Telstra Health UK - HES, ECDS, Civil Registration (Deaths) Secondary Care Cut

Telstra Health UK requires access to NHS England for the purpose of providing the following services to clients in the health sector:

• Online tools and services – management information, analysis and clinical benchmarking, and consultancy;

• Bespoke analytics – customised projects to meet individual customer needs;

• Research for publication – thought leadership in the field of healthcare data analytics, with the aim of improving the planning, delivery and outcome of health and social care.

NHS clients access analysis of the data to:

• Track and trend performance, identify areas for efficiency savings and understand and influence demand and patient flow throughout the health and care system.

• Investigate risk-adjusted quality, patient safety and clinical outcomes data including mortality, benchmark against other healthcare organisations and to help improve the quality of patient care and identify areas for improvement.

Telstra Health UK products and services are used by:

• NHS Provider Trusts - Subscribed authorised users in customer organisations can view data that relate to their organisation at a record level. They can view aggregated, small-number suppressed outputs relating to other organisations for benchmarking and peer analysis. They cannot access record level data relating to other organisations.

• Other NHS organisations - Subscribed authorised users in customer organisations can view aggregated analysis which provides valuable insight but prevents any patients from being identified, in accordance with guidance provided by NHS England.

• Care Quality Commission (CQC) - CQC can view aggregated analysis.

The Analytics team provides analysis (in line with the HES Analysis Guide) and insight to a number of NHS customers including:

• NHS Trusts

• Integrated Care Systems

• Integrated Care Boards

• Commissioning Support Units

• Department of Health and Social Care

• NHS England

• Care Quality Commission

• UK Health Security Agency and Office for Health Improvement and Disparities

• National Institute for Health and Care Excellence

Telstra Health UK also work with:

• Non-NHS organisations providing services to benefit the NHS - these are only supplied with aggregate, small-number suppressed analyses in line with the HES analysis guide.

• Non-NHS organisations to benefit public health and social care - these are only supplied with aggregate, small-number suppressed analyses where benefits can be identified for the health and social care system. Algorithms or coefficients that have been derived through research on HES data may be provided directly to a customer for implementation on their own local data. Data provided in all outputs to non-NHS organisations will be at an aggregate level and small number suppression will be implemented in line with HES analysis guidelines.

Telstra Health UK use the data provided under this agreement to provide a management information function in the form of analysis and clinical benchmarking for healthcare organisations and to increase the power of predictive models for rare diseases, procedures and events. Telstra Health UK build standard casemix adjustment models for 259 diagnosis groups and 200 procedure groups which include some rarer conditions. Casemix is a system that measures hospital performance, aiming to reward initiatives that increase efficiency in hospitals. It also serves as an information tool that allows policy makers to understand the nature and complexity of health care delivery.

At a high-level Telstra Health UK analyses break down into the following:

• Quality measures of healthcare services by providers/area/clinical interest/trend analysis

• Variations in health outcomes

• Health inequalities and needs analysis

• Predictions

• Performance data and changes in clinical practice

• Management information

• Efficiency monitoring

• Benchmarking

• Contract management and variance analysis

• Activity monitoring

• National target performance

• Pathway design, redesign and improvement.

• Practice performance monitoring

• Capacity and utilisation management

• Cross checking of commissioning data

• Systems to support and monitor the pattern of healthcare usage

• Patient segmentation analysis

• Overall data quality

The data allow Telstra Health UK to provide a wide array of relevant indicators to give end users as complete a picture of hospital performance as possible to allow health and social care organisations to effectively:

• Monitor quality of services provided

• Identify efficiency opportunities

• Identify pathways where services can be improved for the benefit of patients

The following NHS England data will be accessed:

• Hospital Episode Statistics Admitted Patient Care, Accident & Emergency, Critical Care, Outpatients – necessary to understand demand and patient flow through the health and care system; investigate quality, patient safety and clinical outcomes data; and benchmark against other healthcare organisations

• Emergency Care Data Set (ECDS) – necessary for the above reasons, and improve understanding of the complexity of attending patients and the causes of rising demand; capture diagnostic data for richer information on the diagnosis with which patients are presenting to emergency departments; enhance the understanding of the value of emergency departments; and better understand patient pathways such as type 5 emergency admissions (same day emergency care), which are currently not coded within HES.

• Civil Registration Mortality – necessary for performing survival analyses. This data is also extremely critical because mortality information may be a surrogate metric for success of medical care. This dataset will enable identification of factors that drive successful treatment of a patient. Cause and date of death may also be used to identify trends in causes of death in particular groups of patients. Telstra Health UK hold historical death data which is necessary for identifying trends over time.

Civil Registrations of Death data linked to HES and ECDS provides valuable insights into how and why some patients with the same condition and at the same stage can have very different outcomes. In addition, it is used to:

• Compare hospital mortality rates for in-hospital deaths with rates for all deaths to evaluate the effect of differential discharge policies

• Calculate total post-operative mortality rates, e.g. when comparing operative techniques such as laparoscopy and open approaches

• Assess potential quality of care issues by comparing the cause of death with the reason(s) for admission, e.g. for surgical patients who are discharged within 30 days of the procedure but who die at home and whether the death is related to their disease process or to complications of treatment

• Develop and validate indicators of quality and safety of healthcare, particularly by consultant and hospital

• Show variations in performance by unit and socio demographic stratum

• Predict risk and adjust risk of indicators and variations and any other methodological aspects as they arise

• Establish seasonal patterns of mortality

• Support organisations in delivering their Learning from Deaths agenda and timely mortality reviews

• Help organisations improve quality of care and identify where they could do more to help patients and their families

• Providing 30 day mortality analysis. This is a well published and accepted standard for comparing post-operative and post-admission hospital mortality which is expected to improve engagement with clinicians, and allow comparisons with other published analyses.

Using all the requested datasets means that Telstra Health UK have the most up to date information and can inform customers of potential issues around quality and in turn allowing them to make better informed decisions for the improvement of healthcare and outcomes for patients.

The level of the data will be pseudonymised.

The data will be minimised as follows:

• Limited to 11 full years of data at any one time

• Limited to data fields which are necessary to deliver products and services that benefit health and care in the UK

Telstra Health UK is the controller as the organisation responsible for ensuring that the data will only be processed for the purposes described above.

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

Article 6(1)(f) - processing is necessary for the purposes of the legitimate interests pursued by the controller or by a third party.

Telstra Health UK has a legitimate interest in being able to provide tools and services that healthcare organisations will find useful and that will benefit the health and social care system. Without processing NHS England data, Telstra Health UK would not be able to deliver these tools and services, which would be to the detriment of health professionals who use them. Telstra Health UK's customers can be assured that the tools and services are based on evidence provided by data from a trusted source. There is no viable alternative as relying on public domain data would lead to gaps and not allow the same support for decision making. Using pseudonymised data allows Telstra Health UK to deliver evidence-based insight and analysis while minimising intrusion into a patient's privacy.

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

Article 9(2)(j) - processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject.

This processing is in the public interest because it helps to ensure high standards of quality and safety of health care. Although Telstra Health UK are not a public body, they provide services to help public healthcare organisations to monitor and improve their services. Processing is designed to benefit patients and society as a whole through better healthcare.

Microsoft Ltd and Amazon Web Services (AWS) provide Cloud hosting services to Telstra Health UK and will store the data as contracted by Telstra Health UK.

Telstra Health UK provide commercial tools, insight and analysis to healthcare professionals. They also provide freely available online resources for healthcare professionals and the public (using anonymised outputs) to help improve professional and public understanding of health.

The majority of Telstra Health UK outputs are delivered through:

• Online tools and services including the Healthcare Intelligence Portal

• Bespoke analytics

• Research for publication.

Telstra Health UK will continue to develop its outputs for NHS customers. Specific outputs include benchmarked or standardised healthcare indicators and analysis such as mortality, LOS (Length of Stay), admission trends, readmission rates, patient safety indicators, referral patterns, market share analysis etc.

The above outputs depend on processing of all the requested data. Outputs are typically provided in data tables to NHS customers. Telstra Health UK may also produce data visualisations (e.g. bar charts, box plots, funnel plots) based on the aggregate-level information from the data tables. Outputs produced by the team 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. Outputs for Trusts may include data that relate to their organisation at a record level, but with suppression applied for any peer analysis.

Specific outputs dependent on the processing of Civil Registration mortality data are:

• Analysis of cause of death

• Analysis of death following discharge, 7, 14, 30 days

• Comparative analysis of cause of death and deaths following discharge

• Development of outputs to further help users understand patient outcomes through analysis of survival rates

• Analysis of variation in mortality across geographical boundaries

• Support customers with out of hospital mortality queries

• Additional level of insight for customers to investigate the care pathway for their patients

Subscribers to the tools have continual access which allows them to meet their own internal target dates.

Outputs of bespoke analytics projects are dependent on the nature of the project and can include tabulations, dashboards, reports, spreadsheets, presentations or articles. In some instances, algorithms or coefficients that have been derived through research on the data may be provided directly to a customer for implementation on their own local data. Data provided in all 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. Bespoke analytics projects are conducted on an ad hoc basis and target dates for delivery of outputs are thus defined upon commencement of each project.

Examples of previous publications produced by Telstra Health UK include the Dr Foster Hospital Guide that published analysis of the variations in acute hospital care for the benefit of healthcare professionals, patients and the public, and insight articles published on the Telstra Health UK website.

In September 2022 Telstra Health UK published a research report with Cancer Research UK which explores the potential impact of the COVID-19 pandemic on cancer surgery and cancer mortality, including place of death. This work has been showcased at a number of conferences including the European Cancer Summit 2022.

In January 2020, Telstra Health UK undertook statistical analyses of abdominal aortic aneurisms and trans-catheter aortic valve implementations and found interesting correlations between surgeon annual volume and mortality. Following on from this, the team carried out an analysis that examined how the number of annual knee replacement procedures performed within a trust influences the rate of readmission. Insights from this are published on the Telstra Health UK website.

From April 2020, Telstra Health UK provided an interactive dashboard on its website to provide information to help manage and predict the risk of COVID-19 for England and which was updated regularly throughout the pandemic.

Telstra Health UK have provided analysis to the following non-NHS organisations:

• British Red Cross (2020) – COVID-19 analysis relating to frailty and mobility (percentages, no small numbers)

• Sodexo (2021) - aggregate data on the rates of readmission, long length of stay (LOS), LOS over 20 days and day case procedures as inpatient admissions for acute, non-specialist trusts.

• Imperial College Health Partners (ICHP) (2022-2023). Telstra Health UK developed a respiratory dashboard for ICHP using HES data. The dashboard was refreshed quarterly by Telstra Health UK and sent to ICHP for publication on their website for anyone in the NHS to view (https://imperialcollegehealthpartners.com/resource/respiratory-population-health-dashoard/).

• Royal College of Surgeons (RCS) (2023) – Telstra Health UK developed metrics to evaluate a study run by the RCS. All output provided by Telstra Health UK to RCS as part of this development work conformed to HES analysis guidance and did not include small numbers.

2023

An ongoing project with Buckinghamshire Healthcare NHS Foundation Trust utilises the HES data that Telstra Health UK hold over a 10-year period to plot the impact of both internal and external initiatives and policy change to understand changes in mortality outcomes. This long-term view is extremely valuable to the Trust, especially when a similar 10-year peer view can also be overlaid to understand whether initiatives or new policy impact all provider organisations in the region to a similar level.

Northampton General Hospital NHS Trust have fully embedded the HES derived analysis provided by Telstra Health UK into their performance processes. As part of performance monitoring the Trust has produced its own data and evidence that shows a clear link between the formation of improvement workstreams that utilise HES derived intelligence supplied by THUK and better patient outcomes.

Guy’s & St Thomas’ NHS Trust have used HES derived intelligence and information to optimise care pathways for patient cohorts who appear to have a low likelihood of mortality whilst admitted to the Trust, but who subsequently die out of hospital. This project uses the THUK Hospital Standardised Mortality Ratio (HSMR) to identify patient groups with a statistically low risk of mortality. Generally, provider Trusts use HSMR to understand mortality outcomes for their admitted patients. As this Trust already has good mortality outcomes in the HSMR model this innovative work is expanding the improvement work further into the patient journey to improve patients’ outcomes even when they have left the immediate care of the acute Trust.

2022

“Imperial uses data and expertise provided by Telstra Health UK to support clinical quality performance improvement and assurance. Telstra Health UK produces routine reports on a monthly basis on, for example, mortality rates, which feed into our clinical governance meetings and performance scorecards. We are a large provider of acute services in NW London and around 100 of our patients die every month. Without the data and the service provided by Telstra Health UK we would not be able the closely monitor mortality rates at specialty level, which is an essential aspect of clinical safety. The data and service provided also allows us to monitor the quality of our clinical coding to ensure that our reporting and analysis is accurate.”

Deputy CIO, Imperial College Healthcare NHS Trust, October 2022

Furthering public and professional understanding of public health through publication of thought leadership pieces and research including “Impact of the COVID-19 pandemic on cancer surgery and cancer mortality” (September 2022).

2021

Covid-19 dashboard providing analysis of Trusts' crude and risk-adjusted mortality rates and in comparison to peers and a national benchmark. (March 2021).

Telstra Health UK developed a COVID-19 mortality risk model on the HES (Hospital Episode Statistics) Admitted Patient Care dataset to:

1. Create national benchmarks allowing Trusts to compare their COVID-19 mortality against peers taking into account patient case-mix

2. Provide a COVID-19 mortality relative risk for each Trust to be surfaced in a dashboard

3. Identify the most important factors within the COVID-19 cohort leading to mortality at a Trust and/or site level and comparing these to a national or peer group average.

"It's a great tool and gives exactly the kind of external assurance we need, I think the demographic and risk factor analysis is very helpful". Director for Safety and Medical Director, Deputy Chief Executive, Gloucestershire Hospitals NHS FT.

Analysis of homeless patient inequalities (February 2021)

After consultation with University College London Hospitals, which recently established a multidisciplinary collaboration in response to homelessness, Telstra Health UK set out to produce a suite of analysis using the Hospital Episode Statistics (HES) Admitted Patent Care data to identify and understand comparative characteristics of homeless patients nationally. The analysis sought to identify the shared characteristics of homeless patients, what their needs are, and to highlight some of the differences they have in experiences and outcomes to the rest of the population. The report is freely available on the Telstra Health UK website.

2020

Analysis of decline in admissions during first wave of pandemic (October 2020)

Telstra Health UK's analysis published in the Daily Telegraph, and then picked up by other media organisations, showed that during the height of the first wave of the COVID-19 pandemic in the UK in April-May 2020, there was a sharp drop in admissions relating to a number of diseases. The reporting informed public awareness and sparked discussion with healthcare professionals, including for example, warnings of longer term impacts and encouragement for people to contact their GP if they need medical treatment.

Frailty analysis for British Red Cross (May 2020)

Telstra Health UK's frailty analysis has been used by the British Red Cross create a COVID-19 vulnerability index for the UK, mapping clinical vulnerability, economic vulnerability, social vulnerability and other health and wellbeing needs. This is helping the British Red Cross focus help on the most vulnerable people whose needs aren't being met.

COVID-19 heatmaps (April 2020)

Telstra Health UK's awareness raising publications have provided professionals and the public with insight into the progression of COVID-19. Their interactive dashboard, first released in April 2020, uses heatmaps to show the spread of the disease. It also shows historical perspectives within the past 10 years by using respiratory and frailty data from HES.

Pan-London respiratory dashboard (March 2020)

Development of a pan-London respiratory dashboard in conjunction with Imperial College Health Partners which provides information on a range of metrics looking at disease prevalence and medicines management. Dashboard has been made available on the ICHP website for anyone with an NHS HSCN connection.

2019

High Intensity User (HIU) report (January 2019)

Telstra Health UK continues to raise public and professional awareness. Its High Intensity User (HIU) report of January 2019 uncovered important characteristics of HIU patients and patterns in their attendances of A&E. It showed that the vast majority of HIUs are living in the most deprived areas of England, suggesting that the most vulnerable members of society may be more prone to high intensity use. Smoking, drugs and alcohol all appear to play an important role in frequent A&E use, in relation to the most common reasons that HIUs are admitted to hospital.

Telstra Health UK requires access to NHS England for the purpose of providing the following services to clients in the health sector:

• Online tools and services – management information, analysis and clinical benchmarking, and consultancy;

• Bespoke analytics – customised projects to meet individual customer needs;

• Research for publication – thought leadership in the field of healthcare data analytics, with the aim of improving the planning, delivery and outcome of health and social care.

NHS clients access analysis of the data to:

• Track and trend performance, identify areas for efficiency savings and understand and influence demand and patient flow throughout the health and care system.

• Investigate risk-adjusted quality, patient safety and clinical outcomes data including mortality, benchmark against other healthcare organisations and to help improve the quality of patient care and identify areas for improvement.

Telstra Health UK products and services are used by:

• NHS Provider Trusts - Subscribed authorised users in customer organisations can view data that relate to their organisation at a record level. They can view aggregated, small-number suppressed outputs relating to other organisations for benchmarking and peer analysis. They cannot access record level data relating to other organisations.

• Other NHS organisations - Subscribed authorised users in customer organisations can view aggregated analysis which provides valuable insight but prevents any patients from being identified, in accordance with guidance provided by NHS England.

• Care Quality Commission (CQC) - CQC can view aggregated analysis.

The Analytics team provides analysis (in line with the HES Analysis Guide) and insight to a number of NHS customers including:

• NHS Trusts

• Integrated Care Systems

• Integrated Care Boards

• Commissioning Support Units

• Department of Health and Social Care

• NHS England

• Care Quality Commission

• UK Health Security Agency and Office for Health Improvement and Disparities

• National Institute for Health and Care Excellence

Telstra Health UK also work with:

• Non-NHS organisations providing services to benefit the NHS - these are only supplied with aggregate, small-number suppressed analyses in line with the HES analysis guide.

• Non-NHS organisations to benefit public health and social care - these are only supplied with aggregate, small-number suppressed analyses where benefits can be identified for the health and social care system. Algorithms or coefficients that have been derived through research on HES data may be provided directly to a customer for implementation on their own local data. Data provided in all outputs to non-NHS organisations will be at an aggregate level and small number suppression will be implemented in line with HES analysis guidelines.

Telstra Health UK use the data provided under this agreement to provide a management information function in the form of analysis and clinical benchmarking for healthcare organisations and to increase the power of predictive models for rare diseases, procedures and events. Telstra Health UK build standard casemix adjustment models for 259 diagnosis groups and 200 procedure groups which include some rarer conditions. Casemix is a system that measures hospital performance, aiming to reward initiatives that increase efficiency in hospitals. It also serves as an information tool that allows policy makers to understand the nature and complexity of health care delivery.

At a high-level Telstra Health UK analyses break down into the following:

• Quality measures of healthcare services by providers/area/clinical interest/trend analysis

• Variations in health outcomes

• Health inequalities and needs analysis

• Predictions

• Performance data and changes in clinical practice

• Management information

• Efficiency monitoring

• Benchmarking

• Contract management and variance analysis

• Activity monitoring

• National target performance

• Pathway design, redesign and improvement.

• Practice performance monitoring

• Capacity and utilisation management

• Cross checking of commissioning data

• Systems to support and monitor the pattern of healthcare usage

• Patient segmentation analysis

• Overall data quality

The data allow Telstra Health UK to provide a wide array of relevant indicators to give end users as complete a picture of hospital performance as possible to allow health and social care organisations to effectively:

• Monitor quality of services provided

• Identify efficiency opportunities

• Identify pathways where services can be improved for the benefit of patients

The following NHS England data will be accessed:

• Hospital Episode Statistics Admitted Patient Care, Accident & Emergency, Critical Care, Outpatients – necessary to understand demand and patient flow through the health and care system; investigate quality, patient safety and clinical outcomes data; and benchmark against other healthcare organisations

• Emergency Care Data Set (ECDS) – necessary for the above reasons, and improve understanding of the complexity of attending patients and the causes of rising demand; capture diagnostic data for richer information on the diagnosis with which patients are presenting to emergency departments; enhance the understanding of the value of emergency departments; and better understand patient pathways such as type 5 emergency admissions (same day emergency care), which are currently not coded within HES.

• Civil Registration Mortality – necessary for performing survival analyses. This data is also extremely critical because mortality information may be a surrogate metric for success of medical care. This dataset will enable identification of factors that drive successful treatment of a patient. Cause and date of death may also be used to identify trends in causes of death in particular groups of patients. Telstra Health UK hold historical death data which is necessary for identifying trends over time.

Civil Registrations of Death data linked to HES and ECDS provides valuable insights into how and why some patients with the same condition and at the same stage can have very different outcomes. In addition, it is used to:

• Compare hospital mortality rates for in-hospital deaths with rates for all deaths to evaluate the effect of differential discharge policies

• Calculate total post-operative mortality rates, e.g. when comparing operative techniques such as laparoscopy and open approaches

• Assess potential quality of care issues by comparing the cause of death with the reason(s) for admission, e.g. for surgical patients who are discharged within 30 days of the procedure but who die at home and whether the death is related to their disease process or to complications of treatment

• Develop and validate indicators of quality and safety of healthcare, particularly by consultant and hospital

• Show variations in performance by unit and socio demographic stratum

• Predict risk and adjust risk of indicators and variations and any other methodological aspects as they arise

• Establish seasonal patterns of mortality

• Support organisations in delivering their Learning from Deaths agenda and timely mortality reviews

• Help organisations improve quality of care and identify where they could do more to help patients and their families

• Providing 30 day mortality analysis. This is a well published and accepted standard for comparing post-operative and post-admission hospital mortality which is expected to improve engagement with clinicians, and allow comparisons with other published analyses.

Using all the requested datasets means that Telstra Health UK have the most up to date information and can inform customers of potential issues around quality and in turn allowing them to make better informed decisions for the improvement of healthcare and outcomes for patients.

The level of the data will be pseudonymised.

The data will be minimised as follows:

• Limited to 11 full years of data at any one time

• Limited to data fields which are necessary to deliver products and services that benefit health and care in the UK

Telstra Health UK is the controller as the organisation responsible for ensuring that the data will only be processed for the purposes described above.

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

Article 6(1)(f) - processing is necessary for the purposes of the legitimate interests pursued by the controller or by a third party.

Telstra Health UK has a legitimate interest in being able to provide tools and services that healthcare organisations will find useful and that will benefit the health and social care system. Without processing NHS England data, Telstra Health UK would not be able to deliver these tools and services, which would be to the detriment of health professionals who use them. Telstra Health UK's customers can be assured that the tools and services are based on evidence provided by data from a trusted source. There is no viable alternative as relying on public domain data would lead to gaps and not allow the same support for decision making. Using pseudonymised data allows Telstra Health UK to deliver evidence-based insight and analysis while minimising intrusion into a patient's privacy.

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

Article 9(2)(j) - processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject.

This processing is in the public interest because it helps to ensure high standards of quality and safety of health care. Although Telstra Health UK are not a public body, they provide services to help public healthcare organisations to monitor and improve their services. Processing is designed to benefit patients and society as a whole through better healthcare.

Microsoft Ltd and Amazon Web Services (AWS) provide Cloud hosting services to Telstra Health UK and will store the data as contracted by Telstra Health UK.

Telstra Health UK provide commercial tools, insight and analysis to healthcare professionals. They also provide freely available online resources for healthcare professionals and the public (using anonymised outputs) to help improve professional and public understanding of health.

The majority of Telstra Health UK outputs are delivered through:

• Online tools and services including the Healthcare Intelligence Portal

• Bespoke analytics

• Research for publication.

Telstra Health UK will continue to develop its outputs for NHS customers. Specific outputs include benchmarked or standardised healthcare indicators and analysis such as mortality, LOS (Length of Stay), admission trends, readmission rates, patient safety indicators, referral patterns, market share analysis etc.

The above outputs depend on processing of all the requested data. Outputs are typically provided in data tables to NHS customers. Telstra Health UK may also produce data visualisations (e.g. bar charts, box plots, funnel plots) based on the aggregate-level information from the data tables. Outputs produced by the team 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. Outputs for Trusts may include data that relate to their organisation at a record level, but with suppression applied for any peer analysis.

Specific outputs dependent on the processing of Civil Registration mortality data are:

• Analysis of cause of death

• Analysis of death following discharge, 7, 14, 30 days

• Comparative analysis of cause of death and deaths following discharge

• Development of outputs to further help users understand patient outcomes through analysis of survival rates

• Analysis of variation in mortality across geographical boundaries

• Support customers with out of hospital mortality queries

• Additional level of insight for customers to investigate the care pathway for their patients

Subscribers to the tools have continual access which allows them to meet their own internal target dates.

Outputs of bespoke analytics projects are dependent on the nature of the project and can include tabulations, dashboards, reports, spreadsheets, presentations or articles. In some instances, algorithms or coefficients that have been derived through research on the data may be provided directly to a customer for implementation on their own local data. Data provided in all 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. Bespoke analytics projects are conducted on an ad hoc basis and target dates for delivery of outputs are thus defined upon commencement of each project.

Examples of previous publications produced by Telstra Health UK include the Dr Foster Hospital Guide that published analysis of the variations in acute hospital care for the benefit of healthcare professionals, patients and the public, and insight articles published on the Telstra Health UK website.

In September 2022 Telstra Health UK published a research report with Cancer Research UK which explores the potential impact of the COVID-19 pandemic on cancer surgery and cancer mortality, including place of death. This work has been showcased at a number of conferences including the European Cancer Summit 2022.

In January 2020, Telstra Health UK undertook statistical analyses of abdominal aortic aneurisms and trans-catheter aortic valve implementations and found interesting correlations between surgeon annual volume and mortality. Following on from this, the team carried out an analysis that examined how the number of annual knee replacement procedures performed within a trust influences the rate of readmission. Insights from this are published on the Telstra Health UK website.

From April 2020, Telstra Health UK provided an interactive dashboard on its website to provide information to help manage and predict the risk of COVID-19 for England and which was updated regularly throughout the pandemic.

Telstra Health UK have provided analysis to the following non-NHS organisations:

• British Red Cross (May 2020) – COVID-19 analysis relating to frailty and mobility (percentages, no small numbers)

• Sodexo (August 2021) - aggregate data on the rates of readmission, long length of stay (LOS), LOS over 20 days and day case procedures as inpatient admissions for acute, non-specialist trusts.

• Imperial College Health Partners (ICHP) – ongoing. Telstra Health UK developed a respiratory dashboard for ICHP using HES data. The dashboard is refreshed on a quarterly basis by Telstra Health UK and sent to ICHP for publication on their website for anyone in the NHS to view (https://imperialcollegehealthpartners.com/resource/respiratory-population-health-dashoard/).

• Royal College of Surgeons (RCS) – Telstra Health UK are developing metrics to evaluate a study run by the RCS. All output provided by Telstra Health UK to RCS as part of this development work will conform to HES analysis guidance and will not include small numbers.

“Imperial uses data and expertise provided by Telstra Health UK to support clinical quality performance improvement and assurance. Telstra Health UK produces routine reports on a monthly basis on, for example, mortality rates, which feed into our clinical governance meetings and performance scorecards. We are a large provider of acute services in NW London and around 100 of our patients die every month. Without the data and the service provided by Telstra Health UK we would not be able the closely monitor mortality rates at specialty level, which is an essential aspect of clinical safety. The data and service provided also allows us to monitor the quality of our clinical coding to ensure that our reporting and analysis is accurate.”

Deputy CIO, Imperial College Healthcare NHS Trust, October 2022

Furthering public and professional understanding of public health through publication of thought leadership pieces and research including “Impact of the COVID-19 pandemic on cancer surgery and cancer mortality” (September 2022).

Covid-19 dashboard providing analysis of Trusts' crude and risk-adjusted mortality rates and in comparison to peers and a national benchmark. (March 2021).

Telstra Health UK developed a COVID-19 mortality risk model on the HES (Hospital Episode Statistics) Admitted Patient Care dataset to:

1. Create national benchmarks allowing Trusts to compare their COVID-19 mortality against peers taking into account patient case-mix

2. Provide a COVID-19 mortality relative risk for each Trust to be surfaced in a dashboard

3. Identify the most important factors within the COVID-19 cohort leading to mortality at a Trust and/or site level and comparing these to a national or peer group average.

"It's a great tool and gives exactly the kind of external assurance we need, I think the demographic and risk factor analysis is very helpful". Director for Safety and Medical Director, Deputy Chief Executive, Gloucestershire Hospitals NHS FT.

Analysis of homeless patient inequalities (February 2021)

After consultation with University College London Hospitals, which recently established a multidisciplinary collaboration in response to homelessness, Telstra Health UK set out to produce a suite of analysis using the Hospital Episode Statistics (HES) Admitted Patent Care data to identify and understand comparative characteristics of homeless patients nationally. The analysis sought to identify the shared characteristics of homeless patients, what their needs are, and to highlight some of the differences they have in experiences and outcomes to the rest of the population. The report is freely available on the Telstra Health UK website.

Analysis of decline in admissions during first wave of pandemic (October 2020)

Telstra Health UK's analysis published in the Daily Telegraph, and then picked up by other media organisations, showed that during the height of the first wave of the COVID-19 pandemic in the UK in April-May 2020, there was a sharp drop in admissions relating to a number of diseases. The reporting informed public awareness and sparked discussion with healthcare professionals, including for example, warnings of longer term impacts and encouragement for people to contact their GP if they need medical treatment.

Frailty analysis for British Red Cross (May 2020)

Telstra Health UK's frailty analysis has been used by the British Red Cross create a COVID-19 vulnerability index for the UK, mapping clinical vulnerability, economic vulnerability, social vulnerability and other health and wellbeing needs. This is helping the British Red Cross focus help on the most vulnerable people whose needs aren't being met.

COVID-19 heatmaps (April 2020)

Telstra Health UK's awareness raising publications have provided professionals and the public with insight into the progression of COVID-19. Their interactive dashboard, first released in April 2020, uses heatmaps to show the spread of the disease. It also shows historical perspectives within the past 10 years by using respiratory and frailty data from HES.

Pan-London respiratory dashboard (March 2020)

Development of a pan-London respiratory dashboard in conjunction with Imperial College Health Partners which provides information on a range of metrics looking at disease prevalence and medicines management. Dashboard has been made available on the ICHP website for anyone with an NHS HSCN connection.

High Intensity User (HIU) report (January 2019)

Telstra Health UK continues to raise public and professional awareness. Its High Intensity User (HIU) report of January 2019 uncovered important characteristics of HIU patients and patterns in their attendances of A&E. It showed that the vast majority of HIUs are living in the most deprived areas of England, suggesting that the most vulnerable members of society may be more prone to high intensity use. Smoking, drugs and alcohol all appear to play an important role in frequent A&E use, in relation to the most common reasons that HIUs are admitted to hospital.

Dr Foster has rebranded as Telstra Health UK. There is no change to how Telstra Health UK process the data received under this agreement.

The Dr Foster name and branding is being kept around the Telstra Health UK benchmarking tools and services, so users will see some legacy branding as well as the Healthcare Intelligence Portal now being referenced as the “Dr Foster Healthcare Intelligence Portal”.

Providing high quality, data-led population health management in the UK is the main priority for Telstra Health. That is why Dr Foster is being rebranded to Telstra Health UK. The commitment to continuing investment in the UK health sector offers the perfect opportunity for Telstra Health UK to keep improving the health data and analytics services they deliver. Dr Foster has a long and proven-track record of analytics-led benchmarking and performance improvement for healthcare providers in the UK, which they remain committed to and will continue to deliver and innovate on.

Telstra Health UK (formerly Dr Foster) has provided objective insight and analysis since 1999 and aims to help health and social care organisations make better and faster decisions with data and insight and, ultimately, to benefit patients. This is delivered in three main strands:

• Dr Foster tools and services – to provide management information, analysis and clinical benchmarking through online products and services

• Bespoke analytics – to deliver customised projects to meet individual customer needs

• Research for publication – to provide thought leadership in the field of healthcare data analytics, with the aim of improving the planning, delivery and outcome of health and social care

This Agreement will permit the following disseminations of data for the duration of this agreement. Disseminations will occur on a monthly basis.

• Pseudonymised Hospital Episodes Statistics (HES)

• Pseudonymised Civil Registration (Deaths) - Secondary Care Cut (CRD) plus bridge files

• Pseudonymised Emergency Care Data Set (ECDS)

Telstra Health UK previously received these datasets via the Dr Foster Unit at Imperial College London (DFU), this flow of data was supported by agreement DARS-NIC-68697-R6F1T with NHS Digital. However, Telstra Health UK now receive this data directly from NHS Digital and will stop receiving data under DARS-NIC-68697-R6F1T at the expiry of that agreement.

A transition period is underway to ensure that Telstra Health UK can continue to provide its NHS customers with its services. This includes testing of outputs so that NHS customers can be assured that they are receiving the same quality of service. The end of the transition period will coincide with the expiry of agreement DARS-NIC-68697-R6F1T with NHS Digital. During this transition period, Telstra Health UK has been receiving data via DFU and directly from NHS Digital. At the end of this transition period, data will be deleted securely so that Telstra Health UK is only processing HES, CRD and ECDS data provided under this agreement. This transition period is still ongoing.

Telstra Health UK require the requested data to help healthcare organisations achieve sustainable improvements in their performance, to gain insight and to inform decision making.

Telstra Health UK’s NHS customers have access to analysis of the data so that they can:

• Track and trend performance, identify areas for efficiency savings and understand and influence demand and patient flow throughout the health and care system.

• Investigate risk-adjusted quality, patient safety and clinical outcomes data including mortality, benchmark against other healthcare organisations and identify areas for improvement.

Telstra Health UK products and services are used by:

• NHS Provider Trusts– Subscribed authorised users in customer organisations can view data that relate to their organisation at a record level. They cannot access record level HES data relating to other organisations.

• Other NHS organisations – Subscribed authorised users in customer organisations can view aggregated analysis which provides valuable insight but prevents any patients from being identified, in accordance with guidance provided by NHS Digital.

• Care Quality Commission – CQC can view aggregated analysis.

The Analytics team provides analysis (in line with the HES Analysis Guide) and insight to a number of NHS customers including:

• NHS Trusts

• Clinical Commissioning Groups (CCGs), and following the disbandment of CCGs services will be provided to the Integrated Care Systems who will replace their function

• Commissioning Support Units

• Department of Health

• NHS England

• NHS Improvement

• Care Quality Commission

• Public Health England

• National Institute for Health and Care Excellence

The Analytics team also provides analysis with small numbers included as part of the Getting It Right First Time (GIRFT) programme. This is a national programme that identifies best practice and where changes can be made to improve care and patient outcomes. This is described more under ‘processing activities’.

Telstra Health UK also work with:

• Non-NHS organisations providing services to benefit the NHS – these are only supplied with aggregate, small-number suppressed analyses in line with the HES analysis guide.

• Non-NHS organisations to benefit public health and social care - these are only supplied with aggregate, small-number suppressed analyses where benefits can be identified for the health and social care system. It is also proposed that algorithms or coefficients that have been derived through research on HES data may be provided directly to a customer for implementation on their own local data. Data provided in all outputs will be at an aggregate level and small number suppression will be implemented in line with HES analysis guidelines.

Any request for such analysis is reviewed to determine if it benefits the health and social care system. Telstra Health UK will inform NHS Digital of analysis it provides to non-NHS organisations and will list this in any renewal or amendment to this agreement.

Telstra Health UK provided analysis on COVID-19 to the British Red Cross in May 2020. This was frailty analysis by Lower Super Output Area (LSOA) which included the following:

• Proportion of frail patients with mobility problems

• Proportion of frail patients with mobility problems and a fracture.

These were percentages only and included no small numbers.

Telstra Health UK provided aggregated, small-number suppressed analysis of HES for Sodexo in August 2021. The output was in line with HES analysis guidelines and consisted of aggregate data on the rates of readmission, long length of stay (LOS), LOS over 20 days and day case procedures as inpatient admissions for acute, non-specialist trusts.

Customers have access to Telstra Health UK’s team of qualified data scientists, clinicians, statisticians, mathematicians, and economists. They supplement in-house analytical teams with Telstra Health UK’s expert advice and guidance linking, modelling and visualising data and insight.

The Analytics team provides bespoke analytics and data science tailored to specific needs to identify clinical variation, efficiency savings, predict patient risk and improve patient outcomes.

They are a skilled team of experts in advanced healthcare analytics and data science including predicative analytics, machine learning techniques and advanced statistical methods. The team use this expertise to investigate issues and transform healthcare services.

Telstra Health UK use the data provided under this agreement to provide a management information function in the form of analysis and clinical benchmarking for healthcare organisations and to increase the power of predictive models for rare diseases, procedures and events. Telstra Health UK build standard casemix adjustment models for 259 diagnosis groups and 200 procedure groups which include some rarer conditions. Casemix is a system that measures hospital performance, aiming to reward initiatives that increase efficiency in hospitals. It also serves as an information tool that allows policy makers to understand the nature and complexity of health care delivery. Using all the requested datasets means that Telstra Health UK have the most up to date information and can inform customers of potential issues around quality and in turn allowing them to make better informed decisions for the improvement of healthcare and outcomes for patients.

At a high-level Telstra Health UK analyses break down into the following:

• Quality measures of healthcare services by providers/area/clinical interest/trend analysis

• Variations in health outcomes

• Health inequalities and needs analysis

• Predictions

• Performance data and changes in clinical practice

• Management information

• Efficiency Monitoring

• Benchmarking

• Contract Management and Variance Analysis

• Activity Monitoring

• National Target Performance

• Pathway design, redesign and improvement.

• Practice Performance Monitoring

• Capacity and utilisation management

• Cross checking of commissioning data

• Systems to support and monitor the pattern of healthcare usage

• Patient segmentation analysis

• Overall data quality

The data allow Telstra Health UK to provide a wide array of relevant indicators to give end users as complete a picture of hospital performance as possible to allow health and social care organisations to effectively:

• Monitor quality of services provided

• Identify efficiency opportunities

• Identify pathways where services can be improved for the benefit of patients

Civil Registration (Deaths) - Secondary Care Cut data is requested to provide more timely and accurate analysis and insight for Telstra Health UK’s customers. This data is essential for performing survival analyses, representing a very valuable source of data. It will improve the output of Telstra Health UK’s products for the benefit of NHS customers and for the broader improvement of health and social care for the public.

This data is extremely critical because mortality information may be a surrogate metric for success of medical care. Therefore, this dataset will enable identification of factors that drive successful treatment of a patient. Cause and date of death may also be used to identify trends in causes of death in particular groups of patients. Telstra Health UK hold historical death data which is necessary for identifying trends overtime.

Telstra Health UK request that the Civil Registry (Deaths data) is linked to the requested HES datasets, this linkage provides valuable insights into how and why some patients with the same condition and at the same stage can have very different outcomes. In addition, it would be used to:

• Compare hospital mortality rates for in-hospital deaths with rates for all deaths to evaluate the effect of differential discharge policies

• Calculate total post-operative mortality rates, e.g. when comparing operative techniques such as laparoscopy and open approaches

• Assess potential quality of care issues by comparing the cause of death with the reason(s) for admission, e.g. for surgical patients who are discharged within 30 days of the procedure but who die at home and whether the death is related to their disease process or to complications of treatment

• Develop and validate indicators of quality and safety of healthcare, particularly by consultant and hospital

• Show variations in performance by unit and socio demographic stratum

• Predict risk and adjust risk of indicators and variations and any other methodological aspects as they arise

• Establish seasonal patterns of mortality

• Support organisations in delivering their Learning from Deaths agenda and timely mortality reviews

• Help organisations improve quality of care and identify where they could do more to help patients and their families

30 day mortality (both in and out of hospital) is a well published and accepted standard for comparing post-operative and post-admission hospital mortality. Linking Civil Registration (Deaths) - Secondary Care Cut data with HES data allows Telstra Health UK to provide this outcome, which will improve engagement with clinicians, and allow comparisons with other published analyses.

Telstra Health UK process the minimum data necessary to meet the purpose and build privacy into their designs.

Telstra Health UK requested the dissemination of the 2019/20 Emergency Care Data Set (ECDS), in parallel to the 2019/20 HES A&E data, so that it can:

• continue to deliver products and services that provide insight into and analysis of emergency care provision;

• develop enhancements to its services that utilise the greater detail provided by ECDS,

• transition its products from A&E data to reduce any interruption for NHS healthcare professionals that rely on these tools and services;

• quality assure its processing of ECDS.

Historical ECDS data is necessary for more useful trend analysis, research and quality assurance. The additional fields within ECDS will help Telstra Health UK to:

• improve understanding of the complexity of attending patients and the causes of rising demand;

• capture diagnostic data for richer information on the diagnosis with which patients are presenting to emergency departments;

• enhance the understanding of the value of emergency departments;

• enhance understanding of need, activity and outcomes;

• better understand patient pathways such as type 5 emergency admissions (same day emergency care), which are currently not coded within HES.

Mental health fields within ECDS will be used by Telstra Health UK:

• To help better understand the cohort of patients seen in the Emergency Department with mental health conditions who are both formally and informally detained under the Mental Health Act.

• To help emergency care departments understand how the above patients use their services and what affect this may have on departments.

To address the GDPR Principle of Data Minimisation, Telstra Health UK have reviewed its requirements to ensure that only the minimum data necessary is requested. It has refined its processing to require a reduced minimum of 11 years of historic data to deliver results to customers. (This is a reduction from the 15 years required under DARS-NIC-68697-R6F1T).

A data period of 11 years of historical data is essential to enable Telstra Health UK to:

• Obtain longitudinal data on prior admissions for patients. Risk modelling will also require access to variables on prior admissions including previously recorded co-morbidities.

• Create, update and maintain statistical risk models to enable the regular production of risk adjusted measures of mortality, quality and efficiency (including Hospital Standardised Mortality Ratio (HSMR) and Cumulative Sum Control Chart (CUSUM) alerts as used by NHS organisations and regulators).

Telstra Health UK is the sole Data Controller who also process the data for the purposes described within this Agreement.

The lawful basis of processing falls under General Data Protection Regulation (GDPR) articles 6(1)(f) (legitimate interests) and 9(2)(j) (archiving in the public interest). Telstra Health UK have undertaken a legitimate interests assessment and a data protection impact assessment, and intend to maintain and update these documents where necessary.

Processing under GDPR Article 6(1)(f) can be justified as Telstra Health UK has a legitimate interest in being able to provide tools and services that healthcare organisations will find useful and that will benefit the health and social care system. Without processing NHS Digital data, Telstra Health UK would not be able to deliver these tools and services, this would be to the detriment of health professionals who use them. Telstra Health UK's customers can be assured that the tools and services are based on evidence provided by data from a trusted source. There is no viable alternative as relying on public domain data would lead to gaps and not allow the same support for decision making. Using pseudonymised data allows Telstra Health UK to deliver evidence-based insight and analysis while minimising intrusion into a patient's privacy.

The processing of this data is also necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) of GDPR. The processing is proportionate to its aims, respects data protection rights and provides suitable and specific measures to protect the rights and interests of individuals. It is necessary for reasons of public interest in public health, in particular to ensure high standards of quality and safety of health care. Although Telstra Health UK are not a public body, they provide services to help public healthcare organisations to monitor and improve their services. Processing is designed to benefit patients and society as a whole through better healthcare.

Telstra Health UK provide commercial tools, insight and analysis to healthcare professionals. They also provide freely available online resources for healthcare professionals and the public (using anonymised outputs) to help improve professional and public understanding of health. For example, Telstra Health UK analysts have developed an indicator to help local public health teams monitor any increases in Covid-19 infections to help prevent lockdown situations. The interactive graph allows public health teams to monitor any increases in cases of Covid-19 by recent daily case rate compared to a prior eight-week daily case rate. It provides an early indication of a potential spike, allowing local authorities to act early and implement restrictions and is available on the Telstra Health UK website. Telstra Health UK also carried out a detailed analysis of accident and emergency (A&E) attendances nationally with the aim of uncovering common characteristics of High Intensity Users (HIUs) - people who attended 10 or more times in a 12-month period - and patterns in HIU attendances to provide valuable insight and a better understanding of the reasons they attend with such high frequency. This was published on the Dr Foster (now Telstra Health UK) website and reported on in the media. Press coverage of Telstra Health UK’s freely available analysis helps disseminate knowledge and understanding further.

The majority of Telstra Health UK outputs are delivered through:

• Online tools and services including the Healthcare Intelligence Portal

• Bespoke analytics

• Research for publication. Specific outputs include benchmarked or standardised healthcare indicators and analysis such as mortality (Summary Hospital-level Mortality Indicator (SHMI)/HSMR), LOS (Length of Stay), admission trends, readmission rates, patient safety indicators, referral patterns, market share analysis etc.

Outputs will be used by customers to investigate clinical quality, performance and business development, specifically:

• Assess and manage clinical quality and patient safety within NHS Organisations

• Identify pathways where there is potential for improvement

• Identify areas of best practice either within the Provider Trust or local/national health economies

• Better understand how they compare to other Provider Trusts with similar case mixes

• Identify improvements in operational efficiency

• Understand patient outcomes

• Identify and understand market activity

• Monitor the impact of implemented changes

• Identify variations in outcomes

The above outputs depend on processing of all the requested data. Outputs are typically provided in data tables to NHS customers. Telstra Health UK may also produce data visualisations (e.g. bar charts, box plots, funnel plots) based on the aggregate-level information from the data tables. Outputs produced by the team are at an aggregate level and small numbers are suppressed in line with the HES Analysis Guide Guidelines. However, some analysis with small numbers included may be provided where necessary to the GIRFT programme overseen by NHS Improvement.

Civil Registration mortality data specific outputs

Specific outputs dependent on the processing of Civil Registration mortality data are:

• Analysis of cause of death

• Analysis of death following discharge, 7, 14, 30 days

• Comparative analysis of cause of death and deaths following discharge

• Development of outputs to further help users understand patient outcomes through analysis of survival rates

• Analysis of variation in mortality across geographical boundaries

• Support customers with out of hospital mortality queries

• Additional level of insight for customers to investigate the care pathway for their patients

Timeframe for outputs

Subscribers to the tools have continual access which allows them to meet their own internal target dates.

Outputs of bespoke analytics projects are dependent on the nature of the project and can include tabulations, dashboards, reports, spreadsheets, presentations or articles. Outputs may be surfaced through tools including Microsoft Office suite (Excel, Word and PowerPoint etc) or other tools (Tableau, QlikView) depending on the requirements of the customer. In some instances, algorithms or coefficients that have been derived through research on the data may be provided directly to a customer for implementation on their own local data. Data provided in all outputs is in line with HES analysis guidelines, meeting aggregation and small number suppression requirements. Bespoke analytics projects are conducted on an ad hoc basis and target dates for delivery of outputs are thus defined upon commencement of each project.

Publications

Examples of previous publications produced by Telstra Health UK include the Dr Foster Hospital Guide that published analysis of the variations in acute hospital care for the benefit of healthcare professionals, patients and the public and insight articles published on the Telstra Health UK website.

In January 2020, Telstra Health UK undertook statistical analyses of abdominal aortic aneurisms and trans-catheter aortic valve implementations and found interesting correlations between surgeon annual volume and mortality. Following on from this, the Dr Foster team carried out an analysis that examined how the number of annual knee replacement procedures performed within a trust influences the rate of readmission. Insights from this are published on the Telstra Health UK website.

Telstra Health UK provide an interactive dashboard on its website to provide information to help manage and predict the risk of COVID-19 for England. The respiratory and frailty data are from HES. The dashboard was initially published in April 2020 and is updated regularly on their website.

Telstra Health UK are aware that publications, whether inside or outside the NHS, must adhere to strict guidelines in terms of disclosure, and ensure that any such publications are aggregated and comply with small number suppression in line with the HES Analysis Guide and other relevant legislation. Analyses for use in publications can be in the form of text, tables, or other data visualisations such as diagrams/graphs using aggregate data. Publications will also meet standards as defined in the Terms and Conditions of the Data Sharing Agreement.

All publications will contain only data that is aggregated with small numbers suppressed in line with the HES Analysis Guide.

Covid-19 dashboard providing analysis of Trusts’ crude and risk-adjusted mortality rates and in comparison to peers and a national benchmark. (March 2021).

Telstra Health UK developed a COVID-19 mortality risk model on the HES (Hospital Episode Statistics) Admitted Patient Care dataset to:

1. Create national benchmarks allowing Trusts to compare their COVID-19 mortality against peers taking into account patient case-mix

2. Provide a COVID-19 mortality relative risk for each Trust to be surfaced in a dashboard

3. Identify the most important factors within the COVID-19 cohort leading to mortality at a Trust and/or site level and comparing these to a national or peer group average.

“It’s a great tool and gives exactly the kind of external assurance we need, I think the demographic and risk factor analysis is very helpful”.Director for Safety and Medical Director, Deputy Chief Executive, Gloucestershire Hospitals NHS FT.

Analysis of homeless patient inequalities (February 2021)

After consultation with University College London Hospitals, which recently established a multidisciplinary collaboration in response to homelessness, Telstra Health UK set out to produce a suite of analysis using the Hospital Episode Statistics (HES) Admitted Patent Care data to identify and understand comparative characteristics of homeless patients nationally. The analysis sought to identify the shared characteristics of homeless patients, what their needs are, and to highlight some of the differences they have in experiences and outcomes to the rest of the population. The report is freely available on the Telstra Health UK website.

Analysis of decline in admissions during first wave of pandemic (October 2020)

Telstra Health UK's analysis published in the Daily Telegraph, and then picked up by other media organisations, showed that during the height of the first wave of the COVID-19 pandemic in the UK in April-May 2020, there was a sharp drop in admissions relating to a number of diseases. The reporting informed public awareness and sparked discussion with healthcare professionals, including for example, warnings of longer term impacts and encouragement for people to contact their GP if they need medical treatment.

COVID-19 heatmaps (April 2020)

Telstra Health UK's awareness raising publications have provided professionals and the public with insight into the progression of COVID-19. Their interactive dashboard, first released in April 2020, uses heatmaps to show the spread of the disease. It also shows historical perspectives within the past 10 years by using respiratory and frailty data from HES.

Frailty analysis for British Red Cross (May 2020)

Telstra Health UK's frailty analysis has been used by the British Red Cross create a COVID-19 vulnerability index for the UK, mapping clinical vulnerability, economic vulnerability, social vulnerability and other health and wellbeing needs. This is helping the British Red Cross focus help on the most vulnerable people whose needs aren’t being met.

High Intensity User (HIU) report (January 2019)

Telstra Health UK continues to raise public and professional awareness. Its High Intensity User (HIU) report of January 2019 uncovered important characteristics of HIU patients and patterns in their attendances of A&E. It showed that the vast majority of HIUs are living in the most deprived areas of England, suggesting that the most vulnerable members of society may be more prone to high intensity use. Smoking, drugs and alcohol all appear to play an important role in frequent A&E use, in relation to the most common reasons that HIUs are admitted to hospital.

Dr Foster has rebranded as Telstra Health UK. There is no change to how Telstra Health UK process the data received under this agreement.

The Dr Foster name and branding is being kept around the Telstra Health UK benchmarking tools and services, so users will see some legacy branding as well as the Healthcare Intelligence Portal now being referenced as the “Dr Foster Healthcare Intelligence Portal”.

Providing high quality, data-led population health management in the UK is the main priority for Telstra Health. That is why Dr Foster is being rebranded to Telstra Health UK. The commitment to continuing investment in the UK health sector offers the perfect opportunity for Telstra Health UK to keep improving the health data and analytics services they deliver. Dr Foster has a long and proven-track record of analytics-led benchmarking and performance improvement for healthcare providers in the UK, which they remain committed to and will continue to deliver and innovate on.

Telstra Health UK (formerly Dr Foster) has provided objective insight and analysis since 1999 and aims to help health and social care organisations make better and faster decisions with data and insight and, ultimately, to benefit patients. This is delivered in three main strands:

• Dr Foster tools and services – to provide management information, analysis and clinical benchmarking through online products and services

• Bespoke analytics – to deliver customised projects to meet individual customer needs

• Research for publication – to provide thought leadership in the field of healthcare data analytics, with the aim of improving the planning, delivery and outcome of health and social care

This Agreement will permit the following disseminations of data for the duration of this agreement. Disseminations will occur on a monthly basis.

• Pseudonymised Hospital Episodes Statistics (HES)

• Pseudonymised Civil Registration (Deaths) - Secondary Care Cut (CRD) plus bridge files

• Pseudonymised Emergency Care Data Set (ECDS)

Telstra Health UK previously received these datasets via the Dr Foster Unit at Imperial College London (DFU), this flow of data was supported by agreement DARS-NIC-68697-R6F1T with NHS Digital. However, Telstra Health UK now receive this data directly from NHS Digital and will stop receiving data under DARS-NIC-68697-R6F1T at the expiry of that agreement.

A transition period is underway to ensure that Telstra Health UK can continue to provide its NHS customers with its services. This includes testing of outputs so that NHS customers can be assured that they are receiving the same quality of service. The end of the transition period will coincide with the expiry of agreement DARS-NIC-68697-R6F1T with NHS Digital. During this transition period, Telstra Health UK has been receiving data via DFU and directly from NHS Digital. At the end of this transition period, data will be deleted securely so that Telstra Health UK is only processing HES, CRD and ECDS data provided under this agreement. This transition period is still ongoing.

Telstra Health UK require the requested data to help healthcare organisations achieve sustainable improvements in their performance, to gain insight and to inform decision making.

Telstra Health UK’s NHS customers have access to analysis of the data so that they can:

• Track and trend performance, identify areas for efficiency savings and understand and influence demand and patient flow throughout the health and care system.

• Investigate risk-adjusted quality, patient safety and clinical outcomes data including mortality, benchmark against other healthcare organisations and identify areas for improvement.

Telstra Health UK products and services are used by:

• NHS Provider Trusts– Subscribed authorised users in customer organisations can view data that relate to their organisation at a record level. They cannot access record level HES data relating to other organisations.

• Other NHS organisations – Subscribed authorised users in customer organisations can view aggregated analysis which provides valuable insight but prevents any patients from being identified, in accordance with guidance provided by NHS Digital.

• Care Quality Commission – CQC can view aggregated analysis.

The Analytics team provides analysis (in line with the HES Analysis Guide) and insight to a number of NHS customers including:

• NHS Trusts

• Clinical Commissioning Groups (CCGs), and following the disbandment of CCGs services will be provided to the Integrated Care Systems who will replace their function

• Commissioning Support Units

• Department of Health

• NHS England

• NHS Improvement

• Care Quality Commission

• Public Health England

• National Institute for Health and Care Excellence

The Analytics team also provides analysis with small numbers included as part of the Getting It Right First Time (GIRFT) programme. This is a national programme that identifies best practice and where changes can be made to improve care and patient outcomes. This is described more under ‘processing activities’.

Telstra Health UK also work with:

• Non-NHS organisations providing services to benefit the NHS – these are only supplied with aggregate, small-number suppressed analyses in line with the HES analysis guide.

• Non-NHS organisations to benefit public health and social care - these are only supplied with aggregate, small-number suppressed analyses where benefits can be identified for the health and social care system. It is also proposed that algorithms or coefficients that have been derived through research on HES data may be provided directly to a customer for implementation on their own local data. Data provided in all outputs will be at an aggregate level and small number suppression will be implemented in line with HES analysis guidelines.

Any request for such analysis is reviewed to determine if it benefits the health and social care system. Telstra Health UK will inform NHS Digital of analysis it provides to non-NHS organisations and will list this in any renewal or amendment to this agreement.

Telstra Health UK provided analysis on COVID-19 to the British Red Cross in May 2020. This was frailty analysis by Lower Super Output Area (LSOA) which included the following:

• Proportion of frail patients with mobility problems

• Proportion of frail patients with mobility problems and a fracture.

These were percentages only and included no small numbers.

Customers have access to Telstra Health UK’s team of qualified data scientists, clinicians, statisticians, mathematicians, and economists. They supplement in-house analytical teams with Telstra Health UK’s expert advice and guidance linking, modelling and visualising data and insight.

The Analytics team provides bespoke analytics and data science tailored to specific needs to identify clinical variation, efficiency savings, predict patient risk and improve patient outcomes.

They are a skilled team of experts in advanced healthcare analytics and data science including predicative analytics, machine learning techniques and advanced statistical methods. The team use this expertise to investigate issues and transform healthcare services.

Telstra Health UK use the data provided under this agreement to provide a management information function in the form of analysis and clinical benchmarking for healthcare organisations and to increase the power of predictive models for rare diseases, procedures and events. Telstra Health UK build standard casemix adjustment models for 259 diagnosis groups and 200 procedure groups which include some rarer conditions. Casemix is a system that measures hospital performance, aiming to reward initiatives that increase efficiency in hospitals. It also serves as an information tool that allows policy makers to understand the nature and complexity of health care delivery. Using all the requested datasets means that Telstra Health UK have the most up to date information and can inform customers of potential issues around quality and in turn allowing them to make better informed decisions for the improvement of healthcare and outcomes for patients.

At a high-level Telstra Health UK analyses break down into the following:

• Quality measures of healthcare services by providers/area/clinical interest/trend analysis

• Variations in health outcomes

• Health inequalities and needs analysis

• Predictions

• Performance data and changes in clinical practice

• Management information

• Efficiency Monitoring

• Benchmarking

• Contract Management and Variance Analysis

• Activity Monitoring

• National Target Performance

• Pathway design, redesign and improvement.

• Practice Performance Monitoring

• Capacity and utilisation management

• Cross checking of commissioning data

• Systems to support and monitor the pattern of healthcare usage

• Patient segmentation analysis

• Overall data quality

The data allow Telstra Health UK to provide a wide array of relevant indicators to give end users as complete a picture of hospital performance as possible to allow health and social care organisations to effectively:

• Monitor quality of services provided

• Identify efficiency opportunities

• Identify pathways where services can be improved for the benefit of patients

Civil Registration (Deaths) - Secondary Care Cut data is requested to provide more timely and accurate analysis and insight for Telstra Health UK’s customers. This data is essential for performing survival analyses, representing a very valuable source of data. It will improve the output of Telstra Health UK’s products for the benefit of NHS customers and for the broader improvement of health and social care for the public.

This data is extremely critical because mortality information may be a surrogate metric for success of medical care. Therefore, this dataset will enable identification of factors that drive successful treatment of a patient. Cause and date of death may also be used to identify trends in causes of death in particular groups of patients. Telstra Health UK hold historical death data which is necessary for identifying trends overtime.

Telstra Health UK request that the Civil Registry (Deaths data) is linked to the requested HES datasets, this linkage provides valuable insights into how and why some patients with the same condition and at the same stage can have very different outcomes. In addition, it would be used to:

• Compare hospital mortality rates for in-hospital deaths with rates for all deaths to evaluate the effect of differential discharge policies

• Calculate total post-operative mortality rates, e.g. when comparing operative techniques such as laparoscopy and open approaches

• Assess potential quality of care issues by comparing the cause of death with the reason(s) for admission, e.g. for surgical patients who are discharged within 30 days of the procedure but who die at home and whether the death is related to their disease process or to complications of treatment

• Develop and validate indicators of quality and safety of healthcare, particularly by consultant and hospital

• Show variations in performance by unit and socio demographic stratum

• Predict risk and adjust risk of indicators and variations and any other methodological aspects as they arise

• Establish seasonal patterns of mortality

• Support organisations in delivering their Learning from Deaths agenda and timely mortality reviews

• Help organisations improve quality of care and identify where they could do more to help patients and their families

30 day mortality (both in and out of hospital) is a well published and accepted standard for comparing post-operative and post-admission hospital mortality. Linking Civil Registration (Deaths) - Secondary Care Cut data with HES data allows Telstra Health UK to provide this outcome, which will improve engagement with clinicians, and allow comparisons with other published analyses.

Telstra Health UK process the minimum data necessary to meet the purpose and build privacy into their designs.

Telstra Health UK requested the dissemination of the 2019/20 Emergency Care Data Set (ECDS), in parallel to the 2019/20 HES A&E data, so that it can:

• continue to deliver products and services that provide insight into and analysis of emergency care provision;

• develop enhancements to its services that utilise the greater detail provided by ECDS,

• transition its products from A&E data to reduce any interruption for NHS healthcare professionals that rely on these tools and services;

• quality assure its processing of ECDS.

Historical ECDS data is necessary for more useful trend analysis, research and quality assurance. The additional fields within ECDS will help Telstra Health UK to:

• improve understanding of the complexity of attending patients and the causes of rising demand;

• capture diagnostic data for richer information on the diagnosis with which patients are presenting to emergency departments;

• enhance the understanding of the value of emergency departments;

• enhance understanding of need, activity and outcomes;

• better understand patient pathways such as type 5 emergency admissions (same day emergency care), which are currently not coded within HES.

Mental health fields within ECDS will be used by Telstra Health UK:

• To help better understand the cohort of patients seen in the Emergency Department with mental health conditions who are both formally and informally detained under the Mental Health Act.

• To help emergency care departments understand how the above patients use their services and what affect this may have on departments.

To address the GDPR Principle of Data Minimisation, Telstra Health UK have reviewed its requirements to ensure that only the minimum data necessary is requested. It has refined its processing to require a reduced minimum of 11 years of historic data to deliver results to customers. (This is a reduction from the 15 years required under DARS-NIC-68697-R6F1T).

A data period of 11 years of historical data is essential to enable Telstra Health UK to:

• Obtain longitudinal data on prior admissions for patients. Risk modelling will also require access to variables on prior admissions including previously recorded co-morbidities.

• Create, update and maintain statistical risk models to enable the regular production of risk adjusted measures of mortality, quality and efficiency (including Hospital Standardised Mortality Ratio (HSMR) and Cumulative Sum Control Chart (CUSUM) alerts as used by NHS organisations and regulators).

Telstra Health UK is the sole Data Controller who also process the data for the purposes described within this Agreement.

The lawful basis of processing falls under General Data Protection Regulation (GDPR) articles 6(1)(f) (legitimate interests) and 9(2)(j) (archiving in the public interest). Telstra Health UK have undertaken a legitimate interests assessment and a data protection impact assessment, and intend to maintain and update these documents where necessary.

Processing under GDPR Article 6(1)(f) can be justified as Telstra Health UK has a legitimate interest in being able to provide tools and services that healthcare organisations will find useful and that will benefit the health and social care system. Without processing NHS Digital data, Telstra Health UK would not be able to deliver these tools and services, this would be to the detriment of health professionals who use them. Telstra Health UK's customers can be assured that the tools and services are based on evidence provided by data from a trusted source. There is no viable alternative as relying on public domain data would lead to gaps and not allow the same support for decision making. Using pseudonymised data allows Telstra Health UK to deliver evidence-based insight and analysis while minimising intrusion into a patient's privacy.

The processing of this data is also necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) of GDPR. The processing is proportionate to its aims, respects data protection rights and provides suitable and specific measures to protect the rights and interests of individuals. It is necessary for reasons of public interest in public health, in particular to ensure high standards of quality and safety of health care. Although Telstra Health UK are not a public body, they provide services to help public healthcare organisations to monitor and improve their services. Processing is designed to benefit patients and society as a whole through better healthcare.

Telstra Health UK provide commercial tools, insight and analysis to healthcare professionals. They also provide freely available online resources for healthcare professionals and the public (using anonymised outputs) to help improve professional and public understanding of health. For example, Telstra Health UK analysts have developed an indicator to help local public health teams monitor any increases in Covid-19 infections to help prevent lockdown situations. The interactive graph allows public health teams to monitor any increases in cases of Covid-19 by recent daily case rate compared to a prior eight-week daily case rate. It provides an early indication of a potential spike, allowing local authorities to act early and implement restrictions and is available on the Telstra Health UK website. Telstra Health UK also carried out a detailed analysis of accident and emergency (A&E) attendances nationally with the aim of uncovering common characteristics of High Intensity Users (HIUs) - people who attended 10 or more times in a 12-month period - and patterns in HIU attendances to provide valuable insight and a better understanding of the reasons they attend with such high frequency. This was published on the Dr Foster (now Telstra Health UK) website and reported on in the media. Press coverage of Telstra Health UK’s freely available analysis helps disseminate knowledge and understanding further.

The majority of Telstra Health UK outputs are delivered through:

• Online tools and services including the Healthcare Intelligence Portal

• Bespoke analytics

• Research for publication. Specific outputs include benchmarked or standardised healthcare indicators and analysis such as mortality (Summary Hospital-level Mortality Indicator (SHMI)/HSMR), LOS (Length of Stay), admission trends, readmission rates, patient safety indicators, referral patterns, market share analysis etc.

Outputs will be used by customers to investigate clinical quality, performance and business development, specifically:

• Assess and manage clinical quality and patient safety within NHS Organisations

• Identify pathways where there is potential for improvement

• Identify areas of best practice either within the Provider Trust or local/national health economies

• Better understand how they compare to other Provider Trusts with similar case mixes

• Identify improvements in operational efficiency

• Understand patient outcomes

• Identify and understand market activity

• Monitor the impact of implemented changes

• Identify variations in outcomes

The above outputs depend on processing of all the requested data. Outputs are typically provided in data tables to NHS customers. Telstra Health UK may also produce data visualisations (e.g. bar charts, box plots, funnel plots) based on the aggregate-level information from the data tables. Outputs produced by the team are at an aggregate level and small numbers are suppressed in line with the HES Analysis Guide Guidelines. However, some analysis with small numbers included may be provided where necessary to the GIRFT programme overseen by NHS Improvement.

Civil Registration mortality data specific outputs

Specific outputs dependent on the processing of Civil Registration mortality data are:

• Analysis of cause of death

• Analysis of death following discharge, 7, 14, 30 days

• Comparative analysis of cause of death and deaths following discharge

• Development of outputs to further help users understand patient outcomes through analysis of survival rates

• Analysis of variation in mortality across geographical boundaries

• Support customers with out of hospital mortality queries

• Additional level of insight for customers to investigate the care pathway for their patients

Timeframe for outputs

Subscribers to the tools have continual access which allows them to meet their own internal target dates.

Outputs of bespoke analytics projects are dependent on the nature of the project and can include tabulations, dashboards, reports, spreadsheets, presentations or articles. Outputs may be surfaced through tools including Microsoft Office suite (Excel, Word and PowerPoint etc) or other tools (Tableau, QlikView) depending on the requirements of the customer. In some instances, algorithms or coefficients that have been derived through research on the data may be provided directly to a customer for implementation on their own local data. Data provided in all outputs is in line with HES analysis guidelines, meeting aggregation and small number suppression requirements. Bespoke analytics projects are conducted on an ad hoc basis and target dates for delivery of outputs are thus defined upon commencement of each project.

Publications

Examples of previous publications produced by Telstra Health UK include the Dr Foster Hospital Guide that published analysis of the variations in acute hospital care for the benefit of healthcare professionals, patients and the public and insight articles published on the Telstra Health UK website.

In January 2020, Telstra Health UK undertook statistical analyses of abdominal aortic aneurisms and trans-catheter aortic valve implementations and found interesting correlations between surgeon annual volume and mortality. Following on from this, the Dr Foster team carried out an analysis that examined how the number of annual knee replacement procedures performed within a trust influences the rate of readmission. Insights from this are published on the Telstra Health UK website.

Telstra Health UK provide an interactive dashboard on its website to provide information to help manage and predict the risk of COVID-19 for England. The respiratory and frailty data are from HES. The dashboard was initially published in April 2020 and is updated regularly on their website.

Telstra Health UK are aware that publications, whether inside or outside the NHS, must adhere to strict guidelines in terms of disclosure, and ensure that any such publications are aggregated and comply with small number suppression in line with the HES Analysis Guide and other relevant legislation. Analyses for use in publications can be in the form of text, tables, or other data visualisations such as diagrams/graphs using aggregate data. Publications will also meet standards as defined in the Terms and Conditions of the Data Sharing Agreement.

All outputs will contain only data that is aggregated with small numbers suppressed in line with the HES Analysis Guide.

Covid-19 dashboard providing analysis of Trusts’ crude and risk-adjusted mortality rates and in comparison to peers and a national benchmark. (March 2021).

Telstra Health UK developed a COVID-19 mortality risk model on the HES (Hospital Episode Statistics) Admitted Patient Care dataset to:

1. Create national benchmarks allowing Trusts to compare their COVID-19 mortality against peers taking into account patient case-mix

2. Provide a COVID-19 mortality relative risk for each Trust to be surfaced in a dashboard

3. Identify the most important factors within the COVID-19 cohort leading to mortality at a Trust and/or site level and comparing these to a national or peer group average.

“It’s a great tool and gives exactly the kind of external assurance we need, I think the demographic and risk factor analysis is very helpful”.Director for Safety and Medical Director, Deputy Chief Executive, Gloucestershire Hospitals NHS FT.

Analysis of homeless patient inequalities (February 2021)

After consultation with University College London Hospitals, which recently established a multidisciplinary collaboration in response to homelessness, Telstra Health UK set out to produce a suite of analysis using the Hospital Episode Statistics (HES) Admitted Patent Care data to identify and understand comparative characteristics of homeless patients nationally. The analysis sought to identify the shared characteristics of homeless patients, what their needs are, and to highlight some of the differences they have in experiences and outcomes to the rest of the population. The report is freely available on the Telstra Health UK website.

Analysis of decline in admissions during first wave of pandemic (October 2020)

Telstra Health UK's analysis published in the Daily Telegraph, and then picked up by other media organisations, showed that during the height of the first wave of the COVID-19 pandemic in the UK in April-May 2020, there was a sharp drop in admissions relating to a number of diseases. The reporting informed public awareness and sparked discussion with healthcare professionals, including for example, warnings of longer term impacts and encouragement for people to contact their GP if they need medical treatment.

COVID-19 heatmaps (April 2020)

Telstra Health UK's awareness raising publications have provided professionals and the public with insight into the progression of COVID-19. Their interactive dashboard, first released in April 2020, uses heatmaps to show the spread of the disease. It also shows historical perspectives within the past 10 years by using respiratory and frailty data from HES.

Frailty analysis for British Red Cross (May 2020)

Telstra Health UK's frailty analysis has been used by the British Red Cross create a COVID-19 vulnerability index for the UK, mapping clinical vulnerability, economic vulnerability, social vulnerability and other health and wellbeing needs. This is helping the British Red Cross focus help on the most vulnerable people whose needs aren’t being met.

High Intensity User (HIU) report (January 2019)

Telstra Health UK continues to raise public and professional awareness. Its High Intensity User (HIU) report of January 2019 uncovered important characteristics of HIU patients and patterns in their attendances of A&E. It showed that the vast majority of HIUs are living in the most deprived areas of England, suggesting that the most vulnerable members of society may be more prone to high intensity use. Smoking, drugs and alcohol all appear to play an important role in frequent A&E use, in relation to the most common reasons that HIUs are admitted to hospital.

Dr Foster has provided objective insight and analysis since 1999. Dr Foster’s aim is to help health and social care organisations make better and faster decisions with data and insight and, ultimately, to benefit patients. This is delivered in three main strands:

• Dr Foster tools and services – to provide management information, analysis and clinical benchmarking through online products and services

• Bespoke analytics – to deliver customised projects to meet individual customer needs

• Research for publication – to provide thought leadership in the field of healthcare data analytics, with the aim of improving the planning, delivery and outcome of health and social care

This Agreement will permit the following disseminations of data for the duration of this agreement.

• Pseudonymised Hospital Episodes Statistics (HES)

• Pseudonymised Civil Registration (Deaths) - Secondary Care Cut (CRD) plus bridge files

• Pseudonymised Emergency Care Data Set (ECDS)

Dr Foster previously received these datasets via the Dr Foster Unit at Imperial College London (DFU) under agreement DARS-NIC-68697-R6F1T with NHS Digital. DFU first receive this data under agreement DARS-NIC-12828-M0K2D. Dr Foster now want to receive this data directly from NHS Digital.

A transition period is required to ensure that Dr Foster can continue to provide its NHS customers with its services. This will include testing of outputs so that NHS customers can be assured that they are receiving the same quality of service. The end of the transition period will coincide with the expiry of agreement DARS-NIC-68697-R6F1T with NHS Digital, but Dr Foster will work to complete this sooner. Dr Foster requests that, during this transition period, it receives data via DFU and directly from NHS Digital. At the end of this transition period, data will be deleted securely so that Dr Foster is only processing HES, CRD and ECDS data provided under this agreement. This transition period is still ongoing.

Dr Foster require the requested data to help healthcare organisations achieve sustainable improvements in their performance, to gain insight and to inform decision making.

NHS subscribers to Dr Foster tools have access to analysis of the data so that they can:

• Track and trend performance, identify areas for efficiency savings and understand and influence demand and patient flow throughout the health and care system.

• Investigate risk-adjusted quality, patient safety and clinical outcomes data including mortality, benchmark against other healthcare organisations and identify areas for improvement.

Dr Foster online products are used by:

• NHS Provider Trusts– Subscribed authorised users in customer organisations can view data that relate to their organisation at a record level. They cannot access record level HES data relating to other organisations.

• Other NHS organisations – Subscribed authorised users in customer organisations can view aggregated analysis which provides valuable insight but prevents any patients from being identified, in accordance with guidance provided by NHS Digital.

• Care Quality Commission – CQC can view aggregated analysis.

The Analytics team provides aggregate level and small number suppressed analysis (in line with the HES Analysis Guide) and insight to a number of NHS customers including:

• NHS Trusts

• Clinical Commissioning Groups

• Commissioning Support Units

• Department of Health

• NHS England

• NHS Improvement

• Care Quality Commission

• Public Health England

• National Institute for Health and Care Excellence

The Analytics team also provides analysis with small numbers included as part of the Getting It Right First Time (GIRFT) programme. This is a national programme that identifies best practice and where changes can be made to improve care and patient outcomes. This is described more under ‘processing activities’.

Dr Foster also work with:

• Non-NHS organisations providing services to benefit the NHS – these are only supplied with aggregate, small-number suppressed analyses in line with the HES analysis guide.

• Non-NHS organisations to benefit public health and social care - these are only supplied with aggregate, small-number suppressed analyses where benefits can be identified for the health and social care system. It is also proposed that algorithms or coefficients that have been derived through research on HES data may be provided directly to a customer for implementation on their own local data. Data provided in all outputs will be at an aggregate level and small number suppression will be implemented in line with HES analysis guidelines.

Any request for such analysis is reviewed to determine if it benefits the health and social care system. Dr Foster will inform NHS Digital of analysis it provides to non-NHS organisations and will list this in any renewal or amendment to this agreement.

Dr Foster provided analysis on COVID-19 to the British Red Cross in May 2020. This was frailty analysis by Lower Super Output Area (LSOA) which included the following:

• Proportion of frail patients with mobility problems

• Proportion of frail patients with mobility problems and a fracture.

These were percentages only and included no small numbers.

Customers have access to Dr Foster’s team of qualified data scientists, clinicians, statisticians, mathematicians, and economists. They supplement in-house analytical teams with Dr Foster’s expert advice and guidance linking, modelling and visualising data and insight.

The Analytics team provides bespoke analytics and data science tailored to specific needs to identify clinical variation, efficiency savings, predict patient risk and improve patient outcomes.

They are a skilled team of experts in advanced healthcare analytics and data science including predicative analytics, machine learning techniques and advanced statistical methods. The team use this expertise to investigate issues and transform healthcare services.

Dr Foster use the data provided under this agreement to provide a management information function in the form of analysis and clinical benchmarking for healthcare organisations and to increase the power of predictive models for rare diseases, procedures and events. Dr Foster build standard casemix adjustment models for 259 diagnosis groups and 200 procedure groups which include some rarer conditions. Casemix is a system that measures hospital performance, aiming to reward initiatives that increase efficiency in hospitals. It also serves as an information tool that allows policy makers to understand the nature and complexity of health care delivery. Using all the requested datasets means that Dr Foster have the most up to date information and can inform customers of potential issues around quality and in turn allowing them to make better informed decisions for the improvement of healthcare and outcomes for patients.

At a high-level Dr Foster analyses break down into the following:

• Quality measures of healthcare services by providers/area/clinical interest/trend analysis

• Variations in health outcomes

• Health inequalities and needs analysis

• Predictions

• Performance data and changes in clinical practice

• Management information

• Efficiency Monitoring

• Benchmarking

• Contract Management and Variance Analysis

• Activity Monitoring

• National Target Performance

• Pathway design, redesign and improvement.

• Practice Performance Monitoring

• Capacity and utilisation management

• Cross checking of commissioning data

• Systems to support and monitor the pattern of healthcare usage

• Patient segmentation analysis

• Overall data quality

The data allow Dr Foster to provide a wide array of relevant indicators to give end users as complete a picture of hospital performance as possible to allow health and social care organisations to effectively:

• Monitor quality of services provided

• Identify efficiency opportunities

• Identify pathways where services can be improved for the benefit of patients

Civil Registration (Deaths) - Secondary Care Cut data is requested to provide more timely and accurate analysis and insight for Dr Foster’s customers. This data is essential for performing survival analyses, representing a very valuable source of data. It will improve the output of Dr Foster’s products for the benefit of NHS customers and for the broader improvement of health and social care for the public.

This data is extremely critical because mortality information may be a surrogate metric for success of medical care. Therefore, this dataset will enable identification of factors that drive successful treatment of a patient. Cause and date of death may also be used to identify trends in causes of death in particular groups of patients. Doctor Foster Limited hold historical death which is necessary for identifying trends overtime.

Doctor Foster Limited request that the Civil Registry (Deaths data) is linked to the requested HES datasets, this linkage provides valuable insights into how and why some patients with the same condition and at the same stage can have very different outcomes. In addition, it would be used to:

• Compare hospital mortality rates for in-hospital deaths with rates for all deaths to evaluate the effect of differential discharge policies

• Calculate total post-operative mortality rates, e.g. when comparing operative techniques such as laparoscopy and open approaches

• Assess potential quality of care issues by comparing the cause of death with the reason(s) for admission, e.g. for surgical patients who are discharged within 30 days of the procedure but who die at home and whether the death is related to their disease process or to complications of treatment

• Develop and validate indicators of quality and safety of healthcare, particularly by consultant and hospital

• Show variations in performance by unit and socio demographic stratum

• Predict risk and adjust risk of indicators and variations and any other methodological aspects as they arise

• Establish seasonal patterns of mortality

• Support organisations in delivering their Learning from Deaths agenda and timely mortality reviews

• Help organisations improve quality of care and identify where they could do more to help patients and their families

30 day mortality (both in and out of hospital) is a well published and accepted standard for comparing post-operative and post-admission hospital mortality. Linking Civil Registration (Deaths) - Secondary Care Cut data with HES data allows Dr Foster to provide this outcome, which will improve engagement with clinicians, and allow comparisons with other published analyses.

Dr Foster process the minimum data necessary to meet the purpose and build privacy into their designs.

Dr Foster Limited are requesting dissemination of the 2019/20 Emergency Care Data Set (ECDS), in parallel to the 2019/20 HES A&E data, so that it can:

• continue to deliver products and services that provide insight into and analysis of emergency care provision;

• develop enhancements to its services that utilise the greater detail provided by ECDS,

• transition its products from A&E data to reduce any interruption for NHS healthcare professionals that rely on these tools and services;

• quality assure its processing of ECDS.

Historical ECDS data is necessary for more useful trend analysis, research and quality assurance. The additional fields within ECDS will help Dr Foster to:

• improve understanding of the complexity of attending patients and the causes of rising demand;

• capture diagnostic data for richer information on the diagnosis with which patients are presenting to emergency departments;

• enhance the understanding of the value of emergency departments;

• enhance understanding of need, activity and outcomes;

• better understand patient pathways such as type 5 emergency admissions (same day emergency care), which are currently not coded within HES.

Mental health fields within ECDS will be used by Dr Foster:

• To help better understand the cohort of patients seen in the Emergency Department with mental health conditions who are both formally and informally detained under the Mental Health Act.

• To help emergency care departments understand how the above patients use their services and what affect this may have on departments.

To address the GDPR Principle of Data Minimisation, Dr Foster have reviewed its requirements to ensure that only the minimum data necessary is requested. It has refined its processing to require a reduced minimum of 11 years of historic data to deliver results to customers. (This is a reduction from the 15 years required under DARS-NIC-68697-R6F1T).

A data period of 11 years of historical data is essential to enable Dr Foster to:

• Obtain longitudinal data on prior admissions for patients. Risk modelling will also require access to variables on prior admissions including previously recorded co-morbidities.

• Create, update and maintain statistical risk models to enable the regular production of risk adjusted measures of mortality, quality and efficiency (including Hospital Standardised Mortality Ratio (HSMR) and Cumulative Sum Control Chart (CUSUM) alerts as used by NHS organisations and regulators).

Dr Foster Limited is the sole Data Controller who also process the data for the purposes described within this Agreement.

The lawful basis of processing falls under General Data Protection Regulation (GDPR) articles 6(1)(f) (legitimate interests) and 9(2)(j) (archiving in the public interest). Dr Foster Limited have undertaken a legitimate interests assessment and a data protection impact assessment, and intend to maintain and update these documents where necessary.

Processing under GDPR Article 6(1)(f) can be justified as Dr Foster Limited has a legitimate interest in being able to provide tools and services that healthcare organisations will find useful and that will benefit the health and social care system. Without processing NHS Digital data, Dr Foster would not be able to deliver these tools and services, this would be to the detriment of health professionals who use them. Dr Foster's customers can be assured that the tools and services are based on evidence provided by data from a trusted source. There is no viable alternative as relying on public domain data would lead to gaps and not allow the same support for decision making. Using pseudonymised data allows Dr Foster to deliver evidence-based insight and analysis while minimising intrusion into a patient's privacy.

The processing of this data is also necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) of GDPR. The processing is proportionate to its aims, respects data protection rights and provides suitable and specific measures to protect the rights and interests of individuals. It is necessary for reasons of public interest in public health, in particular to ensure high standards of quality and safety of health care. Although Dr Foster are not a public body, they provide services to help public healthcare organisations to monitor and improve their services. Processing is designed to benefit patients and society as a whole through better healthcare.

Dr Foster provide commercial tools, insight and analysis to healthcare professionals. They also provide freely available online resources for healthcare professionals and the public (using anonymised outputs) to help improve professional and public understanding of health. For example, Dr Foster analysts have developed an indicator to help local public health teams monitor any increases in Covid-19 infections to help prevent lockdown situations. The interactive graph allows public health teams to monitor any increases in cases of Covid-19 by recent daily case rate compared to a prior eight-week daily case rate. It provides an early indication of a potential spike, allowing local authorities to act early and implement restrictions. This is available on the Dr Foster website: https://drfoster.com/2020/08/12/dr-foster-covid-19-hotspot-indicator/. Dr Foster also carried out a detailed analysis of accident and emergency (A&E) attendances nationally with the aim of uncovering common characteristics of High Intensity Users (HIUs) - people who attended 10 or more times in a 12-month period - and patterns in HIU attendances to provide valuable insight and a better understanding of the reasons they attend with such high frequency. This was published on the Dr Foster website and reported on in the media. Press coverage of Dr Foster’s freely available analysis helps disseminate knowledge and understanding further.

The majority of Dr Foster outputs are delivered through:

• Dr Foster online tools and services including the Healthcare Intelligence Portal

• Bespoke analytics

• Research for publication. Specific outputs include benchmarked or standardised healthcare indicators and analysis such as mortality (Summary Hospital-level Mortality Indicator (SHMI)/HSMR), LOS (Length of Stay), admission trends, readmission rates, patient safety indicators, referral patterns, market share analysis etc.

Outputs will be used by customers to investigate clinical quality, performance and business development, specifically:

• Assess and manage clinical quality and patient safety within NHS Organisations

• Identify pathways where there is potential for improvement

• Identify areas of best practice either within the Provider Trust or local/national health economies

• Better understand how they compare to other Provider Trusts with similar case mixes

• Identify improvements in operational efficiency

• Understand patient outcomes

• Identify and understand market activity

• Monitor the impact of implemented changes

• Identify variations in outcomes

The above outputs depend on processing of all the requested data. Outputs are typically provided in data tables to NHS customers. Dr Foster may also produce data visualisations (e.g. bar charts, box plots, funnel plots) based on the aggregate-level information from the data tables. Outputs produced by the team are at an aggregate level and small numbers are suppressed in line with the HES Analysis Guide Guidelines. However, some analysis with small numbers included may be provided where necessary to the GIRFT programme overseen by NHS Improvement.

Civil Registration mortality data specific outputs

Specific outputs dependent on the processing of Civil Registration mortality data are:

• Analysis of cause of death

• Analysis of death following discharge, 7, 14, 30 days

• Comparative analysis of cause of death and deaths following discharge

• Development of outputs to further help users understand patient outcomes through analysis of survival rates

• Analysis of variation in mortality across geographical boundaries

• Support customers with out of hospital mortality queries

• Additional level of insight for customers to investigate the care pathway for their patients

Timeframe for outputs

Subscribers to the tools have continual access which allows them to meet their own internal target dates.

Outputs of bespoke analytics projects are dependent on the nature of the project and can include tabulations, dashboards, reports, spreadsheets, presentations or articles. Outputs may be surfaced through tools including Microsoft Office suite (Excel, Word and PowerPoint etc) or other tools (Tableau, QlikView) depending on the requirements of the customer. In some instances, algorithms or coefficients that have been derived through research on the data may be provided directly to a customer for implementation on their own local data. Data provided in all outputs are at an aggregate level and small number suppression is implemented in line with HES analysis guidelines. Bespoke analytics projects are conducted on an ad hoc basis and target dates for delivery of outputs are thus defined upon commencement of each project.

Publications

Examples of previous publications produced by Dr Foster include the Hospital Guide that published analysis of the variations in acute hospital care for the benefit of healthcare professionals, patients and the public and insight articles published on the Dr Foster website.

In January 2020, Dr Foster undertook statistical analyses of abdominal aortic aneurisms and trans-catheter aortic valve implementations and found interesting correlations between surgeon annual volume and mortality. Following on from this, the Dr Foster team carried out an analysis that examined how the number of annual knee replacement procedures performed within a trust influences the rate of readmission. Insights from this are published at https://drfoster.com/2020/01/30/detailed-analysis-of-knee-replacement-annual-volume-reveals-its-significant-effect-on-readmission-rates/. Other Insights reports and briefings are available at https://drfoster.com/insights/.

Dr Foster provide an interactive dashboard on its website to provide information to help manage and predict the risk of COVID-19 for England. The respiratory and frailty data are from HES. The dashboard was initially published in April 2020 and is updated regularly at https://drfoster.com/2020/04/06/uk-covid-19-progression-dashboard.

Dr Foster are aware that publications, whether inside or outside the NHS, must adhere to strict guidelines in terms of disclosure, and ensure that any such publications are aggregated and comply with small number suppression in line with the HES Analysis Guide and other relevant legislation. Analyses for use in publications can be in the form of text, tables, or other data visualisations such as diagrams/graphs using aggregate data. Publications will also meet standards as defined in the Terms and Conditions of the Data Sharing Agreement.

All outputs will contain only data that is aggregated with small numbers suppressed in line with the HES Analysis Guide.

COVID-19 heatmaps (April 2020)

Dr Foster’s awareness raising publications have provided professionals and the public with insight into the progression of COVID-19. Their interactive dashboard, first released in April 2020, uses heatmaps to show the spread of the disease. It also shows historical perspectives within the past 10 years by using respiratory and frailty data from HES.

Frailty analysis for British Red Cross (May 2020)

Dr Foster’s frailty analysis has been used by the British Red Cross create a COVID-19 vulnerability index for the UK, mapping clinical vulnerability, economic vulnerability, social vulnerability and other health and wellbeing needs. This is helping the British Red Cross focus help on the most vulnerable people whose needs aren’t being met.

High Intensity User (HIU) report (January 2019)

Dr Foster continues to raise public and professional awareness. Its High Intensity User (HIU) report of January 2019 uncovered important characteristics of HIU patients and patterns in their attendances of A&E. It showed that the vast majority of HIUs are living in the most deprived areas of England, suggesting that the most vulnerable members of society may be more prone to high intensity use. Smoking, drugs and alcohol all appear to play an important role in frequent A&E use, in relation to the most common reasons that HIUs are admitted to hospital.

Dr Foster also measure benefits through customer feedback for their products and services.

Case study - North Cumbria University Hospitals NHS Trust (2016)

“We find Dr Foster’s combination of knowledgeable experts and powerful tools enormously helpful in our work to improve the quality of care we are providing to our patients. With Dr Foster’s help we’ve made significant progress in understanding quality and its drivers, and identifying how we can make sustainable improvements in our hospitals. Dr Foster’s insightful analysis, practical recommendations and ongoing support help us extract maximum value from our data, and their impact is far-reaching.”

Case study – Lancashire Teaching Hospitals NHS Trust (January 2015)

Dr Foster’s HIP is used on at least a weekly basis by the corporate and business intelligence teams and clinical staff to:

• inform and direct the Trust’s mortality and morbidity review processes

• scrutinise care standards and their impact on patient outcomes

• provide analysis and reassurance to the board, governors and the public

• monitor trends in readmissions and complications and investigate if these were justified clinically

Instigated several quality improvement initiatives including:

• Improved documentation of complexity in perinatal conditions that has:

o reduced mortality ratios

o increased income

o engaged clinicians in a wider quality initiative introducing an enhanced model of care for potentially vulnerable babies

• Development of an improvement programme for patients suffering from chronic obstructive pulmonary disease across the whole care pathway in the local health economy

Case study – University Hospital of South Manchester NHS Foundation Trust (January 2015)

The Trust specialises in cardiac surgery activity, for which it is a tertiary centre, and performs a high number of coronary artery bypass grafts (CABG) and heart valve replacements. Dr Foster’s Practice and Provider Monitor enabled benchmarking of productivity and efficiency measures, giving the user the ability to compare mean-price-per-spell at both procedure and diagnosis HRG level.

The Trust used the Dr Foster tool to look more deeply at other influences on the efficiency of the pathway compared with others and highlighted that the length-of-stay for these procedures was one of the longest of its peer group. This clearly has an impact on income as the amount earned per bed day is lower, and the capacity to put more patients through the system is reduced. From a patient’s point of view, this is also good news: a longer length-of-stay may increase risk.

UHSM then used Practice and Provider Monitor to move through the specialties to highlight areas of variance and focus on where they could improve productivity and efficiency across the Trust.

Case study - Imperial College Healthcare NHS Trust (October 2018)

Imperial College Healthcare NHS Trust has been a longstanding customer of Dr Foster with a dedicated Business Insight Manager based at the trust who has been delivering bespoke analytic support and expertise in clinical benchmarking. This dedicated, expert resource supports mortality monitoring, market share analysis and efficiency indicator benchmarking. Dr Foster data is now integrated into strategic planning and service redesign and has been used to explore growth opportunities for services previously provided by other trusts. As part of North West London’s Shaping a Healthier Future, Dr Foster’s analytic support has helped the trust in service redesign work, for example in integrating services previously provided by Ealing Hospital.

The Deputy Chief Information Officer, Imperial College Healthcare NHS Trust stated that, “National benchmarking is possible, but you have to do a lot of work with the data yourselves. With Dr Foster tools the data is easy to access and we can make sure we are keeping pace with other high-performing organisations. Having a Dr Foster analyst on site has been very successful. […] Dr Foster understands what our objectives are and is able to carry out complex analysis on our behalf. It is a fast track way of getting good benchmarking. For example, our performance framework has over 100 different metrics. The Dr Foster tools are useful looking across the Sustainability and Transformation Plan (STP) area to understand what is happening with indicators such as length of stay.”

Northampton General Hospital NHS Trust (February 2015)

“Clinicians and analysts use Healthcare Intelligence Portal (HIP) on a daily basis to analyse new patient safety alerts, high standardised mortality ratios and individual cases. Dr Foster investigate areas of concern in clinical coding and data analysis and look to improve future patient care through retrospective review and analysis.”

Northern Devon Healthcare NHS Trust (February 2015)

“Our data quality team use HIP to identify patients with missing or duplicate information and whether the problem is ongoing and needs a change in process to rectify it or whether it’s due to individual oversight.”

Wrightington, Wigan and Leigh NHS Foundation Trust (February 2015)

“We carried out a review of dermatological deaths and the data in HIP identified that the deaths were due to cellulitis. We reviewed treatment options based on this and identified where improvements could be made.”

The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust (February 2015)

“We use HIP to undertake many audits and reviews at any one time. For example, ten sets of case notes are reviewed each month by an emergency department consultant as part of our programme to improve performance on sepsis.”

Aim and purpose of this application:

Dr Foster has provided objective insight and analysis since 1999. Dr Foster’s aim is to help health and social care organisations make better and faster decisions with data and insight and, ultimately, to benefit patients. This is delivered in three main strands:

• Dr Foster tools and services – to provide management information, analysis and clinical benchmarking through online products and services

• Bespoke analytics – to deliver customised projects to meet individual customer needs

• Research for publication – to provide thought leadership in the field of healthcare data analytics, with the aim of improving the planning, delivery and outcome of health and social care

This application is to request the direct dissemination of data from NHS Digital to Dr Foster.

The requested data are:

• Hospital Episodes Statistics (HES)

• Civil Registration (Deaths) - Secondary Care Cut (CRD) plus bridge files

• Emergency Care Data Set (ECDS)

Dr Foster currently receives these via the Dr Foster Unit at Imperial College London (DFU) under agreement DARS-NIC-68697-R6F1T with NHS Digital. DFU first receive this data under agreement DARS-NIC-12828-M0K2D.

Dr Foster will end this process and replace it with the direct receipt of data from NHS Digital. A transition period will be required to ensure that Dr Foster can continue to provide its NHS customers with its services. This will include testing of outputs so that NHS customers can be assured that they are receiving the same quality of service. The end of the transition period will coincide with the expiry of agreement DARS-NIC-68697-R6F1T with NHS Digital, but Dr Foster will work to complete this sooner. Dr Foster requests that, during this transition period, it receives data via DFU and directly from NHS Digital. At the end of this transition period, data will be deleted securely so that Dr Foster is only processing HES, CRD and ECDS data provided under this agreement. Under this agreement Dr Foster will cease offering any services to trusts which would enable them to re-identify patients. Dr Foster would not have the ability to identify any patients

Dr Foster is requesting pseudonymised data only under this agreement.

Data controller

Dr Foster are the sole Data Controller who also process the data provided under this agreement.

General Data Protection Regulation legal bases

Dr Foster process the data under General Data Protection Regulation (GDPR) articles 6(1)(f) (legitimate interests) and 9(2)(j) (archiving in the public interest). Dr Foster determined the legal bases by undertaking a legitimate interests assessment and a data protection impact assessment. These documents are maintained and updated as necessary by Dr Foster.

Dr Foster has a legitimate interest in being able to provide tools and services that healthcare organisations will find useful and that will benefit the health and social care system. Without processing this data, Dr Foster would not be able to deliver these tools and services. Withdrawing these would be to the detriment of health professionals who use them. Dr Foster's customers can be assured that the tools and services are based on evidence provided by data from a trusted source. There is no viable alternative as relying on public domain data would lead to gaps and not allow the same support for decision making. Using pseudonymised data allows Dr Foster to deliver evidence-based insight and analysis while minimising intrusion into a patient's privacy.

Dr Foster has a legitimate interest in developing new ways to help its customers improve their services and utilise the data to its full potential. This will be used to drive improved patient care, which is in the broader interest of everyone using the health and social care services in England.

The processing of this data is also necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) of GDPR. The processing is proportionate to its aims, respects data protection rights and provides suitable and specific measures to protect the rights and interests of individuals. It is necessary for reasons of public interest in the area of public health, in particular to ensure high standards of quality and safety of health care. Although Dr Foster are not a public body, they provide services to help public healthcare organisations to monitor and improve their services. Processing is designed to benefit patients and society as a whole through better healthcare.

Purpose of the request

Dr Foster require the requested data to help healthcare organisations achieve sustainable improvements in their performance, to gain insight and to inform decision making.

The required data to meet the purpose are:

HES critical care

HES Admitted Patient Care

HES Outpatients

HES Accident and Emergency

Civil Registration (Deaths) - Secondary Care Cut

HES:Civil Registration (Deaths) bridge

Emergency Care Data Set (ECDS)

Dr Foster use the data provided under this agreement to provide a management information function in the form of analysis and clinical benchmarking for healthcare organisations and to increase the power of predictive models for rare diseases, procedures and events. Dr Foster build standard casemix adjustment models for 259 diagnosis groups and 200 procedure groups which include some rarer conditions. Casemix is a system that measures hospital performance, aiming to reward initiatives that increase efficiency in hospitals. It also serves as an information tool that allows policy makers to understand the nature and complexity of health care delivery. Using all the requested datasets means that Dr Foster have the most up to date information and can inform customers of potential issues around quality and in turn they can make better informed decisions for the improvement of healthcare and outcomes for patients.

At a high-level Dr Foster analyses break down into the following:

• Quality measures of healthcare services by providers/area/clinical interest/trend analysis

• Variations in health outcomes

• Health inequalities and needs analysis

• Predictions

• Performance data and changes in clinical practice

• Management information

• Efficiency Monitoring

• Benchmarking

• Contract Management and Variance Analysis

• Activity Monitoring

• National Target Performance

• Pathway design, redesign and improvement.

• Practice Performance Monitoring

• Capacity and utilisation management

• Cross checking of commissioning data

• Systems to support and monitor the pattern of healthcare usage

• Patient segmentation analysis

• Overall data quality

The data allow Dr Foster to provide a wide array of relevant indicators to give end users as complete a picture of hospital performance as possible to allow health and social care organisations to effectively:

• Monitor quality of services provided

• Identify efficiency opportunities

• Identify pathways where services can be improved for the benefit of patients

Civil Registration (Deaths) - Secondary Care Cut specific purposes

Civil Registration (Deaths) - Secondary Care Cut data are requested to provide more timely and accurate analysis and insight for Dr Foster’s customers. It is essential for performing survival analyses and so represents a very valuable source of data. It will improve the output of Dr Foster’s products for the benefit of NHS customers and for the broader improvement of health and social care for the public.

These data are extremely critical because mortality information may be a surrogate metric for success of medical care. Therefore, this dataset will enable identification of factors that drive successful treatment of a patient. Cause and date of death may also be used to identify trends in causes of death in particular groups of patients. Historical death data are necessary for identifying trends.

Linking HES datasets with mortality data could provide valuable insights into how and why some patients with the same condition and at the same stage can have very different outcomes. In addition, it would be used to:

• Compare hospital mortality rates for in-hospital deaths with rates for all deaths to evaluate the effect of differential discharge policies

• Calculate total post-operative mortality rates, e.g. when comparing operative techniques such as laparoscopy and open approaches

• Assess potential quality of care issues by comparing the cause of death with the reason(s) for admission, e.g. for surgical patients who are discharged within 30 days of the procedure but who die at home and whether the death is related to their disease process or to complications of treatment

• Develop and validate indicators of quality and safety of healthcare, particularly by consultant and hospital

• Show variations in performance by unit and socio demographic stratum

• Predict risk and adjust risk of indicators and variations and any other methodological aspects as they arise

• Establish seasonal patterns of mortality

• Support organisations in delivering their Learning from Deaths agenda and timely mortality reviews

• Help organisations improve quality of care and identify where they could do more to help patients and their families

30 day mortality (both in and out of hospital) is a well published and accepted standard for comparing post-operative and post-admission hospital mortality. Linking Civil Registration (Deaths) - Secondary Care Cut data with HES data allows Dr Foster to provide this outcome, which will improve engagement with clinicians, and allow comparisons with other published analyses.

Dr Foster process the minimum data necessary to meet the purpose and build privacy into their designs. Dr Foster have no requirement to re-identify the individuals within the data they receive and will make no attempt to carry out any re-identification.

In the context of the above statement, while Dr Foster and NHS Digital recognise that the inclusion of record-level Date of Death linked to all four HES datasets will theoretically increase the risk of re-identification, for clarity it is pointed out that:

a) as stated above, Dr Foster will not re-identify; in addition, given the volumes of data, identification serves no purpose to Dr Foster anyway

b) raw Date of Death allows Dr Foster to carry out better analyses and provide a better service to their customers:

- using an alternative such as “death 30/60/90 days from Discharge” does not enable the calculation of median survival rates, nor does it enable Dr Foster to produce aggregated survival curves

- in some cases, Dr Foster calculates mortality rates with reference to particular Procedures not to Discharge; the above flag would not support this as “day 0” would need to be set at different events in different cases for different purposes

c) record-level data is only shared by Dr Foster with customer Trusts only for those patients treated by that Trust

Emergency Care Data Set (ECDS) specific purposes

Dr Foster are requesting Emergency Care Data Set (ECDS), in parallel to HES A&E, so that it can:

• continue to deliver products and services that provide insight into and analysis of emergency care provision;

• develop enhancements to its services that utilise the greater detail provided by ECDS,

• transition its products from A&E data to reduce any interruption for NHS healthcare professionals that rely on these tools and services;

• quality assure its processing of ECDS.

Historical ECDS data is necessary for more useful trend analysis, research and quality assurance. The additional fields within ECDS will help Dr Foster to:

• improve understanding of the complexity of attending patients and the causes of rising demand;

• capture diagnostic data for richer information on the diagnosis with which patients are presenting to emergency departments;

• enhance the understanding of the value of emergency departments;

• enhance understanding of need, activity and outcomes;

• better understand patient pathways such as type 5 emergency admissions (same day emergency care), which are currently not coded within HES.

Mental health fields within ECDS will be used by Dr Foster:

• To help better understand the cohort of patients seen in the Emergency Department with mental health conditions who are both formally and informally detained under the Mental Health Act.

• To help emergency care departments understand how the above patients use their services and what affect this may have on departments.

Number of years requested

Dr Foster has reviewed its requirements to ensure that only the minimum data necessary is requested. It has refined its processing to require a reduced minimum of 11 years of historic data to deliver results to customers. (This is a reduction from the 15 years required under DARS-NIC-68697-R6F1T).

A data period of 11 years of historical data is essential to enable Dr Foster to:

• Obtain longitudinal data on prior admissions for patients. Risk modelling will also require access to variables on prior admissions including previously recorded co-morbidities.

• Create, update and maintain statistical risk models to enable the regular production of risk adjusted measures of mortality, quality and efficiency (including Hospital Standardised Mortality Ratio (HSMR) and Cumulative Sum Control Chart (CUSUM) alerts as used by NHS organisations and regulators).

Users of Dr Foster products and services

NHS subscribers to Dr Foster tools have access to analysis of the data so that they can:

• Track and trend performance, identify areas for efficiency savings and understand and influence demand and patient flow throughout the health and care system.

• Investigate risk-adjusted quality, patient safety and clinical outcomes data including mortality, benchmark against other healthcare organisations and identify areas for improvement.

Dr Foster online products are used by:

• NHS Provider Trusts– Subscribed authorised users in customer organisations can view data that relate to their organisation at a record level. They cannot access record level HES data relating to other organisations.

• Other NHS organisations – Subscribed authorised users in customer organisations can view aggregated analysis which provides valuable insight but prevents any patients from being identified, in accordance with guidance provided by NHS Digital.

• Care Quality Commission – CQC can view aggregated analysis.

The Analytics team provides aggregate level and small number suppressed analysis (in line with the HES Analysis Guide) and insight to a number of NHS customers including:

• NHS Trusts

• Clinical Commissioning Groups

• Commissioning Support Units

• Department of Health

• NHS England

• NHS Improvement

• Care Quality Commission

• Public Health England

• National Institute for Health and Care Excellence

The Analytics team also provides analysis with small numbers included as part of the Getting It Right First Time (GIRFT) programme. This is a national programme that identifies best practice and where changes can be made to improve care and patient outcomes. This is described more under ‘processing activities’.

Dr Foster also work with:

• Non-NHS organisations providing services to benefit the NHS – these are only supplied with aggregate, small-number suppressed analyses in line with the HES analysis guide.

• Non-NHS organisations to benefit public health and social care - these are only supplied with aggregate, small-number suppressed analyses where benefits can be identified for the health and social care system. It is also proposed that algorithms or coefficients that have been derived through research on HES data may be provided directly to a customer for implementation on their own local data. Data provided in all outputs will be at an aggregate level and small number suppression will be implemented in line with HES analysis guidelines.

Any request for such analysis is reviewed to determine if it benefits the health and social care system. Dr Foster will inform NHS Digital of analysis it provides to non-NHS organisations and will list this in any renewal or amendment to this agreement.

Dr Foster provided analysis on COVID-19 to the British Red Cross in May 2020. This was frailty analysis by Lower Super Output Area (LSOA) which included the following:

• Proportion of frail patients with mobility problems

• Proportion of frail patients with mobility problems and a fracture.

These were percentages only and included no small numbers.

Customers have access to Dr Foster’s team of qualified data scientists, clinicians, statisticians, mathematicians, and economists. They supplement in-house analytical teams with Dr Foster’s expert advice and guidance linking, modelling and visualising data and insight.

The Analytics team provides bespoke analytics and data science tailored to specific needs to identify clinical variation, efficiency savings, predict patient risk and improve patient outcomes.

They are a skilled team of experts in advanced healthcare analytics and data science including predicative analytics, machine learning techniques and advanced statistical methods. The team use this expertise to investigate issues and transform healthcare services.

Dr Foster provide commercial tools, insight and analysis to healthcare professionals. They also provide freely available online resources for healthcare professionals and the public (using anonymised outputs) to help improve professional and public understanding of health. For example, Dr Foster analysts have developed an indicator to help local public health teams monitor any increases in Covid-19 infections to help prevent lockdown situations. The interactive graph allows public health teams to monitor any increases in cases of Covid-19 by recent daily case rate compared to a prior eight-week daily case rate. It provides an early indication of a potential spike, allowing local authorities to act early and implement restrictions. This is available on the Dr Foster website: https://drfoster.com/2020/08/12/dr-foster-covid-19-hotspot-indicator/. Dr Foster also carried out a detailed analysis of accident and emergency (A&E) attendances nationally with the aim of uncovering common characteristics of High Intensity Users (HIUs) - people who attended 10 or more times in a 12-month period - and patterns in HIU attendances to provide valuable insight and a better understanding of the reasons they attend with such high frequency. This was published on the Dr Foster website and reported on in the media. Press coverage of Dr Foster’s freely available analysis helps disseminate knowledge and understanding further.

The majority of Dr Foster outputs are delivered through:

• Dr Foster online tools and services including the Healthcare Intelligence Portal

• Bespoke analytics

• Research for publication. Specific outputs include benchmarked or standardised healthcare indicators and analysis such as mortality (Summary Hospital-level Mortality Indicator (SHMI)/HSMR), LOS (Length of Stay), admission trends, readmission rates, patient safety indicators, referral patterns, market share analysis etc.

Outputs will be used by customers to investigate clinical quality, performance and business development, specifically:

• Assess and manage clinical quality and patient safety within NHS Organisations

• Identify pathways where there is potential for improvement

• Identify areas of best practice either within the Provider Trust or local/national health economies

• Better understand how they compare to other Provider Trusts with similar case mixes

• Identify improvements in operational efficiency

• Understand patient outcomes

• Identify and understand market activity

• Monitor the impact of implemented changes

• Identify variations in outcomes

The above outputs depend on processing of all the requested data.

Civil Registration mortality data specific outputs

Specific outputs dependent on the processing of Civil Registration mortality data are:

• Analysis of cause of death

• Analysis of death following discharge, 7, 14, 30 days

• Comparative analysis of cause of death and deaths following discharge

• Development of outputs to further help users understand patient outcomes through analysis of survival rates

• Analysis of variation in mortality across geographical boundaries

• Support customers with out of hospital mortality queries

• Additional level of insight for customers to investigate the care pathway for their patients

Timeframe for outputs

Subscribers to the tools have continual access which allows them to meet their own internal target dates.

Outputs of bespoke analytics projects are dependent on the nature of the project and can include tabulations, dashboards, reports, spreadsheets, presentations or articles. Outputs may be surfaced through tools including Microsoft Office suite (Excel, Word and PowerPoint etc) or other tools (Tableau, QlikView) depending on the requirements of the customer. In some instances, algorithms or coefficients that have been derived through research on the data may be provided directly to a customer for implementation on their own local data. Data provided in all outputs are at an aggregate level and small number suppression is implemented in line with HES analysis guidelines. Bespoke analytics projects are conducted on an ad hoc basis and target dates for delivery of outputs are thus defined upon commencement of each project.

Publications

Examples of previous publications produced by Dr Foster include the Hospital Guide that published analysis of the variations in acute hospital care for the benefit of healthcare professionals, patients and the public and insight articles published on the Dr Foster website.

In January 2020, Dr Foster undertook statistical analyses of abdominal aortic aneurisms and trans-catheter aortic valve implementations and found interesting correlations between surgeon annual volume and mortality. Following on from this, the Dr Foster team carried out an analysis that examined how the number of annual knee replacement procedures performed within a trust influences the rate of readmission. Insights from this are published at https://drfoster.com/2020/01/30/detailed-analysis-of-knee-replacement-annual-volume-reveals-its-significant-effect-on-readmission-rates/. Other Insights reports and briefings are available at https://drfoster.com/insights/.

Dr Foster provide an interactive dashboard on its website to provide information to help manage and predict the risk of COVID-19 for England. The respiratory and frailty data are from HES. The dashboard was initially published in April 2020 and is updated regularly at https://drfoster.com/2020/04/06/uk-covid-19-progression-dashboard.

Dr Foster are aware that publications, whether inside or outside the NHS, must adhere to strict guidelines in terms of disclosure, and ensure that any such publications are aggregated and comply with small number suppression in line with the HES Analysis Guide and other relevant legislation. Analyses for use in publications can be in the form of text, tables, or other data visualisations such as diagrams/graphs using aggregate data. Publications will also meet standards as defined in the Terms and Conditions of the Data Sharing Agreement.

All outputs will contain only data that is aggregated with small numbers suppressed in line with the HES Analysis Guide.

COVID-19 heatmaps (April 2020)

Dr Foster’s awareness raising publications have provided professionals and the public with insight into the progression of COVID-19. Their interactive dashboard, first released in April 2020, uses heatmaps to show the spread of the disease. It also shows historical perspectives within the past 10 years by using respiratory and frailty data from HES.

Frailty analysis for British Red Cross (May 2020)

Dr Foster’s frailty analysis has been used by the British Red Cross create a COVID-19 vulnerability index for the UK, mapping clinical vulnerability, economic vulnerability, social vulnerability and other health and wellbeing needs. This is helping the British Red Cross focus help on the most vulnerable people whose needs aren’t being met.

High Intensity User (HIU) report (January 2019)

Dr Foster continues to raise public and professional awareness. Its High Intensity User (HIU) report of January 2019 uncovered important characteristics of HIU patients and patterns in their attendances of A&E. It showed that the vast majority of HIUs are living in the most deprived areas of England, suggesting that the most vulnerable members of society may be more prone to high intensity use. Smoking, drugs and alcohol all appear to play an important role in frequent A&E use, in relation to the most common reasons that HIUs are admitted to hospital.

Dr Foster also measure benefits through customer feedback for their products and services.

Case study - North Cumbria University Hospitals NHS Trust (2016)

“We find Dr Foster’s combination of knowledgeable experts and powerful tools enormously helpful in our work to improve the quality of care we are providing to our patients. With Dr Foster’s help we’ve made significant progress in understanding quality and its drivers, and identifying how we can make sustainable improvements in our hospitals. Dr Foster’s insightful analysis, practical recommendations and ongoing support help us extract maximum value from our data, and their impact is far-reaching.”

Case study – Lancashire Teaching Hospitals NHS Trust (January 2015)

Dr Foster’s HIP is used on at least a weekly basis by the corporate and business intelligence teams and clinical staff to:

• inform and direct the Trust’s mortality and morbidity review processes

• scrutinise care standards and their impact on patient outcomes

• provide analysis and reassurance to the board, governors and the public

• monitor trends in readmissions and complications and investigate if these were justified clinically

Instigated several quality improvement initiatives including:

• Improved documentation of complexity in perinatal conditions that has:

o reduced mortality ratios

o increased income

o engaged clinicians in a wider quality initiative introducing an enhanced model of care for potentially vulnerable babies

• Development of an improvement programme for patients suffering from chronic obstructive pulmonary disease across the whole care pathway in the local health economy

Case study – University Hospital of South Manchester NHS Foundation Trust (January 2015)

The Trust specialises in cardiac surgery activity, for which it is a tertiary centre, and performs a high number of coronary artery bypass grafts (CABG) and heart valve replacements. Dr Foster’s Practice and Provider Monitor enabled benchmarking of productivity and efficiency measures, giving the user the ability to compare mean-price-per-spell at both procedure and diagnosis HRG level.

The Trust used the Dr Foster tool to look more deeply at other influences on the efficiency of the pathway compared with others and highlighted that the length-of-stay for these procedures was one of the longest of its peer group. This clearly has an impact on income as the amount earned per bed day is lower, and the capacity to put more patients through the system is reduced. From a patient’s point of view, this is also good news: a longer length-of-stay may increase risk.

UHSM then used Practice and Provider Monitor to move through the specialties to highlight areas of variance and focus on where they could improve productivity and efficiency across the Trust.

Case study - Imperial College Healthcare NHS Trust (October 2018)

Imperial College Healthcare NHS Trust has been a longstanding customer of Dr Foster with a dedicated Business Insight Manager based at the trust who has been delivering bespoke analytic support and expertise in clinical benchmarking. This dedicated, expert resource supports mortality monitoring, market share analysis and efficiency indicator benchmarking. Dr Foster data is now integrated into strategic planning and service redesign and has been used to explore growth opportunities for services previously provided by other trusts. As part of North West London’s Shaping a Healthier Future, Dr Foster’s analytic support has helped the trust in service redesign work, for example in integrating services previously provided by Ealing Hospital.

The Deputy Chief Information Officer, Imperial College Healthcare NHS Trust stated that, “National benchmarking is possible, but you have to do a lot of work with the data yourselves. With Dr Foster tools the data is easy to access and we can make sure we are keeping pace with other high-performing organisations. Having a Dr Foster analyst on site has been very successful. […] Dr Foster understands what our objectives are and is able to carry out complex analysis on our behalf. It is a fast track way of getting good benchmarking. For example, our performance framework has over 100 different metrics. The Dr Foster tools are useful looking across the Sustainability and Transformation Plan (STP) area to understand what is happening with indicators such as length of stay.”

Northampton General Hospital NHS Trust (February 2015)

“Clinicians and analysts use Healthcare Intelligence Portal (HIP) on a daily basis to analyse new patient safety alerts, high standardised mortality ratios and individual cases. Dr Foster investigate areas of concern in clinical coding and data analysis and look to improve future patient care through retrospective review and analysis.”

Northern Devon Healthcare NHS Trust (February 2015)

“Our data quality team use HIP to identify patients with missing or duplicate information and whether the problem is ongoing and needs a change in process to rectify it or whether it’s due to individual oversight.”

Wrightington, Wigan and Leigh NHS Foundation Trust (February 2015)

“We carried out a review of dermatological deaths and the data in HIP identified that the deaths were due to cellulitis. We reviewed treatment options based on this and identified where improvements could be made.”

The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust (February 2015)

“We use HIP to undertake many audits and reviews at any one time. For example, ten sets of case notes are reviewed each month by an emergency department consultant as part of our programme to improve performance on sepsis.”