthcare shocks. All patient episodes are required to ensure all direct and indirect effects are captured and to prevent bias in Imperial’s analyses. Only admissions related to maternity are required to account for the demand of healthcare services affected by shocks. Unborn child and neonatal records are not required. Only calendar date is necessary to match shocks such as daily temperature extremes to healthcare services provided on specific dates. (7) Research on the impact of policy to increase competition and choice in the NHS on patient outcomes - Imperial College London’s assessment of the resilience of the healthcare sector to shocks requires the inclusion of all healthcare service types, and for record requests all fields are necessary to achieve the study purpose. The current research programme will address (1) - (3) above. The outcomes the research team will examine include: critical care admissions, presentations to A&E, road traffic accidents, and death from heart and respiratory conditions. Examples of longer-term impacts include future presentations for care from chronic conditions such as COPD, diabetes and mental health issues. The specific projects are (numbering as above) This agreement also enables the research team to use PROMs to investigate the extent to which greater private and voluntary provision of publicly funded care helps or hinders the resilience of the NHS to deal with unexpected events. Research will focus on the impact on patient outcomes, equity of access to care and cost. Project (1) The General Data Protection Regulations Article 6 (1) (e) ‘processing is necessary for the performance of a task in the public interest…’ as Imperial College London is recognised as an official authority with a royal charter granting them a right to perform research would therefore be considered to be exercising a function of the Crown in undertaking research, and Article 9 (2) (j) ‘processing is necessary for archiving purposes in the public interest, scientific or historical research purposes …’ are the legal basis for the processing of pseudonymised data. There have been several large changes to NHS pay, and the pay available in alternative careers, that could impact the ability of NHS and social care providers to recruit and retain the appropriate numbers and mix of staff, and have negative consequences for patient health outcomes as a result. This includes recent policy changes to NHS pensions (which have been argued by the BMA to have led to a shortage of senior consultants in the NHS), changes to immigration rules following Brexit, and general labour market changes that have affected the wages available to staff if they left the NHS or the social care sector (and therefore affect the competitiveness of pay on offer in these sectors). The research (which is currently on-going) uses staffing data to examine the extent to which these changes have affected the amount of work staff do in the NHS. These results indicate that these shocks have affected NHS staffing numbers and mix. The aim of this project is therefore to examine whether such staffing changes have significantly affected waiting lists and patient outcomes measured in Hospital Episode Statistics (HES) Data. Project (2) This work examines the effects of increasing area-level funding on access to hospital care for patients. The study team will use “shocks” to local purchaser funding that arise from (i) changes to the allocation formula and (ii) aggregate changes in government spending. Preliminary research indicated that increasing local purchaser funding increases volume of emergency admissions and reduces wait time. The additional patients treated are lower severity. In related work on the efficiency and distributional consequences of capacity constraints in health care, the study team will investigate the costs and benefits of hospitals investing in additional capacity. The study team will estimate the effects of building new hospital sites and expanding capacity on wait times, crowding and hospital finances. Project (3) This work aims to provide data-based evidence for improving operational processes. The project aims to understand the determinants of patient outcomes as a function of process, location, hospital type by analysing patient pathways for the same condition over multiple years. This work will specifically look at situations where care is divided between the Principal Treatment Centre (PTC) and a Shared Care Centres (SCC). NHS Trusts may not routinely share patient records, which may have an adverse impact on patient outcomes. The project will consider patient length of stay, frequency of complications and eventual outcomes, primarily for patients with cancer. Research Aims: • Understand how, and which, individuals are affected • estimate whether the system was able to adapt (measured in terms of quantity and quality of care delivered to NHS patients) • analyse the direct gains where possible, in terms of lives saved, and the costs in terms of deferred emergency treatments and cancelled elective treatments • assess what types of policies allow better management of these exogenous shocks, and which will support the NHS to prepare, anticipate and adapt to future shocks with the aim of improving the delivery of healthcare within the NHS" The following NHS England Data will be accessed: • Hospital Episode Statistics (HES) - Admitted Patient Care (APC), Accident & Emergency (A&E), Critical Care (CC) and Outpatients (OP) • Emergency Care Data Set (ECDS) • Civil Registration Mortality • Patient Reported Outcome Measures (PROMs) These datasets are necessary to measure provider performance along with patient outcomes. Performance measures include those of patient safety (e.g. avoidable deaths, adverse incidents), quality of care (including improvement in PROMs, readmission rates, infection rates, adverse events), measures of access (e.g. median or mean waiting times for both elective and emergency care, the distribution of the service across SES of the provider’s catchment area), measures of throughput (e.g. FTEs for particular treatment), and mortality outside the healthcare sector. The datasets are necessary to provide a model of the patients’ journey and needs, attendance characteristics to describe demand, patient characteristics to assess heterogeneity in demand for care, clinical Data - clinical injury, Healthcare Resource Groups (HRG), patient pathway and diagnosis variables, clinical investigations and treatments, commissioning - cost that is relevant to understand the impact of demand shocks on NHS budget, discharge details and referrer type, geographical information. From this the study team can quantify how shocks to demand for care affect the demand and the care that can be delivered and investigate the extent to which greater private and voluntary provision of publicly funded care helps or hinders the resilience of the NHS to deal with unexpected events. The level of the Data will be pseudonymised. The Data will be minimised as follows: • The research examining policy changes that impact NHS staff will only use Data from 2012 onwards. • Each analysis will be limited to a subset of conditions that are relevant to the analysis, as identified by specific ICD or OPCS codes. - The Data for analysis of policy changes affecting pensions and working conditions will be at the trust-speciality level (Project 1) - Data for the analysis of funding changes will be aggregated to local area level (Project 2) - The analysis of the impact of increased demand for services will be confined to the following conditions: cancer, diabetes, kidney failure and heart conditions. Initial focus will be on cancer treatment (Project 3) • Data from across England is required in order to understand the heterogeneity of any impacts on healthcare and to identify regions most affected to inform policy decisions. It is not possible to narrow the Data by demographics as it would potentially bias the study analysis and any narrowing of clinical factors would prevent identification of the indirect effects of healthcare shocks. • Unborn child and neonatal records are not required. Imperial College London is the research sponsor and the controller as the organisation responsible for ensuring that the Data will only be processed for the purpose described above. The lawful basis for processing personal data under the UK GDPR is: Article 6(1)(e) - processing is necessary for the performance of a task carried out in the public interest or in the exercise of official authority vested in the controller; The lawful basis for processing special category data under the UK GDPR is: Article 9(2)(j) - processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject. This processing is in the public interest because it adheres to the UK Policy Framework for Health and Social Care Research, which protects and promotes the interests of patients, service users and the public, and aims to produce generalisable and publicly available information to inform future decisions over patients’ treatments or care. The funding is provided by European Research Council. The funding is principally provided for the study described. Funding is in place until September 2024. Funding to continue the work described will be sought on an ongoing basis. The funder will have no ability to suppress or otherwise limit the publication of findings. Virtus SDC Limited host the Imperial College London data servers. Virtus SDC Limited do not access Data held under this agreement as they only supply the building. Therefore, any access to the Data held under this agreement would be considered a breach of the agreement. This includes granting of access to the database[s] containing the Data. Data will be accessed by: • substantive employees of Imperial College London. • students enrolled with Imperial College London. Any student working with the Data held under this Agreement are subject to Imperial College London’s policies on data protection and confidentiality. Any students accessing the Data will do so under the supervision of a substantive employee of Imperial college London. • visiting researchers engaged on projects (1)-(3) with honorary Imperial College London contracts. For these individuals to access the Data, Imperial College London must provide to NHS England the following details of the individual(s) to be given access under an honorary contract: - Their substantive employer - Their role in respect of the purpose for processing specified in the DSA - The necessity for the data to be accessed by the person(s) holding an honorary contract instead of by a substantive employee of an organisation named as a Data Controller or Data Processor in the DSA - Confirmation that an appropriate contract is in place which follows the relevant guidance and that is countersigned by the substantive employer of the honorary contract holder. There has been no direct patient and public involvement and engagement (PPIE) for this study.

Processing activities

Data will be processed to identify the impact of policy reforms on (a) service providers and (b) service users. No data will flow to NHS England for the purposes of this Agreement. The unit of analysis in the research is both of the patient and the provider. The provider will generally be an NHS Trust level, but may, in some cases, be the site level within Trusts. NHS England will provide the relevant records from the Civil Registrations Mortality, PROMS, HES APC, HES OP, HES CC, ECDS and HES A&E datasets to Imperial College London. The Data will contain no direct identifying data items. The Data will be pseudonymised and individuals cannot be reidentified through linkage with other data in the possession of the recipient. Data requested under this iteration of the data sharing agreement: The Data will be stored on servers at Virtus SDC Ltd. The Data will not be transferred to any other location. - Civil Registrations Deaths - Secondary Care Cut Data from 2000/01 to 2021/2022 Imperial College London will extract a subset of the Data comprised of Data required for each specific project and make this available to the project’s research team within the same organisation on the same servers. Each research project will access only a subset of the Data. - PROMS data 2019/20 to 2021/22 The Data will be accessed by authorised personnel via remote access. The Data will remain on the servers at Virtus SDC Ltd at all times. - HES APC for AR 2000/01 to 2004/05, plus 2019/20 to 2021/2022 Remote processing will only be through a secure electronic network and organisational controls prohibit personnel from downloading or copying Data to local devices. - HES OP for AR 2003/04 to 2004/05, plus 2019/20 to 2021/2022 The Data will also be accessed by authorised personnel via remote access. - HES CC for AR 2008/09 to 2021/2022 The Controller(s) must confirm and provide evidence upon audit by NHS England that access via any remote device complies with the data security obligations within this DSA and the Data Sharing Framework Contract. - ECDS for AR 2019/20 to 2021/2022 For remote access: This will come in 3 drops of data. The first in Sept/Oct 2020 for all historic and AR 19/20 data (when AR 19/20 is published, then Sept 2021, then Sept 2022. - Remote access will only be from secure locations situated within the territory of use (as further restricted elsewhere within the DSA if so done) stated within this DSA; Data extracts will be pseudonymised. - Access controls granting users the minimum level of access required are in place; The research Team at the Imperial College Business School will measure provider performance along with patient outcomes. Performance measures include those of patient safety (e.g. avoidable deaths, adverse incidents), quality of care (including improvement in PROMs, readmission rates, infection rates, adverse events), measures of access (e.g. median or mean waiting times for both elective and emergency care, the distribution of the service across SES of the provider’s catchment area), measures of throughput (e.g. FTEs for particular treatment), and mortality outside the healthcare sector, - Remote access is only via secure connections (e.g., VPNs or secure protocols) to protect data; Some of these measures are available publicly, but these measures often change from year to year, and are not available at the patient level. To create a consistent time series covering a number of years, with appropriate controls for patient severity and other factors that may influence outcomes, Imperial College Business School’s research team need to be able to link PROMS with HES data. - Multifactor authentication (MFA) is required for remote access; Using these, plus mortality data, the research team will derive patient outcome measures to allow for the control of case-mix. In addition, the research team will continue to work with publicly available administrative data from other sources, where matching is only undertaken at the provider level or the regional. In some cases, patient level data is aggregated to site level (for example, to conduct sensitivity tests to measures which are available at site level e.g. measures of competition). - Device security, including up-to-date software and operating systems, antivirus software, and enabled firewalls are utilised for the remote access; Imperial College Business School’s administrative trust-level data will be updated and matched with Trust financial returns; from providers’ management accounting systems (e.g. cost data); from health care regulators; from the annual staff satisfaction survey of all NHS employees; from local authorities; socio-economic data at the Middle Layer Super Output Area (MSOA) or Lower Layer Super Output Area (LSOA) level, pollution and weather data. Matched data depends on the specific research question. For example, will add pollution data to assess its impact on admissions and mortality. - All remote access is undertaken within the scope of the organisation’s DSPT (or other security arrangements as per this DSA) and complies with the organisation’s remote access policy. All the data Imperial College Business Schools matches is at Trust or site level and is all in the public domain. No attempt will be made to match data at the patient level. Matching does not increase the risk of re-identification. Following the same practice as in the previous projects, no data will be published to the Trust, site, or lower level. All published analyses will remain statistical or graphical and will be in line with NHS Digital Information Governance and Data Protection policies. The above applies in addition to any condition set out elsewhere within the DSA (e.g. who may carry out processing, and for what purpose). Part of the data received from this application will be tied to a new programme of work into weather variations and their impact on policy. Imperial College Business School’s research team will update and match publicly available weather data to HES data. The weather data comes from the Met Office Integrated Data Archive System (MIDAS) database, which provides a large range of weather measures. Daily weather will be estimated using each Trust's location. This will then be supplemented by daily and yearly pollution metrics (such as the concentration of particulates and nitrogen dioxide) matched at the hospital or postcode level. The Data will not leave England at any time. Access is restricted to employees or agents of Imperial College London who have authorisation from the Principal Investigator. All personnel accessing the Data have been appropriately trained in data protection and confidentiality. The record level Data will not be linked with any other data. Only aggregate NHS England Data with small numbers suppressed will be linked with other datasets as described below. The research team will work with publicly available administrative data from other sources. Matching will be undertaken at the provider-speciality level or the local area (postcode district or local authority) level. In some cases, patient level data may be aggregated to Trust site level (for example, to conduct sensitivity tests to measures which are available at site level e.g. measures of competition). Data sets to be matched at this level include data from Trust financial returns; from providers’ management accounting systems (e.g. cost data); from health care regulators data; from Electronic Staff records (ESR); from the annual staff satisfaction survey of all NHS employees; from local authorities; socio-economic data at the Middle Layer Super Output Area (MSOA) or Lower Layer Super Output Area (LSOA) level. Which data will be matched will be project specific. For project (1) data will be matched at the Trust-specialty level from the ESR, the annual staff satisfaction survey and SES data at LSOA level. For project (2), matched data will be at LSOA level, local purchaser level and MSOA level. For project (3) data will be matched at purchaser and Trust level. No attempt will be made to match Data at the patient level. Matching does not increase the risk of re-identification. No Data will be published to the Trust, site, or a lower level. All published analyses will remain statistical or graphical and will be in line with NHS England Information Governance and Data Protection policies. There will be no requirement and no attempt to reidentify individuals when using the Data. [1 paragraph unchanged] HES and ECDS DISCLOSURE RULES In order to protect patient confidentiality, when presenting results calculated from HES record level data, outputs will contain only aggregate level data with small numbers suppressed in line with HES Analysis Guide. When publishing HES data, you must make sure that: · cell values from 1 to 7 are suppressed at a local level to prevent possible identification of individuals from small counts within the table. · Zeros (0) do not need to be suppressed. · All other counts will be rounded to the nearest 5. Data will not be made available to any third parties other than those specified except in the form of aggregated outputs with small numbers suppressed in line with the HES Analysis Guide. The Centre for Health Economics & Policy Innovation holds its data in the Big Data & Analytical Unit (BDAU) at Imperial College London. The Imperial College London's Big Data Analytics Unit Secure Environment (BDAU SE) is a fully certified ISO 27001:2013 research environment within Imperial College London. They also are 100% compliant with NHS IG Toolkit Level 3 (EE133887) and they have resources for securely storing and accessing data. In 2019, the BDAU server was relocated from South Kensington to Virtus SDC Limited in Slough, who host the servers. This is the new location of all Imperial College data servers. Virtus SDC Limited do not access data held under this agreement as they only supply the building. Therefore, any access to the data held under this agreement would be considered a breach of the agreement. This includes granting of access to the database[s] containing the data. All processing will be completed by substantive employees of Imperial College London, students at Imperial College London under the supervision of Imperial College London substantive employees, and a small number of visiting researchers with honorary Imperial College London contracts. No NHS Digital data will be accessed or processed by any other third parties not mentioned in this agreement. All users will be required to pass GDPR and Information Security Awareness (ISA) training and will be required to agree, with possible disciplinary action for non-compliance, to BDAU SE standard operating procedures. All processing will take place in the BDAU SE, abiding by BDAU ISO certified standard operating procedures, and all data which is exported will be suppressed in line with NHS Digital guidance. Data access is strictly controlled by the Imperial College London's BDAU SE through a robust data set registration process. No one other than Imperial College London's BDAU SE staff can authorise access to the data. The data will not be used to establish a protocol for a clinical trial. 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 in this application will not be used by third parties. No record level data will be made available to any individual provider and from the published research individual providers and patients will not be able to be identified. Imperial College Business School research team will only present aggregate level data with small numbers suppressed in line with the HES Analysis Guidance. PROMS data is only available for non-commercial purposes, such as academic research, or in connection with delivering services to the NHS.

Expected output

The outputs from this application will be a set of contributions intended to promote further discussion around the impact, benefits and costs of the policies listed above. Imperial College Business School research team aim is to prepare several types of output, each type aimed at different audiences. Examples of academic publications from the projects completed under this Data Sharing Agreement (projects 4-7): The primary aim is to improve the delivery of healthcare within the NHS. Given the nature of the research questions, the key stakeholders and primary routes to outputs and benefits are policy makers in the UK healthcare. This is a diverse community, which uses both internal and external research to inform policy making, Imperial College London’s BDAU has experience of providing outputs to inform policy making over the years. Advice has been provided to DHSC, NHS England, NHS Improvement, Monitor, Treasury, Public Health England and the Chief Medical Officer. Pimpin L, Retat L, Fecht D, de Preux L, Sassi F, Gulliver J, Belloni A, Ferguson B, Corbould E, Jaccard A, Webber Let al., 2018, Estimating the costs of air pollution to the National Health Service and social care: An assessment and forecast up to 2035, PLoS Medicine, Vol: 15, ISSN: 1549-1277 (Project 4) In direct relation to COVID-19 outputs the BDAU is taking part in webinars organised by the London School of Economics, Compassion in Politics, Pro-Bono Economics (links can be found at https://www.imperial.ac.uk/business-school/news/coronavirus-carol-propper-argues-pressure-increase-nhs-spending-will-rise-post-covid-19/). Rizmie D, de Preux L, Fecht D, Wang W, Gulliver J, 2023. Does it measure up? A comparison of pollution exposure assessment techniques applied across hospitals in England. International Journal of Environmental Research and Public Health [SUBMITTED] (Project 4) The BDAU has provided early advice to senior policy officials in the Government Economic Service and the Treasury as to the potential impact of COVID19 on the NHS, specifically focusing on the impact on users who do not have COVID19) arising from delayed treatment and likely upcoming staff shortages (all based on previous research using HES and other NHS data). Rizmie D, Miraldo M, Atun R, de Preux Let al., 2019. The effect of extreme temperature on emergency admissions across vulnerable populations in England: an observational study, Lancet Public Health Science 2019 Conference, Publisher: Elsevier, Pages: S7-S7 (Project 4) https://coronavirusandtheeconomy.com/ which provides two page briefings on economic issues – including healthcare and health issues – relating to COVID19. Rizmie, D, L de Preux, M Miraldo and R Atun, 2022. Impact of extreme temperatures on emergency hospital admissions by age and socio-economic deprivation in England. Social Science & Medicine, 308:115193. (Project 4) Briefings to policy makers will be produced when requested by policy makers and MPs. Banks J, Karjalainen H, Propper C (2020) “Recessions and health: the long‐term health consequences of responses to the coronavirus” Fiscal Studies, Vol 41: 337-344. (Project 5) Further outputs will include: Warner M, Burn S, Stoye G, Aylin PP, Bottle A, Propper C. Socioeconomic deprivation and ethnicity inequalities in disruption to NHS hospital admissions during the COVID-19 pandemic: a national observational study. BMJ Quality & Safety. 2022 Aug 1;31(8):590-8. * Voted one of the top 10 articles published in the last year by the BMJ Q&S Editorial Board. (Preliminary analysis was made using the Data under this agreement, but the final analysis used another Data set). (Project 5) a. Publication in peer reviewed international journals — These will be a mixture of health service research, social medicine and community health journals, as well as health and environmental economics journals. Imperial College Business School research team will target: The Lancet and the other Lancet Journals such as Lancet Public Health, the British Medical Journal (BMJ), Medical Care, Health Services Research, Health Policy. The economics journals include: Journal of Health Economics, Health Economics, European Journal of Health Economics, Journal of Health Services Research and Policy, Journal of Environmental Economics and Management. All these are read by international policy makers and are for the most part open access. Janke, K, K Lee, C Propper, K Shields and M Shields (2023), “Macroeconomic conditions and health in Britain: Aggregation, Dynamics and local area heterogeneity”, Journal of Economics and Behaviour forthcoming. (Project 6) b. Publication in outputs aimed at a general readership — e.g. the Economics and Social Research Council (ESRC’s) media publications, Institute for Fiscal Studies briefings (e.g. Banks et al. 2020 — https://www.ifs.org.uk/publications/14799) Propper, C 2018, Competition in health care: Lessons from the English experience, Health Economics, Policy and Law, 13: 492-508. (Project 7) c. Presentation of research at conferences and events aimed at policy makers. Past research has been presented at statutory bodies including the Department of Health and Social Care; international organizations involved in healthcare policy (e.g. Organisation for Economic Co-operation and Development (OECD), World Health Organization (WHO), The World Bank, The Institute for Health Metrics and Evaluation, the Center for Global Development, Public Health England); policy think tanks in the UK (including the Institute of Government, Reform, Policy Exchange, the Nuffield Trust, the King’s Fund and the Health Foundation); the Royal Colleges; and overseas health economics organizations that have large practitioner membership (e.g. Finnish, Portuguese, Italian, Australian, German, and US health economics societies). These outlets will continue to be targeted. Future outputs will be communicated to relevant recipients through the following dissemination channels: d. Presentation of the research to individual policy makers and politicians. Based on Imperial College Business School research team’s past experience, future findings could be relevant to the Secretary of State for Health, the Prime Minister’s office, the Prime Minister's delivery and strategy units, the Treasury, and the Department of Health and Social Care. At present, members of the Centre for Health Economics & Policy Innovation (CHEPI) group are providing evidence to the Treasury, the Bank of England and the Department of Health and Social Care (DHSC). • Journals: Publication in peer reviewed international journals (for examples, see list above). Most targeted journals are open access. e. Presentation of the research, where requested, at individual trusts considering strategic direction and with patient groups. Presentations of the research at small round table events organized by industry (e.g. in the past Imperial College Business School research team have presented to Arup) • Workshops: Presentation of research at conferences and events aimed at policy makers. Past research has been presented at statutory bodies including the Department of Health and Social Care; Organisation for Economic Co-operation and Development (OECD), World Health Organization (WHO), The World Bank, The Institute for Health Metrics and Evaluation, the Center for Global Development, Public Health England; policy think tanks in the UK including the Institute of Government, Reform, Policy Exchange, the Nuffield Trust, the King’s Fund and the Health Foundation; the Royal Colleges; and overseas health economics organizations that have large practitioner membership (e.g. Finnish, Portuguese, Italian, Australian, German, and US health economics societies). Target dates for new outputs under this iteration of the application: • Webinars aimed at policy audiences, open to all. Examples of past activity are webinars organised by the London School of Economics, Compassion in Politics, Pro-Bono Economics (links can be found at https://www.imperial.ac.uk/business-school/news/coronavirus-carol-propper-argues-pressure-increase-nhs-spending-will-rise-post-covid-19/). - Research on impact of Covid-19 pandemic on the economy [2021] • Social media: Used by Imperial College to disseminate research findings. - Research on how temperature changes impact on quantity, costs and quality of hospital admissions [publication expected in 2020]. • Public reports: Past examples include the development of several outputs in collaboration with the Institute for Fiscal Studies (IFS), including, news articles, publications, and book chapters. Examples include: - Research on whether air pollution and temperature are related to trends in hospital admissions, outpatient care and emergency admissions [publication expected in 2023] o Burn S, Propper C, Stoye G, Warner M, Aylin P, Bottle A. What happened to English NHS Hospital activity during the COVID-19 pandemic. Institute for Fiscal Studies. Available: https://ifs.org.uk/publications/what-happened-english-nhs-hospital-activity-during-covid-19-pandemic [Accessed 24/10/22]. 2021 May. - Research on the impact of climate shocks, including heat waves, on the number and cost of hospital admissions [publication expected in 2021]. o Warner M, Zaranko B. Pressures on the NHS. Institute for Fiscal Studies. Available: https://ifs.org.uk/books/pressures-nhs [Accessed 24/10/22]. 2021 September. - Research on the impact of COVID-19 on hospital admissions for chronic conditions (with focus on COPD, diabetes, CVD) Publication in 2022/3). o Johnson P, Emmerson C, Miller H, Phillips D, Stoye G, Delestre I, Stockton I, Ogden K, Joyce R, Adam S, Waters T. An initial response to the Prime Minister’s announcement on health, social care and National Insurance’. Institute for Fiscal Studies. Available at: https://ifs.org.uk/articles/initial-response-prime-ministers-announcement-health-social-care-and-national-insurance [Accessed 24/10/22]. 2021 September. o Stoye G, Warner M. Direct and Indirect health impacts of COVID-19 in England. Institute for Fiscal Studies. Available at: https://ifs.org.uk/publications/direct-and-indirect-health-impacts-covid-19-england [Accessed 24/10/22]. 2021 September. o Stoye G, Warner M. IFS contribution to new SAGE report shows sustained falls in NHS hospital activity during the first year of the pandemic. Institute for Fiscal Studies. Available at: https://ifs.org.uk/articles/ifs-contribution-new-sage-report-shows-sustained-falls-nhs-hospital-activity-during-first [Accessed 24/10/22]. 2021 o Publication in outputs aimed at a general readership — e.g. the Economics and Social Research Council (ESRC’s) media publications, o Institute for Fiscal Studies briefings (e.g. Banks et al. 2020 — https://www.ifs.org.uk/publications/14799) o de Preux, L., 2022. Winter of discontent? How extreme temperatures in England expose inequalities in hospital use. Forbes. https://www.forbes.com/sites/imperialinsights/2022/12/23/winter-of-discontent-how-extreme-temperatures-in-england-expose-inequalities-in-hospital-use/?sh=446891321923 o de Preux L, Rizmie D, 2021, How is the healthcare sector dealing with climate change?, Economics Observatory, Vol: 2021, link. https://www.economicsobservatory.com/how-is-the-healthcare-sector-dealing-with-climate-change • Direct bilateral engagement with individual policy makers and politicians. Target dates for production and dissemination of the outputs: All remaining projects (1-3) will be completed by the end of this Data Sharing Agreement (2025). Dissemination will be undertaken using the channels outlined above.

Expected measurable benefits

This application will allow Imperial College Business School’s research team to analyse the impact of two types of exogenous shock on the healthcare system. The findings of this research study are expected to contribute to evidence-based decision-making for policy-makers, local decision-makers such as doctors, and patients to inform best practice to improve the care, treatment and experience of health care users relevant to the subject matter of the study. First, the Covid-19 pandemic provides a unique opportunity to study the impact of an unprecedented shock that has completely changed the demand for and supply of healthcare; whereas work on climate-related shocks enables the study of more regular and in some cases more predictable shocks to the healthcare system. The use of the Data could help the system to better understand the health and care needs of populations. On Covid-19, this work will produce estimates of the impacts of the pandemic across different dimensions including short-term and long-term impacts, and impacts across age, geography and SES. • lead to the identification of health and care system design to improve health and care outcomes. It is too soon to say how the additional COVID-19 research will be used in policy making, but at present input has already been provided to policy making on COVID to Treasury, DHSC economists, and will be providing evidence to the Science and Technology Select Committee in June 2020 • advance understanding of regional and national trends in health and social care needs. Direct input has been provided into improving patient outcomes during COVID (for example in developing the J-IDEA coronavirus planning tool https://www.imperial.ac.uk/news/197353/j-idea-launches-coronavirus-pandemic-hospital-planning/ intended explicitly to help hospitals across the world deal with the demands of treatment of COVID-19. • inform planning health services and programmes, for example to improve equity of access, experience and outcomes. On climate-related shocks, the study aims to understand which individuals and how they are affected by weather extremes, as well as the policy reforms that have permitted to best respond to these increased shocks in demand. • inform decisions on how to effectively allocate and evaluate funding according to health needs. Together, this work will assess whether granting greater autonomy to NHS leads to improved care. Imperial College Business School research team’s results will allow the assessment of what types of policies allow better management of these exogenous shocks, and will support the NHS to prepare, anticipate and adapt to future shocks. It will also ensure that the healthcare system is continuously optimising to ensure that patients receive the greatest level of care and achieve positive outcomes. • support knowledge creation or exploratory research (and the innovations and developments that might result from that exploratory work). The expected benefits of the on-going projects are: Project (1): The NHS is currently suffering from major shortages of labour. Imperial College London’s research on whether doctors have responded to important changes in their pension arrangements will allow an estimate of the responsiveness of their working hours to remuneration. It will therefore be of direct use to those in NHS England involved in workforce planning and other bodies, such as the Doctors and Dentists pay review body. Expected date: working paper end of 2023; dissemination from beginning of 2024. As a result of earlier research undertaken using the Data detailed in this Data Sharing Agreement, research is currently being undertaken for a single large multisite Trust on the impact of nursing staff absences on patient outcomes. This is intended to help the Trust manage absences and identify where reducing absences may most benefit patients. (Project 1) Project (2): The aim is to establish the benefits and costs of increasing funding to the NHS. It will include an assessment of which patients benefit and the costs and benefits of hospitals investing in additional capacity. Expected date: end 2024. Project (3): The project aims to provide data-based evidence for improving operational processes in NHS Trusts for patients with cancer in the first instance, and subsequently, diabetes, kidney and heart conditions. The focus will be on reducing length of stay and improving outcomes for patients. Expected date for working paper: mid 2024. Actions taken to optimise the potential public benefits from the use of the Data are primarily dissemination through the wide number of channels outlined in the section on how future outputs will be disseminated.

Benefits reported

Past work using HES has been very influential in decisions over setting of regulated prices in the NHS, research showed that moving away from regulated prices harmed healthcare users by increasing mortality. It has also been shown that waiting list targets for elective care designed to eliminate very long waiting lists do not harm healthcare users and this has informed policy on use of waiting lists. Research is currently being undertaken for a single large multisite Trust on the impact of staff absences on patient outcomes, intended to help the Trust manage absences and identify where reducing absences may most benefit patients. Examples of benefits realised for completed projects 4, 5, 6 and 7. Exogenous influences (or shocks) on demand for secondary care including temperature extremes and epidemics Project 4: "Excess Hospital Admissions Due to Seasonality and Temperature Extremes in the UK” – Laure de Preux, Marisa Miraldo and Rifat Atun The research on the impact of pollution on health has led to the development of a tool to provide local authorities with projections of the NHS and social care costs associated with ambient air pollution. This tool https://www.gov.uk/government/publications/air-pollution-a-tool-to-estimate-healthcare-costs empowers local authorities, health professionals, and policy makers to quantify the anticipated forthcoming impact of diseases related to air pollution and subsequent costs to the NHS and social care system. The cost estimates can inform on the magnitude of the effect of current guidelines, and highlight the differential impact that various policies may have, allowing policy makers to establish their priorities on the basis of cost-benefit comparisons. Across regions comparisons are also made possible and can support further the prioritisation of the most deprived areas, or identify regions where the greatest health benefits could be achieved. (Project 4) •Dissemination to public: Project 5: •Presented at International Health Economics Association Milan 2015 Congress, July 2015 Based on initial research using the Data detailed in this Data Sharing Agreement direct input has been provided into improving patient outcomes during COVID (see the J-IDEA coronavirus planning tool https://www.imperial.ac.uk/news/197353/j-idea-launches-coronavirus-pandemic-hospital-planning/ ) intended explicitly to help hospitals across the world deal with the demands of treatment of COVID-19. "The Impact of Heatwaves on inpatient admissions to the English National Health Service between 2001 and 2012” – Marisa Miraldo, Dheeya Rizmie, and Laure de Preux Project 6: Dissemination to public: Advice provided to officials at Department of Health and Social Care on the local impact of macroeconomic conditions was part of a Department of Health and Social Care paper on the impacts of COVID https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/957265/s0980-direct-indirect-impacts-covid-19-excess-deaths-morbidity-sage-december-update-final.pdf (relates to Janke et al 2023). •Presented at Imperial College Business School as part of an MRes project, July 2017 Project 7: •iHEA 12th World Congress in Health Economics, Boston University, USA 2017 Past work using these Data have been very influential in decisions over setting of regulated prices in the NHS. Research showed that moving away from regulated prices harmed healthcare users by increasing mortality and led directly to changes in the way that NHS provider trusts were reimbursed (Project 7). Work using HES Data have shown that waiting list targets for elective care designed to eliminate very long waiting lists do not harm healthcare users and this has informed past policy on use of waiting lists (Project 7). This is relevant in the light of the current extremely long waiting lists for care. •Royal Economic Society annual conference, Bristol, UK 2017 Related to Projects 5,6,7: •EuHEA Maastricht 2018 The research on the impact of COVID initially examined with Data under this Data Sharing Agreement (part of Project 5) has been fed into advice provided by IFS to SAGE, which it has provided to the government in their handling of the COVID pandemic. The researchers provided early advice to senior policy officials in the Government Economic Service and the Treasury as to the potential impact of COVID19 on the NHS, specifically focusing on the impact on users who did not have COVID19, arising from delayed treatment and likely upcoming staff shortages. Direct advice was provided to senior Treasury officials during COVID relating to the resilience of the NHS. •Oxford International Health Congress 2018 Summary •EuHEA PhD Workshop Catania 2018 More generally, the main benefits from policy orientated research come primarily through policy briefings to key officials and politicians. It is difficult to establish which pieces of advice impact policy, as there is very rarely a direct line from evidence to policy making. However, in general, the larger the extent of research dissemination to key officials and ministers, the larger the eventual impact of the research. To this end the researchers actively engage with policy makers and political figures. Examples include advice provided by the researchers to DHSC, NHS England, NHS Improvement, Monitor, Treasury, Public Health England and the Chief Medical Officer. •EAERE Venice Summer School 2019. Rizmie D, Miraldo M, Atun R, de Preux Let al., 2019, The effect of extreme temperature on emergency admissions across vulnerable populations in England: an observational study, Lancet Public Health Science 2019 Conference, Publisher: Elsevier, Pages: S7-S7 Pimpin L, Retat L, Fecht D, de Preux L, Sassi F, Gulliver J, Belloni A, Ferguson B, Corbould E, Jaccard A, Webber Let al., 2018, Estimating the costs of air pollution to the National Health Service and social care: An assessment and forecast up to 2035, PLoS Medicine, Vol: 15, ISSN: 1549-1277 Janke, K, K Lee, C Propper, K Shields and M Shields (2020), “Macroeconomic conditions and health in Britain: Aggregation, Dynamics and local area heterogeneity”, CEPR Discussion Paper 14507, IFS Discussion paper 2020, IZA Discussion Paper No. 13091.

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

Datasets: + Civil Registrations of Death - Secondary Care Cut; + Emergency Care Data Set (ECDS); + HES-ID to MPS-ID HES Accident and Emergency; + HES-ID to MPS-ID HES Admitted Patient Care; + HES-ID to MPS-ID HES Outpatients; + HES:Civil Registration (Deaths) bridge; + Hospital Episode Statistics Critical Care (HES Critical Care)

Objective for processing

The agreement is being amended to append the latest years of HES APC, A&E and OP data from 2015/2016 until 2019/2020 along with PROMS data to match the corresponding HES years, released on an annual basis. The purpose of this agreement is to support ongoing research into the impact for patients and health service users of UK health policy reforms begun in the 2000s. The research is being undertaken by members of the Centre for Health Economics & Policy Innovation (formerly the Healthcare Management Group) at Imperial College Business School based in Imperial College London. Imperial College London will continue to use HES APC, A&E and OP data already provided for the same purposes as before. Additional years are required to evaluate the medium run effects of the policy changes occurring in the mid-2000s up to the Health and Social Care Act 2012 (e.g. the lead time for private hospital chains opening new sites is several years). From 2000 onwards, there have been reforms to the NHS in England which have been some of the most radical in the Organisations for Economic Cooperation and Development (OECD). These reforms consisted of a series of policy initiatives, beginning in the early part of the 2000s and carried out for the next 10 years, which were intended to improve care for patients. The broad remit of these reforms was to promote choice for patients and greater competition between providers of care, greater freedom for well managed organisations within the NHS within a tightly regulated system of publicly available standards and central guidance, and improvements in the patients’ experience in the form of enhanced quality of care and reduced waiting times. These reforms thus instigated changes to the (a) organisational and management structure for health care providers and (b) delivery arrangements, mandated or facilitated at the overall health system level, for specific services or specific treatments. The study will use PROMs linked to HES data to investigate the effects of greater private and voluntary provision of publicly-funded care on outcomes for NHS patients, equity of access to care and overall NHS costs. It will concentrate on the elective procedures most commonly done by private providers, specifically hip and knee replacements. PROMs data are crucial for this study, as they will be the basis for measuring quality of elective surgery at NHS trusts and private hospitals. These reforms were expensive and their effects were, and still are, highly contested, both in terms of patient benefits and benefits to tax-payer. Understanding the impact of these reforms on the efficiency of service provision, the quality of care experienced by patients, and their wider impact on the society is vital. The additional research will focus on policy 2 detailed further on in this section. Use of the private sector for elective surgery has continued to grow, with private providers now conducting more than a quarter of NHS-funded primary hip and knee replacement (National Joint Registry, 2018). The research will investigate how public providers differ in terms of quality, selection of patients for treatment and efficiency. The research programme examines the impact of these wide changing reforms on the delivery of the NHS of the quantity and quality of patient care. The focus of this present amended application is to examine how resilient these structures are to exogenous shocks. The data requested will allow the research team at Imperial College London to assess how the effects of these external shocks impacted these reforms and whether the system was able to adapt, measured in terms of quantity and quality of care delivered to NHS patients. Original Purpose The specific shocks the research team wish to examine are climate-related weather shocks and, building on their past work on infectious diseases, the new unprecedented shocks such as the Covid-19 pandemic. The data will be used in a programme of on-going research into UK health policy reform undertaken by members of the healthcare management group at Imperial College Business School. Weather related shocks since the early 2000s have led to large increases in deaths due to both extreme heat, pollution levels, and conditions which encourage infectious diseases to spread more rapidly. The Covid-19 pandemic is an example of an enormous shock to the NHS in England. The research methodology developed in previous versions of this application on the resilience of the NHS to external shocks is well placed to study the impact of this pandemic on our healthcare system. The methodology allows Imperial College London to look at the direct gains — in terms of lives saved — and the costs — in terms of deferred emergency treatments and cancelled elective treatments — as well as the impact on demand of longer term health problems that are a consequence of the economic recessions that are accompanying and will follow global social distancing measures. The reforms to the NHS in England since 2000 have been some of the most radical in the Organisations for Economic Cooperation and Development (OECD). The reforms consist of a series of policy initiatives, beginning in the early part of the 2000s and carried out for the next 10 years, which were intended to improve care for patients. The broad remit of these reforms was to promote choice for patients and greater competition between providers of care, greater freedom for well managed organizations within the NHS within a tightly regulated system of publicly available standards and central guidance, and improvements in the patients’ experience in the form of enhanced quality of care and reduced waiting times. These reforms thus instigated changes to the The Covid-19 epidemic has direct effects on the ability of the NHS to deliver care, with many staff being brought back from retirement along with newly qualified graduates entering the nursing labour force early. This allows the NHS to increase staffing capacity to meet urgent needs; but, to the detriment of other activities, thereby decreasing the quantity of care for patients and causing disruptions to existing teams, which has been shown in research to decrease the quality of care that patients receive (Banks et al. 2020 — https://www.ifs.org.uk/publications/14799). (a) organizational and management structure for health care providers and The pandemic will also have wider effects on the economy which will spill over into demand for healthcare. With the economic shutdown predicting GDP to fall by around 25% in the next year, if not by more, the incomes of those in the most precarious economic positions will be hit hardest. Government policy may mitigate this to some degree, but the nationwide lockdown is already impacting both the demand for goods, and also the ability of companies to supply, which will have on going effects beyond the current year; although the scale of this impact is not yet known. Research on the relationships between the economic downturn of the late 2000s suggest that this will translate into increased prevalence of chronic conditions and therefore demand for health care (Janke et al. 2020 — https://voxeu.org/article/impact-covid-19-chronic-health-uk). (b) delivery arrangements, mandated or facilitated at the overall health system level, for specific services or specific treatments Imperial College London will continue to use HES APC, A&E (and subsequently ECDS) and OP data already provided for the same purposes as before. The research team have additionally requested Civil Registration data to match the corresponding HES years and HES Critical Care data. Critical Care data will allow Imperial to specifically quantify the Covid-19 shock on the demand of care as critical care was hit hardest in the early months of the pandemic; while, APC, ECDS, OP and PROMS data will allow for an assessment of the impact of Covid-19 on all other types of care. These reforms were expensive and their effects are highly contested, both in terms of patient benefits and benefit to tax payers. Understanding their impact on efficiency of service provision and the quality of care experienced by patients is therefore important. The research team at Imperial College Business School will use the new data requested, together with the data they already hold, to examine the impacts of Covid-19 and weather-related shocks on patient care. The research team will examine both short-term and longer-term impacts, the distribution of these impacts across individuals of different ages and Social-Economic Status (SES), and the impacts across different locations in the UK. The research programme focuses on the following policies within this reform agenda. DATA MINIMISATION (1) The policy of choice and competition between NHS providers of care. This policy has operated since the introduction of the Chose and Book system for referrals in the mid-2000s, which coupled with a prospective payment system (PbR), gave incentives to increase activity. Imperial College has examined the short-term impact of these policies (pre-2010). The focus will now be on the longer term, and impact and will be analysed until 2017. Imperial has minimised all data being requested where possible and has given special consideration to the following points: (2) The policy of promoting a greater role for private and voluntary providers in the provision of publicly funded care. This policy has operated since the introduction of independent sector providers (ISTCs) in the early 2000s, but has subsequently been extended. It currently includes the widespread use of contracting for both hospital and community-based services and franchising of hospital management to private sector bodies (e.g. Circle). Imperial College will examine the impact of this policy on outcomes for patients undergoing joint replacements and other common elective surgeries. - Imperial College London aim to provide a comprehensive assessment of shocks on the healthcare sector and as the extent of the shocks is unknown, Imperial College London have to consider possible direct and indirect effects across all healthcare services. It is not possible to further reduce the number of data sets requested as this could bias analyses. All data requested is pseudonymised in order to be less intrusive. (3) The use of networks and guidelines to increase quality of care and patient safety, innovation and the diffusion of good practice in important hospital-based treatments. NICE guidance, in particular clinical guidelines, has transformed clinical practice over the past 10 years, in particular in the treatment of stroke, heart attack and cancer patients, and it has led to reductions in many preventable complications. In addition, there has been the formation of stroke and cancer networks, in which hospitals cooperate to improve care for patients. - The Covid-19 pandemic is expected to last until a proven vaccine has been deployed globally, which is not expected until the end of 2021. As a result, Imperial College London are requesting data until 2021/2022 (June) to assess how the direct impact on the healthcare system and its subsequent recovery. The number of years requested cannot be reduced further as these data will also be used to assess the impact of the other healthcare shocks (e.g. weather extremes) occurring at different time points. A period with limited shocks is also required to act as a baseline. (4) The policy of granting greater autonomy to NHS providers who perform well on measured outcomes. This policy is most strongly embodied in the NHS Foundation Trust system. This is intended to allow trusts greater control over their working practices (e.g. remuneration of staff and staffing levels), but also requires that they operate within a stronger system of regulation and guidance. - Imperial College London require data from across England in order to understand the heterogeneity of any impacts on healthcare and to identify regions most affected to inform policy decisions. Imperial College London Cannot narrow the data by demographics as it would potentially bias the study analysis and any narrowing of clinical factors would prevent Imperial College London from identifying the indirect effects of healthcare shocks. All patient episodes are required to ensure all direct and indirect effects are captured and to prevent bias in Imperial’s analyses. Only admissions related to maternity are required to account for the demand of healthcare services affected by shocks. Unborn child and neonatal records are not required. Only calendar date is necessary to match shocks such as daily temperature extremes to healthcare services provided on specific dates. The research aims to understand the impact of these high-level policy changes on service providers, health service users, and tax payers. The aim is to make a cost-benefit assessment of the impact of these policies. Imperial College will focus on particular outcomes and treatments, described in the processing activities below. - Imperial College London’s assessment of the resilience of the healthcare sector to shocks requires the inclusion of all healthcare service types, and for record requests all fields are necessary to achieve the study purpose. These policy reforms impact on the organisational structure for health care delivery in England, and work continues in all these areas, with new programmes of work identified and explored. In the context of current concerns over the level of hospital funding with in the NHS, and the healthcare delivery system’s ability to cope with shocks to the system under research programme number 4 (the granting of greater autonomy to NHS providers), Imperial College will examine the impact of these changes on resilience to one particular shock. The shock chosen is that of weather variation and what is the impact of weather on the amount and costs of hospital admissions at Trust level. The outcomes the research team will examine include: critical care admissions, presentations to A&E, road traffic accidents, and death from heart and respiratory conditions. Examples of longer-term impacts include future presentations for care from chronic conditions such as COPD, diabetes and mental health issues. This agreement also enables the research team to use PROMs to investigate the extent to which greater private and voluntary provision of publicly funded care helps or hinders the resilience of the NHS to deal with unexpected events. Research will focus on the impact on patient outcomes, equity of access to care and cost. The General Data Protection Regulations Article 6 (1) (e) ‘processing is necessary for the performance of a task in the public interest…’ as Imperial College London is recognised as an official authority with a royal charter granting them a right to perform research would therefore be considered to be exercising a function of the Crown in undertaking research, and Article 9 (2) (j) ‘processing is necessary for archiving purposes in the public interest, scientific or historical research purposes …’ are the legal basis for the processing of pseudonymised data.

Processing activities

The data Data will be used processed to identify the impact of the policies listed above policy reforms on (a) service providers and (b) service users. This will allow evaluation of the costs and benefits of the policies. The unit of analysis in the research is both of the provider (for policy areas 1,2 4) patient and the patient for the work under policy area (3). provider. The provider will generally be the an NHS Trust level, but may may, in some cases cases, be the site level within Trusts. The measures to assess the impact of policies that Imperial College will construct will be robust measures of performance of the provider, and the outcomes directly experienced by patients. The measures of performance include measures of patient safety (e.g. avoidable deaths, adverse incidents), quality of care (including improvement in PROMs, readmission rates, infection rates, adverse events), measures of access (e.g. median or mean waiting times for both elective and emergency care, the distribution of the service across SES of the provider’s catchment area), measures of throughput (e.g. FTEs for particular treatment). Some of these measures are available publicly, but the measures that are made available often change from year to year, and they are not available at patient level. To create a consistent time series covering a number of years, with appropriate controls for patient severity and other factors that may influence outcomes, Imperial College need to be able to use the raw HES data and linked PROMs. These measures will be constructed from the analysis of individual patient level data using appropriate statistical methods to deal with sampling and other statistical issues (detailed below). Data requested under this iteration of the data sharing agreement: From HES data and PROMS linked to HES, Imperial College derive measures of outcomes for patients (specifics given below for each policy area) and data on patient severity, to allow the study to control for case-mix. To these data Imperial College will match publicly available administrative data from other sources, where matching is only undertaken at the provider level or the regional level (This will almost always be the trust level as that is the level for which publicly available data is available. In some cases, the patient level data will be aggregated to site level (for example, to conduct sensitivity tests to measures which are available at site level e.g. measures of competition). Imperial College will not be matching to data sources at the patient level. - Civil Registrations Deaths - Secondary Care Cut Data from 2000/01 to 2021/2022 The administrative trust-level data Imperial College will match includes data from Trust financial returns; from providers’ management accounting systems (e.g. cost data); from health care regulators; from the annual staff satisfaction survey of all NHS employees; from local authorities; and socio-economic data at the Middle Layer Super Output Area (MSOA) or Lower Layer Super Output Area (LSOA) level. The data to be matched depends on the specific research question. For example, the customer will match data on trust financial performance for policy areas (2) and (4) but not for policy area (3). For policy area (3) the customer will match data on provider networks for strokes. This will not be used for analyses for policy area (4). - PROMS data 2019/20 to 2021/22 All the data Imperial College will match is at Trust or site level and it is all in the public domain (for example, data on Trust financial returns which are available on Trust websites). Matching these data will not increase the risk of re-identification individual patients or clinicians. No data will be published from the research at the Trust, site, or lower level. All published analyses will be statistical or graphical and will be in line with the HES analysis guide. - HES APC for AR 2000/01 to 2004/05, plus 2019/20 to 2021/2022 For policy area (1) identified above, Imperial College will use HES and linked PROMs data on hip and knee replacements to examine outcomes for patients under-going these procedures. Imperial College will construct measures of volume, case-mix, waiting times, improvement in functional mobility (measured using Oxford hip/knee scores) and readmissions, and procedure revision rates. Imperial College will also examine HES data on maternity patients and examine within hospital deaths of babies, and foetal and maternal complications. - HES OP for AR 2003/04 to 2004/05, plus 2019/20 to 2021/2022 For policy area (2) Imperial College will examine the impact of greater involvement of private and voluntary providers in the provision of publicly funded care on NHS patients’ outcomes, focusing on hip and knee replacement surgery. Imperial College will use PROMs data linked to HES to construct the same measures of performance of NHS providers and private providers as detailed for policy area (1) above. These data will be matched with location data on private and public providers. Measures of market structure (e.g. HHI indices) will be calculated from the patient flow data in HES. The location data will also be used to carry out instrumental variables analysis, to reduce the potential bias from being unable to control fully for case-mix using HES. Specifically, an instrument for patient choice of hospital will be constructed using differential distance of patients from NHS/private hospitals. - HES CC for AR 2008/09 to 2021/2022 For policy area (3) Imperial College will examine the impact of the introduction of specific guidelines, including the introduction of the surgical safety checklist, on in-hospital mortality, 30-day mortality and readmissions, and on the occurrence of complications that Imperial College identify from the diagnoses codes of patient records. Among the complications Imperial College investigates are pressure ulcer, death in low-mortality HRGs, deep-vein thrombosis, sepsis, central line infection, post-operative hip fracture, obstetric complications, and some of the rarer events including foreign body left in body after surgery. These indicators will be constructed at the patient level. Imperial College will use controls for potential patient level confounders. - ECDS for AR 2019/20 to 2021/2022 Imperial College will also look at the impact of guidelines for various forms of cancer treatment. The customer will begin with outcomes following surgery for colorectal cancer, where laparoscopic surgery has been shown to have patient outcomes advantages over traditional surgery. The outcomes Imperial College will be examining are re-admissions and other subsequent complications that can be extracted from HES data. This will come in 3 drops of data. The first in Sept/Oct 2020 for all historic and AR 19/20 data (when AR 19/20 is published, then Sept 2021, then Sept 2022. For policy area (4) the focus is on the impact of management on trust performance and on the role of board level remuneration in this. To examine this Imperial College will construct data from HES on patient outcomes and process measures, aggregated up to the Trust level. The measures Imperial College will focus on are those that have been published by the quality regulators of NHS care (e.g. the Care Quality Commission) but which are not always available on an annual basis. The measures will include amenable mortality, within hospital deaths from emergency AMI admissions and surgery, waiting times in both elective and emergency care, and readmissions following stroke and hip and knee replacements. These data, along with the case-mix of patients undergoing these treatments, will be aggregated to Trust level. These will be matched to publicly available data on NHS trust Board remuneration (from the Trust Annual returns and made available on Trust web sites), data from Monitor and other financial data from the Trust annual returns. Data extracts will be pseudonymised. The type of analyses Imperial College will undertake for all four policy areas will be statistical. It will account for the fact that in all the analyses Imperial College will be using patient level data to analyse the performance of provider units. Among the statistical methods Imperial College will use to construct provider level measures from the underlying patient are multilevel techniques to account for the hierarchical nature of the data (e.g. the construction of squeezed estimators, and the use of fixed and random effects at the provider level). The research Team at the Imperial College Business School will measure provider performance along with patient outcomes. Performance measures include those of patient safety (e.g. avoidable deaths, adverse incidents), quality of care (including improvement in PROMs, readmission rates, infection rates, adverse events), measures of access (e.g. median or mean waiting times for both elective and emergency care, the distribution of the service across SES of the provider’s catchment area), measures of throughput (e.g. FTEs for particular treatment), and mortality outside the healthcare sector, To identify the impact of policies Imperial College in some cases will have to deal with environments in which more than one policy change may take place at once. An example is the introduction of networks to encourage cooperation between providers at the same time as policies to encourage competition. Techniques and tools Imperial College will use include propensity score matching, difference in difference analysis and other panel data econometric techniques. Imperial College will supplement this with graphical presentation of the results and Imperial College has extensive experience in these techniques. Some of these measures are available publicly, but these measures often change from year to year, and are not available at the patient level. To create a consistent time series covering a number of years, with appropriate controls for patient severity and other factors that may influence outcomes, Imperial College Business School’s research team need to be able to link PROMS with HES data. The data will not be used by third parties. No record level data will be made available to any individual provider and from the published research individual providers and patients will not be able to be identified. Imperial College will only present aggregate level data with small numbers suppressed in line with the HES analysis guide. Using these, plus mortality data, the research team will derive patient outcome measures to allow for the control of case-mix. In addition, the research team will continue to work with publicly available administrative data from other sources, where matching is only undertaken at the provider level or the regional. In some cases, patient level data is aggregated to site level (for example, to conduct sensitivity tests to measures which are available at site level e.g. measures of competition). The data will not be used to establish a protocol for a clinical trial. Imperial College Business School’s administrative trust-level data will be updated and matched with Trust financial returns; from providers’ management accounting systems (e.g. cost data); from health care regulators; from the annual staff satisfaction survey of all NHS employees; from local authorities; socio-economic data at the Middle Layer Super Output Area (MSOA) or Lower Layer Super Output Area (LSOA) level, pollution and weather data. Matched data depends on the specific research question. For example, will add pollution data to assess its impact on admissions and mortality. Tied to the new programme of work into weather variations, Imperial College will match publicly available weather station data to the HES information. The weather data will come from the Met Office Integrated Data Archive System (MISAD) database, which provides a large range of weather measures collected by the met office. The daily weather will be approximated at the Trust's location. this matching will not increase the risk of any re-identification and will be done in line with the HES analysis guide. All the data Imperial College Business Schools matches is at Trust or site level and is all in the public domain. No attempt will be made to match data at the patient level. Matching does not increase the risk of re-identification. Following the same practice as in the previous projects, no data will be published to the Trust, site, or lower level. All published analyses will remain statistical or graphical and will be in line with NHS Digital Information Governance and Data Protection policies. 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 ie: employees, agents and contractors of the Data Recipient who may have access to that data Part of the data received from this application will be tied to a new programme of work into weather variations and their impact on policy. Imperial College Business School’s research team will update and match publicly available weather data to HES data. The weather data comes from the Met Office Integrated Data Archive System (MIDAS) database, which provides a large range of weather measures. Daily weather will be estimated using each Trust's location. This will then be supplemented by daily and yearly pollution metrics (such as the concentration of particulates and nitrogen dioxide) matched at the hospital or postcode level. Data will only be accessed and processed by substantive employees of Imperial College London and will not be accessed or processed by any other third parties not mentioned in this agreement. All analyses will be statistical and Imperial College Business School’s research team will continue to construct provider level measures from underlying patient data using multi-level techniques to account for the hierarchical nature of the data (e.g. the construction of squeezed estimators, and the use of fixed and random effects at the provider level). To identify the impact of policies in some cases they will have to deal with environments in which more than one policy change takes place at once. An example is the introduction of networks to encourage cooperation between providers at the same time as policies to encourage competition. The techniques and tools that the Imperial College Business School’s research team will use include propensity score matching, difference in difference analysis and other panel data econometric techniques. The research team will supplement this with graphical presentations of their results. PROMS data is only available for non-commercial purposes, such as academic research, or in connection with delivering services to the NHS. HES and ECDS DISCLOSURE RULES In order to protect patient confidentiality, when presenting results calculated from HES record level data, outputs will contain only aggregate level data with small numbers suppressed in line with HES Analysis Guide. When publishing HES data, you must make sure that: · cell values from 1 to 7 are suppressed at a local level to prevent possible identification of individuals from small counts within the table. · Zeros (0) do not need to be suppressed. · All other counts will be rounded to the nearest 5. Data will not be made available to any third parties other than those specified except in the form of aggregated outputs with small numbers suppressed in line with the HES Analysis Guide. The Centre for Health Economics & Policy Innovation holds its data in the Big Data & Analytical Unit (BDAU) at Imperial College London. The Imperial College London's Big Data Analytics Unit Secure Environment (BDAU SE) is a fully certified ISO 27001:2013 research environment within Imperial College London. They also are 100% compliant with NHS IG Toolkit Level 3 (EE133887) and they have resources for securely storing and accessing data. In 2019, the BDAU server was relocated from South Kensington to Virtus SDC Limited in Slough, who host the servers. This is the new location of all Imperial College data servers. Virtus SDC Limited do not access data held under this agreement as they only supply the building. Therefore, any access to the data held under this agreement would be considered a breach of the agreement. This includes granting of access to the database[s] containing the data. All processing will be completed by substantive employees of Imperial College London, students at Imperial College London under the supervision of Imperial College London substantive employees, and a small number of visiting researchers with honorary Imperial College London contracts. No NHS Digital data will be accessed or processed by any other third parties not mentioned in this agreement. All users will be required to pass GDPR and Information Security Awareness (ISA) training and will be required to agree, with possible disciplinary action for non-compliance, to BDAU SE standard operating procedures. All processing will take place in the BDAU SE, abiding by BDAU ISO certified standard operating procedures, and all data which is exported will be suppressed in line with NHS Digital guidance. Data access is strictly controlled by the Imperial College London's BDAU SE through a robust data set registration process. No one other than Imperial College London's BDAU SE staff can authorise access to the data. The data will not be used to establish a protocol for a clinical trial. 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 in this application will not be used by third parties. No record level data will be made available to any individual provider and from the published research individual providers and patients will not be able to be identified. Imperial College Business School research team will only present aggregate level data with small numbers suppressed in line with the HES Analysis Guidance. PROMS data is only available for non-commercial purposes, such as academic research, or in connection with delivering services to the NHS.

Expected output

The outputs from this application will be a set of contributions intended to input into the assessment of promote further discussion around the impact, benefits and costs of the policies listed in the objective for processing. The above. Imperial College Business School research team aim is to prepare several types of output, each type aimed at different audiences. a. Publication in peer reviewed international journals. These will be a mixture of health service research journals and economics journals. The health service research journals Imperial College will target, and in which Imperial College have published analyses using HES data for which Imperial College held licenses in the past, include: The Lancet, the BMJ, Medical Care, Health Services Research, Health Policy. The economics journals include: Journal of Health Economics, Health Economics, European Journal of Health Economics, Journal of Health Services Research and Policy. All these are read by policy makers nationally and internationally who wish to evaluate system reform. The primary aim is to improve the delivery of healthcare within the NHS. Given the nature of the research questions, the key stakeholders and primary routes to outputs and benefits are policy makers in the UK healthcare. This is a diverse community, which uses both internal and external research to inform policy making, Imperial College London’s BDAU has experience of providing outputs to inform policy making over the years. Advice has been provided to DHSC, NHS England, NHS Improvement, Monitor, Treasury, Public Health England and the Chief Medical Officer. b. Publication in outputs aimed at a general readership e.g. the Economics and Social Research Council (ESRC’s) media publications Britain in 2014 and Society Now. The former is sold in WHSmith and other outlets and is published annually. The latter is widely distributed to Whitehall and other policy making bodies. In direct relation to COVID-19 outputs the BDAU is taking part in webinars organised by the London School of Economics, Compassion in Politics, Pro-Bono Economics (links can be found at https://www.imperial.ac.uk/business-school/news/coronavirus-carol-propper-argues-pressure-increase-nhs-spending-will-rise-post-covid-19/). c. Presentation of the research at conferences and events aimed at policy makers. Imperial College have been asked to give presentation of the research findings to statutory bodies including the Department of Health and Monitor; international organizations involved in healthcare policy (e.g. OECD, WHO, The World Bank, The Institute for Health Metrics and Evaluation, the Center for Global Development); all the main policy think tanks in the UK (including the Institute of Government, Reform, Policy Exchange, the Nuffield Trust, the King’s Fund and the Health Foundation); the Royal Colleges; and overseas health economics organizations that have large practitioner membership (e.g. Finnish, Portuguese, Italian, Australian, German, and US health economics societies). The BDAU has provided early advice to senior policy officials in the Government Economic Service and the Treasury as to the potential impact of COVID19 on the NHS, specifically focusing on the impact on users who do not have COVID19) arising from delayed treatment and likely upcoming staff shortages (all based on previous research using HES and other NHS data). d. Presentation of the research to individual policy makers and politicians. Past research by members of the health care group that have used HES data have been presented to the then Secretary of State for Health, to the Prime Minister’s office, to the Prime Minister's delivery and strategy units, to the Treasury, and the Department of Health, Monitor and the Cooperation and Competition Commission (now part of Monitor). https://coronavirusandtheeconomy.com/ which provides two page briefings on economic issues – including healthcare and health issues – relating to COVID19. e. Presentation of the research, where requested, at individual trusts considering strategic direction and with patient groups. Presentations of the research at small round table events organized by industry (e.g. Arup) Briefings to policy makers will be produced when requested by policy makers and MPs. Target dates for outputs - some of which have now been achieved. Further outputs will include: Imperial College list target dates by the policy areas identified above. a. Publication in peer reviewed international journals — These will be a mixture of health service research, social medicine and community health journals, as well as health and environmental economics journals. Imperial College Business School research team will target: The Lancet and the other Lancet Journals such as Lancet Public Health, the British Medical Journal (BMJ), Medical Care, Health Services Research, Health Policy. The economics journals include: Journal of Health Economics, Health Economics, European Journal of Health Economics, Journal of Health Services Research and Policy, Journal of Environmental Economics and Management. All these are read by international policy makers and are for the most part open access. 1. The policy of choice and competition between NHS providers of care. b. Publication in outputs aimed at a general readership — e.g. the Economics and Social Research Council (ESRC’s) media publications, Institute for Fiscal Studies briefings (e.g. Banks et al. 2020 — https://www.ifs.org.uk/publications/14799) •Research on the impact of management on NHS acute care provider performance (initial paper 2015 (achieved), later papers to be produced up to 2018/19) c. Presentation of research at conferences and events aimed at policy makers. Past research has been presented at statutory bodies including the Department of Health and Social Care; international organizations involved in healthcare policy (e.g. Organisation for Economic Co-operation and Development (OECD), World Health Organization (WHO), The World Bank, The Institute for Health Metrics and Evaluation, the Center for Global Development, Public Health England); policy think tanks in the UK (including the Institute of Government, Reform, Policy Exchange, the Nuffield Trust, the King’s Fund and the Health Foundation); the Royal Colleges; and overseas health economics organizations that have large practitioner membership (e.g. Finnish, Portuguese, Italian, Australian, German, and US health economics societies). These outlets will continue to be targeted. •Research on the effect of choose and book on mortality of patients who have had coronary artery graft bypass surgery (CABG) (2016) (achieved with research continuing) d. Presentation of the research to individual policy makers and politicians. Based on Imperial College Business School research team’s past experience, future findings could be relevant to the Secretary of State for Health, the Prime Minister’s office, the Prime Minister's delivery and strategy units, the Treasury, and the Department of Health and Social Care. At present, members of the Centre for Health Economics & Policy Innovation (CHEPI) group are providing evidence to the Treasury, the Bank of England and the Department of Health and Social Care (DHSC). 2. The policy of promoting a greater role for private and voluntary providers in the provision of publicly funded care. e. Presentation of the research, where requested, at individual trusts considering strategic direction and with patient groups. Presentations of the research at small round table events organized by industry (e.g. in the past Imperial College Business School research team have presented to Arup) •Research on the impact of private providers of hip and knee replacements on NHS workload (2016) Target dates for new outputs under this iteration of the application: •Imperial now have plans to use PROMS data to further support this work with research starting late 2018. - Research on impact of Covid-19 pandemic on the economy [2021] 3. The use of networks and guidelines to increase innovation, patient safety and the diffusion of good practice in important hospital based treatments (e.g. the use of networks and guidelines for treatment for stroke, heart attack and cancer patients). - Research on how temperature changes impact on quantity, costs and quality of hospital admissions [publication expected in 2020]. •Research on the costs to patients and hospitals of patient safety incidents (2015) (achieved) - Research on whether air pollution and temperature are related to trends in hospital admissions, outpatient care and emergency admissions [publication expected in 2023] •Research on the impact of the surgical safety checklist (2015) (work continues to produce this) - Research on the impact of climate shocks, including heat waves, on the number and cost of hospital admissions [publication expected in 2021]. •Research on the impact of stroke networks on patient outcomes (2017) - Research on the impact of COVID-19 on hospital admissions for chronic conditions (with focus on COPD, diabetes, CVD) Publication in 2022/3). •Research on the impact of networks on the diffusion of laparoscopic surgery for colorectal cancer (2017, 2018) 4. The policy of granting greater autonomy to NHS providers who perform well on measured outcomes. •Research on waiting times in A&E departments of NHS acute care providers (2016) (achieved) •Research on the link between chief executive pay and the performance of NHS acute care providers (2017, 2018) 5. The impact of seasonal weather variation on the number and cost of hospital admissions [This project relates to work being carried out following the August 2016 update]. •Research on whether seasonal climate variations, such as temperature and air pollution, are related to trends in hospital admissions •On impact of climate shocks, such as a heat wave, on the number and cost of hospital admissions. All outputs will be at an anonymised and aggregated level, in line with the HES Analysis Guide. No record level data will be passed to third parties. Data will not be used for commercial purposes. Completed Outputs The following outputs have been achieved using the data so far: 1. Policy of choice and competition between NHS providers a. Management of acute provider performance Bloom N, Propper C, Seiler S, Van Reenen J. The impact of competition on management quality: evidence from public hospitals. The Review of Economic Studies. 2015 Jan 24;82(2):457-89 •One of top five economics journals worldwide Dissemination to public: •Seminar at Imperial Business in the City, May 2017 •Seminar at Melbourne Institute, February 2017 •Seminar at Monash University Centre for Health Economics, February 2017 •Seminar at the Department of Health, January 2017 •Seminar at the Paris School of Economics, January 2017 •Seminar at ISER University in Essex, January 2017 •Microeconomic Insights blog post: “Healthcare: how competition can improve management quality and save lives”: http://microeconomicinsights.org/healthcare-how-competition-can-improve-management-quality/ •City A.M. “From the NHS to Brexit, give people a choice and they'll make a good one”: http://www.cityam.com/253234/nhs-brexit-give-people-choice-and-theyll-make-good-one •The Market and Health Care Production – Project Overview: https://www.imperial.ac.uk/business-school/research/management/management-research/projects-and-centres/the-market-and-health-care-production/ b. Research on effect of Choose and Book on Coronary artery bypass graft patients Gaynor M, Propper C, Seiler S. Free to choose? Reform, choice, and consideration sets in the English National Health Service. The American Economic Review. 2016 Nov 1;106(11):3521-57 •One of the top economics journals worldwide •Won the International Health Economics Association’s (iHEA) 25th Arrow Award, which recognises excellence in the field of health economics, for the best paper published in 2017 •http://healtheconomics.site-ym.com/?page=ArrowAward •http://www3.imperial.ac.uk/newsandeventspggrp/imperialcollege/newssummary/news_9-5-2017-15-34-58 Dissemination to public: •Microeconomic Insights blog post: “Hospital competition and patient choice can improve healthcare quality”: http://microeconomicinsights.org/hospital-competition-patient-choice-can-improve-healthcare-quality/ c. Research on competition in the NHS Gaynor M, Moreno-Serra R, Propper C. Death by market power: reform, competition, and patient outcomes in the National Health Service. American Economic Journal: Economic Policy. 2013 Nov 1;5(4):134-66 •One of the top economics journals worldwide •Won the 2016 American Economic Journal (AEJ) Best Paper Award Propper et al. Does competition and equality do good things in England. Health Economics, Policy and Law [Forthcoming] Dissemination to public: •Opening plenary at International Health Economics Association Boston 2017 Congress, July 2017 •https://www.healtheconomics.org/page/Livestream •Associated Medical Services (AMS) Healthcare Symposium – Canadian Medicare 2017: Historical Reflections, Future Directions – Toronto, May 2017 •Globe and Mail “There’s room for competition in public health care” •https://www.theglobeandmail.com/opinion/theres-room-for-competition-in-public-health-care/article34956444/ •Keynote speech at South Danish Universities, COHERE Annual Conference, Denmark, May 2017 •Talk given to International Consulting Economists' Association (ICEA) members, London, January 2017 •Invited Knoop Lecture 2016 to general public, University of Sheffield, November 2016 •https://www.youtube.com/watch?v=ZlLEq-WQBGw •Annual seminar at Valtion Taloudellinen Tutkimuskeskus (VATT) Institute for Economic Research to Finnish Policy Makers, November 2016 •http://www.hs.fi/kotimaa/art-2000002928405.html •Keynote at Competent in Competition + Health (CINCH) – Essen Health Symposium, October 2016 – Germany d. Research on equity in health care Cookson R, Propper C, Asaria M, Raine R. Socio-Economic Inequalities in Health Care in England. Fiscal Studies. 2016 Sep 1;37(3-4):371-403. •Presented at Institute for Fiscal Studies Conference, March 2016 2. The policy of promoting a greater role for private and voluntary providers •Policy of greater competition in hip and knee replacement •We now have plans to use PROMS in our research starting late 2018 3. The use of networks and guidelines Hauck KD, Wang S, Vincent C, Smith PC. Healthy life-years lost and excess bed-days due to 6 patient safety incidents: empirical evidence from English hospitals. Medical Care. 2017 Feb;55(2):125. •Paper illustrates that among six safety incidents, the greatest loss in healthy life years is caused by pressure ulcers. They lead to a greater loss of life than central line infections, deep vein thrombosis/pulmonary embolism and sepsis combined. This has come as a surprise to policy makers, because the latter safety events are more prevalent in the public and policy debate. It is interesting that our findings are confirmed by US evidence that highest payouts from litigation involving preventable safety incidents is due to pressure ulcers. •The findings of our research will have implications on the cost-effectiveness of novel smart bed platforms for monitoring and ulcer prevention. These platforms collect information from various sensors incorporated into the bed, and analyzes the data to create a whole-body pressure distribution map, and commands the bed’s actuators to periodically adjust its surface profile to redistribute pressure over the entire body. This technology is expensive, but considering the great potential health gains, are more cost-effective than previously thought. Dissemination to public: •Presented to policy makers at The Health Foundation, October 2015 R Friebel, K Hauck and P Aylin. Centralisation of acute stroke services in London: Impact evaluation using two treatment groups. Health Economics [UNDER REVIEW] Dissemination to public: •Seminar given at The Health Foundation, 2016 •Presented at Health Economics Research Group Meeting, Imperial College London, 2015 Laudicella M, Walsh B, Munasinghe A, Faiz O. Impact of laparoscopic versus open surgery on hospital costs for colon cancer: a population-based retrospective cohort study. BMJ open. 2016 Nov 1;6(11):e012977. Dissemination to public: •Presented at the National Cancer Research Institute (NCRI) conference in Liverpool, November 2014 4. The policy of granting greater autonomy to NHS providers Kosova R, Marini G, Miraldo M, Shaick M. The Impact of Organizational Change on Firm Performance: Evidence from the Healthcare Sector. Management Science. 2017 [UNDER REVIEW] Dissemination to public: •Presented at International Health Economics Association Boston 2017 Congress, July 2017 •Presented at European Health Economics Association (EuHEA) Conference, Hamburg, July 2016 •Industry Studies Association (ISA) Conference, Washington DC, May 2017 Miraldo M, Shaick M, Stieglitz N. Competition, Aspirations & Organizational Change: Evidence from the English NHS. 2017. [IN PREPARATION] Dissemination to public: •Presented at International Health Economics Association Boston 2017 Congress, July 2017 •Presented at European Health Economics Association (EuHEA) Conference, Hamburg, July 2016 •Presented at Strategic Management Society (SMS) Annual International Conference, Berlin, September 2016 5. Exogenous influences (or shocks) on demand for secondary care including temperature extremes and epidemics "Excess Hospital Admissions Due to Seasonality and Temperature Extremes in the UK” – Laure de Preux, Marisa Miraldo and Rifat Atun •Dissemination to public: •Presented at International Health Economics Association Milan 2015 Congress, July 2015 "The Impact of Heatwaves on inpatient admissions to the English National Health Service between 2001 and 2012” – Marisa Miraldo, Dheeya Rizmie, and Laure de Preux Dissemination to public: •Presented at Imperial College Business School as part of an MRes project, July 2017 Research continues in the stated areas, and once the impact of the benefits has been realised specific feedback will be provided.

Expected measurable benefits

The outcomes Imperial College examines are of direct interest to patients as they include measures of amenable mortality, patient safety, waiting times and access. They are also of direct interest to providers as they include meeting key targets for quality of care and financial performance and to taxpayers, as they pay for NHS care. But, they are primarily of interest to those charged with getting best value from the NHS i.e. policy makers. Hence the outputs and dissemination strategy outlined above focus at this level. Imperial College intend to influence policy with the work as it proceeds, but most impact will be at the end of the research in 2018 when Imperial College have produced a large body of evidence. This application will allow Imperial College Business School’s research team to analyse the impact of two types of exogenous shock on the healthcare system. Using the data provided under this agreement has resulted in a vast array of outputs aimed at policy makers and the public, the benefits which will be achieved from these out puts are primarily focused on the evaluation of policy decisions and changes which all impact on patient pathways, outcomes and thus providing a benefit to the healthcare system. First, the Covid-19 pandemic provides a unique opportunity to study the impact of an unprecedented shock that has completely changed the demand for and supply of healthcare; whereas work on climate-related shocks enables the study of more regular and in some cases more predictable shocks to the healthcare system. The reforms were expensive and their effects are highly contested, both in terms of patient benefits and benefit to tax payers, the extensive outputs produced enable the reforms to be assessed. Understanding their impact on efficiency of service provision and the quality of care experienced by patients is therefore important and will bring benefits to patients through more informed choice and providers through better informed care decisions. On Covid-19, this work will produce estimates of the impacts of the pandemic across different dimensions including short-term and long-term impacts, and impacts across age, geography and SES. Ultimately testing the choices and policy decisions gives patients more choice and an ability to make better decisions. It is too soon to say how the additional COVID-19 research will be used in policy making, but at present input has already been provided to policy making on COVID to Treasury, DHSC economists, and will be providing evidence to the Science and Technology Select Committee in June 2020 The addition of PROMS data permits examination of the gain in health status for patients treated under the NHS, in either NHS or private hospitals. This allows the fact that patients treated in private facilities may be healthier and so easier to treat to be controlled and cannot be done with HES data alone. Direct input has been provided into improving patient outcomes during COVID (for example in developing the J-IDEA coronavirus planning tool https://www.imperial.ac.uk/news/197353/j-idea-launches-coronavirus-pandemic-hospital-planning/ intended explicitly to help hospitals across the world deal with the demands of treatment of COVID-19. On climate-related shocks, the study aims to understand which individuals and how they are affected by weather extremes, as well as the policy reforms that have permitted to best respond to these increased shocks in demand. Together, this work will assess whether granting greater autonomy to NHS leads to improved care. Imperial College Business School research team’s results will allow the assessment of what types of policies allow better management of these exogenous shocks, and will support the NHS to prepare, anticipate and adapt to future shocks. It will also ensure that the healthcare system is continuously optimising to ensure that patients receive the greatest level of care and achieve positive outcomes.

Benefits reported

Past research using HES data has been highly influential in policy design in the English NHS. For example, in an assessment for the 2014 Research Evaluation Framework (REF) assessment of the impact of research in UK Universities, a former head of policy at the Department of Health and a current member of the NHS England Board commented on the impact of research by Propper on competition policy in the NHS as follows: “In my 20 years’ experience in Government it is most unusual for even the best research work to have such influence as that on competition undertaken by Professor Propper”. Imperial College aim to make a similar impact with the research outlined above (2017). Past work using HES has been very influential in decisions over setting of regulated prices in the NHS, research showed that moving away from regulated prices harmed healthcare users by increasing mortality. It has also been shown that waiting list targets for elective care designed to eliminate very long waiting lists do not harm healthcare users and this has informed policy on use of waiting lists. Research is currently being undertaken for a single large multisite Trust on the impact of staff absences on patient outcomes, intended to help the Trust manage absences and identify where reducing absences may most benefit patients. Research has illustrated that the greatest loss of healthy life years, among six safety incidents in English hospitals, is caused by pressure ulcers. They lead to a greater loss of life than central line infections, deep vein thrombosis/pulmonary embolism and sepsis combined. This has come as a surprise to policy makers, because the latter safety events are more prevalent in the public and policy debate. It is interesting that findings are confirmed by US evidence, that highest payouts from litigation involving preventable safety incidents is due to pressure ulcers. The findings of the research will have implications on the cost-effectiveness of novel smart bed platforms for monitoring and ulcer prevention. This technology is expensive, but considering the great potential health gains, are more cost-effective than previously thought. Exogenous influences (or shocks) on demand for secondary care including temperature extremes and epidemics "Excess Hospital Admissions Due to Seasonality and Temperature Extremes in the UK” – Laure de Preux, Marisa Miraldo and Rifat Atun •Dissemination to public: •Presented at International Health Economics Association Milan 2015 Congress, July 2015 "The Impact of Heatwaves on inpatient admissions to the English National Health Service between 2001 and 2012” – Marisa Miraldo, Dheeya Rizmie, and Laure de Preux Dissemination to public: •Presented at Imperial College Business School as part of an MRes project, July 2017 •iHEA 12th World Congress in Health Economics, Boston University, USA 2017 •Royal Economic Society annual conference, Bristol, UK 2017 •EuHEA Maastricht 2018 •Oxford International Health Congress 2018 •EuHEA PhD Workshop Catania 2018 •EAERE Venice Summer School 2019. Rizmie D, Miraldo M, Atun R, de Preux Let al., 2019, The effect of extreme temperature on emergency admissions across vulnerable populations in England: an observational study, Lancet Public Health Science 2019 Conference, Publisher: Elsevier, Pages: S7-S7 Pimpin L, Retat L, Fecht D, de Preux L, Sassi F, Gulliver J, Belloni A, Ferguson B, Corbould E, Jaccard A, Webber Let al., 2018, Estimating the costs of air pollution to the National Health Service and social care: An assessment and forecast up to 2035, PLoS Medicine, Vol: 15, ISSN: 1549-1277 Janke, K, K Lee, C Propper, K Shields and M Shields (2020), “Macroeconomic conditions and health in Britain: Aggregation, Dynamics and local area heterogeneity”, CEPR Discussion Paper 14507, IFS Discussion paper 2020, IZA Discussion Paper No. 13091.

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

Datasets: + Patient Reported Outcome Measures (Linkable to HES)

Objective for processing

The agreement is being amended to append the latest years of HES APC, A&E and OP data from 2015/2016 until 2019/2020 along with PROMS data to match the corresponding HES years, released on an annual basis. Imperial College London will continue to use HES APC, A&E and OP data already provided for the same purposes as before. Additional years are required to evaluate the medium run effects of the policy changes occurring in the mid-2000s up to the Health and Social Care Act 2012 (e.g. the lead time for private hospital chains opening new sites is several years). The study will use PROMs linked to HES data to investigate the effects of greater private and voluntary provision of publicly-funded care on outcomes for NHS patients, equity of access to care and overall NHS costs. It will concentrate on the elective procedures most commonly done by private providers, specifically hip and knee replacements. PROMs data are crucial for this study, as they will be the basis for measuring quality of elective surgery at NHS trusts and private hospitals. The additional research will focus on policy 2 detailed further on in this section. Use of the private sector for elective surgery has continued to grow, with private providers now conducting more than a quarter of NHS-funded primary hip and knee replacement (National Joint Registry, 2018). The research will investigate how public providers differ in terms of quality, selection of patients for treatment and efficiency. Original Purpose [6 paragraphs unchanged] (1) The policy of choice and competition between NHS providers of care. [24 words unchanged] system (PbR), gave incentives to increase activity. Imperial College has examined the short term short-term impact of these policies (pre-2010). The focus will now be on the longer term, and impact and will be analysed until 2015. 2017. (2) The policy of promoting a greater role for private and voluntary [18 words unchanged] providers (ISTCs) in the early 2000s, but has subsequently been extended. It now currently includes the extensive widespread use of contracting for both hospital and community based community-based services and franchising of hospital management to private sector bodies (e.g. Circle). Imperial College will be examining examine the impact of this policy on outcomes for patients undergoing joint replacements as these are widely provided by private sector providers. and other common elective surgeries. (3) The use of networks and guidelines to increase quality of care and patient safety, innovation and the diffusion of good practice in important hospital based hospital-based treatments. NICE guidance, in particular clinical guidelines, has transformed clinical practice over [35 words unchanged] and cancer networks, in which hospitals cooperate to improve care for patients. [2 paragraphs unchanged] These policy reforms impact on the organisational structure for health care delivery in England England, and work continues in all these areas, with new programmes of work [6 words unchanged] of current concerns over the level of hospital funding with in the NHS NHS, and the healthcare delivery system’s ability to cope with shocks to the [43 words unchanged] weather on the amount and costs of hospital admissions at Trust level.

Processing activities

[2 paragraphs unchanged] The measures to assess the impact of policies that Imperial College will [22 words unchanged] measures of patient safety (e.g. avoidable deaths, adverse incidents), quality of care (e.g. pressure sores, (including improvement in PROMs, readmission rates, infection rates, adverse events), measures of access (e.g. median or [80 words unchanged] outcomes, Imperial College need to be able to use the raw HES data. data and linked PROMs. These measures will be constructed from the analysis of individual patient level data using appropriate statistical methods to deal with sampling and other statistical issues (detailed below). From HES data and PROMS linked to HES, Imperial College derive measures of outcomes for patients (specifics given below for each policy area) and data on patient severity, to allow us the study to control for case-mix. To these data Imperial College will match publicly [28 words unchanged] that is the level for which publicly available data is available. In a few some cases, the patient level data will be aggregated to site level [19 words unchanged] College will not be matching to data sources at the patient level. The administrative trust-level data Imperial College will match includes data from Trust [20 words unchanged] of all NHS employees; from local authorities; and socio-economic data at the MSOA Middle Layer Super Output Area (MSOA) or LSOA Lower Layer Super Output Area (LSOA) level. The data to be matched depends on the specific research question. For example, the customer will match data on trust financial performance for policy area areas (2) and (4) but not for policy area (3). For policy area (3) the [8 words unchanged] strokes. This will not be used for analyses for policy area (4). All the data Imperial College will match in is at Trust or site level and it is all in the [50 words unchanged] or graphical and will be in line with the HES analysis guide. For policy area (1) identified above above, Imperial College will use HES and linked PROMs data on hip and knee replacements to examine outcomes for patient’s patients under-going these procedures. Imperial College will construct measures of volume, case-mix, waiting times, improvement in functional mobility (measured using Oxford hip/knee scores) and readmissions for hip readmissions, and knees. procedure revision rates. Imperial College will also examine HES data on maternity patients and examine within hospital deaths of babies, and fetal foetal and maternal complications. For policy area (2) Imperial College will examine the impact of greater involvement of private and voluntary providers in the provision of publicly funded care on NHS providers. Imperial College will focus patients’ outcomes, focusing on hip and knee replacement surgery. Imperial College will use PROMs data linked to HES data to construct the same measures of performance of NHS providers and private providers as detailed for policy area (1) above. These data will be matched with location data on private and public providers. This will allow us to construct technical measures Measures of market structure (HHI (e.g. HHI indices) will be calculated from the patient flow data in HES. The location data will also be used to carry out instrumental variables analysis, to reduce the potential bias from being unable to control fully for case-mix using HES. Specifically, an instrument for patient choice of hospital will be constructed using differential distance of patients from NHS/private hospitals. For policy area (3) Imperial College will examine the impact of the [52 words unchanged] central line infection, post-operative hip fracture, obstetric complications, and some of the more rare rarer events including foreign body left in body after surgery. These indicators will be constructed at the patient level. Imperial College will use controls for potential patient level confounders. [6 paragraphs unchanged] Tied to the new programme of work into weather variations, Imperial College will match publicly available weather station data to the HES information. The weather data will comes come from the Met Office Integrated Data Archive System (MISAD) database, which provides [30 words unchanged] re-identification and will be done in line with the HES analysis guide. 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 ie: employees, agents and contractors of the Data Recipient who may have access to that data Data will only be accessed and processed by substantive employees of Imperial College London and will not be accessed or processed by any other third parties not mentioned in this agreement. PROMS data is only available for non-commercial purposes, such as academic research, or in connection with delivering services to the NHS.

Expected output

[6 paragraphs unchanged] Target dates for outputs - some of which have now been achieved. [2 paragraphs unchanged] •Research on the impact of management on NHS acute care provider performance (initial paper 2015 (achieved), later papers to be produced up to 2018) 2018/19) [3 paragraphs unchanged] •Access has not been granted to PROMS data for this project •Imperial now have plans to use PROMS data to further support this work with research starting late 2018. •An additional new project examines this topic and outputs are expected in 2019 [10 paragraphs unchanged] •On impact of climate shocks, such as a heat wave, on the number and cost of hospital admissions admissions. [1 paragraph unchanged] Current Completed Outputs [46 paragraphs unchanged] •We now have plans to use PROMS in our research starting late 2018 [32 paragraphs unchanged]

Expected measurable benefits

[4 paragraphs unchanged] The addition of PROMS data permits examination of the gain in health status for patients treated under the NHS, in either NHS or private hospitals. This allows the fact that patients treated in private facilities may be healthier and so easier to treat to be controlled and cannot be done with HES data alone.

Benefits reported

[1 paragraph unchanged] Research by Katharina Hauck has illustrated that the greatest loss of healthy life years, among six [44 words unchanged] more prevalent in the public and policy debate. It is interesting that our findings are confirmed by US evidence evidence, that highest payouts from litigation involving preventable safety incidents is due to pressure ulcers. The findings of our the research will have implications on the cost-effectiveness of novel smart bed platforms [10 words unchanged] considering the great potential health gains, are more cost-effective than previously thought.