National Audit Office - Various Value-for-Money (VFM) audit reports

The National Audit Office (NAO) scrutinises public spending for Parliament. The NAO’s public audit duties help Parliament hold government to account and improve public services.

The NAO is led by the Comptroller and Auditor General (C&AG) who is an officer of the House of Commons. The C&AG and the staff of the NAO are independent of government. They are not civil servants and do not report to a minister. The NAO is funded directly by Parliament.

In addition to auditing the financial statements of all central government departments, agencies and other specified public bodies, the NAO performs examinations into the economy, efficiency and effectiveness with which audited bodies have used their resources. The NAO reports the results of its work to Parliament and this informs meetings of the Public Accounts Committee – a select committee of the House of Commons where government officials are held to account.

The NAO publishes around sixty reports a year. Typically referred to as “value for money” (VFM) reports or “investigations” these cover a wide range of issues. For example, in the health area, recent reports have covered topics from those on specific services such as cancer services and diabetes to system wide issues such as the financial sustainability of the NHS. Data provided by NHS Digital, including Hospital Episode Statistics, have played an important role in informing these reports and therefore helping Parliament to challenge and hold the Department of Health and Social Care and the NHS to account. For example, the HES data NAO had in house allowed the NAO to carry out timely analysis of the types of activity and case mix by NHS trusts and foundation trusts, as well as their exposure to payments which are based on national tariff. Findings from these analyses were used to inform NAO’s regression analysis to better understand the underlying drivers of a trust’s financial position which in turn formed part of NAO’s evidence base for our VFM conclusion.

For NAO’s report on managing emergency admissions, both admitted patient HES data and A&E data were analysed in detail to provide the NAO with the independent evidence required on the trends and variations in A&E attendances, admissions (including readmissions) and discharge patterns as well as trends in length of stay both at national level, by trusts and by CCGs. Findings from these analyses were used extensively as evidence in NAO’s published reports on the subjects.

The C&AG audit powers are widely drawn and allows the officer to exercise discretion in the choice of examinations performed and how to report the results of the officer’s examinations. The C&AG also has broad powers of access to documents, information and explanations that the C&AG officer reasonably requires to support his/her work. When undertaking an examination, the C&AG is not permitted to question the merits of policy objectives.

Key legislation relating to the C&AG and the NAO includes:

• National Audit Act 1983 – which provides the C&AG with a power to perform examinations into the economy, efficiency and effectiveness with which specified bodies have used their resources.

• Government Resources and Accounts Act 2000 – which makes the C&AG the financial auditor of bodies specified in the Act.

• Budget Responsibility and National Audit Act 2011 – which puts in place the administrative and governance framework for the C&AG and the NAO.

In exercising the C&AG officer’s statutory responsibilities, the C&AG is committed to meeting his/her obligations under wider public law – for example, the Data Protection Act 2018 and the General Data Protection Regulation.

The NAO requires data from NHS Digital to inform its decision making about which examinations to undertake and to assist the conduct of such examinations. The NAO’s work can range across the entirety of the NHS, looking at value for money issues which are likely to encompass some or all of the following objectives.

Objective One

Improving financial management and reporting including through the production of timely and well-targeted VFM reports.

Objective Two

Helping the Department of Health and the NHS to deliver services more cost-effectively.

Objective Three

Enabling the Department of Health and the NHS to make better use of the information they hold.

Objective Four

Providing responses to parliamentary and public enquiries, in particular from the Public Accounts Committee and the Health and Social Care Committee.

Objective Five

Carrying out investigative work where there is a risk to public money.

Objective Six

Data will also be used to increase the effectiveness of the NAO Health audit team and to monitor the impact of NAO's work and the progress Government makes in implementing NAO and Public Accounts Committee recommendations.

To help the NAO perform its statutory role, it needs to continue to utilise the unfiltered pseudonymised healthcare data shown below. As in the past, the NAO would be a data controller in respect of its use of the following:

• Hospital Episode Statistics: Admitted Patient Care

• Hospital Episode Statistics: Outpatients

• Hospital Episode Statistics: Critical Care

• Hospital Episode Statistics: Accident & Emergency

• Secondary Uses Service: Episodes

• Secondary Uses Service: Spells

• Secondary Uses Service: Outpatients

• Secondary Uses Service: Accident & Emergency

• Mental Health Minimum Data Set

• Mental Health and Learning Disabilities Data Set

• Mental Health Services Data Set

• Improving Access to Psychological Therapies Data Set

• Civil Registration Mortality (Secondary Care Cut)

The role of the NAO in relation to Health VFM is such that it covers the entirety of England, and all services funded by public money. To understand the effectiveness, efficiency and economy with which the Department of Health and the NHS have implemented their policies, and provided the services to meet their wide ranging objectives, the NAO needs to examine trends and variations (for example, by provides, commissioners or by different patient groups) on a frequent basis as outlined in the processing activities section below. Given the frequency of use of HES data in NAO’s VFM studies, the NAO considered that holding these data routinely at the NAO is the least burdensome to both NAO’s clients and the NAO as opposed to request this on a case by case basis (otherwise, the NAO will have to go through this process on a number of occasions each year). Given the wide ranging of topics NAO cover each year and the speed with which NAO carry out VFM fieldwork (2-6 months for most of the studies), it is not practical to request this on a case by case basis unless NHS Digital give free access as and when required by the NAO. NAO have sought to minimise the requested data by excluding all sensitive data and excluding any datasets that NAO are unlikely to use over the next two to three years.

To clarify, the National Audit Office is the data controller who also processes the data for these purposes. The data will be processed under GDPR article 6(1)(e) and article 9(2)(g).

Outputs will only contain aggregate level data with small numbers suppressed in line with the HES Analysis Guide. Data may be used to provide insights only or to provide evidence, in that case, only data at aggregated level, for example, by geographic area or demographic characteristics, will be disclosed. Descriptive data and other analytical outputs may be reported as evidence in published reports. Some analysis and insights generated will be shared with NHS and other health and social care bodies to help them to improve services. Record-level data will be not be commented on or published.

Client bodies (the Department of Health, its Arms-length bodies, the NHS and other relevant bodies funded by public money) which are audited on behalf of Parliament may have access to outputs of the analysis with the data but will not be granted access to the datasets that are held.

The linked civil registration mortality data will be used to inform a range of the outputs. These outputs include VFM reports, investigations, replies to correspondence and a range of other outputs at the request of Health Select Committee and other parliamentary committees, and additionally respond to public enquires including whistle blowing. For example, some of the planned VFM/investigation work require examining the trend in demand for health care by people towards the end of their life. The linked HES mortality data will help NAO examine the trends and variations in service utilisations (for example, by geographic location or by NHS providers) by people towards the end of their life.

For previous evidence of VFM studies and other reports, see http://www.nao.org.uk/search/type/report/sector/health-and-social-care

Value for Money

In general, the Health VFM team will produce approximately seven VFM reports per year to Parliament on the economy, efficiency and effectiveness with which the Department of Health and its constituent bodies use public money. The actual number of reports, the subject covered and the timing of the reports will be agreed with the Public Accounts Committee on an annual basis and may be subject to change at short notice based on current events, timing with other studies and PAC demand, and will vary from year to year. For this reason it is difficult to disclose specific study topics, though all studies will fall under the guidelines outlined here.

A typical VFM study will last between 3-12 months but can be longer depending on the subject. A typical VFM study will include findings (and evidence to support these findings) on the performance by Government Departments and other public bodies, a conclusion on whether VFM has been achieved and recommendations for the Department in order to improve services. The target date for a given study depends on when it begins, which can be at any point during the year when Parliament is sitting.

Other objectives

A range of other outputs are produced at the request of Health Select Committee and other parliamentary committees, and additionally respond to public enquires including whistle-blowing.

Investigative work is carried out if there a risk to public money or suspicions of wrongdoing within central government. Actual content, timing and format of these outputs will vary and can be unpredictable, but the objective will be the same, to hold the Government and other public bodies accountable and to help them to improve services.

Support is provided to Health Select Committee and other smaller investigatory pieces of work conducted. This is triggered by correspondence from committee members, with other work typically triggered by correspondence from other concerned MPs and members of the public. It is expected on average to produce four pieces over a given year, but this depends on if and when NAO is contacted. Outputs will typically be a shorter piece of research and without a VFM conclusion, but will otherwise follow a similar format to the VFM studies. Again, there are clear restrictions in using individual level data.

All NAO published reports will be publicly available on the website http://www.nao.org.uk under reports by sector. If the evidence used in the report is based on analysis using HES data, either from NAO analysis of record level data or HES online summary, NAO will clearly attribute this to the source, including who carried out the analysis.

In 2018 the NAO published 11 reports into health and social care on the website, covering topics from A review of the role and costs of clinical commissioning groups, Improving children and young people’s mental health services, a Departmental Overview for the Department of Health and Social Care 2017 – 18; Adult Social Care at a glance; The health and social care interface, Developing new care models through NHS vanguards, Investigation on NHS spending on generic medicines in primary care, NHS England’s management of the primary care support services contract with Capita, Reducing emergency admissions, The adult social care workforce in England, Investigation into clinical correspondence handling in the NHS and sustainability and transformation in the NHS.

In 2019 there have been 6 reports published on the NAO website, covering Local Auditor reporting in England 2018, Investigation in to the management screening, NHS waiting times for elective and cancer screening, Investigation in to penalty charge notices in healthcare and Investigation into NHS Property Services Limited.

Apart from public access to NAO outputs, NHS Digital (as part of the DH group) will have access to NAO outputs in different ways at different stages of the NAO report. Depending on the nature of the report and the main body being audited, relevant outputs from analysis based on data provided by NHS Digital, on some occasions, NAO may clear directly with relevant staff from NHS Digital; on other occasions, NAO may clear the analysis with Department of Health or NHS England and other bodies from DH group, who in turn may seek advice from NHS Digital for the accuracy of NAO analysis. NAO analysis will be cleared with the Department and other relevant bodies in the DH group for factual accuracy.

If the outcomes from NAO analysis of HES data are used for intelligence only or for discussions with the Department of Health and their constituent bodies, then these information will not be published for public access and NHS Digital will not usually have access to these outputs (unless HSCIC is involved directly in the discussion). However, NAO will always seek advice from NHS Digital if unsure about certain data items or the appropriateness of the methods applied given the nature of the HES data.

Studies cannot be confirmed until they have been cleared by the Comptroller and Auditor General and the Public Accounts Committee at a reasonable point after initial development on the study has begun. NAO are therefore unable to provide a list and ETA for future studies. For all studies in progress the information will be made available on the NAO website under the work in progress page: http://www.nao.org.uk/work-in-progress/

The NAO publish 6 - 7 value for money studies / investigations, as well as 2 - 3 health insights each year. Most but not all of these studies have been informed by analysis of these datasets. Each of NAO’s reports contains recommendations to the Department of Health and Social Care which help the Department make better use of public money to improve healthcare. In the last 12 months these have included value for money studies into NHS waiting times for elective cancer treatment and Improving children and young people’s mental health services. NAO’s studies have helped Parliament to hold the Department of Health and Social Care and other NHS bodies to account for the money they spent on health and social care, and for improving health outcomes for the population. Many of the studies have not only helped NHS to improve its services, but also led to financial savings, for example:

Case study 1 (see NAO annual report 2017-18):

Improving patient access to general practice

NAO’s January 2017 study into improving patient access to general practice highlighted that 18% of practices closed by 3pm on at least one weekday. This was despite three-quarters of practices that closed receiving additional payments to provide access outside core hours. NAO’s evidence suggested shorter opening hours are associated with poorer outcomes, including an increased chance of attending accident and emergency. (this analysis was informed by the HES data NAO have in house)

IMPACT

NHS England committed to review whether GP practices’ opening hours are meeting patients’ needs. In addition, NHS England and the British Medical Association agreed that, from October 2017, no practice that closes for half a day on a weekly basis would receive additional payments for extending their opening hours, unless by written prior agreement of NHS England. (To date, no practice has applied to do so.) This change ensures that patient access is maintained during core hours, while providing additional incentives to GP practices to open for longer, increasing patients’ access to their GP.

Case study 2:

Delivering the cancer reform strategy:

NAO’s 2010 study examined the admissions patterns for patients with cancer using the HES data NAO had in house at the time. NAO highlighted the variations in hospital admissions in particular the number of emergency admissions and recommended the NHS to focus on this area for further improvement.

IMPACT:

The report helped the NHS to renew its focus on improving services for cancer patients and led to a reduction in hospital emergency admissions by cancer patients. NAO reviewed the service utilisation patterns in hospitals by cancer patients, using HES data in 2017-18, and identified 9 million savings that could be contributed to NAO’s recommendations (see NAO annual report 2017-18).

The National Audit Office (NAO) scrutinises public spending for Parliament. The NAO’s public audit duties help Parliament hold government to account and improve public services.

The NAO is led by the Comptroller and Auditor General (C&AG) who is an officer of the House of Commons. The C&AG and the staff of the NAO are independent of government. They are not civil servants and do not report to a minister. The NAO is funded directly by Parliament.

In addition to auditing the financial statements of all central government departments, agencies and other specified public bodies, the NAO performs examinations into the economy, efficiency and effectiveness with which audited bodies have used their resources. The NAO reports the results of its work to Parliament and this informs meetings of the Public Accounts Committee – a select committee of the House of Commons where government officials are held to account.

The NAO publishes around sixty reports a year. Typically referred to as “value for money” (VFM) reports or “investigations” these cover a wide range of issues. For example, in the health area, recent reports have covered topics from those on specific services such as cancer services and diabetes to system wide issues such as the financial sustainability of the NHS. Data provided by NHS Digital, including Hospital Episode Statistics, have played an important role in informing these reports and therefore helping Parliament to challenge and hold the Department of Health and Social Care and the NHS to account. For example, the HES data NAO had in house allowed the NAO to carry out timely analysis of the types of activity and case mix by NHS trusts and foundation trusts, as well as their exposure to payments which are based on national tariff. Findings from these analyses were used to inform NAO’s regression analysis to better understand the underlying drivers of a trust’s financial position which in turn formed part of NAO’s evidence base for our VFM conclusion.

For NAO’s report on managing emergency admissions, both admitted patient HES data and A&E data were analysed in detail to provide the NAO with the independent evidence required on the trends and variations in A&E attendances, admissions (including readmissions) and discharge patterns as well as trends in length of stay both at national level, by trusts and by CCGs. Findings from these analyses were used extensively as evidence in NAO’s published reports on the subjects.

The C&AG audit powers are widely drawn and allows the officer to exercise discretion in the choice of examinations performed and how to report the results of the officer’s examinations. The C&AG also has broad powers of access to documents, information and explanations that the C&AG officer reasonably requires to support his/her work. When undertaking an examination, the C&AG is not permitted to question the merits of policy objectives.

Key legislation relating to the C&AG and the NAO includes:

• National Audit Act 1983 – which provides the C&AG with a power to perform examinations into the economy, efficiency and effectiveness with which specified bodies have used their resources.

• Government Resources and Accounts Act 2000 – which makes the C&AG the financial auditor of bodies specified in the Act.

• Budget Responsibility and National Audit Act 2011 – which puts in place the administrative and governance framework for the C&AG and the NAO.

In exercising the C&AG officer’s statutory responsibilities, the C&AG is committed to meeting his/her obligations under wider public law – for example, the Data Protection Act 2018 and the General Data Protection Regulation.

The NAO requires data from NHS Digital to inform its decision making about which examinations to undertake and to assist the conduct of such examinations. The NAO’s work can range across the entirety of the NHS, looking at value for money issues which are likely to encompass some or all of the following objectives.

Objective One

Improving financial management and reporting including through the production of timely and well-targeted VFM reports.

Objective Two

Helping the Department of Health and the NHS to deliver services more cost-effectively.

Objective Three

Enabling the Department of Health and the NHS to make better use of the information they hold.

Objective Four

Providing responses to parliamentary and public enquiries, in particular from the Public Accounts Committee and the Health and Social Care Committee.

Objective Five

Carrying out investigative work where there is a risk to public money.

Objective Six

Data will also be used to increase the effectiveness of the NAO Health audit team and to monitor the impact of NAO's work and the progress Government makes in implementing NAO and Public Accounts Committee recommendations.

To help the NAO perform its statutory role, it needs to continue to utilise the unfiltered pseudonymised healthcare data shown below. As in the past, the NAO would be a data controller in respect of its use of the following:

• Hospital Episode Statistics: Admitted Patient Care

• Hospital Episode Statistics: Outpatients

• Hospital Episode Statistics: Critical Care

• Hospital Episode Statistics: Accident & Emergency

• Secondary Uses Service: Episodes

• Secondary Uses Service: Spells

• Secondary Uses Service: Outpatients

• Secondary Uses Service: Accident & Emergency

• Mental Health Minimum Data Set

• Mental Health and Learning Disabilities Data Set

• Mental Health Services Data Set

• Improving Access to Psychological Therapies Data Set

• Civil Registration Mortality (Secondary Care Cut)

The role of the NAO in relation to Health VFM is such that it covers the entirety of England, and all services funded by public money. To understand the effectiveness, efficiency and economy with which the Department of Health and the NHS have implemented their policies, and provided the services to meet their wide ranging objectives, the NAO needs to examine trends and variations (for example, by provides, commissioners or by different patient groups) on a frequent basis as outlined in the processing activities section below. Given the frequency of use of HES data in NAO’s VFM studies, the NAO considered that holding these data routinely at the NAO is the least burdensome to both NAO’s clients and the NAO as opposed to request this on a case by case basis (otherwise, the NAO will have to go through this process on a number of occasions each year). Given the wide ranging of topics NAO cover each year and the speed with which NAO carry out VFM fieldwork (2-6 months for most of the studies), it is not practical to request this on a case by case basis unless NHS Digital give free access as and when required by the NAO. NAO have sought to minimise the requested data by excluding all sensitive data and excluding any datasets that NAO are unlikely to use over the next two to three years.

To clarify, the National Audit Office is the data controller who also processes the data for these purposes. The data will be processed under GDPR article 6(1)(e) and article 9(2)(g).

Outputs will only contain aggregate level data with small numbers suppressed in line with the HES Analysis Guide. Data may be used to provide insights only or to provide evidence, in that case, only data at aggregated level, for example, by geographic area or demographic characteristics, will be disclosed. Descriptive data and other analytical outputs may be reported as evidence in published reports. Some analysis and insights generated will be shared with NHS and other health and social care bodies to help them to improve services. Record-level data will be not be commented on or published.

Client bodies (the Department of Health, its Arms-length bodies, the NHS and other relevant bodies funded by public money) which are audited on behalf of Parliament may have access to outputs of the analysis with the data but will not be granted access to the datasets that are held.

The linked civil registration mortality data will be used to inform a range of the outputs. These outputs include VFM reports, investigations, replies to correspondence and a range of other outputs at the request of Health Select Committee and other parliamentary committees, and additionally respond to public enquires including whistle blowing. For example, some of the planned VFM/investigation work require examining the trend in demand for health care by people towards the end of their life. The linked HES mortality data will help NAO examine the trends and variations in service utilisations (for example, by geographic location or by NHS providers) by people towards the end of their life.

For previous evidence of VFM studies and other reports, see http://www.nao.org.uk/search/type/report/sector/health-and-social-care

Value for Money

In general, the Health VFM team will produce approximately seven VFM reports per year to Parliament on the economy, efficiency and effectiveness with which the Department of Health and its constituent bodies use public money. The actual number of reports, the subject covered and the timing of the reports will be agreed with the Public Accounts Committee on an annual basis and may be subject to change at short notice based on current events, timing with other studies and PAC demand, and will vary from year to year. For this reason it is difficult to disclose specific study topics, though all studies will fall under the guidelines outlined here.

A typical VFM study will last between 3-12 months but can be longer depending on the subject. A typical VFM study will include findings (and evidence to support these findings) on the performance by Government Departments and other public bodies, a conclusion on whether VFM has been achieved and recommendations for the Department in order to improve services. The target date for a given study depends on when it begins, which can be at any point during the year when Parliament is sitting.

Other objectives

A range of other outputs are produced at the request of Health Select Committee and other parliamentary committees, and additionally respond to public enquires including whistle-blowing.

Investigative work is carried out if there a risk to public money or suspicions of wrongdoing within central government. Actual content, timing and format of these outputs will vary and can be unpredictable, but the objective will be the same, to hold the Government and other public bodies accountable and to help them to improve services.

Support is provided to Health Select Committee and other smaller investigatory pieces of work conducted. This is triggered by correspondence from committee members, with other work typically triggered by correspondence from other concerned MPs and members of the public. It is expected on average to produce four pieces over a given year, but this depends on if and when NAO is contacted. Outputs will typically be a shorter piece of research and without a VFM conclusion, but will otherwise follow a similar format to the VFM studies. Again, there are clear restrictions in using individual level data.

All NAO published reports will be publicly available on the website http://www.nao.org.uk under reports by sector. If the evidence used in the report is based on analysis using HES data, either from NAO analysis of record level data or HES online summary, NAO will clearly attribute this to the source, including who carried out the analysis.

In 2018 the NAO published 11 reports into health and social care on the website, covering topics from A review of the role and costs of clinical commissioning groups, Improving children and young people’s mental health services, a Departmental Overview for the Department of Health and Social Care 2017 – 18; Adult Social Care at a glance; The health and social care interface, Developing new care models through NHS vanguards, Investigation on NHS spending on generic medicines in primary care, NHS England’s management of the primary care support services contract with Capita, Reducing emergency admissions, The adult social care workforce in England, Investigation into clinical correspondence handling in the NHS and sustainability and transformation in the NHS.

In 2019 there have been 6 reports published on the NAO website, covering Local Auditor reporting in England 2018, Investigation in to the management screening, NHS waiting times for elective and cancer screening, Investigation in to penalty charge notices in healthcare and Investigation into NHS Property Services Limited.

Apart from public access to NAO outputs, NHS Digital (as part of the DH group) will have access to NAO outputs in different ways at different stages of the NAO report. Depending on the nature of the report and the main body being audited, relevant outputs from analysis based on data provided by NHS Digital, on some occasions, NAO may clear directly with relevant staff from NHS Digital; on other occasions, NAO may clear the analysis with Department of Health or NHS England and other bodies from DH group, who in turn may seek advice from NHS Digital for the accuracy of NAO analysis. NAO analysis will be cleared with the Department and other relevant bodies in the DH group for factual accuracy.

If the outcomes from NAO analysis of HES data are used for intelligence only or for discussions with the Department of Health and their constituent bodies, then these information will not be published for public access and NHS Digital will not usually have access to these outputs (unless HSCIC is involved directly in the discussion). However, NAO will always seek advice from NHS Digital if unsure about certain data items or the appropriateness of the methods applied given the nature of the HES data.

Studies cannot be confirmed until they have been cleared by the Comptroller and Auditor General and the Public Accounts Committee at a reasonable point after initial development on the study has begun. NAO are therefore unable to provide a list and ETA for future studies. For all studies in progress the information will be made available on the NAO website under the work in progress page: http://www.nao.org.uk/work-in-progress/

The NAO publish 6 - 7 value for money studies / investigations, as well as 2 - 3 health insights each year. Most but not all of these studies have been informed by analysis of these datasets. Each of NAO’s reports contains recommendations to the Department of Health and Social Care which help the Department make better use of public money to improve healthcare. In the last 12 months these have included value for money studies into NHS waiting times for elective cancer treatment and Improving children and young people’s mental health services. NAO’s studies have helped Parliament to hold the Department of Health and Social Care and other NHS bodies to account for the money they spent on health and social care, and for improving health outcomes for the population. Many of the studies have not only helped NHS to improve its services, but also led to financial savings, for example:

Case study 1 (see NAO annual report 2017-18):

Improving patient access to general practice

NAO’s January 2017 study into improving patient access to general practice highlighted that 18% of practices closed by 3pm on at least one weekday. This was despite three-quarters of practices that closed receiving additional payments to provide access outside core hours. NAO’s evidence suggested shorter opening hours are associated with poorer outcomes, including an increased chance of attending accident and emergency. (this analysis was informed by the HES data NAO have in house)

IMPACT

NHS England committed to review whether GP practices’ opening hours are meeting patients’ needs. In addition, NHS England and the British Medical Association agreed that, from October 2017, no practice that closes for half a day on a weekly basis would receive additional payments for extending their opening hours, unless by written prior agreement of NHS England. (To date, no practice has applied to do so.) This change ensures that patient access is maintained during core hours, while providing additional incentives to GP practices to open for longer, increasing patients’ access to their GP.

Case study 2:

Delivering the cancer reform strategy:

NAO’s 2010 study examined the admissions patterns for patients with cancer using the HES data NAO had in house at the time. NAO highlighted the variations in hospital admissions in particular the number of emergency admissions and recommended the NHS to focus on this area for further improvement.

IMPACT:

The report helped the NHS to renew its focus on improving services for cancer patients and led to a reduction in hospital emergency admissions by cancer patients. NAO reviewed the service utilisation patterns in hospitals by cancer patients, using HES data in 2017-18, and identified 9 million savings that could be contributed to NAO’s recommendations (see NAO annual report 2017-18).

The data will be used to focus on three areas that impact on all departments’ performance in achieving value for money (as defined by objectives one to three) as well as additional objectives four to eight.

Objective One

Improving financial management and reporting including production of Value For Money (VFM) reports

Objective Two

Making better use of information

Objective Three

Ensuring that services are delivered cost-effectively.

Objective Four

Providing responses to public enquiries and whistle blowing e.g. Public Accounts Committee, Health Select Committee and in some cases other Select Committees from Parliament.

Objective Five

Carrying out investigative work where there is risk to public money.

Objective Six

Generating insights into client bodies internally.

Objective Seven

Sharing insights with the Government including the Treasury and the Cabinet Office, local governments and NHS bodies to help them to improve services as required.

Objective Eight

Data will also be used to monitor the impact of the work and the progress made by the Government in improving services following recommendations from the Public Accounts Committee.

Outputs will only contain aggregate level data with small numbers suppressed in line with the HES Analysis Guide. Data may be used to provide insights only or to provide evidence, in that case, only data at aggregated level, for example, by geographic area or demographic characteristics, will be disclosed. Descriptive data and other analytical outputs may be reported as evidence in published reports. Some analysis and insights generated will be shared with NHS and other health and social care bodies to help them to improve services. Record-level data will be not be commented on or published.

Client bodies (the Department of Health, its Arms-length bodies, the NHS and other relevant bodies funded by public money) which are audited on behalf of Parliament may have access to outputs of the analysis with the data but will not be granted access to the datasets that are held.

The linked ONS mortality data will be used to inform a range of the outputs. These outputs include VFM reports, investigations, replies to correspondence and a range of other outputs at the request of Health Select Committee and other parliamentary committees, and additionally respond to public enquires including whistle blowing. For example, some of the planned VFM/investigation work require examining the trend in demand for health care by people towards the end of their life. The linked HES-ONS mortality data will help NAO examine the trends and variations in service utilisations (for example, by geographic location or by NHS providers) by people towards the end of their life.

For previous evidence of VFM studies and other reports, see http://www.nao.org.uk/search/type/report/sector/health-and-social-care

Value for Money

In general, the Health VFM team will produce approximately seven VFM reports per year to Parliament on the economy, efficiency and effectiveness with which the Department of Health and its constituent bodies use public money. The actual number of reports, the subject covered and the timing of the reports will be agreed with the Public Accounts Committee on an annual basis and may be subject to change at short notice based on current events, timing with other studies and PAC demand, and will vary from year to year. For this reason it is difficult to disclose specific study topics, though all studies will fall under the guidelines outlined here.

A typical VFM study will last between 3-12 months but can be longer depending on the subject. A typical VFM study will include findings (and evidence to support these findings) on the performance by Government Departments and other public bodies, a conclusion on whether VFM has been achieved and recommendations for the Department in order to improve services. The target date for a given study depends on when it begins, which can be at any point during the year when Parliament is sitting.

Other objectives

A range of other outputs are produced at the request of Health Select Committee and other parliamentary committees, and additionally respond to public enquires including whistle-blowing.

Investigative work is carried out if there a risk to public money or suspicions of wrongdoing within central government. Actual content, timing and format of these outputs will vary and can be unpredictable, but the objective will be the same, to hold the Government and other public bodies accountable and to help them to improve services.

Support is provided to Health Select Committee and other smaller investigatory pieces of work conducted. This is triggered by correspondence from committee members, with other work typically triggered by correspondence from other concerned MPs and members of the public. It is expected on average to produce four pieces over a given year, but this depends on if and when NAO is contacted. Outputs will typically be a shorter piece of research and without a VFM conclusion, but will otherwise follow a similar format to the VFM studies. Again, there are clear restrictions in using individual level data.

All NAO published reports will be publicly available on the website http://www.nao.org.uk under reports by sector. If the evidence used in the report is based on analysis using HES data, either from NAO analysis of record level data or HES online summary, NAO will clearly attribute this to the source, including who carried out the analysis.

In 2016 the NAO published 11 reports into health and social care on the website, covering topics from social care, staffing, commissioning, discharge of older patients, treatment of vulnerable people in immigration centres, recovering costs for overseas patients, and finances more generally.

So far in 2017 there have been 7 reports published on the website, covering mental health, learning disability, access to primary care, demand for ambulances, the backlog of unprocessed clinical correspondence, and the integration of health and social care (Better Care Fund).

Apart from public access to NAO outputs, NHS Digital (as part of the DH group) will have access to NAO outputs in different ways at different stages of the NAO report. Depending on the nature of the report and the main body being audited, relevant outputs from analysis based on data provided by NHS Digital, on some occasions, NAO may clear directly with relevant staff from NHS Digital; on other occasions, NAO may clear the analysis with Department of Health or NHS England and other bodies from DH group, who in turn may seek advice from NHS Digital for the accuracy of NAO analysis. NAO analysis will always be cleared with the Department and other relevant bodies in the DH group.

If the outcomes from NAO analysis of HES data are used for intelligence only or for discussions with the Department of Health and their constituent bodies, then these information will not be published for public access and NHS Digital will not usually have access to these outputs (unless HSCIC is involved directly in the discussion). However, NAO will always seek advice from NHS Digital if unsure about certain data items or the methods used in NAO analysis.

Studies cannot be confirmed until they have been cleared by the Comptroller and Auditor General and the Public Accounts Committee at a reasonable point after initial development on the study has begun. NAO are therefore unable to provide a list and ETA for future studies. For all studies in progress the information will be made available on the NAO website under the work in progress page: http://www.nao.org.uk/work-in-progress/