Request for remote access to data in NHS England's environment for exploratory purposes

Office for National Statistics (ONS) requires access to NHS England data for the purpose of supporting statistical analysis through analysing the feasibility and usefulness of NHS England data.

The work will improve understanding of the data available and support the development of statistics to determine how the data can be used to:

• Support numerical analysis on the quality of the underlying data itself and statistics produced in the two broad areas mentioned, so that the data can be used appropriately by others, and so that the statistics can be interpreted appropriately.

• To gain a better understanding of the datasets, its volume and variables, to inform the request for acquisition into the ONS for future linkage projects.

To support these statistical analyses, ONS will process NHS England data within the Secure Data Environment (SDE) to understand the data available; to assess its suitability to answer questions, and to provide initial ad hoc analysis. Data access is to provide ONS analysts with a better understanding of the dataset, the volume of data and the variables present, to inform the request for acquisition into the ONS for future linkage projects. Data assessed under this agreement will support structuring of specifications to inform separate requests for data to perform analysis supporting statistics produced under a definitive user need or request from key Government officials. Specifically, The Scientific Advisory Group for Emergencies (SAGE), the Chief Medical Officer, Department of Health and Social Care (DHSC), and the British Government itself.

The following NHS England data will be accessed:

• Mental Health Services Dataset – is necessary to supply ONS with information on the data’s variables, episodes, and suitability for statistical analysis to determine its use within future analysis. The view is that the dataset will provide relevant information on referrals and events related to national mental health services. Examples of which could include identification of mental health outcomes for different population groups and occupations; risk of suicide or death by drugs or alcohol for people who have received treatment recorded in MHSDS; those who have committed suicide and the contacts they may have had with different services for their mental health prior to their death and also specific mental health conditions (such as eating disorders, dementia or people detained under the mental health act).

The level of the data will be pseudonymised. ONS requires access to all available pseudonymised records within the Mental Health Services Dataset at a national level to adequately assess the usefulness and suitability of the dataset for statistical analysis. ONS may be required to produce statistics on mental health outcomes for any variants of population groups within England and the interactions these individuals have had with mental health services. There may also be a requirement to link this data with other national datasets, such as Hospital Episode Statistics data, to support the publication of statistics further.

Office for National Statistics (ONS) is the controller as the organisation responsible for ensuring that the data will only be processed for the purpose described above.

The lawful basis for processing personal data under the UK GDPR is:

Article 6(1)(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 authority for ONS to produce, promote and safeguard official statistics is found in the Statistics and Registration Service Act 2007.

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.

ONS is the United Kingdom's National Statistical Institute and largest independent producer of official statistics. It is responsible for producing statistics on a range of key economic, social and demographic topics in order to inform the needs of Government, society, academia and business and enable better decisions to be made. Access to NHS England data will allow ONS to produce statistics which are more granular and timelier at a lower cost to the public, therefore enabling better decisions and resource allocation.

ONS refer to the National Statistics Data Ethics Advisory Committee (NSDEC) for ethical review, the group was set up specifically to serve an equivalent role to a Research Ethics Committee for government statistical studies. Input from ONS’s Ethical Committee has not been sought for the purpose of this request as this request is not for the purpose of research & includes processing of pseudonymised data only. ONS will ensure that any further request for access to the data included in this agreement as a result of the data being deemed feasible for statistical analysis, will have ethical approval before requesting access to the dataset regardless of statutory route.

Analysis outputs will be shared with colleagues at the Office for National Statistics and NHS England for scrutiny and quality assurance. NHS England will support ONS in understanding the data (e.g. variable definitions, limitations).

No outputs will be published based on the MHSDS data accessed in the secure NHS environment alone. This processing work is exclusively aimed at gaining a better understanding of the dataset to inform which variables are required in planned projects. The expected data outputs are aggregate summary statistics and plots, counts indicating sample sizes.

The expected outputs of the processing within ONS will be:

• A report of findings to ONS colleagues. Outputs are expected to be produced within 12 months of access to the data.

• ONS’ work to develop new official statistics may involve testing to investigate whether statistics of sufficient quality can be produced and may also involve the production of statistics badged as ‘experimental’ while further work is done to improve quality aspects such as accuracy.

Any outputs will not contain NHS England data and will only contain aggregated information with small numbers suppressed as appropriate in line with the relevant disclosure rules for the dataset(s) from which the information was derived.

The outputs will be communicated to relevant recipients through the following dissemination channels:

• Reports aimed at ONS colleagues

Target date for initial analysis is 3 months from start of data access to inform future analytical plans, and then 12 months from access for complete analysis to inform future analysis if data is then acquired.

The following have been realised through processing of data previously accessed by ONS under previous versions of this Agreement via NHS England's SDE relate to processing of the data being removed from this agreement:

Using linked administrative datasets (primary care and hospitalisation records, death registration data), ONS investigated the post-COVID complications associated with hospitalisation for COVID-19.

ONS produced a briefing on its analysis of long-COVID symptoms and COVID-19 complications which was presented to the National Statistician and subsequently shared with NHS England's Profession Advisory Group and the Cabinet Offices long COVID roundtable. The information produced by ONS has been briefed to ministers enabling them to reach appropriate decisions in their response to the pandemic. An updated set of slides (February 2021) was also presented to the Secretary of State for Health and Social Care, the CMO for England, and at the DHSC long COVID roundtable chaired by Lord Bethell have been shared with NHS England's Profession Advisory Group.

ONS have explored the demographic and clinical characteristics of patients diagnosed with post-COVID-19 syndrome in primary care, and compared patterns in these characteristics to what ONS see for self-reported long COVID from the Coronavirus Infection Survey. Long COVID is obviously an increasingly important area, with an additional £100m funding announced in June 2021 in the NHS 2021/22 plan, and understanding the risk factors for developing long-term symptoms is central to this.

ONS’s more recent work, identified some similarities and some differences when comparing between clinically diagnosed post-COVID-19 syndrome and self-reported long COVID. For example, ethnic minorities appear to be more likely to be diagnosed but less likely to self-report. ONS have investigated these similarities and differences in more detail, and plan to discuss findings with academic and clinical collaborators to agree the next analytical steps. This work is essential for understanding the risk factors for long COVID and therefore ensuring treatment is well targeted, and also for identifying potentially under-served or under-diagnosed communities. This research, is being used by NHS England and Improvement (NHSEI) and Department for Health and Social Care (DHSC) for ongoing decision-making around the provision of long COVID clinics and rehabilitation services. It is expected the analysis will go on to inform the NHS, and ONS are hoping to publish in a journal in the next months.

The Office for National Statistics (ONS) has been asked to provide rapid responses to the coronavirus pandemic on emerging research questions which are arising as the pandemic continues and as understanding of COVID-19 and its impact increases. This work is to support the ongoing government response and has been requested by central government leaders and advisors such as Scientific Advisory Group for Emergencies (SAGE) and the government. The work will improve understanding of and support the development of statistics on what the data can be used to learn about:

- the short, medium and long-term impacts of having had COVID-19

- the impact COVID-19 and its associated social, economic and environmental impacts has had on health and well-being

For example, ONS has been tasked by the government, via the National Statistician, to scope out an analysis around the prevalence and risk factors for ‘long-COVID’- i.e. symptoms and conditions that persist/develop beyond the acute phase. This analysis is intended to inform public health messaging and interventions relating to long COVID.

As another example, ONS has been requested as a priority to look at the impact of the pandemic and the lockdown on mental health for the whole population. This work will initially focus on the GPES Data for Pandemic Planning and Research (GDPPR) data working with NHS Digital to identify common mental health conditions in these new data. The work includes understanding the characteristics of the population at risk, identifying specific conditions, identifying new diagnoses and identifying changes in existing conditions.

While GDPPR data have now been transferred to ONS they are currently being processed to become ‘analysis ready’ (for example this includes restructuring the data from event level activity to person level records to allow for person level analysis). ONS need uninterrupted access to these linked data to allow these priority investigations to continue and to respond to new research questions and emerging phenomenon such as long-COVID.

In order to answer these emerging questions ONS is working collaboratively with NHS Digital to understand the data available; to assess its suitability to answer questions, and to provide initial ad hoc analysis. The work is being carried out in NHS Digital systems being remotely accessed by individually authorised ONS analysts and may also lead to collaborative working in acquiring new data, for example from GP systems when long-COVID diagnostic codes are included in the GDPPR, and to support the onward acquisition of data into ONS systems.

As the pandemic continues and understanding of coronavirus increases and changes, ONS need this ability to respond to emerging questions quickly. ONS will use the data under this Agreement to produce rapid responses to emerging questions driven by clinical issues relating to the COVID-19 pandemic as requested by either the Scientific Advisory Group for Emergencies (SAGE) or the Chief Medical Officer (CMO) via the National Statistician.

As new questions emerge which require investigation using the data under this Agreement, ONS will submit a briefing paper to NHS Digital outlining the question(s) to be answered and identify the source of the request as either SAGE or the CMO.

Under version 0.2 of this Data Sharing Agreement, analysts working for the Office for National Statistics (ONS) were granted remote access to linked GDPPR, HES and Mortality data within NHS Digital’s data environment.

Version 0.2 of this Agreement set out ONS’ intentions, prior to being granted data access, to review and analyse the data to determine if and how the data might be used to address gaps in ONS’ analyses of the risks associated with COVID-19. Since access was granted, the work undertaken by ONS analysts has led to subsets of GDPPR data being requested and approved for dissemination under a separate Agreement (DARS-NIC-400304-S1P1B).

Following collaborative work with NHS Digital, ONS has since identified the requirement for access to the following datasets containing information about COVID testing:

• COVID-19 Second Generation Surveillance System (Beta version) –

• COVID-19 UK Non-hospital Antigen Testing Results (pillar 2) Service Types

The datasets ONS have access to in the remote area are required to be linked in order to answer a wide range of emerging questions about the impact of the pandemic. For example:

• Mortality data – identifies deaths involving COVID-19

• HES data – can identify COVID-19 hospitalisations as well as more severe existing conditions or comorbidities

• Critical care data – can allow grading of morbidity according to severity, e.g. to stratify analysis of COVID-19 patients into those hospitalised with and without ICU admission

• GDPPR data – provide a complete history of conditions, comorbidities and risk factors and so the underlying health of the population

• Testing data – identifies people testing positive for COVID-19 including those who may not have been in contact with primary or secondary care services

Taken together these data will allow ONS to build a rich picture of the health state and experiences of the population due to COVID-19 and answer the emerging questions.

To expand on the use of testing data, as an example, a first stage of the analysis for long-COVID is to identify long-COVID symptoms. One of the current limitations of the data ONS have access to in the remote NHS Digital area is that they can only include cases of COVID-19 that have been clinically diagnosed and so appear in one of the current datasets (deaths, HES, GDPPR). These cases are therefore likely to consist of only the most serious cases, so the long-COVID incidence rates will not be generalisable to the broader population.

As such a second stage of the analysis planned is the inclusion of the different COVID-19 ‘testing data’.

The testing data will allow ONS to improve on the first stage of the long-COVID analysis by broadening the definition of COVID-19 cases to include those testing positive thereby reducing the impact of the current limitation. However, a continued limitation is acknowledged that a large proportion of people who have had COVID-19 were not tested, so the resulting long-COVID incidence rates based on testing data will still not be generalisable to the broader population.

In general, by linking COVID-19 testing data to the mortality, HES and GDPPR data, ONS would have a dataset containing a wide range of information on people who tested positive to COVID-19. This could:

• help improve estimates of prevalence and incidence of COVID-19 and understand things such as repeat infections and duration of infection;

• allow ONS to investigate the factors that predict severe outcomes (hospitalisation and mortality).

This work would aim to identify groups of people who are at particular risk of experiencing severe outcomes from COVID-19, which could have important public health and clinical recommendations.

In due course the intention is to combine these testing data with the Census, mortality, HES and GDPPR data held within ONS systems but the testing data will likely be directly acquired from Public Health England for this purpose.

ONS require continued remote access to the NHS Digital system and for this to continue for the next year. This is largely because the remote access area currently contains ‘live’ or much more up-to-date data from the GDPPR dataset which is required to support response to emerging pandemic questions with the most timely data possible.

Analysis outputs will be shared with colleagues at the Office for National Statistics and NHS Digital for scrutiny and quality assurance. NHS Digital will support ONS in understanding the data (e.g. variable definitions, limitations) and in the production of any publications with a focus on statistical accuracy, quality assurance and robust peer review.

The use of the data will determine the viability of producing official statistics using the datasets. The processing outlined above may directly result in the production of official statistics or may inform a subsequent methodology which is then used to produce official statistics.

As part of this, a key output is that this work will inform what minimisation can be applied to the GDPPR data in the event that ONS subsequently compels NHS Digital to transfer an extract to ONS.

Any official statistics produced will be shared with MPs, members of SAGE and other government officials to inform the government’s response to the COVID-19 pandemic. Any official statistics produced will be published, for example on the Office for National Statistics website. Briefings for technical/expert audiences such as SAGE will not include any new statistics/figures that are not in the publicly available release (written in such a way as to be accessible to all including the general public). ONS will share any briefings produced for technical/expert audiences with the British Medical Association (BMA) and Royal College of General Practitioners.

In the event that ONS determines that use of any given dataset is unsuitable for the purpose of producing official or identifies issues of significance with the data, it is possible that ONS would publish its findings in the form of methodological reports. ONS’ work to development new official statistics may involve testing to investigate whether statistics of sufficient quality can be produced and may also involve the production of statistics badged as ‘experimental’ while further work is done to improve quality aspects such as accuracy.

No patient-level data will be extracted from NHS systems. The expected data outputs are aggregate summary statistics, regression coefficients, and summary plots. All data outputs will be subject to any required disclosure control practices.

In support of ONS's request to extend the end date of this agreement ONS provide the following rationale.

ONS require continued remote access to the NHS Digital system and for this to continue for the next year. This is largely because the remote access area currently contains ‘live’ or much more up-to-date data from the GDPPR dataset which is required to support response to emerging pandemic questions with the most timely data possible. In addition, the continued access is required to:

• follow up on long-covid outcomes particularly for the pandemic wave 2. ONS currently only hold the latest available GDPPR data in house. The data is delivered on a monthly basis.

• access the new long-covid codes when they start filtering through.

• allow analysts to start to familiarise themselves with more recent and new long-covid codes

• allow analysts to carry out initial urgent analysis as outlined in the agreement as well as plan and carry out exploratory analysis to be transferred to ONS systems (where linkage to the Census can be included)

• continue access to covid-19 testing data which ONS do not yet have available and linked in-house should urgent question emerge

• refine and add to analysis already complete in the remote area and support refinement of analysis following feedback on publications

ONS presented long-COVID complications to: Sir Ian Diamond (National Statistician), Matt Hancock (then Health Secretary), Chris Whitty (Chief Medical Officer), NHS Digital's Profession Advisory Group, Cabinet Offices long COVID roundtable.

Published work:

https://www.bmj.com/content/372/bmj.n693, https://www.ons.gov.uk/news/statementsandletters/theprevalenceoflongcovidsymptomsandcovid19complications, https://www.ons.gov.uk/releases/estimatingtheprevalenceoflongcovidsymptomsandcovid19complications, https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/prevalenceofongoingsymptomsfollowingcoronaviruscovid19infectionintheuk/4june2021

Publications:

Ayoubkhani D, Khunti K, Nafilyan V, Maddox T, Humberstone B, Diamond I & Banerjee, A. (2021) Post-covid syndrome in individuals admitted to hospital with covid-19: retrospective cohort study BMJ 2021; 372 :n693 https://doi.org/10.1136/bmj.n693

ONS (2021) Estimating the prevalence of long COVID symptoms and COVID-19 complications https://www.ons.gov.uk/news/statementsandletters/theprevalenceoflongcovidsymptomsandcovid19complications

https://www.ons.gov.uk/releases/estimatingtheprevalenceoflongcovidsymptomsandcovid19complications

Long COVID:

Using linked administrative datasets (primary care and hospitalisation records, death registration data), ONS investigated the post-COVID complications associated with hospitalisation for COVID-19.

ONS produced a briefing on its analysis of long-COVID symptoms and COVID-19 complications which was presented to the National Statistician and subsequently shared with NHS Digital's Profession Advisory Group and the Cabinet Offices long COVID roundtable. The information produced by ONS has been briefed to ministers enabling them to reach appropriate decisions in their response to the pandemic. An updated set of slides (February 2021) was also presented to the Secretary of State for Health and Social Care, the CMO for England, and at the DHSC long COVID roundtable chaired by Lord Bethell have been shared with NHS Digital's Profession Advisory Group.

ONS have explored the demographic and clinical characteristics of patients diagnosed with post-COVID-19 syndrome in primary care, and compared patterns in these characteristics to what ONS see for self-reported long COVID from the Coronavirus Infection Survey. Long COVID is obviously an increasingly important area, with an additional £100m funding announced in June 2021 in the NHS 2021/22 plan, and understanding the risk factors for developing long-term symptoms is central to this.

ONS’s more recent work, identified some similarities and some differences when comparing between clinically diagnosed post-COVID-19 syndrome and self-reported long COVID. For example, ethnic minorities appear to be more likely to be diagnosed but less likely to self-report. ONS have investigated these similarities and differences in more detail, and plan to discuss findings with academic and clinical collaborators to agree the next analytical steps. This work is essential for understanding the risk factors for long COVID and therefore ensuring treatment is well targeted, and also for identifying potentially under-served or under-diagnosed communities. This research, is being used by NHS England and Improvement (NHSEI) and Department for Health and Social Care (DHSC) for ongoing decision-making around the provision of long COVID clinics and rehabilitation services. It is expected the analysis will go on to inform the NHS, and ONS are hoping to publish in a journal in the next months.

These statistics and analysis are used to inform government policy and health campaign decisions, impacts include:

Presented findings to 3,000 medical practitioners and health researchers at a British Medical Journal (BMJ) webinar, and to over 25,000 health professionals across 12 different countries at a long COVID training event to raise awareness of long covid across health professions, disseminate the findings and get clinical input to future analysis https://www.youtube.com/watch?v=z0ucL8MJzt8

Extensively cited in the National Institute for Health Research (NIHR) recent review of international evidence on long COVID prevalence and impact which is used to inform future diagnosis, treatment and research https://evidence.nihr.ac.uk/themedreview/living-with-covid19-second-review/

Fed into government thinking to inform on the response to the pandemic, by directly discussing the results with Matt Hancock and Chris Whitty, and providing written briefing to the PM https://www.gov.uk/government/publications/ons-post-covid-19-complications-following-hospitalisation-3-february-2021

The Office for National Statistics (ONS) has been asked to provide rapid responses to the coronavirus pandemic on emerging research questions which are arising as the pandemic continues and as understanding of COVID-19 and its impact increases. This work is to support the ongoing government response and has been requested by central government leaders and advisors such as SAGE and the government. The work will improve understanding of and support the development of statistics on what the data can be used to learn about:

- the short, medium and long-term impacts of having had COVID-19

- the impact COVID-19 and its associated social, economic and environmental impacts has had on health and well-being

For example, ONS has been tasked by the government, via the National Statistician, to scope out an analysis around the prevalence and risk factors for ‘long-COVID’- i.e. symptoms and conditions that persist/develop beyond the acute phase. This analysis is intended to inform public health messaging and interventions relating to long COVID.

As another example, ONS has been requested as a priority to look at the impact of the pandemic and the lockdown on mental health for the whole population. This work will initially focus on the GDPPR data working with NHS Digital to identify common mental health conditions in these new data. The work includes understanding the characteristics of the population at risk, identifying specific conditions, identifying new diagnoses and identifying changes in existing conditions.

While GDPPR data have now been transferred to ONS they are currently being processed to become ‘analysis ready’ (for example this includes restructuring the data from event level activity to person level records to allow for person level analysis). ONS need uninterrupted access to these linked data to allow these priority investigations to continue and to respond to new research questions and emerging phenomenon such as long-COVID.

In order to answer these emerging questions ONS is working collaboratively with NHS Digital to understand the data available; to assess its suitability to answer questions, and to provide initial ad hoc analysis. The work is being carried out in NHS Digital systems being remotely accessed by individually authorised ONS analysts and may also lead to collaborative working in acquiring new data, for example from GP systems when long-COVID diagnostic codes are included in the GDPPR, and to support the onward acquisition of data into ONS systems.

As the pandemic continues and understanding of coronavirus increases and changes, ONS need this ability to respond to emerging questions quickly. ONS will use the data under this Agreement to produce rapid responses to emerging questions driven by clinical issues relating to the COVID-19 pandemic as requested by either the Scientific Advisory Group for Emergencies (SAGE) or the Chief Medical Officer (CMO) via the National Statistician.

As new questions emerge which require investigation using the data under this Agreement, ONS will submit a briefing paper to NHS Digital outlining the question(s) to be answered and identify the source of the request as either SAGE or the CMO.

Under version 0.2 of this Data Sharing Agreement, analysts working for the Office for National Statistics (ONS) were granted remote access to linked GDPPR, HES and Mortality data within NHS Digital’s data environment.

Version 0.2 of this Agreement set out ONS’ intentions, prior to being granted data access, to review and analyse the data to determine if and how the data might be used to address gaps in ONS’ analyses of the risks associated with COVID-19. Since access was granted, the work undertaken by ONS analysts has led to subsets of GDPPR data being requested and approved for dissemination under a separate Agreement (DARS-NIC-400304-S1P1B).

Following collaborative work with NHS Digital, ONS has since identified the requirement for access to the following datasets containing information about COVID testing:

• COVID-19 Second Generation Surveillance System (Beta version) –

• COVID-19 UK Non-hospital Antigen Testing Results (pillar 2) Service Types

The datasets ONS have access to in the remote area are required to be linked in order to answer a wide range of emerging questions about the impact of the pandemic. For example:

• Mortality data – identifies deaths involving COVID-19

• HES data – can identify COVID-19 hospitalisations as well as more severe existing conditions or comorbidities

• Critical care data – can allow grading of morbidity according to severity, e.g. to stratify analysis of COVID-19 patients into those hospitalised with and without ICU admission

• GDPPR data – provide a complete history of conditions, comorbidities and risk factors and so the underlying health of the population

• Testing data – identifies people testing positive for COVID-19 including those who may not have been in contact with primary or secondary care services

Taken together these data will allow ONS to build a rich picture of the health state and experiences of the population due to COVID-19 and answer the emerging questions.

To expand on the use of testing data, as an example, a first stage of the analysis for long-COVID is to identify long-COVID symptoms. One of the current limitations of the data ONS have access to in the remote NHS Digital area is that they can only include cases of COVID-19 that have been clinically diagnosed and so appear in one of the current datasets (deaths, HES, GDPPR). These cases are therefore likely to consist of only the most serious cases, so the long-COVID incidence rates will not be generalisable to the broader population.

As such a second stage of the analysis planned is the inclusion of the different COVID-19 ‘testing data’.

The testing data will allow ONS to improve on the first stage of the long-COVID analysis by broadening the definition of COVID-19 cases to include those testing positive thereby reducing the impact of the current limitation. However, a continued limitation is acknowledged that a large proportion of people who have had COVID-19 were not tested, so the resulting long-COVID incidence rates based on testing data will still not be generalisable to the broader population.

In general, by linking COVID-19 testing data to the mortality, HES and GDPPR data, ONS would have a dataset containing a wide range of information on people who tested positive to COVID-19. This could:

• help improve estimates of prevalence and incidence of COVID-19 and understand things such as repeat infections and duration of infection;

• allow ONS to investigate the factors that predict severe outcomes (hospitalisation and mortality).

This work would aim to identify groups of people who are at particular risk of experiencing severe outcomes from COVID-19, which could have important public health and clinical recommendations.

In due course the intention is to combine these testing data with the Census, mortality, HES and GDPPR data held within ONS systems but the testing data will likely be directly acquired from Public Health England for this purpose.

Analysis outputs will be shared with colleagues at the Office for National Statistics and NHS Digital for scrutiny and quality assurance. NHS Digital will support ONS in understanding the data (e.g. variable definitions, limitations) and in the production of any publications with a focus on statistical accuracy, quality assurance and robust peer review.

The use of the data will determine the viability of producing official statistics using the datasets. The processing outlined above may directly result in the production of official statistics or may inform a subsequent methodology which is then used to produce official statistics.

As part of this, a key output is that this work will inform what minimisation can be applied to the GDPPR data in the event that ONS subsequently compels NHS Digital to transfer an extract to ONS.

Any official statistics produced will be shared with MPs, members of SAGE and other government officials to inform the government’s response to the COVID-19 pandemic. Any official statistics produced will be published, for example on the Office for National Statistics website. Briefings for technical/expert audiences such as SAGE will not include any new statistics/figures that are not in the publicly available release (written in such a way as to be accessible to all including the general public). ONS will share any briefings produced for technical/expert audiences with the British Medical Association (BMA) and Royal College of General Practitioners.

In the event that ONS determines that use of any given dataset is unsuitable for the purpose of producing official or identifies issues of significance with the data, it is possible that ONS would publish its findings in the form of methodological reports. ONS’ work to development new official statistics may involve testing to investigate whether statistics of sufficient quality can be produced and may also involve the production of statistics badged as ‘experimental’ while further work is done to improve quality aspects such as accuracy.

No patient-level data will be extracted from NHS systems. The expected data outputs are aggregate summary statistics, regression coefficients, and summary plots. All data outputs will be subject to any required disclosure control practices.

In support of ONS's request to extend the end date of this agreement ONS provide the following rationale.

ONS require continued remote access to the NHS Digital system and for this to continue for the next year. This is largely because the remote access area currently contains ‘live’ or much more up-to-date data from the GDPPR dataset which is required to support response to emerging pandemic questions with the most timely data possible. In addition, the continued access is required to:

• follow up on long-covid outcomes particularly for the pandemic wave 2. ONS currently only hold the latest available GDPPR data in house. The data is delivered on a monthly basis.

• access the new long-covid codes when they start filtering through.

• allow analysts to start to familiarise themselves with more recent and new long-covid codes

• allow analysts to carry out initial urgent analysis as outlined in the agreement as well as plan and carry out exploratory analysis to be transferred to ONS systems (where linkage to the Census can be included)

• continue access to covid-19 testing data which ONS do not yet have available and linked in-house should urgent question emerge

• refine and add to analysis already complete in the remote area and support refinement of analysis following feedback on publications

ONS presented long-COVID complications to: Sir Ian Diamond (National Statistician), Matt Hancock (then Health Secretary), Chris Whitty (Chief Medical Officer), NHS Digital's Profession Advisory Group, Cabinet Offices long COVID roundtable.

Published work:

https://www.bmj.com/content/372/bmj.n693, https://www.ons.gov.uk/news/statementsandletters/theprevalenceoflongcovidsymptomsandcovid19complications, https://www.ons.gov.uk/releases/estimatingtheprevalenceoflongcovidsymptomsandcovid19complications, https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/prevalenceofongoingsymptomsfollowingcoronaviruscovid19infectionintheuk/4june2021

Publications:

Ayoubkhani D, Khunti K, Nafilyan V, Maddox T, Humberstone B, Diamond I & Banerjee, A. (2021) Post-covid syndrome in individuals admitted to hospital with covid-19: retrospective cohort study BMJ 2021; 372 :n693 https://doi.org/10.1136/bmj.n693

ONS (2021) Estimating the prevalence of long COVID symptoms and COVID-19 complications https://www.ons.gov.uk/news/statementsandletters/theprevalenceoflongcovidsymptomsandcovid19complications

https://www.ons.gov.uk/releases/estimatingtheprevalenceoflongcovidsymptomsandcovid19complications

Long Covid

Using linked administrative datasets (primary care and hospitalisation records, death registration data), ONS investigated the post-COVID complications associated with hospitalisation for COVID-19.

ONS produced a briefing on its analysis of long-COVID symptoms and COVID-19 complications which was presented to the National Statistician and subsequently shared with NHS Digital's Profession Advisory Group and the Cabinet Offices long COVID roundtable. The information produced by ONS has been briefed to ministers enabling them to reach appropriate decisions in their response to the pandemic. An updated set of slides (February 2021) was also presented to the Secretary of State for Health and Social Care, the CMO for England, and at the DHSC long COVID roundtable chaired by Lord Bethell have been shared with NHS Digital's Profession Advisory Group.

ONS have explored the demographic and clinical characteristics of patients diagnosed with post-COVID-19 syndrome in primary care, and compared patterns in these characteristics to what ONS see for self-reported long COVID from the Coronavirus Infection Survey. Long COVID is obviously an increasingly important area, with an additional £100m funding announced in June 2021 in the NHS 2021/22 plan, and understanding the risk factors for developing long-term symptoms is central to this.

ONS’s more recent work, identified some similarities and some differences when comparing between clinically diagnosed post-COVID-19 syndrome and self-reported long COVID. For example, ethnic minorities appear to be more likely to be diagnosed but less likely to self-report. ONS have investigated these similarities and differences in more detail, and plan to discuss findings with academic and clinical collaborators to agree the next analytical steps. This work is essential for understanding the risk factors for long COVID and therefore ensuring treatment is well targeted, and also for identifying potentially under-served or under-diagnosed communities. This research, is being used by NHSEI and DHSC for ongoing decision-making around the provision of long COVID clinics and rehabilitation services. The analysis will go on to inform the NHS, and we’re hoping to publish in a journal in the next months.

These statistics and analysis are used to inform government policy and health campaign decisions, impacts include:

Presented findings to 3,000 medical practitioners and health researchers at a BMJ webinar, and to over 25,000 health professionals across 12 different countries at a long COVID training event to raise awareness of long covid across health professions, disseminate the findings and get clinical input to future analysis https://www.youtube.com/watch?v=z0ucL8MJzt8

Extensively cited in the National Institute for Health Research (NIHR) recent review of international evidence on long COVID prevalence and impact which is used to inform future diagnosis, treatment and research https://evidence.nihr.ac.uk/themedreview/living-with-covid19-second-review/

Fed into government thinking to inform on the response to the pandemic, by directly discussing the results with Matt Hancock and Chris Whitty, and providing written briefing to the PM https://www.gov.uk/government/publications/ons-post-covid-19-complications-following-hospitalisation-3-february-2021

The Office for National Statistics (ONS) has been asked to provide rapid responses to the coronavirus pandemic on emerging research questions which are arising as the pandemic continues and as understanding of COVID-19 and its impact increases. This work is to support the ongoing government response and has been requested by central government leaders and advisors such as SAGE and the government. The work will improve understanding of and support the development of statistics on what the data can be used to learn about:

- the short, medium and long-term impacts of having had COVID-19

- the impact COVID-19 and its associated social, economic and environmental impacts has had on health and well-being

For example, ONS has been tasked by the government, via the National Statistician, to scope out an analysis around the prevalence and risk factors for ‘long-COVID’- i.e. symptoms and conditions that persist/develop beyond the acute phase. This analysis is intended to inform public health messaging and interventions relating to long COVID.

As another example, ONS has been requested as a priority to look at the impact of the pandemic and the lockdown on mental health for the whole population. This work will initially focus on the GDPPR data working with NHS Digital to identify common mental health conditions in these new data. The work includes understanding the characteristics of the population at risk, identifying specific conditions, identifying new diagnoses and identifying changes in existing conditions.

While GDPPR data have now been transferred to ONS they are currently being processed to become ‘analysis ready’ (for example this includes restructuring the data from event level activity to person level records to allow for person level analysis). ONS need uninterrupted access to these linked data to allow these priority investigations to continue and to respond to new research questions and emerging phenomenon such as long-COVID.

In order to answer these emerging questions ONS is working collaboratively with NHS Digital to understand the data available; to assess its suitability to answer questions, and to provide initial ad hoc analysis. The work is being carried out in NHS Digital systems being remotely accessed by individually authorised ONS analysts and may also lead to collaborative working in acquiring new data, for example from GP systems when long-COVID SNOMED codes are included in the GDPPR, and to support the onward acquisition of data into ONS systems.

As the pandemic continues and understanding of coronavirus increases and changes, ONS need this ability to respond to emerging questions quickly. ONS will use the data under this Agreement to produce rapid responses to emerging questions driven by clinical issues relating to the COVID-19 pandemic as requested by either the Scientific Advisory Group for Emergencies (SAGE) or the Chief Medical Officer (CMO) via the National Statistician.

As new questions emerge which require investigation using the data under this Agreement, ONS will submit a briefing paper to NHS Digital outlining the question(s) to be answered and identify the source of the request as either SAGE or the CMO.

Under version 0.2 of this Data Sharing Agreement, analysts working for the Office for National Statistics (ONS) were granted remote access to linked GDPPR, HES and Mortality data within NHS Digital’s data environment.

Version 0.2 of this Agreement set out ONS’ intentions, prior to being granted data access, to review and analyse the data to determine if and how the data might be used to address gaps in ONS’ analyses of the risks associated with COVID-19. Since access was granted, the work undertaken by ONS analysts has led to subsets of GDPPR data being requested and approved for dissemination under a separate Agreement (DARS-NIC-400304-S1P1B).

Following collaborative work with NHS Digital, ONS has since identified the requirement for access to the following datasets containing information about COVID testing:

• COVID-19 Second Generation Surveillance System (Beta version) –

• COVID-19 UK Non-hospital Antigen Testing Results (pillar 2) Service Types

The datasets ONS have access to in the remote area are required to be linked in order to answer a wide range of emerging questions about the impact of the pandemic. For example:

• Mortality data – identifies deaths involving COVID-19

• HES data – can identify COVID-19 hospitalisations as well as more severe existing conditions or comorbidities

• Critical care data – can allow grading of morbidity according to severity, e.g. to stratify analysis of COVID-19 patients into those hospitalised with and without ICU admission

• GDPPR data – provide a complete history of conditions, comorbidities and risk factors and so the underlying health of the population

• Testing data – identifies people testing positive for COVID-19 including those who may not have been in contact with primary or secondary care services

Taken together these data will allow ONS to build a rich picture of the health state and experiences of the population due to COVID-19 and answer the emerging questions.

To expand on the use of testing data, as an example, a first stage of the analysis for long-COVID is to identify long-COVID symptoms. One of the current limitations of the data ONS have access to in the remote NHS Digital area is that they can only include cases of COVID-19 that have been clinically diagnosed and so appear in one of the current datasets (deaths, HES, GDPPR). These cases are therefore likely to consist of only the most serious cases, so the long-COVID incidence rates will not be generalisable to the broader population.

As such a second stage of the analysis planned is the inclusion of the different COVID-19 ‘testing data’.

The testing data will allow ONS to improve on the first stage of the long-COVID analysis by broadening the definition of COVID-19 cases to include those testing positive thereby reducing the impact of the current limitation. However, a continued limitation is acknowledged that a large proportion of people who have had COVID-19 were not tested, so the resulting long-COVID incidence rates based on testing data will still not be generalisable to the broader population.

In general, by linking COVID-19 testing data to the mortality, HES and GDPPR data, ONS would have a dataset containing a wide range of information on people who tested positive to COVID-19. This could:

• help improve estimates of prevalence and incidence of COVID-19 and understand things such as repeat infections and duration of infection;

• allow ONS to investigate the factors that predict severe outcomes (hospitalisation and mortality).

This work would aim to identify groups of people who are at particular risk of experiencing severe outcomes from COVID-19, which could have important public health and clinical recommendations.

In due course the intention is to combine these testing data with the Census, mortality, HES and GDPPR data held within ONS systems but the testing data will likely be directly acquired from Public Health England for this purpose.

Analysis outputs will be shared with colleagues at the Office for National Statistics and NHS Digital for scrutiny and quality assurance. NHS Digital will support ONS in understanding the data (e.g. variable definitions, limitations) and in the production of any publications with a focus on statistical accuracy, quality assurance and robust peer review.

The use of the data will determine the viability of producing official statistics using the datasets. The processing outlined above may directly result in the production of official statistics or may inform a subsequent methodology which is then used to produce official statistics.

As part of this, a key output is that this work will inform what minimisation can be applied to the GDPPR data in the event that ONS subsequently compels NHS Digital to transfer an extract to ONS.

Any official statistics produced will be shared with MPs, members of SAGE and other government officials to inform the government’s response to the COVID-19 pandemic. Any official statistics produced will be published, for example on the Office for National Statistics website. Briefings for technical/expert audiences such as SAGE will not include any new statistics/figures that are not in the publicly available release (written in such a way as to be accessible to all including the general public). ONS will share any briefings produced for technical/expert audiences with the British Medical Association (BMA) and Royal College of General Practitioners.

In the event that ONS determines that use of any given dataset is unsuitable for the purpose of producing official or identifies issues of significance with the data, it is possible that ONS would publish its findings in the form of methodological reports. ONS’ work to development new official statistics may involve testing to investigate whether statistics of sufficient quality can be produced and may also involve the production of statistics badged as ‘experimental’ while further work is done to improve quality aspects such as accuracy.

No patient-level data will be extracted from NHS systems. The expected data outputs are aggregate summary statistics, regression coefficients, and summary plots. All data outputs will be subject to any required disclosure control practices.

*********************

In support of ONS's request to extend the end date of this agreement ONS provide the following rationale.

ONS require continued remote access to the NHS Digital system and for this to continue for the next year. This is largely because the remote access area currently contains ‘live’ or much more up-to-date data from the GDPPR dataset which is required to support response to emerging pandemic questions with the most timely data possible. In addition, the continued access is required to:

• follow up on long-covid outcomes particularly for the pandemic wave 2 (ONS currently only hold GDPPR data to March 2021 in house)

• access the new long-covid codes when they start filtering through from March 2021

• allow analysts to start to familiarise themselves with more recent and new long-covid codes

• allow analysts to carry out initial urgent analysis as outlined in the agreement as well as plan and carry out exploratory analysis to be transferred to ONS systems (where linkage to the Census can be included)

• continue access to covid-19 testing data which ONS do not yet have available and linked in-house should urgent question emerge

• refine and add to analysis already complete in the remote area and support refinement of analysis following feedback on publications

ONS produced a briefing on its analysis of long-COVID symptoms and COVID-19 complications which was presented to the National Statistician and subsequently shared with NHS Digital's Profession Advisory Group. The findings have been published on ONS' website - see: https://www.ons.gov.uk/releases/estimatingtheprevalenceoflongcovidsymptomsandcovid19complications. The information produced by ONS has been briefed to ministers enabling them to reach appropriate decisions in their response to the pandemic.

The Office for National Statistics (ONS) has been asked to provide rapid responses to the coronavirus pandemic on emerging research questions which are arising as the pandemic continues and as understanding of COVID-19 and its impact increases. This work is to support the ongoing government response and has been requested by central government leaders and advisors such as SAGE and the government. The work will improve understanding of and support the development of statistics on what the data can be used to learn about:

- the short, medium and long-term impacts of having had COVID-19

- the impact COVID-19 and its associated social, economic and environmental impacts has had on health and well-being

For example, ONS has been tasked by the government, via the National Statistician, to scope out an analysis around the prevalence and risk factors for ‘long-COVID’- i.e. symptoms and conditions that persist/develop beyond the acute phase. This analysis is intended to inform public health messaging and interventions relating to long COVID.

As another example, ONS has been requested as a priority to look at the impact of the pandemic and the lockdown on mental health for the whole population. This work will initially focus on the GDPPR data working with NHS Digital to identify common mental health conditions in these new data. The work includes understanding the characteristics of the population at risk, identifying specific conditions, identifying new diagnoses and identifying changes in existing conditions.

While GDPPR data have now been transferred to ONS they are currently being processed to become ‘analysis ready’ (for example this includes restructuring the data from event level activity to person level records to allow for person level analysis). ONS need uninterrupted access to these linked data to allow these priority investigations to continue and to respond to new research questions and emerging phenomenon such as long-COVID.

In order to answer these emerging questions ONS is working collaboratively with NHS Digital to understand the data available; to assess its suitability to answer questions, and to provide initial ad hoc analysis. The work is being carried out in NHS Digital systems being remotely accessed by individually authorised ONS analysts and may also lead to collaborative working in acquiring new data, for example from GP systems when long-COVID SNOMED codes are included in the GDPPR, and to support the onward acquisition of data into ONS systems.

As the pandemic continues and understanding of coronavirus increases and changes, ONS need this ability to respond to emerging questions quickly. ONS will use the data under this Agreement to produce rapid responses to emerging questions driven by clinical issues relating to the COVID-19 pandemic as requested by either the Scientific Advisory Group for Emergencies (SAGE) or the Chief Medical Officer (CMO) via the National Statistician.

As new questions emerge which require investigation using the data under this Agreement, ONS will submit a briefing paper to NHS Digital outlining the question(s) to be answered and identify the source of the request as either SAGE or the CMO.

Under version 0.2 of this Data Sharing Agreement, analysts working for the Office for National Statistics (ONS) were granted remote access to linked GDPPR, HES and Mortality data within NHS Digital’s data environment.

Version 0.2 of this Agreement set out ONS’ intentions, prior to being granted data access, to review and analyse the data to determine if and how the data might be used to address gaps in ONS’ analyses of the risks associated with COVID-19. Since access was granted, the work undertaken by ONS analysts has led to subsets of GDPPR data being requested and approved for dissemination under a separate Agreement (DARS-NIC-400304-S1P1B).

Following collaborative work with NHS Digital, ONS has since identified the requirement for access to the following datasets containing information about COVID testing:

• COVID-19 Second Generation Surveillance System (Beta version) –

• COVID-19 UK Non-hospital Antigen Testing Results (pillar 2) Service Types

The datasets ONS have access to in the remote area are required to be linked in order to answer a wide range of emerging questions about the impact of the pandemic. For example:

• Mortality data – identifies deaths involving COVID-19

• HES data – can identify COVID-19 hospitalisations as well as more severe existing conditions or comorbidities

• Critical care data – can allow grading of morbidity according to severity, e.g. to stratify analysis of COVID-19 patients into those hospitalised with and without ICU admission

• GDPPR data – provide a complete history of conditions, comorbidities and risk factors and so the underlying health of the population

• Testing data – identifies people testing positive for COVID-19 including those who may not have been in contact with primary or secondary care services

Taken together these data will allow ONS to build a rich picture of the health state and experiences of the population due to COVID-19 and answer the emerging questions.

To expand on the use of testing data, as an example, a first stage of the analysis for long-COVID is to identify long-COVID symptoms. One of the current limitations of the data ONS have access to in the remote NHS Digital area is that they can only include cases of COVID-19 that have been clinically diagnosed and so appear in one of the current datasets (deaths, HES, GDPPR). These cases are therefore likely to consist of only the most serious cases, so the long-COVID incidence rates will not be generalisable to the broader population.

As such a second stage of the analysis planned is the inclusion of the different COVID-19 ‘testing data’.

The testing data will allow ONS to improve on the first stage of the long-COVID analysis by broadening the definition of COVID-19 cases to include those testing positive thereby reducing the impact of the current limitation. However, a continued limitation is acknowledged that a large proportion of people who have had COVID-19 were not tested, so the resulting long-COVID incidence rates based on testing data will still not be generalisable to the broader population.

In general, by linking COVID-19 testing data to the mortality, HES and GDPPR data, ONS would have a dataset containing a wide range of information on people who tested positive to COVID-19. This could:

• help improve estimates of prevalence and incidence of COVID-19 and understand things such as repeat infections and duration of infection;

• allow ONS to investigate the factors that predict severe outcomes (hospitalisation and mortality).

This work would aim to identify groups of people who are at particular risk of experiencing severe outcomes from COVID-19, which could have important public health and clinical recommendations.

In due course the intention is to combine these testing data with the Census, mortality, HES and GDPPR data held within ONS systems but the testing data will likely be directly acquired from Public Health England for this purpose.

Analysis outputs will be shared with colleagues at the Office for National Statistics and NHS Digital for scrutiny and quality assurance. NHS Digital will support ONS in understanding the data (e.g. variable definitions, limitations) and in the production of any publications with a focus on statistical accuracy, quality assurance and robust peer review.

The use of the data will determine the viability of producing official statistics using the datasets. The processing outlined above may directly result in the production of official statistics or may inform a subsequent methodology which is then used to produce official statistics.

As part of this, a key output is that this work will inform what minimisation can be applied to the GDPPR data in the event that ONS subsequently compels NHS Digital to transfer an extract to ONS.

Any official statistics produced will be shared with MPs, members of SAGE and other government officials to inform the government’s response to the COVID-19 pandemic. Any official statistics produced will be published, for example on the Office for National Statistics website. Briefings for technical/expert audiences such as SAGE will not include any new statistics/figures that are not in the publicly available release (written in such a way as to be accessible to all including the general public). ONS will share any briefings produced for technical/expert audiences with the British Medical Association (BMA) and Royal College of General Practitioners.

In the event that ONS determines that use of any given dataset is unsuitable for the purpose of producing official or identifies issues of significance with the data, it is possible that ONS would publish its findings in the form of methodological reports. ONS’ work to development new official statistics may involve testing to investigate whether statistics of sufficient quality can be produced and may also involve the production of statistics badged as ‘experimental’ while further work is done to improve quality aspects such as accuracy.

No patient-level data will be extracted from NHS systems. The expected data outputs are aggregate summary statistics, regression coefficients, and summary plots. All data outputs will be subject to any required disclosure control practices.

*********************

In support of ONS's request to extend the end date of this agreement ONS provide the following rationale.

ONS require continued remote access to the NHS Digital system and for this to continue for the next year. This is largely because the remote access area currently contains ‘live’ or much more up-to-date data from the GDPPR dataset which is required to support response to emerging pandemic questions with the most timely data possible. In addition, the continued access is required to:

• follow up on long-covid outcomes particularly for the pandemic wave 2 (ONS currently only hold GDPPR data to August 2020 in house)

• access the new long-covid codes when they start filtering through from March 2021

• allow analysts to start to familiarise themselves with more recent and new long-covid codes

• allow analysts to carry out initial urgent analysis as outlined in the agreement as well as plan and carry out exploratory analysis to be transferred to ONS systems (where linkage to the Census can be included)

• continue access to covid-19 testing data which ONS do not yet have available and linked in-house should urgent question emerge

• refine and add to analysis already complete in the remote area and support refinement of analysis following feedback on publications

ONS produced a briefing on its analysis of long-COVID symptoms and COVID-19 complications which was presented to the National Statistician and subsequently shared with NHS Digital's Profession Advisory Group. The findings have been published on ONS' website - see: https://www.ons.gov.uk/releases/estimatingtheprevalenceoflongcovidsymptomsandcovid19complications. The information produced by ONS has been briefed to ministers enabling them to reach appropriate decisions in their response to the pandemic.

The Office for National Statistics (ONS) has been asked to provide rapid responses to the coronavirus pandemic on emerging research questions which are arising as the pandemic continues and as understanding of COVID-19 and its impact increases. This work is to support the ongoing government response and has been requested by central government leaders and advisors such as SAGE and the government. The work will improve understanding of and support the development of statistics on what the data can be used to learn about:

- the short, medium and long-term impacts of having had COVID-19

- the impact COVID-19 and its associated social, economic and environmental impacts has had on health and well-being

For example, ONS has been tasked by the government, via the National Statistician, to scope out an analysis around the prevalence and risk factors for ‘long-COVID’- i.e. symptoms and conditions that persist/develop beyond the acute phase. This analysis is intended to inform public health messaging and interventions relating to long COVID.

As another example, ONS has been requested as a priority to look at the impact of the pandemic and the lockdown on mental health for the whole population. This work will initially focus on the GDPPR data working with NHS Digital to identify common mental health conditions in these new data. The work includes understanding the characteristics of the population at risk, identifying specific conditions, identifying new diagnoses and identifying changes in existing conditions.

While GDPPR data have now been transferred to ONS they are currently being processed to become ‘analysis ready’ (for example this includes restructuring the data from event level activity to person level records to allow for person level analysis). ONS need uninterrupted access to these linked data to allow these priority investigations to continue and to respond to new research questions and emerging phenomenon such as long-COVID.

In order to answer these emerging questions ONS is working collaboratively with NHS Digital to understand the data available; to assess its suitability to answer questions, and to provide initial ad hoc analysis. The work is being carried out in NHS Digital systems being remotely accessed by individually authorised ONS analysts and may also lead to collaborative working in acquiring new data, for example from GP systems when long-COVID SNOMED codes are included in the GDPPR, and to support the onward acquisition of data into ONS systems.

As the pandemic continues and understanding of coronavirus increases and changes, ONS need this ability to respond to emerging questions quickly. ONS will use the data under this Agreement to produce rapid responses to emerging questions driven by clinical issues relating to the COVID-19 pandemic as requested by either the Scientific Advisory Group for Emergencies (SAGE) or the Chief Medical Officer (CMO) via the National Statistician.

As new questions emerge which require investigation using the data under this Agreement, ONS will submit a briefing paper to NHS Digital outlining the question(s) to be answered and identify the source of the request as either SAGE or the CMO.

Under version 0.2 of this Data Sharing Agreement, analysts working for the Office for National Statistics (ONS) were granted remote access to linked GDPPR, HES and Mortality data within NHS Digital’s data environment.

Version 0.2 of this Agreement set out ONS’ intentions, prior to being granted data access, to review and analyse the data to determine if and how the data might be used to address gaps in ONS’ analyses of the risks associated with COVID-19. Since access was granted, the work undertaken by ONS analysts has led to subsets of GDPPR data being requested and approved for dissemination under a separate Agreement (DARS-NIC-400304-S1P1B).

Following collaborative work with NHS Digital, ONS has since identified the requirement for access to the following datasets containing information about COVID testing:

• COVID-19 Second Generation Surveillance System (Beta version) –

• COVID-19 UK Non-hospital Antigen Testing Results (pillar 2) Service Types

The datasets ONS have access to in the remote area are required to be linked in order to answer a wide range of emerging questions about the impact of the pandemic. For example:

• Mortality data – identifies deaths involving COVID-19

• HES data – can identify COVID-19 hospitalisations as well as more severe existing conditions or comorbidities

• Critical care data – can allow grading of morbidity according to severity, e.g. to stratify analysis of COVID-19 patients into those hospitalised with and without ICU admission

• GDPPR data – provide a complete history of conditions, comorbidities and risk factors and so the underlying health of the population

• Testing data – identifies people testing positive for COVID-19 including those who may not have been in contact with primary or secondary care services

Taken together these data will allow ONS to build a rich picture of the health state and experiences of the population due to COVID-19 and answer the emerging questions.

To expand on the use of testing data, as an example, a first stage of the analysis for long-COVID is to identify long-COVID symptoms. One of the current limitations of the data ONS have access to in the remote NHS Digital area is that they can only include cases of COVID-19 that have been clinically diagnosed and so appear in one of the current datasets (deaths, HES, GDPPR). These cases are therefore likely to consist of only the most serious cases, so the long-COVID incidence rates will not be generalisable to the broader population.

As such a second stage of the analysis planned is the inclusion of the different COVID-19 ‘testing data’.

The testing data will allow ONS to improve on the first stage of the long-COVID analysis by broadening the definition of COVID-19 cases to include those testing positive thereby reducing the impact of the current limitation. However, a continued limitation is acknowledged that a large proportion of people who have had COVID-19 were not tested, so the resulting long-COVID incidence rates based on testing data will still not be generalisable to the broader population.

In general, by linking COVID-19 testing data to the mortality, HES and GDPPR data, ONS would have a dataset containing a wide range of information on people who tested positive to COVID-19. This could:

• help improve estimates of prevalence and incidence of COVID-19 and understand things such as repeat infections and duration of infection;

• allow ONS to investigate the factors that predict severe outcomes (hospitalisation and mortality).

This work would aim to identify groups of people who are at particular risk of experiencing severe outcomes from COVID-19, which could have important public health and clinical recommendations.

In due course the intention is to combine these testing data with the Census, mortality, HES and GDPPR data held within ONS systems but the testing data will likely be directly acquired from Public Health England for this purpose.

Analysis outputs will be shared with colleagues at the Office for National Statistics and NHS Digital for scrutiny and quality assurance. NHS Digital will support ONS in understanding the data (e.g. variable definitions, limitations) and in the production of any publications with a focus on statistical accuracy, quality assurance and robust peer review.

The use of the data will determine the viability of producing official statistics using the datasets. The processing outlined above may directly result in the production of official statistics or may inform a subsequent methodology which is then used to produce official statistics.

As part of this, a key output is that this work will inform what minimisation can be applied to the GDPPR data in the event that ONS subsequently compels NHS Digital to transfer an extract to ONS.

Any official statistics produced will be shared with MPs, members of SAGE and other government officials to inform the government’s response to the COVID-19 pandemic. Any official statistics produced will be published, for example on the Office for National Statistics website. Briefings for technical/expert audiences such as SAGE will not include any new statistics/figures that are not in the publicly available release (written in such a way as to be accessible to all including the general public). ONS will share any briefings produced for technical/expert audiences with the British Medical Association (BMA) and Royal College of General Practitioners.

In the event that ONS determines that use of any given dataset is unsuitable for the purpose of producing official or identifies issues of significance with the data, it is possible that ONS would publish its findings in the form of methodological reports. ONS’ work to development new official statistics may involve testing to investigate whether statistics of sufficient quality can be produced and may also involve the production of statistics badged as ‘experimental’ while further work is done to improve quality aspects such as accuracy.

No patient-level data will be extracted from NHS systems. The expected data outputs are aggregate summary statistics, regression coefficients, and summary plots. All data outputs will be subject to any required disclosure control practices.

ONS produced a briefing on its analysis of long-COVID symptoms and COVID-19 complications which was presented to the National Statistician and subsequently shared with NHS Digital's Profession Advisory Group. The findings have been published on ONS' website - see: https://www.ons.gov.uk/releases/estimatingtheprevalenceoflongcovidsymptomsandcovid19complications. The information produced by ONS has been briefed to ministers enabling them to reach appropriate decisions in their response to the pandemic.

Under version 0.2 of this Data Sharing Agreement, analysts working for the Office for National Statistics (ONS) were granted remote access to linked GDPPR, HES and Mortality data within NHS Digital’s data environment.

This Agreement extends the period for which ONS analysts are permitted to access the data within NHS Digital’s environment.

Version 0.2 of this Agreement set out ONS’ intentions, prior to being granted data access, to review and analyse the data to determine if and how the data might be used to address gaps in ONS’ analyses of the risks associated with COVID-19. Since access was granted, the work undertaken by ONS analysts has led to subsets of GDPPR data being requested and approved for dissemination under a separate Agreement (DARS-NIC-400304-S1P1B).

Due to the size of the GDPPR data extract, it will take time before the dataset is fully transferred to ONS, ingested, data engineered and linked for analysis. In the meantime, ONS require uninterrupted access to linked GDPPR, HES and Mortality data to continue analyses in progress and to allow further investigations into the potential utilisation of the data to answer new questions in relation to COVID-19 which continue to be raised such as in relation to the phenomenon of ‘long-covid’.

The remainder of this section is unchanged from version 0.2 of this Data Sharing Agreement.

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The Office for National Statistics (ONS) is working on urgent analysis to determine the population-level relative risk of hospitalisation or death that COVID-19 presents to different people. This is being achieved by linking information on outcomes with information on characteristics and underlying health conditions at a record level. The data being used so far are being processed and analysed on ONS’s secure data platform. These data are either owned by ONS or have been acquired through its statutory powers.

However, there are some important information gaps in the data ONS has linked and has analysed so far. Primarily, this is to do with comorbidities and primary care data. Without a complete picture of comorbidities, it is difficult to give a fuller account of the differences being found in COVID-19 related mortality and morbidity between different groups/characteristics (such as ethnicity).

The information that has already been linked and is being analysed by ONS are as follows:

• Information on the outcome of death comes from the death registration data ONS already processes and regularly publishes statistics on.

• Information on socio-demographic characteristics such as ethnicity comes from the Census 2011.

• Information on hospitalisation (serious illness) from COVID-19 as an outcome, and information on underlying conditions that result in hospital contact, come from Hospital Episodes Statistics (HES) data that ONS receives from NHS Digital under a separate Data Sharing Agreement. ONS compelled NHS Digital to share this HES data with ONS for the purposes of official statistics under Section 45C of the Statistics and Registration Services Act (2008), as amended by the Digital Economy Act (2017)

ONS is currently unable to control for all comorbidities in statistical models using only the HES data because hospital attendances will only represent the most serious cases, with minor illnesses or managed chronic conditions being handled in primary care. It is likely these missing comorbidities are mediating some of the differences that have been found between different groups/characteristics such as ethnicity.

ONS would like to include primary care data for all or most of the population too. And ideally, this would involve ONS acquiring and transferring the data onto its secure systems where it can be linked to the other data sources described at a record level.

The government’s Scientific Advisory Group for Emergencies (SAGE) and the National Statistician are all keen that such an improvement to the project be enabled. As a result both ONS and NHS Digital are coming under significant pressure share relevant data quickly. More importantly, the insight gained from an improved study will inform decision making that could ultimately save lives.

However, ONS and NHS Digital have agreed that some groundwork is needed in advance of ONS potentially compelling NHS Digital to share the data by issuing a legal Notice under the same statutory powers used to acquire the HES data.

This involves ONS and NHS Digital collaborating to analyse the GPES Data for Pandemic Planning and Research (GDPPR) data on NHS Digital systems, where it can be linked to the HES and mortality data (i.e. the only data missing would be the ONS Census data).

This will allow ONS and NHS Digital analysts to explore and analyse the data in situ, with a view to:

a) confirming there is a strong enough ‘public good’ case for the data being transferred onto ONS systems, and if so

b) refining and minimising any GDPPR extract/specification which ONS then compels NHS Digital to share

This refinement is required because the ONS statutory power to compel data are shared is still subject to GDPR principles, including that data are minimised to that necessary to achieve the purpose. In addition, the powers are only applicable where ONS needs the information for its functions (essentially the production of official statistics for the public good).

The quickest way to ensure these conditions are met is for ONS to gain access to the data remotely and collaborate with NHS Digital analysts as described. Unlike any subsequent transfer of data to ONS under its statutory powers, this remote access by ONS analysts will be covered by the COPI regulation.

To be clear, the present application only covers this refinement stage. If/when ONS compels NHS Digital to share and transfer an extract onto ONS systems under its statutory powers, this will be supported by a separate DARS application and Data Sharing Agreement.

In preparation for access to GDPPR data, ONS has been working with NHS Digital’s analytical experts to better understand GDPPR data and whether it will be fit for the statistical purposes to which ONS wants to put it. The ONS analysts have been provided with a GDPPR user guide and a data specification and have been involved in discussions to plan the setup of the data environment in which the data would be accessed.

Once granted remote access to GDPPR data in a suitable and secure data environment within NHS Digital’s systems, ONS analysts will review the data items, coverage, quality and completeness of these data in line with ONS requirements for producing official statistics under the Code of Practice (particularly transparency, quality and improvement). The collaboration of ONS and NHS Digital analysts during this phase will support NHS Digital’s development and understanding of these new primary care data.

Having access to HES, mortality and GDPPR data containing identifying details will enable ONS analysts to link individuals across the datasets. ONS does not require identifying details for any reason other than for data linkage.

The linked dataset will not fully mirror the linked project dataset that ONS has already produced on its own systems because it will not include the Census 2011 data. However, risk modelling analysis that will inform decision making by bodies such as SAGE will still be possible by ONS and NHS Digital analysts working collaboratively.

This work will also allow further development of the collaborative ONS-NHS Digital view on the quality and utility of the data, and whether there is a ‘public good’ case for any data being transferred to ONS under its statutory powers. Logically, this decision will revolve around the importance of any analyses that are still not possible because the linked data at NHS Digital lacks the Census information, and because the linked data at ONS lacks the GDPPR information.

Note, the only way to bring all four sources together is at ONS. There is no legal gateway which allow the transfer of Census data to NHS Digital systems (whereas there is for the transfer of GDPPR data to ONS systems).

The HES and mortality data included within this linked dataset created on NHS Digital systems will mirror the HES and mortality data that the ONS analysts already have access to on ONS systems. They are suitably security cleared and trained in working with such data.

It is important to note that assessing the quality of the data is a key requirement to produce official statistics so that the strengths and limitations of the different data can be understood and applied or mitigated as required. ONS has to undertake preliminary work to assess the appropriateness of a datasets/data sources for use in the production of official statistics. As an example, noting that Type 1 Patient Objections will be applied to the GDPPR data, ONS will need to assess whether there is a need to make adjustments for that.

As has been made clear, much of the proposed purpose here is to develop an understanding of the data through remote access so that any full acquisition of the data by ONS onto its systems can be minimised appropriately. However, ONS are also keen to minimise the access that ONS analysts get to the GDPPR data on NHS Digital systems where possible.

Based on its current knowledge of the data, ONS considered how it could minimise the data requested as follows:

• Years of data – ideally full histories for patients would be required to ensure we capture the full history of comorbidities but these could be minimised to data from March 2011 onwards in line with census year to allow for data on history of comorbidities to be applied to the study population appropriately. To note this would be for date of activity i.e. when the condition / event happened (not when the patient record was updated).

• Patient groups – the whole population is required because the data are used to predict outcomes associated with COVID-19, and as such ONS needs to ensure it has a big enough population to be able to do the analysis. The risk model aims to identify how COVID-19 patients are different to rest of population so it needs details of all different population groups and needs data to be representative of the population. The linked study dataset ONS has produced includes over 50 million subjects for whom a full Census record is available and for whom it has been possible accurately assign an NHS number to (i.e. those who can then be more easily linked to other datasets that include NHS number such as HES and mortality data).

• Cluster codes – it is currently difficult to specify any minimisation of the data based on cluster codes as the information and guidance on the cluster codes and identification of specific conditions and diagnosis are only just becoming available. A key part of this project is to understand and assess the quality of the data in the context of producing official statistics and as such this area of the data will be a key area requiring quality assessment (in terms of identifying all comorbidities). To minimise access to these data at this time may hamper a full assessment.

• Local area data – postcode data is not required but analysis at a local level is required for the model. Data to Lower Super Output Area (LSOA) is required which will allow a link to socio-demographic variables as provided by the Index of Multiple deprivation (IMD). LSOA is provided in the standard GDPPR dataset so this is fine.

The primary care data to be accessed will be limited to information on:

• patient demographics• diagnoses and findings

• medications and other prescribed items

• investigations, tests and results

• treatments and outcomes

• vaccinations and immunisations

ONS require patient-level data because ONS are interested in patient-level socio-demographics, clinical profiles and outcomes. Use of more aggregated (e.g. regional level) data would result in a lack of statistical precision and risks the analysis being subjected to the so-called ecological fallacy. At present the work ONS has done is only able to control for decade-old socio-demographic factors in its COVID-19 risk models. Up-to-date primary care data on clinical diagnoses, treatments and histories would allow ONS to substantially enhance the risk models, as comorbidities are likely to explain relatively large proportion of the variability in COVID-19 mortality risk.

Whilst certain conditions are known to be risk factors for COVID-19 mortality/morbidity (e.g. patients with severe lung conditions or those on immunosuppressants), it is necessary to have access to the full range of diagnostic and treatment codes (including linkage to HES data) so patients’ comorbidity profiles can be fully explored and controlled for in the models.

Analysis outputs will be shared with colleagues at the Office for National Statistics and NHS Digital for scrutiny and quality assurance. NHS Digital will support ONS in the production of any publications with a focus on statistical accuracy, quality assurance and robust peer review.

The use of the data will determine the viability of producing official statistics using the datasets. The processing outlined above may directly result in the production of official statistics or may inform a subsequent methodology which is then used to produce official statistics.

As part of this, a key output is that this work will inform what minimisation can be applied to the GDPPR data in the event that ONS subsequently compels NHS Digital to transfer an extract to ONS.

Any official statistics produced will be shared with MPs, members of SAGE and other government officials to inform the government’s response to the COVID-19 pandemic. Any official statistics produced will be published, for example on the Office for National Statistics website.

In the event that ONS determines that use of the GDPPR data is unsuitable for the purpose of producing official or identifies issues of significance with the data, it is possible that ONS would publish its findings in the form of methodological reports. ONS’ work to development new official statistics may involve testing to investigate whether statistics of sufficient quality can be produced and may also involve the production of statistics badged as ‘experimental’ while further work is done to improve quality aspects such as accuracy.

No patient-level data will be extracted from NHS systems. The expected data outputs are aggregate summary statistics, regression coefficients, and summary plots. All data outputs will be subject to any required disclosure control practices.

The Office for National Statistics (ONS) is working on urgent analysis to determine the population-level relative risk of hospitalisation or death that COVID-19 presents to different people. This is being achieved by linking information on outcomes with information on characteristics and underlying health conditions at a record level. The data being used so far are being processed and analysed on ONS’s secure data platform. These data are either owned by ONS or have been acquired through its statutory powers.

However, there are some important information gaps in the data ONS has linked and has analysed so far. Primarily, this is to do with comorbidities and primary care data. Without a complete picture of comorbidities, it is difficult to give a fuller account of the differences being found in COVID-19 related mortality and morbidity between different groups/characteristics (such as ethnicity).

This purpose of this application is to seek approval to take the first steps in addressing this information gap.

The information that has already been linked and is being analysed by ONS are as follows:

• Information on the outcome of death comes from the death registration data ONS already processes and regularly publishes statistics on.

• Information on socio-demographic characteristics such as ethnicity comes from the Census 2011.

• Information on hospitalisation (serious illness) from COVID-19 as an outcome, and information on underlying conditions that result in hospital contact, come from Hospital Episodes Statistics (HES) data that ONS receives from NHS Digital under a separate Data Sharing Agreement. ONS compelled NHS Digital to share this HES data with ONS for the purposes of official statistics under Section 45C of the Statistics and Registration Services Act (2008), as amended by the Digital Economy Act (2017)

ONS is currently unable to control for all comorbidities in statistical models using only the HES data because hospital attendances will only represent the most serious cases, with minor illnesses or managed chronic conditions being handled in primary care. It is likely these missing comorbidities are mediating some of the differences that have been found between different groups/characteristics such as ethnicity.

ONS would like to include primary care data for all or most of the population too. And ideally, this would involve ONS acquiring and transferring the data onto its secure systems where it can be linked to the other data sources described at a record level.

The government’s Scientific Advisory Group for Emergencies (SAGE) and the National Statistician are all keen that such an improvement to the project be enabled. As a result both ONS and NHS Digital are coming under significant pressure share relevant data quickly. More importantly, the insight gained from an improved study will inform decision making that could ultimately save lives.

However, ONS and NHS Digital have agreed that some groundwork is needed in advance of ONS potentially compelling NHS Digital to share the data by issuing a legal Notice under the same statutory powers used to acquire the HES data.

This involves ONS and NHS Digital collaborating to analyse the GPES Data for Pandemic Planning and Research (GDPPR) data on NHS Digital systems, where it can be linked to the HES and mortality data (i.e. the only data missing would be the ONS Census data).

This will allow ONS and NHS Digital analysts to explore and analyse the data in situ, with a view to:

a) confirming there is a strong enough ‘public good’ case for the data being transferred onto ONS systems, and if so

b) refining and minimising any GDPPR extract/specification which ONS then compels NHS Digital to share

This refinement is required because the ONS statutory power to compel data are shared is still subject to GDPR principles, including that data are minimised to that necessary to achieve the purpose. In addition, the powers are only applicable where ONS needs the information for its functions (essentially the production of official statistics for the public good).

The quickest way to ensure these conditions are met is for ONS to gain access to the data remotely and collaborate with NHS Digital analysts as described. Unlike any subsequent transfer of data to ONS under its statutory powers, this remote access by ONS analysts will be covered by the COPI regulation.

To be clear, the present application only covers this refinement stage. If/when ONS compels NHS Digital to share and transfer an extract onto ONS systems under its statutory powers, this will be supported by a separate DARS application and Data Sharing Agreement.

In preparation for access to GDPPR data, ONS has been working with NHS Digital’s analytical experts to better understand GDPPR data and whether it will be fit for the statistical purposes to which ONS wants to put it. The ONS analysts have been provided with a GDPPR user guide and a data specification and have been involved in discussions to plan the setup of the data environment in which the data would be accessed.

Once granted remote access to GDPPR data in a suitable and secure data environment within NHS Digital’s systems, ONS analysts will review the data items, coverage, quality and completeness of these data in line with ONS requirements for producing official statistics under the Code of Practice (particularly transparency, quality and improvement). The collaboration of ONS and NHS Digital analysts during this phase will support NHS Digital’s development and understanding of these new primary care data.

Having access to HES, mortality and GDPPR data containing identifying details will enable ONS analysts to link individuals across the datasets. ONS does not require identifying details for any reason other than for data linkage.

The linked dataset will not fully mirror the linked project dataset that ONS has already produced on its own systems because it will not include the Census 2011 data. However, risk modelling analysis that will inform decision making by bodies such as SAGE will still be possible by ONS and NHS Digital analysts working collaboratively.

This work will also allow further development of the collaborative ONS-NHS Digital view on the quality and utility of the data, and whether there is a ‘public good’ case for any data being transferred to ONS under its statutory powers. Logically, this decision will revolve around the importance of any analyses that are still not possible because the linked data at NHS Digital lacks the Census information, and because the linked data at ONS lacks the GDPPR information.

Note, the only way to bring all four sources together is at ONS. There is no legal gateway which allow the transfer of Census data to NHS Digital systems (whereas there is for the transfer of GDPPR data to ONS systems).

The HES and mortality data included within this linked dataset created on NHS Digital systems will mirror the HES and mortality data that the ONS analysts already have access to on ONS systems. They are suitably security cleared and trained in working with such data.

It is important to note that assessing the quality of the data is a key requirement to produce official statistics so that the strengths and limitations of the different data can be understood and applied or mitigated as required. ONS has to undertake preliminary work to assess the appropriateness of a datasets/data sources for use in the production of official statistics. As an example, noting that Type 1 Patient Objections will be applied to the GDPPR data, ONS will need to assess whether there is a need to make adjustments for that.

As has been made clear, much of the proposed purpose here is to develop an understanding of the data through remote access so that any full acquisition of the data by ONS onto its systems can be minimised appropriately. However, ONS are also keen to minimise the access that ONS analysts get to the GDPPR data on NHS Digital systems where possible.

Based on its current knowledge of the data, ONS considered how it could minimise the data requested as follows:

• Years of data – ideally full histories for patients would be required to ensure we capture the full history of comorbidities but these could be minimised to data from March 2011 onwards in line with census year to allow for data on history of comorbidities to be applied to the study population appropriately. To note this would be for date of activity i.e. when the condition / event happened (not when the patient record was updated).

• Patient groups – the whole population is required because the data are used to predict outcomes associated with COVID-19, and as such ONS needs to ensure it has a big enough population to be able to do the analysis. The risk model aims to identify how COVID-19 patients are different to rest of population so it needs details of all different population groups and needs data to be representative of the population. The linked study dataset ONS has produced includes over 50 million subjects for whom a full Census record is available and for whom it has been possible accurately assign an NHS number to (i.e. those who can then be more easily linked to other datasets that include NHS number such as HES and mortality data).

• Cluster codes – it is currently difficult to specify any minimisation of the data based on cluster codes as the information and guidance on the cluster codes and identification of specific conditions and diagnosis are only just becoming available. A key part of this project is to understand and assess the quality of the data in the context of producing official statistics and as such this area of the data will be a key area requiring quality assessment (in terms of identifying all comorbidities). To minimise access to these data at this time may hamper a full assessment.

• Local area data – postcode data is not required but analysis at a local level is required for the model. Data to Lower Super Output Area (LSOA) is required which will allow a link to socio-demographic variables as provided by the Index of Multiple deprivation (IMD). LSOA is provided in the standard GDPPR dataset so this is fine.

The primary care data to be accessed will be limited to information on:

• patient demographics• diagnoses and findings

• medications and other prescribed items

• investigations, tests and results

• treatments and outcomes

• vaccinations and immunisations

ONS require patient-level data because ONS are interested in patient-level socio-demographics, clinical profiles and outcomes. Use of more aggregated (e.g. regional level) data would result in a lack of statistical precision and risks the analysis being subjected to the so-called ecological fallacy. At present the work ONS has done is only able to control for decade-old socio-demographic factors in its COVID-19 risk models. Up-to-date primary care data on clinical diagnoses, treatments and histories would allow ONS to substantially enhance the risk models, as comorbidities are likely to explain relatively large proportion of the variability in COVID-19 mortality risk.

Whilst certain conditions are known to be risk factors for COVID-19 mortality/morbidity (e.g. patients with severe lung conditions or those on immunosuppressants), it is necessary to have access to the full range of diagnostic and treatment codes (including linkage to HES data) so patients’ comorbidity profiles can be fully explored and controlled for in the models.

Analysis outputs will be shared with colleagues at the Office for National Statistics and NHS Digital for scrutiny and quality assurance. NHS Digital will support ONS in the production of any publications with a focus on statistical accuracy, quality assurance and robust peer review.

The use of the data will determine the viability of producing official statistics using the datasets. The processing outlined above may directly result in the production of official statistics or may inform a subsequent methodology which is then used to produce official statistics.

As part of this, a key output is that this work will inform what minimisation can be applied to the GDPPR data in the event that ONS subsequently compels NHS Digital to transfer an extract to ONS.

Any official statistics produced will be shared with MPs, members of SAGE and other government officials to inform the government’s response to the COVID-19 pandemic. Any official statistics produced will be published, for example on the Office for National Statistics website.

In the event that ONS determines that use of the GDPPR data is unsuitable for the purpose of producing official or identifies issues of significance with the data, it is possible that ONS would publish its findings in the form of methodological reports. ONS’ work to development new official statistics may involve testing to investigate whether statistics of sufficient quality can be produced and may also involve the production of statistics badged as ‘experimental’ while further work is done to improve quality aspects such as accuracy.

No patient-level data will be extracted from NHS systems. The expected data outputs are aggregate summary statistics, regression coefficients, and summary plots. All data outputs will be subject to any required disclosure control practices.

Yielded Benefits is not a requirement for new applications.