CVDPREVENT Audit

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Data controllers: − NHS ENGLAND

Objective for processing

As part of the Government’s plan to transform the UK public health system (www.gov.uk/government/publications/transforming-the-public-health-system/transforming-the-public-health-system-reforming-the-public-health-system-for-the-challenges-of-our-times), Public Health England (PHE) was disestablished as of 1st October 2021 and its functions transferred to four receiver organisations. Health improvement functions transferred to the Office for Health Improvement & Disparities (OHID), a new directorate in the Department of Health and Social Care (DHSC). PURPOSES FOR PROCESSING The Office for Health Improvement and Disparities (OHID) is a newly formed department within DHSC and fulfils the statutory health improvement duties of the Secretary of State as set out in section 2B of the NHS Act 2006, as amended by section 12 of the Health and Social Care Act 2012. These functions were previously discharged by PHE and transferred to OHID on 1st October 2021, DHSC is now a direct provider of health improvement services to patients and the public in England, as set out in the PHE annual remit letter from the Parliamentary Under Secretary of State for Public Health and Primary Care. OHID is responsible for addressing health inequalities and improving access to health services and working with partners within and outside of government to respond to wider health determinants. 1. Supporting Department of Health and Social Care (DHSC) policy objectives DHSC has inherited a portion of the remits previously owned by PHE with functions under section 2B of the NHS Act moving into a newly formed Office for Health Improvement and Disparities (OHID) and UK Health Security Agency (UKHSA). The Office for Health Improvement and Disparities (OHID) has regularly used published Cardiovascular Disease Prevention (CVDPREVENT) Audit data to support DHSC policy objectives, such as in the regular DHSC CVD board reports. However, some questions require more detailed analysis which the published CVDPREVENT Audit is not appropriate for. Under this agreement, Department of Health and Social Care (DHSC) and NHS England are joint data controllers who also process the data. OHID is processing the data as part of DHSC. OHID has also carried out ad hoc analysis in specific cases to support new or existing policy areas, an example of this type of ad hoc analysis being: UKHSA are listed as data processors. The data is being hosted on UKHSA internal servers. Flexible analysis to support Health Mission The funding is provided by NHS England through a Memorandum of Understanding (MoU) to support the work done by OHID. The new CVD prevention health mission ambition is to reduce deaths from heart attack and stroke by 25 per cent over the next decade. The Health Mission team at DHSC has developed some supporting indicators (referred to as ‘sub-metrics’) to monitor progress against this ambition. CVDPREVENT Audit data will be required to enable the measurement of progress against these sub-metrics, but analysis of the data is likely to extend beyond the indicators produced routinely. Cardiovascular Disease Prevent (CVDPREVENT) is a national primary care audit commissioned by NHS England (NHSE) to support the NHS Long Term Plan and the GP contract. For example, it is currently proposed that a sub-metric on heart failure treatment will be included. This could be produced using the CVDPREVENT Audit dataset, however it is not anticipated that there will be scope to include a new indicator in the dataset in the short term. OHID could, however, support the development of a sub-metric on heart failure treatment through analysis of the data already collected as part of the CVDPREVENT Audit dataset. OHID could also make any indicator used for the Health Mission available for use in the CVDPREVENT Audit if desired. The NHS Long Term Plan has identified Cardiovascular (CVD) prevention as a national clinical priority, with the potential to prevent 150,000 strokes, heart attacks and cases of dementia over the next ten years by improving the detection and management of high blood pressure, high cholesterol, and atrial fibrillation. In addition, OHID also used the CVDPREVENT Audit dataset as an input source to support internal DHSC modelling of theoretical improvements in the health mission sub-metrics. One example included proportional splits between hypertension adult patients with existing CVD and those with only CVD risk factors, as well as the comorbidity between those with CVD who were prescribed lipid lowering therapy and also prescribed blood pressure lowering medication. Another example included estimating the proportion of recorded obesity in people aged 55 or older who had both hypertension and diabetes comorbidity. These are examples where the rapid analysis of potential impacts of interventions focused on these patient groups could be undertaken to support the health mission analysis requirements and response to ministers. Routine audit is the essential starting point for this ambition which will support professionally led quality improvement. Without up-to-date data, GPs, practices and networks will have no indication of the scale of the problem or the opportunity for improvement for patients and populations. Although GP Practices could do this themselves, by providing this data NHS England can remove the need for practices to set up and run the analysis themselves. The audit will systematically identify individuals whose high-risk conditions are sub-optimally managed, either through non-diagnosis, under treatment or over treatment. There is robust evidence that the National Institute for Health and Care Excellence (NICE) (CG181 https://www.nice.org.uk/guidance/cg181) recommended treatment of cardiovascular high-risk conditions is highly effective at preventing strokes and heart attacks. Equally, it is acknowledged that it is difficult to achieve optimal treatment in many individuals. For example, 44% of people with treated hypertension are not controlled to the blood pressure target of 140/90. This is partly because often, the six high-risk conditions (hypertension, familial hypercholesterolaemia and other hyperlipidaemias, chronic kidney disease (grades 3 to 5), non-diabetic hyperglycaemia, type 1 or type 2 diabetes mellitus or atrial fibrillation), have no symptoms to alert the patient or clinician, and partly because GP consultations are complex and time-pressured with multiple priorities to address. 2. Supporting NHS England policy requirements The audit has and will continue to help focus and optimise the programme locally and nationally. The audit and CVD Prevent audit dataset have allowed for, the first time, the provision of comprehensive locally specific and nationwide information related to CVD prevention and associated outcomes. This work has and will continue to help to highlight opportunities for broader professionally led quality improvement activity associated with the delivery of the NHS Long Term Plan. NHS England policy and analytical teams also work in close collaboration with OHID and request analysis to aid their policy development. For example: In summary, the extraction is needed because the data from the audit supports: Estimating average age of people newly diagnosed or receiving interventions • The monitoring and evaluation of national CVD prevention programme delivery The NHS England CVD analytical team is central to analysing and reviewing policy impacts for both the 10-Year Health Plan and the government’s health mission on CVD prevention, including the detection and management of people with CVD and CVD risk factors. The NHS England team asked OHID to help validate potential impacts of improving lipid control and management of hypertension by understanding the demographics of the primary care population with these conditions. • Local quality improvement activity NHS England asked OHID to calculate the average age of patients for the following three patient groups: • Measurement of the impact on population outcomes • Patients newly diagnosed with hypertension To deliver the audit, routinely recorded GP data about cardiovascular disease and the high-risk conditions that can cause cardiovascular disease, will be extracted by NHS England via General Practice Extraction Service (GPES). The audit data, is then linked to Civil Registrations of Deaths and HES Admitted Patient Care data before a pseudonymised file is returned to OHID. • Patients diagnosed with hypertension and treated to appropriate target New additional resources are being provided to help primary care prioritise CVD prevention activity including an expanded workforce of clinical pharmacists to implement new pathways to diagnosis and treatment (and reduce burden on general practice); a CVD prevention Primary Care Network (PCN) contract (Directed Enhanced Service ʹDES' - https://www.england.nhs.uk/primary-care/primary-care-networks/network-contract-des/) that specifically resources optimisation in the 3 high risk conditions; (AF, BP, Cholesterol) a CVD prevention Quality and Outcomes Framework (QOF) quality improvement module including the lowering of the QOF blood pressure target to 140/90. Outputs from the analysis of CVD Prevent audit data will provide data and information which will both support and show progress in CVD prevention, both nationally and locally. • Patients with no GP recorded CVD and a GP recorded QRISK score of >=10% and currently treated with LLT Data outputs from the audit will be available to all but will be targeted for use by health care economies including practices, primary care networks and Integrated Care Systems (ICS). Information is also generated to inform national policy and improvement work. Outputs show variation in diagnosis and treatment across areas, provide new information on the occurrence and co-existence of CVD morbidities and allow the impact of age, ethnicity and deprivation on CVD to be investigated. The adoption of the business rule set for CVDPREVENT at individual practice level facilitates detailed case finding and quality improvement work within practices. This was extracted using CVDPREVENT Audit data. COHORTS 3. Supporting National Institute for Health and Care Excellence (NICE) guidance and indicator development For the purposes of the CVD Prevent audit dataset, there are three cohorts: The CVDPREVENT Audit Partners (NHS England, OHID, the Healthcare Quality Improvement Partnership (HQIP) and HQIPs commissioned provider NHS Benchmarking Network) and the NICE Quality team regularly liaise to explore questions about potential new NICE guidance and the definition of the NICE indicators. An example of where OHID has used CVDPREVENT Audit data to assist the NICE Quality team’s work is set out below: Supporting the development of NICE recommended cholesterol treatment thresholds NICE updated their lipid modification guidelines (https://www.nice.org.uk/guidance/ng238) in December 2023 and consulted with OHID to provide exploration of current lipid management, specifically recorded lipid levels in the previous 12 months for the population with pre-existing CVD. OHID used the CVDPREVENT Audit data to provide the distribution of non-HDL cholesterol levels in the population of people with pre-existing CVD, which helped inform NICE’s decision-making. 4. Future linkage with an expanded NHS Health Check data collection (or incorporation into the CVDPREVENT Audit) The NHS Health Checks programme is overseen by the DHSC policy team. Currently there is information collected on the overall uptake of the programme but there is a longstanding issue with a lack of detailed data on health inequalities in uptake and onward outcomes. The recent National Audit Office report on CVD prevention (https://www.nao.org.uk/wp-content/uploads/2024/11/progress-in-preventing-cardiovascular-disease.pdf) has highlighted that there is a lack of data on who is taking up the programme and on programme outcomes. The CVDPREVENT Audit is potentially vital in understanding the impacts of the health check programme, as it contains detailed information on treatment in primary care and outcomes for patients, some of whom will have been identified with high-risk conditions via the health check. This has led to the Health and Social Care parliamentary committee (https://committees.parliament.uk/publications/46465/documents/235624/default) recommending that ‘a link between Health Checks and the useful data collected and available through the CVDPREVENT Audit could help greatly in this area.’ OHID is investigating how health check data may be extracted to meet DHSC’s needs and if possible linked to (or incorporated within) CVDPREVENT Audit data. The precise mechanism for doing this is still to be identified. However, if it were able to be done, OHID would like to be able to report on the follow-up, diagnosis and outcomes of people who have received the health check using CVDPREVENT Audit data. 5. Supporting wider research OHID has previously used the CVDPREVENT Audit data to provide further detail about levels of comorbidity in people with CVD and the effect of the COVID-19 pandemic on primary care CVD management. These findings have been reported in the first and second annual reports (https://www.cvdprevent.nhs.uk/outputs). In August 2024 a report on inequalities in cholesterol management was released using further analysis of CVDPREVENT Audit data undertaken by OHID. This outlined differences by sex in lipid lowering therapy prescribing and achievement in cholesterol treatment thresholds for people with CVD. The report was presented to the Chief Medical Officer who advised the team to draft an article for academic publication to complement the short report produced. OHID are keen to complete this work and have the agreement of NHS England. The University of Leicester has approached the audit partners with an interest in working jointly to produce an academic publication, and initial discussions on this took place in February 2025. DATA SUMMARY CVDPREVENT Audit data contains all patients currently registered in a GP practice prior to 31-March-2020 and then at quarterly intervals in line with the cohort details listed below. The subsequent quarterly extracts provide any newly diagnosed patients and any activity regarding measurements that have occurred within distinct time periods. For the purposes of the CVDPREVENT Audit dataset, there are three cohorts: [2 paragraphs unchanged] Cohort 3 -Patients - Patients registered in a GP practice without a coded diagnosis of any of [34 words unchanged] not dissented to their data being used for national audit or collections. [1 paragraph unchanged] People who have applied a Type 1 objection are not included in the collection as the purpose of the audit is classed as planning and research, not direct care. All GP Practices in England are legally required to share CVDPREVENT Audit data with NHS England under section 259(1)(a) and (5) of the 2012 Act. Patients who have applied a Type 1 objection are not included in the collection as the purpose of the audit is classed as planning and research, not direct care. National data opt outs are not applied when the data leaves NHS England as the flow of data to OHID is pseudonymised. The Office for Health Improvement and Disparities (OHID) is the analytical partner of CVDPREVENT and is the recipient of the data shared under this Agreement. OHID have decision-making responsibility for the purposes and means of the processing the data disseminated and therefore OHID is a joint data controller that will also process the data disseminated under the Agreement. CVDPREVENT Audit data has been linked with Hospital Episode Statistics (HES) and Civil Registrations of Deaths data in order to track the monitoring and evaluation of national programme delivery across the life course and care pathway, and to determine impact on outcomes and health inequalities. OHID has received HES admission data relating to heart attacks and strokes for patients within the CVDPREVENT Audit back to 2011. Date and cause of death for patients within the linked dataset have been provided for use in the Outcomes analysis to determine the impacts of cardiovascular disease on death. These death registration details have been provided and updated at each quarterly extract of data. NHSE is also a joint data controller as they have decision-making responsibility for the data disseminated under this Agreement. NHSE may process the shared CVD Prevent audit data for data quality purposes. There are ongoing discussions around the possibility of further linking the CVDPREVENT Audit data with prescribing data (subject to a future amendment to this data sharing agreement). NHS England are relying on Article 6(1)(e) and Article 9(2)(h) as the legal basis for processing of data. NHS England is an executive non-departmental public body of the Department of Health and Social Care. It oversees the budget, planning, delivery and day-to-day operation of the commissioning side of the NHS in England as set out in the Health and Social Care Act 2012 as such the work carried out by NHS England for the CVDPREVENT Audit is necessary for the performance of a task carried out in the public interest (Article 6(1)(e)) and is necessary for the purposes of preventive / occupational medicine, for the assessment of the working capacity of the employee, medical diagnosis, the provision of health or social care or treatment or the management of health or social care systems and services on the basis of Union or Member State law or pursuant to contract with a health professional (Article 9(2)(h)). DATA MINIMISATION The Office for Health Improvement and Disparities are relying on Article 6(1)(e) and Article 9(2)(i) as the legal basis for processing of data. All fields in the CVDPREVENT Audit dataset are required so that OHID can provide analytical support to the ongoing monitoring of the CVDPREVENT Audit programme. This would not be possible without the full amount of data. CVDPREVENT is a national audit, so national data is required in order to assess geographical trends and identify any geographical and demographic variation in CVD risk factors. The data are also required in order to support the policy work of both NHS England and DHSC, in particular our work in supporting the 10-Year Health Plan. The Office for Health Improvement and Disparities is a government unit within the Department of Health and Social Care in the United Kingdom that began operating on 1 October 2021. Its formation came as a result of the reorganisation of the health improvement functions of Public Health England which itself had been established in 2013. OHID is part of DHSCs focus on improving the nation’s health so that everyone can expect to live more of life in good health, and on levelling up health disparities to break the link between background and prospects for a healthy life. Therefore the work carried out by OHID for the CVDPREVENT Audit is necessary for the performance of a task carried out in the public interest (Article 6(1)(e)) and is necessary for reasons of public interest in the area of public health, on the basis of Union or Member State law which provides for suitable and specific measures to safeguard the rights and freedoms of the data subject, in particular professional secrecy (Article 9(2)(i)). Members of the Joint GP IT Committee (JGPITC) were consulted on the technical design of the extraction in December 2019/January 2020 as required under section 258 of the Health and Social Care Act 2012. The findings of the targeted stakeholder consultation have been reflected in the final data specification which has ensured data minimisation of the extraction. In relation to the linkage of CVDPREVENT Audit data with HES and Mortality data, a data minimisation exercise has been undertaken to ensure that the data shared for each patient is kept to a minimum. DATA CONTROLLERSHIP DHSC is the Data Controller which also processes the data disseminated. OHID is processing the data as part of DHSC. UKHSA is a data processor as the data is hosted on UKHSA servers. FUNDING Funding for the wider CVDPREVENT Audit is provided under a Memorandum of Understanding (MoU). OHID has access to the funding provided under the MoU as a partnership arrangement until such that time NHS England and DHSC integrate. LAWFUL BASIS FOR PROCESSING UNDER UK GENERAL DATA PROTECTION REGULATION (UK GDPR) OHID (as a government unit within DHSC) has the following lawful basis for processing the personal data shared under this DSA: • Article 6(1)(e) UK GDPR – performance of a task carried out in the public interest or in the exercise of official authority vested in the controller. OHID is a department within DHSC and fulfils the statutory health improvement duties of the Secretary of State as set out in section 2B of the NHS Act 2006, as amended by section 12 of the Health and Social Care Act 2012. These functions were previously discharged by Public Health England (PHE) and transferred to OHID on 1st October 2021. DHSC is now a direct provider of health improvement services to patients and the public in England, as set out in the PHE annual remit letter from the Parliamentary Under Secretary of State for Public Health and Primary Care. OHID is responsible for addressing health inequalities and improving access to health services and working with partners within and outside of government to respond to wider health determinants. OHID has the following lawful bases for processing special categories of personal data under this DSA: • Article 9(2)(h) UK GDPR – management of health or social care systems; and • Article 9(2)(i) UK GDPR – public interest in the area of public health OHID is part of DHSC’s focus on improving the nation’s health so that everyone can expect to live more of life in good health, and on levelling up health disparities to break the link between background and prospects for a healthy life.

Processing activities

All GP Practices in England are legally required to share data with NHS England for this purpose under section 259(1)(a) and (5) of the 2012 Act. DATA FLOW The legal basis for the transfer of data is given in the ‘Cardiovascular Disease Prevention Audit Directions 2020’ signed on 13th October 2020 please see -https://digital.nhs.uk/about-nhs-digital/corporate-information-and-documents/directions-and-data-provision-notices/nhs-england-directions/cardiovascular-disease-prevention-audit-directions-2020 GP system suppliers (GPSS) extract identifiable data from all participating general practices in England on a quarterly basis and transfer this data to NHS England via GPES. DATA FLOW: NHS England to OHID, in summary: Once the data is collected from GPSS, validation on the file structure and contents is carried out before files are accepted by NHS England’s GP Data Collector (GPDC) system. The data is then processed by the NHS England Data Management Service (DMS) to create a data asset. The processing involves loading the files from GPSS into a secure database and linking to corporate reference data to provide additional demographic information. CVD PREVENT Audit data contain all patients currently registered in a GP practice (people who have applied a Type 1 objection type are not included in the collection as the purpose of the audit is classed as planning and research, not direct care) prior to 31-March-2020 and then at quarterly intervals in line with the cohort details listed in Section 5a of the Data Sharing Agreement. NHS England shares pseudonymised CVDPREVENT Audit data with OHID via Message Exchange for Social Care and Health (MESH). The subsequent quarterly extracts provide any newly diagnosed patients and any activity regarding measurements that have occurred within distinct time periods. To create the linked CVDPREVENT Audit, HES and Civil Registrations of Deaths asset, further processing by NHS England is required: The patient list is linked to prescribing, secondary (HES APC) and death registration data. Data linkage is carried out on the secure NHS England Data Access Environment. A data minimisation exercise is then undertaken to ensure that the data shared for each patient is kept to a minimum. Two summary tables are created to allow for outcome and indicator measures derivation. 1. Create Patient Cohort Table: CVDPREVENT Audit data is processed and filtered to generate a table of eligible patients for data linkage. These are defined as all patients in Cohort 1 or Cohort 2 (Cohort 3 excluded) captured in any of the CVDPREVENT Audit data extracts. Patients with Type 1 opt-outs are not included in the collection and therefore their data will not be linked. This processing can be split into seven stages. 2. Link and pre-process raw data: the raw HES and Mortality data assets are pre-processed and filtered for the eligible patients and events. Journal records from CVDPREVENT Audit data are also processed and filtered for events. 1. Create Patient Cohort Table: CVD PREVENT audit data is processed and filtered to generate a table of eligible patients for data linkage. These are defined as all patients captured in any of the CVD PREVENT data extracts. Patients with Type 1 opt outs are not included in the collection and therefore will not be linked. 2. Link and Pre-process Raw Data: The raw other data assets are pre-processed filtered for the eligible patients and events. [2 paragraphs unchanged] 5. Pseudonymise Asset: Strip strip the events and patient table from patient identifiers, identifiers (i.e. full date of birth (YYYY-MM-DD) replaced with year of birth (YYYY) in patient table; date of birth field removed entirely from events table) using the same pseudonymisation process defined for the original CVD PREVENT CVDPREVENT Audit asset. This will allow NHS England to link the two tables to CVD PREVENT CVDPREVENT Audit data. 6. NHS England sends pseudonymised data to OHID via the Message Exchange for Social Care and Health API (MESH). NHS England then shares the pseudonymised, linked data with OHID via MESH. 7. Data will be stored by OHID either within a dedicated SQL Server Database hosted on UKHSA internal servers, or a dedicated network share both of which are UKHSA approved to store potentially identifiable data (although the data disseminated is pseudonymised). Access to these is strictly controlled and will only be accessed and processed by individuals approved by the core CVDPREVENT team in OHID. The data is only accessed by individuals within OHID who have authorisation from NHSE to access the data for the purpose(s) described, all of whom are substantive employees of OHID. CVDPREVENT Audit data will not be made available to any third parties except in the form of aggregated outputs with appropriate disclosure controls applied. Where aggregated outputs are dependent on HES data (i.e. HES data is used in their construction), small numbers will be disclosure controlled in line with the HES anonymisation standard (https://digital.nhs.uk/data-and-information/data-tools-and-services/data-services/hospital-episode-statistics/change-to-disclosure-control-methodology-for-hes-and-ecds-from-september-2018) OHID processes the record level data and creates defined indicators which are aggregated to different health geographies. It is this aggregated data which is shared with NHS Benchmarking Network. Where aggregated outputs are built in any part from HES or Civil Registrations (mortality) data, small numbers will be disclosure controlled in line with the HES anonymisation standard (https://digital.nhs.uk/data-and-information/data-tools-and-services/data-services/hospital-episode-statistics/change-to-disclosure-control-methodology-for-hes-and-ecds-from-september-2018). No record level data is shared with NHS Benchmarking Network, nor do they have any means to access record level CVDPREVENT Audit data. There has not been and will continue to be no requirement nor attempt to re-identify individuals from the data. DATA FLOW: OHID to NHS Benchmarking NHS Benchmarking has no data controllership responsibilities. Their role is to disseminate the aggregated indicators through a dashboard or report. They only receive data which is aggregated and had the appropriate disclosure method applied DATA SUMMARY A continued supply of CVD Prevent audit data on a quarterly basis is required for the duration of this agreement, or for the length of any subsequent agreements. All fields in the CVD Prevent audit dataset are required so that OHID can provide analytical support to the ongoing monitoring of the CVDPREVENT Audit programme. This would not be possible without the full amount of data. CVDPREVENT is a national audit, so national data is required in order to assess geographical trends and identify any geographical and demographic variation in CVD risk factors. Members of the Joint GP IT Committee (JGPITC) were consulted on the technical design of the extraction in December 2019/January 2020 as required under section 258 of the Health and Social Care Act 2012. The findings of the targeted stakeholder consultation have been reflected in the final data specification which has ensured data minimisation of the extraction. This Data Sharing Agreement, as aforementioned, is also being amended to cover the inclusion of a new linked CVD Prevent audit asset. The CVD Prevent audit data has been linked by NHSE with Hospital Episode Statistics data and Mortality data for the purposes of tracking, monitoring and evaluation of national programme delivery across the life course and care pathway. The enhanced data will also allow the audit partners to determine the impact on outcomes and health inequalities in both primary and secondary care. Linkage of CVD Prevent audit now held by NHS England is permitted under the Directions (Cardiovascular Disease Prevention Audit Directions 2020’ signed on 13th October 2020). There are ongoing discussions around the possibility of further linking the CVD Prevent audit data with prescribing data (subject to a future amendment to this agreement). The data from NHS England will not be used for any other purpose other than that outlined in this Agreement. Further linkage of the data may be sought but only after seeking the appropriate approvals needed to complete and access the linked data. [1 paragraph unchanged] The OHID analysts working on this project will access this unique copy of the data across the UKHSA network via SQL Server Management Studio. Analysts will, in effect, only be viewing the data which will physically remain within the Server environment. If data is required for use outside of the SQL Server environment staff will be given access to a secure area of the UKHSA network where it can be used by other software. Staff will not be permitted to save the record level data on any other part of the network. Access to the data will be granted only to analysts working on the audit and on an individual basis. The data is only accessed by individuals within OHID who have authorisation from NHS England to access the data for the purpose(s) described, all of whom are substantive employees of OHID. CVDPREVENT Audit data will not be made available to any third parties except in the form of aggregated outputs with appropriate disclosure controls applied. Where aggregated outputs are dependent on HES data (i.e. HES data is used in their construction), small numbers will be disclosure controlled in line with the HES anonymisation standard (https://digital.nhs.uk/data-and-information/data-tools-and-services/data-services/hospital-episode-statistics/change-to-disclosure-control-methodology-for-hes-and-ecds-from-september-2018). OHID analysts access the UKHSA network using organisation approved and supplied technology. Analysts log into UKHSA systems using a secure Azure Virtual Desktop connection (AVD). No data are exported from the AVD environment. The OHID analysts working on this project will access this unique copy of the data across the UKHSA network via SQL Server Management Studio. Analysts will, in effect, only be viewing the data which will physically remain within the Server environment. If data is required for use outside of the SQL Server environment staff will be given access to a secure area of the UKHSA network where it can be used by other software. Staff will not be permitted to save the record level data on any other part of the network. Access to the data will be granted only to analysts who require it for the purposes set out within this data sharing agreement and on an individual basis. OHID analysts access the UKHSA network using organisation approved and supplied technology. Analysts log into UKHSA systems using a secure Azure Virtual Desktop connection (AVD). No data is exported from the AVD environment. [2 paragraphs unchanged] The Controllers must confirm and provide evidence upon audit by NHS England that access via any remote device complies with the data security obligations within this DSA data sharing agreement and the Data Sharing Framework Contract. [1 paragraph unchanged] - Remote access will only be from secure locations situated within the territory of use (as further restricted elsewhere within the DSA if so done) stated within this DSA; data sharing agreement; [4 paragraphs unchanged] - All remote access is undertaken within the scope of the organisation’s DSPT (or other security arrangements as per this DSA) data sharing agreement) and complies with the organisation’s remote access policy. The above applies in addition to any condition set out elsewhere within the DSA data sharing agreement (e.g. who may carry out processing, and for what purpose). As stated, OHID currently relies on UKHSA infrastructure to undertake the processing and storing of CVDPREVENT Audit data. This is a legacy arrangement when from when OHID and UKHSA were a part of Public Health England. During the term of this agreement, OHID will assess alternative environments for their suitability, including the NHS England Unified Data Access Layer (UDAL) where CVDPREVENT Audit data is already stored. Any proposed changes to access will be subject to a further amendment to this data sharing agreement. [1 paragraph unchanged] The data will be used to create indicators which can be used to describe, measure and summarise measures of occurrence and treatment of CVD and the associated high-risk conditions. This information will be reported at different geographies and by different descriptors to show variation and identify opportunities for improvement in care and outcomes. Data will be published only in aggregate form with appropriate suppression to ensure that no individual can be identified in any output. Information will be released in different formats for different audiences and will include written reports, slide sets, dashboards and briefings/infographics. The nature of the analysis performed by OHID may include: 1. Calculating average age of newly diagnosed CVD patients 2. Calculating proportions of patients receiving interventions/medications split by age, sex, deprivation, geographical area 3. Calculating duration between diagnosis and treatment for newly diagnosed patients 4. Providing quality assurance support of new indicators as defined by NHS Arden and GEM CSU for inclusion in new rounds of the audit 5. Assessing completeness of component parts of QRISK3 score to assess treatment patterns of patients with a QRISK score greater than 10% 6. Undertaking counts of patients registered with certain CVD conditions and with a learning disability or mental health condition who are receiving appropriate treatment for that condition 7. Estimating the number of people eligible for an NHS Health Check by geographic region by counting the number of people with certain conditions in the CVDPREVENT Audit and subtracting these from either publicly available GP registered populations or Local Authority resident populations 8. Assessing the uptake of relevant medications in eligible populations. OHID may undertake multivariate analysis on the data to determine the effectiveness of treatments on certain CVD conditions. Multivariate analysis is anticipated to allow OHID to understand how factors such as patient demographics influence disease risk within differing populations. There has not been and will continue to be no requirement nor attempt to re-identify individuals from the data. [1 paragraph unchanged]

Expected output

OHID and NHS England's delivery partner - NHS Benchmarking will work together on joint publication/reports that are published and made publicly available. NHS Benchmarking will not access any record level data under this agreement. They will be assisting in the authoring of the report in an advisory capacity only and they will have no process in determining the means by which the data will be processed. OHID may produce the following outputs from continued processing of the data shared under this data sharing agreement: The first report was published in the summer 2021. This report provided the initial findings of the audit and focussed on national data. Information will also be released at lower geographies which will show variation between PCNs. The dashboard of data for lower geographies has been published (https://www.cvdprevent.nhs.uk/quality-improvement) and as the audit develops will present data at other NHS geographies e.g., practices; ICS; ICBs etc. - Analytical outputs to supports NICE’s work to develop potential new NICE guidance and the definition of NICE indicators. All outputs have been and will continue to be published as aggregated data with small numbers suppressed. The outputs will support clinicians to only identify the features of at-risk patients, not actual individual patients. Information will be released in different formats for different audiences and will include written reports, slide sets, dashboards and briefings/infographics. Specifically: - An analytical publication on inequalities in cholesterol management, which the Chief Medical Officer advised OHID to draft. - A National Report: A publicly available summary and detailed report of the findings from the data extraction - Analytical outputs to support DHSC and NHS England policy objectives. For example, in relation to the CVD prevention health mission ambition to reduce deaths from heart attack and stroke by 25 per cent over the next decade, OHID may use CVDPREVENT Audit data to develop a sub-metric on heart failure treatment. - An Interactive dashboard: including national and localised findings. Localised findings will be available at different healthcare geographies. - Depending on the scope for NHS Health Checks data to be extracted, or linked to CVDPREVENT Audit data, reporting on the follow-up, diagnosis and outcomes of people who have received an NHS Health Check using CVDPREVENT Audit data The National reports are published on an annual basis while the dashboard data improvement tool is refreshed and published on a quarterly basis in line with the receipt of data from NHS England. OHID and NHS Benchmarking work collaboratively on the two outputs. As aforementioned NHS Benchmarking operates in an advisory capacity only; they do not determine the purposes and means for the processing of the data. The report and interactive dashboard are made publicly available. The OHID analytical team will continue to work closely with the CVDPREVENT clinical lead and NHS Benchmarking to ensure data outputs have a suitable and sensitive narrative. Future analytical work will be guided by an expert reference group to ensure the audit supports system priorities. Outputs from the audit will be designed to inform a number of different audiences, including but not limited to: - Providers of primary care; - Commissioners of the CVD prevention services; - Policy makers in government and NHS England; - Charities, patients and the public; - UK and international researchers.

Expected measurable benefits

The audit will continue to provide information on a national and local level that has not previously been available. The extract will allow analysis of primary care data beyond that currently published as part of the Quality and Outcomes Framework enabling the reporting of familiar indicators but with greater detail which will be available to inform improvements in service delivery and to reduce inequalities. For example, the audit will be able to provide data and information around blood pressure and atrial fibrillation broken down by age group which will enable Primary Care Networks to be able to optimise care. Other novel analyses will include a review of the extent to which CVD related comorbidities occur within the population. Continued processing of CVDPREVENT Audit data by OHID is expected to benefit both DHSC and NHS England in the delivery of priorities, whilst simultaneously strengthening the evidence base around CVD prevention. Please see the sub-section titled ‘PURPOSES FOR PROCESSING’ within the section ‘Objective for processing’ for information pertaining to the purposes and benefits associated with the processing of the CVDPREVENT Audit data and linked CVDPREVENT Audit, HES and Mortality data shared under this data sharing agreement. Cohort 1 of the extract will specifically audit prevention of cardiovascular disease through the management of six high risk conditions in people who have not had previous cardiovascular events such as heart attack or stroke. Optimal preventive treatment in these conditions is defined in NICE guidance. It is recognised that significant numbers of patients are not treated to NICE recommended targets, and that there is significant geographical variation in treatment. The indicator will support clinicians to identify gaps and inequalities in treatment (including both over and under treatment) to inform professionally led quality improvement. This cohort will also identify people who may have one or more of the six high-risk conditions already but have another that has not been coded as diagnosed. It is not uncommon for patients to have an abnormality recorded (for example abnormal blood pressure, cholesterol, sugar, or kidney function) without appropriate clinical follow up (e.g., repeat measurement, further investigation). This may occur because patients may have no symptoms or do not make a follow up appointment with the information becoming hidden from view over time. This cohort will support clinicians to only identify the features of at-risk patients, not actual individual patients who require further assessment and who may have a further undiagnosed high-risk conditions. Cohort 2 of the extract will support audit prevention of subsequent cardiovascular events in people with pre-existing cardiovascular disease through clinical risk factor management. Optimal secondary preventive treatment in these patients is defined in NICE guidance. It is recognised that significant numbers of patients are not treated to NICE recommended targets, and that there is significant geographical variation in treatment. Some of these patients are also at risk of treatment related harm, particularly those with multi-morbidity or frailty. The indicator will support clinicians to identify gaps and inequalities in treatment (including both over and under treatment) to inform professionally led quality improvement. This cohort will also identify people who may have CVD already but have another of the six high risk conditions. It is not uncommon for patients to have an abnormality recorded (for example abnormal blood pressure, cholesterol, sugar or kidney function) without appropriate clinical follow up (e.g., repeat measurement, further investigation). This may occur because patients may have no symptoms or do not make a follow up appointment with the information becoming hidden from view over time. This data will support clinicians to identify the features of at-risk patients, not actual individual patients who require further assessment and who may have a further undiagnosed high-risk condition. A final cohort will support audit diagnosis of the high-risk conditions for CVD (as listed in cohort 1), identifying people who may have the high-risk conditions but have not been coded as diagnosed. It is not uncommon for patients to have an abnormality recorded (for example abnormal blood pressure, cholesterol, sugar, or kidney function) without appropriate clinical follow up (e.g., repeat measurement, further investigation). This may occur because patients may have no symptoms or do not make a follow up appointment with the information becoming hidden from view over time. This cohort will support clinicians to identify the features of at-risk patients, not actual individual patients who require further assessment and who may have an undiagnosed high-risk condition. In addition, it is acknowledged that CVD outcomes are the biggest component of mortality amendable to health care and addressing them is essential if the NHS is to become the best health system in the world. The development of CVDPREVENT would assist in delivering the current NHS strategic implementation priorities including: NHS Mandate: • Objective 1 – informing better commissioning, resulting in improvements in local and national CVD health outcomes and reductions in inequalities • Objective 2 – supporting the creation of a safe, high quality health and care service • Objective 4 – contributing to a step change in the NHS in preventing ill health and supporting people to live healthier lives by improving and lengthening lives, reducing health inequalities by implementing identified preventative interventions at scale in collaboration with health and care partners. Next Steps NHS Five Year Forward View: • Delivering the CVD prevention opportunities through identification and implementation of optimal value CVD interventions, improving detection and treatment of people with high risk conditions • Supporting the expanded multi-disciplinary primary care staff to focus on those patients of most need, supporting patients to manage their high-risk conditions • Getting best value out of medicines and pharmacy with a drive to improve uptake of NICE recommended medicines thereby generating downstream NHS savings. NHS Right Care CVD prevention pathway is also now being implemented across ICBs and STPs. A paper has been developed with strategic partners (NHS England, Public Health England (now DHSC) and the British Heart Foundation) to develop a world leading plan to reduce killer cardiovascular diseases, tackle inequalities and deliver a genuine shift on prevention. Discussions continue on embedding this vision within the developing NHS Long Term Plan. The CVDPREVENT audit will also specifically support the delivery of NICE guidelines and NICE Quality Standards. The additional linkage of CVDPREVENT audit data and HES along with ONS mortality will further allow the measurement of progress and the burden of disease of prevention measures in secondary care.

Benefits reported

The audit has provided information on a national and local level that has not previously been available - for example breakdowns of indicators by age, ethnicity, and gender. These newly published data of primary care data go beyond that currently published as part of the QOF enabling the reporting of familiar indicators but with greater detail which enables and informs improvements in service delivery and to reduce inequalities. In relation to OHID’s previous responsibilities within Workstream 2 of the CVDPREVENT Audit, the following outputs have been produced: While not all of the expected benefits described previously have occurred, it is hoped that these will be achieved during this version of the agreement. - The first report was published in the summer of 2021. This report provided the initial findings of the audit and focused on national data. Information has also been released at lower geographies to show variation between primary care networks (PCNs). The dashboard of data for lower geographies has been published (https://www.cvdprevent.nhs.uk/quality-improvement) and as the audit has developed data has been presented at other NHS geographies e.g., practices; ICS; ICBs etc. - A National Report: A publicly available summary and detailed report of the findings from the data extraction (published on annual basis) - An Interactive dashboard: including national and localised findings. Localised findings are available at different healthcare geographies (published on quarterly basis) The production of the national report and interactive dashboard was a collaborative effort by OHID and the NHS Benchmarking Network. The above outputs have informed a number of difference audiences, including but not limited to: - Providers of primary care; - Commissioners of the CVD prevention services; - Policy makers in government and NHS England; - Charities, patients and the public; - UK and international researchers. The audit has provided information on a national and local level that has not previously been available - for example breakdowns of indicators by age, ethnicity, and gender. These newly published data of primary care data go beyond that currently published as part of the Quality and Outcomes Framework (QOF) enabling the reporting of familiar indicators but with greater detail which enables and informs improvements in service delivery and to reduce inequalities.

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

Objective for processing

As part of the Government’s plan to transform the UK public health system (www.gov.uk/government/publications/transforming-the-public-health-system/transforming-the-public-health-system-reforming-the-public-health-system-for-the-challenges-of-our-times), Public Health England (PHE) was disestablished at the end as of September 1st October 2021 and its functions transferred to four receiver organisations. Health improvement functions [10 words unchanged] a new directorate in the Department of Health and Social Care (DHSC). The Office for Health Improvement and Disparities (OHID) is a newly formed [93 words unchanged] OHID is responsible for addressing health inequalities and improving access to health services, services and working with partners within and outside of government to respond to wider health determinants. [1 paragraph unchanged] Under this agreement, Department of Health and Social Care (DHSC) and NHS England are joint data controllers. controllers who also process the data. OHID is processing the data as part of DHSC. DHSC and UKHSA are listed as data processors. OHID is processing the data as part of DHSC. The data is being hosted on UKHSA internal servers. The funding is provided by NHS England through a Memorandum of Understanding (MoU) to support the work done by OHID. [1 paragraph unchanged] The NHS Long Term Plan has identified Cardiovascular (CVD) prevention as a [20 words unchanged] years by improving the detection and management of high blood pressure, high cholesterol cholesterol, and atrial fibrillation. Routine audit is the essential starting point for this ambition which will support professionally led quality improvement. Without up to date up-to-date data, GPs, practices and networks will have no indication of the scale [168 words unchanged] because GP consultations are complex and time-pressured with multiple priorities to address. [5 paragraphs unchanged] To deliver the audit, routinely recorded GP data about cardiovascular disease and [32 words unchanged] HES Admitted Patient Care data before a pseudonymised file is returned to the data processor. OHID. [4 paragraphs unchanged] Cohort 1 - Patients registered in a GP practice that have been diagnosed with at least one of the six high risk conditions (hypertension, familial hypercholesterolaemia and other hyperlipidaemias, chronic kidney disease (grades 3 to 5), non-diabetic hyperglycaemia, type 1 or 2 diabetes mellitus or atrial fibrillation) up to and including the end of the quarterly reporting period. period who have not dissented to their data being used for national audit or collections. Cohort 2 - Patients registered in a GP practice with cardiovascular disease diagnosed up to and including the end of the reporting period. period, who have not dissented to their data being used for national audit or collections Cohort 3 - Patients -Patients registered in a GP practice without a coded diagnosis of any of the 6 high-risk conditions (hypertension, familial hypercholesterolaemia and other hyperlipidaemias, chronic kidney disease (grades 3 to 5), non-diabetic hyperglycaemia, type 1 or type 2 diabetes mellitus or atrial fibrillation) or existing CVD, and who have entries in their record that suggest they may have an undiagnosed high-risk condition, up to and including the reporting period end date. date, who have not dissented to their data being used for national audit or collections. [1 paragraph unchanged] People who have applied a Type 1 national data opt out objection are not included in the collection as the purpose of the audit is classed as planning and research, not direct care. [2 paragraphs unchanged] NHSE is also a joint data controller as they have decision-making responsibility for the data disseminated under this Agreement. NHSE will not may process the shared CVD Prevent audit data. data for data quality purposes. [3 paragraphs unchanged]

Processing activities

[1 paragraph unchanged] The legal basis for the transfer of data is given in the ‘Cardiovascular Disease Prevention Audit Directions 2020’ signed on 13th October 2020 which includes 254(1) and (6), section 260(2)(d), section 260(4)(a), section 261(2)(e), section 262(5) and section 304(9), (10) and (12) of the Health and Social Care Act 20121 (the 2012 Act). For further details, please see - https://digital.nhs.uk/about-nhs-digital/corporate-information-and-documents/directions-and-data-provision-notices/data-provision-notices-dpns/cardiovascular-disease-prevention-audit. -https://digital.nhs.uk/about-nhs-digital/corporate-information-and-documents/directions-and-data-provision-notices/nhs-england-directions/cardiovascular-disease-prevention-audit-directions-2020 [1 paragraph unchanged] CVD PREVENT Audit data contain all patients currently registered in a GP practice (people who have applied a national data opt out Type 1 objection type are not included in the collection as the purpose of the audit [5 words unchanged] research, not direct care) prior to 31-March-2020 and then at quarterly intervals in line with the following: cohort details listed in Section 5a of the Data Sharing Agreement. • a diagnosis of cardiovascular disease • diagnosed with at least one of the six high risk conditions • patients without a coded diagnosis who have entries in their record that suggest they may have an undiagnosed condition. [2 paragraphs unchanged] This processing can be split into five seven stages. [6 paragraphs unchanged] 7. Data will be stored by OHID either within a dedicated SQL [14 words unchanged] which are UKHSA approved to store potentially identifiable data (although the data diesseminated disseminated is pseudonymised). [1 paragraph unchanged] The data are is only accessed by individuals within OHID who have authorisation from NHS England NHSE to access the data for the purpose(s) described, all of whom are substantive employees of the OHID. The CVDPREVENT Audit data will not be made available to any third parties except in the form of aggregated outputs with appropriate disclosure controls applied. Where aggregated outputs are dependent on HES data (i.e. HES data is used in their construction), small numbers suppressed will be disclosure controlled in line with the HES anonymisation standard (https://digital.nhs.uk/data-and-information/data-tools-and-services/data-services/hospital-episode-statistics/change-to-disclosure-control-methodology-for-hes-and-ecds-from-september-2018). (https://digital.nhs.uk/data-and-information/data-tools-and-services/data-services/hospital-episode-statistics/change-to-disclosure-control-methodology-for-hes-and-ecds-from-september-2018) OHID processes the record level data and creates defined indicators which are aggregated to different health geographies. It is this aggregated data which is shared with NHS Benchmarking Network. Where aggregated outputs are built in any part from HES or Civil Registrations (mortality) data, small numbers will be disclosure controlled in line with the HES anonymisation standard (https://digital.nhs.uk/data-and-information/data-tools-and-services/data-services/hospital-episode-statistics/change-to-disclosure-control-methodology-for-hes-and-ecds-from-september-2018). No record level data is shared with NHS Benchmarking Network, nor do they have any means to access record level CVDPREVENT Audit data. [2 paragraphs unchanged] (NHS NHS Benchmarking have has no data controllership responsibilities. Their role is to disseminate the aggregated indicators through a dashboard or report. They only receive data which is aggregated in line with and had the HES analysis guide). appropriate disclosure method applied OHID processes the record level data and creates defined indicators which are aggregated to different health geographies described earlier in this application. The data are subject to the HES anonymisation standard and no record level data are shared with NHS Benchmarking nor do they have any access to record level CVDPREVENT data. There has not been and will continue to be no requirement nor attempt to re-identify individuals from the data. The data from NHSE has not been and will not be used for any other purpose other than that outlined in this Agreement. Further linkage of the data may be sought but only after seeking the appropriate approvals needed to complete and access the linked data. [5 paragraphs unchanged] Linkage of CVD Prevent audit now held by NHS England is permitted under the Directions under sections 254(1) and (6), section 260(2)(d), section 260(4)(a), section 261(2)(e), section 262(5) and section 304(9), (10) and (12) of the Health and Social Care Act 2012 - https://digital.nhs.uk/about-nhs-digital/corporate-information-and-documents/directions-and-data-provision-notices/nhs-england-directions/cardiovascular-disease-prevention-audit-directions-2020. (Cardiovascular Disease Prevention Audit Directions 2020’ signed on 13th October 2020). [3 paragraphs unchanged] The named OHID analysts working on this project will access this unique copy of the [85 words unchanged] only to analysts working on the audit and on an individual basis. [2 paragraphs unchanged] The Data will be accessed by authorised personnel via remote access. The Controllers must confirm and provide evidence upon audit by NHS England that access via any remote device complies with the data security obligations within this DSA and the Data Sharing Framework Contract. For remote access: - Remote access will only be from secure locations situated within the territory of use (as further restricted elsewhere within the DSA if so done) stated within this DSA; - Access controls granting users the minimum level of access required are in place; - Remote access is only via secure connections (e.g., VPNs or secure protocols) to protect data; - Multifactor authentication (MFA) is required for remote access; - Device security, including up-to-date software and operating systems, antivirus software, and enabled firewalls are utilised for the remote access; - All remote access is undertaken within the scope of the organisation’s DSPT (or other security arrangements as per this DSA) and complies with the organisation’s remote access policy. The above applies in addition to any condition set out elsewhere within the DSA (e.g. who may carry out processing, and for what purpose). [1 paragraph unchanged] The data will be used to create indicators which can be used to describe, measure and summarise measures of occurrence and treatment of CVD and the associated high risk high-risk conditions. This information will be reported at different geographies and by different [43 words unchanged] different audiences and will include written reports, slide sets, dashboards and briefings/infographics. [1 paragraph unchanged]

Expected output

[1 paragraph unchanged] The first report was published in the summer 2021. This report provided [36 words unchanged] and as the audit develops will present data at other NHS geographies e.g. e.g., practices; ICS; ICBs etc. All outputs have been and will continue to be published as aggregated data with small numbers suppressed. The outputs will support clinicians to only identify the features of at risk at-risk patients, not actual individual patients. Information will be released in different formats for different audiences and will include written reports, slide sets, dashboards and briefings/infographics. Specifically: [2 paragraphs unchanged] The National reports are published on an annual basis while the dashboard data improvement tool is refreshed and published on a quarterly basis in line with the receipt of data from NHS England. [7 paragraphs unchanged]

Expected measurable benefits

[2 paragraphs unchanged] This cohort will also identify people who may have one or more [21 words unchanged] patients to have an abnormality recorded (for example abnormal blood pressure, cholesterol, sugar sugar, or kidney function) without appropriate clinical follow up (e.g. (e.g., repeat measurement, further investigation). This may occur because patients may have no [6 words unchanged] follow up appointment with the information becoming hidden from view over time. This cohort will support clinicians to only identify the features of at risk at-risk patients, not actual individual patients who require further assessment and who may have a further undiagnosed high-risk conditions. [1 paragraph unchanged] This cohort will also identify people who may have CVD already but [22 words unchanged] blood pressure, cholesterol, sugar or kidney function) without appropriate clinical follow up (e.g. (e.g., repeat measurement, further investigation). This may occur because patients may have no [16 words unchanged] over time. This data will support clinicians to identify the features of at risk at-risk patients, not actual individual patients who require further assessment and who may have a further undiagnosed high-risk condition. A final cohort will support audit diagnosis of the high-risk conditions for [26 words unchanged] patients to have an abnormality recorded (for example abnormal blood pressure, cholesterol, sugar sugar, or kidney function) without appropriate clinical follow up (e.g. (e.g., repeat measurement, further investigation). This may occur because patients may have no [16 words unchanged] over time. This cohort will support clinicians to identify the features of at risk at-risk patients, not actual individual patients who require further assessment and who may have an undiagnosed high-risk condition. [9 paragraphs unchanged] NHS RightCare Right Care CVD prevention pathway is also now being implemented across ICBs and STPs. [3 paragraphs unchanged]

Benefits reported

The audit has provided information on a national and local level that has not previously been available - for example breakdowns of indicators by age, ethnicity ethnicity, and gender. These newly published data of primary care data go beyond [18 words unchanged] which enables and informs improvements in service delivery and to reduce inequalities. [1 paragraph unchanged]

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

Data controllers: + DEPARTMENT OF HEALTH AND SOCIAL CARE · − PUBLIC HEALTH ENGLAND (PHE)

Datasets: + Civil Registrations of Death; + Hospital Episode Statistics Admitted Patient Care (HES APC)

Objective for processing

Cardio Vascular Disease Prevent (CVDPREVENT) is a new national primary care audit being commissioned by NHS England to support the NHS Long Term Plan and the GP contract. NHSE require an initial full-year extract of data and thereafter an extract on a quarterly basis to deliver the audit programme. Public Health England (PHE) are the analytical partner of CVDPRVENT and will be the recipients of the data shared under this agreement. PHE will be making decisions about how the data will be analysed and they are joint controllers who will process the data in the agreement. As part of the Government’s plan to transform the UK public health system (www.gov.uk/government/publications/transforming-the-public-health-system/transforming-the-public-health-system-reforming-the-public-health-system-for-the-challenges-of-our-times), Public Health England (PHE) was disestablished at the end of September 2021 and its functions transferred to four receiver organisations. Health improvement functions transferred to the Office for Health Improvement & Disparities (OHID), a new directorate in the Department of Health and Social Care (DHSC). The NHS Long Term Plan has identified CVD prevention as a national clinical priority, with the potential to prevent 150,000 strokes, heart attacks and cases of dementia over the next ten years by improving the detection and management of high blood pressure, high cholesterol and atrial fibrillation. The Office for Health Improvement and Disparities (OHID) is a newly formed department within DHSC and fulfils the statutory health improvement duties of the Secretary of State as set out in section 2B of the NHS Act 2006, as amended by section 12 of the Health and Social Care Act 2012. These functions were previously discharged by PHE and transferred to OHID on 1st October 2021, DHSC is now a direct provider of health improvement services to patients and the public in England, as set out in the PHE annual remit letter from the Parliamentary Under Secretary of State for Public Health and Primary Care. OHID is responsible for addressing health inequalities and improving access to health services, and working with partners within and outside of government to respond to wider health determinants. Routine audit is the essential starting point for this ambition. Without real time data, GPs, practices and networks will have no indication of the scale of the problem or the opportunity for improvement for patients and populations. Audit is the only way to systematically identify individuals whose high-risk conditions are sub-optimally managed, either through non-diagnosis, under treatment or over treatment. There is robust evidence that NICE recommended treatment of cardiovascular high-risk conditions is highly effective at preventing strokes and heart attacks. But equally it is acknowledged that it is difficult to achieve optimal treatment in many individuals. For example, 44% of people with treated hypertension are not controlled to 140/90. Partly this is because these high-risk conditions often have no symptoms to alert the patient or clinician, and partly because GP consultations are complex and time-pressured with multiple priorities to address. The audit will help to focus and optimise the programme locally and nationally. The new audit and dataset will, for the first time, allow the provision of comprehensive locally specific and nationwide information related to CVD prevention and associated outcomes. This will help to highlight opportunities for broader professionally led quality improvement activity associated with the delivery of the NHS Long Term Plan. DHSC has inherited a portion of the remits previously owned by PHE with functions under section 2B of the NHS Act moving into a newly formed Office for Health Improvement and Disparities (OHID) and UK Health Security Agency (UKHSA). In summary, the extraction is needed because the data from the audit will support: Under this agreement, Department of Health and Social Care (DHSC) and NHS England are joint data controllers. DHSC and UKHSA are listed as data processors. OHID is processing the data as part of DHSC. The data is being hosted on UKHSA internal servers. Cardiovascular Disease Prevent (CVDPREVENT) is a national primary care audit commissioned by NHS England (NHSE) to support the NHS Long Term Plan and the GP contract. The NHS Long Term Plan has identified Cardiovascular (CVD) prevention as a national clinical priority, with the potential to prevent 150,000 strokes, heart attacks and cases of dementia over the next ten years by improving the detection and management of high blood pressure, high cholesterol and atrial fibrillation. Routine audit is the essential starting point for this ambition which will support professionally led quality improvement. Without up to date data, GPs, practices and networks will have no indication of the scale of the problem or the opportunity for improvement for patients and populations. Although GP Practices could do this themselves, by providing this data NHS England can remove the need for practices to set up and run the analysis themselves. The audit will systematically identify individuals whose high-risk conditions are sub-optimally managed, either through non-diagnosis, under treatment or over treatment. There is robust evidence that the National Institute for Health and Care Excellence (NICE) (CG181 https://www.nice.org.uk/guidance/cg181) recommended treatment of cardiovascular high-risk conditions is highly effective at preventing strokes and heart attacks. Equally, it is acknowledged that it is difficult to achieve optimal treatment in many individuals. For example, 44% of people with treated hypertension are not controlled to the blood pressure target of 140/90. This is partly because often, the six high-risk conditions (hypertension, familial hypercholesterolaemia and other hyperlipidaemias, chronic kidney disease (grades 3 to 5), non-diabetic hyperglycaemia, type 1 or type 2 diabetes mellitus or atrial fibrillation), have no symptoms to alert the patient or clinician, and partly because GP consultations are complex and time-pressured with multiple priorities to address. The audit has and will continue to help focus and optimise the programme locally and nationally. The audit and CVD Prevent audit dataset have allowed for, the first time, the provision of comprehensive locally specific and nationwide information related to CVD prevention and associated outcomes. This work has and will continue to help to highlight opportunities for broader professionally led quality improvement activity associated with the delivery of the NHS Long Term Plan. In summary, the extraction is needed because the data from the audit supports: [3 paragraphs unchanged] The aim of the audit is to support professionally led quality improvement, optimising diagnosis and treatment in these conditions to prevent heart attacks and strokes at scale. The audit will help clinicians to understand how well they are performing in the diagnosis and management of 6 high risk conditions for CVD. To deliver the audit, routinely recorded GP data about cardiovascular disease and the high-risk conditions that can cause cardiovascular disease, will be extracted by NHS Digital England via General Practice Extraction Service (GPES). The audit data, is then linked to Civil Registrations of Deaths and HES Admitted Patient Care data before a pseudonymised file is returned to the data processor. New additional resources are being provided to help primary care prioritise CVD [22 words unchanged] practice); a CVD prevention Primary Care Network (PCN) contract (Directed Enhanced Service ʹDES ʹscheduled April 2021) ʹDES' - https://www.england.nhs.uk/primary-care/primary-care-networks/network-contract-des/) that will specifically resource resources optimisation in the 3 high risk conditions; (AF, BP, Cholesterol) a CVD prevention QOF Quality and Outcomes Framework (QOF) quality improvement module including the lowering of the Quality Outcome Framework (QOF) QOF blood pressure target to 140/90. Outputs from the analysis of CVDPREVENT CVD Prevent audit data will provide data and information which will both support and show progress in CVD prevention, both nationally and locally. Data outputs from the audit will be available to all but will be targeted for use by health care economies including practices, primary care networks and Clinical Commissioning Groups (CCGs). Integrated Care Systems (ICS). Information will is also be generated to inform national policy and improvement work. Outputs will show variation in diagnosis and treatment across areas, provide new information on [22 words unchanged] adoption of the business rule set for CVDPREVENT at individual practice level will facilitate facilitates detailed case finding and quality improvement work within practices. NHS England and Public Health England are joint data controller under NIC-395236 for the CVDPREVENT Audit. Public Health England are sole data processor. COHORTS For the purposes of the CVD Prevent audit dataset, there are three cohorts: Cohort 1 - Patients registered in a GP practice that have been diagnosed with at least one of the six high risk conditions up to and including the end of the quarterly reporting period. Cohort 2 - Patients registered in GP practice with cardiovascular disease diagnosed up to and including the end of the reporting period. Cohort 3 - Patients registered in GP practice without a coded diagnosis of any of the 6 high-risk conditions (hypertension, familial hypercholesterolaemia and other hyperlipidaemias, chronic kidney disease (grades 3 to 5), non-diabetic hyperglycaemia, type 1 or type 2 diabetes mellitus or atrial fibrillation) or existing CVD, and who have entries in their record that suggest they may have an undiagnosed high-risk condition, up to and including the reporting period end date. A patient will only be selected in to one of these 3 cohorts and only counted once within the cohort. People who have applied a Type 1 national data opt out are not included in the collection as the purpose of the audit is classed as planning and research, not direct care. National data opt outs are not applied when the data leaves NHS England as the flow of data to OHID is pseudonymised. The Office for Health Improvement and Disparities (OHID) is the analytical partner of CVDPREVENT and is the recipient of the data shared under this Agreement. OHID have decision-making responsibility for the purposes and means of the processing the data disseminated and therefore OHID is a joint data controller that will also process the data disseminated under the Agreement. NHSE is also a joint data controller as they have decision-making responsibility for the data disseminated under this Agreement. NHSE will not process the shared CVD Prevent audit data. [1 paragraph unchanged] Public Health England are relying on Article 6(1)(e) and Article 9(2)(i) as the legal basis for processing of data. Public Health England is an executive agency of the Department of Health and Social Care in the United Kingdom that began operating on 1 April 2013. Its formation came as a result of the reorganisation of the National Health Service in England outlined in the Health and Social Care Act 2012. Public Health England exist to protect and improve the nation's health and wellbeing, and reduce health inequalities as such the work carried out by Public Health England for the CVDPREVENT Audit is necessary for the performance of a task carried out in the public interest (Article 6(1)(e)) and is necessary for reasons of public interest in the area of public health, such as protecting against serious cross-border threats to health or ensuring high standards of quality and safety of health care and of medicinal products or medical devices, on the basis of Union or Member State law which provides for suitable and specific measures to safeguard the rights and freedoms of the data subject, in particular professional secrecy (Article 9(2)(i)). The Office for Health Improvement and Disparities are relying on Article 6(1)(e) and Article 9(2)(i) as the legal basis for processing of data. The Office for Health Improvement and Disparities is a government unit within the Department of Health and Social Care in the United Kingdom that began operating on 1 October 2021. Its formation came as a result of the reorganisation of the health improvement functions of Public Health England which itself had been established in 2013. OHID is part of DHSCs focus on improving the nation’s health so that everyone can expect to live more of life in good health, and on levelling up health disparities to break the link between background and prospects for a healthy life. Therefore the work carried out by OHID for the CVDPREVENT Audit is necessary for the performance of a task carried out in the public interest (Article 6(1)(e)) and is necessary for reasons of public interest in the area of public health, on the basis of Union or Member State law which provides for suitable and specific measures to safeguard the rights and freedoms of the data subject, in particular professional secrecy (Article 9(2)(i)).

Processing activities

NHS Digital has been directed by NHS England under section 254 of the Health and Social Care Act 2012 (2012 Act) to establish and operate a system for the collection and analysis of the information specified for this service. All GP Practices in England are legally required to share data with NHS England for this purpose under section 259(1)(a) and (5) of the 2012 Act. All GP Practices in England are legally required to share data with NHS Digital for this purpose under section 259(1)(a) and (5) of the 2012 Act. [1 paragraph unchanged] DATA FLOW: NHS Digital England to PHE, OHID, in summary: a) NHS Digital will send psuedonymised data to PHE via Secure Electronic File Transfer (SEFT) or a similar secure mechanism of sharing data. CVD PREVENT Audit data contain all patients currently registered in a GP practice (people who have applied a national data opt out are not included in the collection as the purpose of the audit is classed as planning and research, not direct care) prior to 31-March-2020 and then at quarterly intervals with the following: b) Data will be stored by PHE either within a dedicated SQL Server 2017 Database hosted on PHE internal servers, or a dedicated network share both of which are PHE approved to store PID. Access to these is strictly controlled. • a diagnosis of cardiovascular disease Data will only be accessed by individuals within PHE who have authorisation from NHS Digital to access the data for the purpose(s) described, all of whom are substantive employees of PHE. The data will not be made available to any third parties except in the form of aggregated outputs with small numbers suppressed in line with the HES Analysis Guide. • diagnosed with at least one of the six high risk conditions There will be no requirement nor attempt to re-identify individuals from the data. • patients without a coded diagnosis who have entries in their record that suggest they may have an undiagnosed condition. Data Requirement The subsequent quarterly extracts provide any newly diagnosed patients and any activity regarding measurements that have occurred within distinct time periods. All fields in the dataset are required so that PHE can provide analytical support to the ongoing monitoring of the CVDPREVENT Audit programme. This would not be possible without the full amount of data. CVDPREVENT is a national audit, so national data is required in order to assess geographical trends and identify any geographical and demographic variation in CVD risk factors. The patient list is linked to prescribing, secondary (HES APC) and death registration data. Data linkage is carried out on the secure NHS England Data Access Environment. A data minimisation exercise is then undertaken to ensure that the data shared for each patient is kept to a minimum. Two summary tables are created to allow for outcome and indicator measures derivation. The business rule set has been developed by (and in partnership with) a wide range of national and clinical partners including primary care clinicians. It is based on an initial feasibility study carried out by PRIMIS at The University of Nottingham in June 2018 and has been kept under review by the CVDPREVENT Implementation Steering Group to ensure that only the necessary data is extracted. This processing can be split into five stages. The extract includes three clearly defined cohorts of patients: those with one or more of the high-risk conditions for CVD, those with pre-existing CVD and those with clinical records that flag the possibility of an undiagnosed high-risk condition. 1. Create Patient Cohort Table: CVD PREVENT audit data is processed and filtered to generate a table of eligible patients for data linkage. These are defined as all patients captured in any of the CVD PREVENT data extracts. Patients with Type 1 opt outs are not included in the collection and therefore will not be linked. Members of the Joint GP IT Committee (JGPITC) were consulted on the technical design of the extraction in December 19/January 20. The findings of the targeted stakeholder consultation have been reflected in the final data specification which has ensured data minimisation of the extraction. 2. Link and Pre-process Raw Data: The raw other data assets are pre-processed filtered for the eligible patients and events. The data from NHS Digital will not be used for any other purpose other than that outlined in this Agreement. Further linkage of the data may be sought but only after seeking the appropriate approvals needed to complete and access the linked data. 3. Create Events Table: Pre-processed data tables are loaded and processed into a row-per-event table keeping only a reduced number of relevant fields as requested in the data specification document. 4. Create Patient Table: Events from the events table are combined and processed into a single row-per-patient table. Patients are unique and this table will be used to define their definitive underlying demographic information. Additional information is also added to the patient table including diagnostic flags and cohort membership. 5. Pseudonymise Asset: Strip the events and patient table from patient identifiers, using the same pseudonymisation process defined for the original CVD PREVENT asset. This will allow NHS England to link the two tables to CVD PREVENT data. 6. NHS England sends pseudonymised data to OHID via the Message Exchange for Social Care and Health API (MESH). 7. Data will be stored by OHID either within a dedicated SQL Server Database hosted on UKHSA internal servers, or a dedicated network share both of which are UKHSA approved to store potentially identifiable data (although the data diesseminated is pseudonymised). Access to these is strictly controlled and will only be accessed and processed by individuals approved by the core CVDPREVENT team in OHID. The data are only accessed by individuals within OHID who have authorisation from NHS England to access the data for the purpose(s) described, all of whom are substantive employees of the OHID. The data will not be made available to any third parties except in the form of aggregated outputs with small numbers suppressed in line with the HES anonymisation standard (https://digital.nhs.uk/data-and-information/data-tools-and-services/data-services/hospital-episode-statistics/change-to-disclosure-control-methodology-for-hes-and-ecds-from-september-2018). There has not been and will continue to be no requirement nor attempt to re-identify individuals from the data. DATA FLOW: OHID to NHS Benchmarking (NHS Benchmarking have no data controllership responsibilities. Their role is to disseminate the aggregated indicators through a dashboard or report. They only receive data which is aggregated in line with the HES analysis guide). OHID processes the record level data and creates defined indicators which are aggregated to different health geographies described earlier in this application. The data are subject to the HES anonymisation standard and no record level data are shared with NHS Benchmarking nor do they have any access to record level CVDPREVENT data. There has not been and will continue to be no requirement nor attempt to re-identify individuals from the data. The data from NHSE has not been and will not be used for any other purpose other than that outlined in this Agreement. Further linkage of the data may be sought but only after seeking the appropriate approvals needed to complete and access the linked data. DATA SUMMARY A continued supply of CVD Prevent audit data on a quarterly basis is required for the duration of this agreement, or for the length of any subsequent agreements. All fields in the CVD Prevent audit dataset are required so that OHID can provide analytical support to the ongoing monitoring of the CVDPREVENT Audit programme. This would not be possible without the full amount of data. CVDPREVENT is a national audit, so national data is required in order to assess geographical trends and identify any geographical and demographic variation in CVD risk factors. Members of the Joint GP IT Committee (JGPITC) were consulted on the technical design of the extraction in December 2019/January 2020 as required under section 258 of the Health and Social Care Act 2012. The findings of the targeted stakeholder consultation have been reflected in the final data specification which has ensured data minimisation of the extraction. This Data Sharing Agreement, as aforementioned, is also being amended to cover the inclusion of a new linked CVD Prevent audit asset. The CVD Prevent audit data has been linked by NHSE with Hospital Episode Statistics data and Mortality data for the purposes of tracking, monitoring and evaluation of national programme delivery across the life course and care pathway. The enhanced data will also allow the audit partners to determine the impact on outcomes and health inequalities in both primary and secondary care. Linkage of CVD Prevent audit now held by NHS England is permitted under the Directions under sections 254(1) and (6), section 260(2)(d), section 260(4)(a), section 261(2)(e), section 262(5) and section 304(9), (10) and (12) of the Health and Social Care Act 2012 - https://digital.nhs.uk/about-nhs-digital/corporate-information-and-documents/directions-and-data-provision-notices/nhs-england-directions/cardiovascular-disease-prevention-audit-directions-2020. There are ongoing discussions around the possibility of further linking the CVD Prevent audit data with prescribing data (subject to a future amendment to this agreement). The data from NHS England will not be used for any other purpose other than that outlined in this Agreement. Further linkage of the data may be sought but only after seeking the appropriate approvals needed to complete and access the linked data. [1 paragraph unchanged] There will be only one physical copy of the data, stored on one of the two servers at the storage locations detailed. The named analysts working on this project will access this unique copy of the data across the UKHSA network via SQL Server Management Studio. Analysts will, in effect, only be viewing the data which will physically remain within the Server environment. If data is required for use outside of the SQL Server environment staff will be given access to a secure area of the UKHSA network where it can be used by other software. Staff will not be permitted to save the record level data on any other part of the network. Access to the data will be granted only to analysts working on the audit and on an individual basis. The named analysts working on this project will access this unique copy of the data across the PHE network via SQL Server Management Studio. They will, in effect, only be viewing the data which will physically remain within the Server environment. If data is required for use outside of the SQL Server environment staff will be given access to a secure area of the PHE network where it can be used by other software (e.g. R or Stata). This secure area of the PHE network will also be located on the Porton or Colindale Servers. Staff will not be permitted to save the record level data on any other part of the network. Access to the data will be granted only to analysts working on the audit and on an individual basis. The data will only be accessed from within PHE offices or private residences that conform to PHE's homeworking policy and by connecting directly to the PHE network using PHE authorised equipment. OHID analysts access the UKHSA network using organisation approved and supplied technology. Analysts log into UKHSA systems using a secure Azure Virtual Desktop connection (AVD). No data are exported from the AVD environment. The data will only be accessed from within OHID/UKHSA offices or private residences that conform to OHID's homeworking policy and by connecting directly to the UKHSA network using OHID authorised equipment. [2 paragraphs unchanged] Public Health England are OHID is requesting data pertaining to the three cohorts only. Public Health England OHID will not process any data items it does not need and any extraneous data items/information that may be provided will be appropriately destroyed on landing. All organisations party to this agreement must comply with the data sharing framework contract requirements, including those regarding the use (and purposes of that use) by “personnel” (as defined within the data sharing framework contract i.e. employees, agents and contractors of the data recipient who may have access to that data). There will be no attempts made to re-identify individuals involved in this project as there is no requirement to do so.

Expected output

PHE OHID and NHS England's delivery partner organisation - NHS Benchmarking will work together on a joint publication/report publication/reports that will be are published and made publicly available. The delivery partner organisation NHS Benchmarking will not access any record level data under this agreement. They will be assisting in the authoring of the report in an advisory capacity only and they will have no process in determining the means by which the data will be processed. The first report will be was published in the summer 2021. This report will provide provided the initial findings of the audit and will focus focussed on national data. Information will also be released at lower geographies which will show variation between PCNs. The format dashboard of data for this lower geographies has yet to be finalised but will ultimately form a dashboard been published (https://www.cvdprevent.nhs.uk/quality-improvement) and as the audit develops and will present data at other NHS geographies eg e.g. practices; ICS; CCGs ICBs etc. All outputs will be anonymous have been and will not report on individual patients and no output will contain any personal identifiable continue to be published as aggregated data the with small numbers suppressed. The outputs will support clinicians to only identify the features of at risk patients, not actual individual patients. . Data will be published only in aggregate form with appropriate suppression to ensure that no individual can be identified in any output. Information will be released in different formats for different audiences and will include written reports, slide sets, dashboards and briefings/infographics. Specifically: [2 paragraphs unchanged] It is intended that PHE OHID and the audit partner will NHS Benchmarking work collaboratively on the two proposed outputs. As aforementioned NHS Benchmarking operates in an advisory capacity only; they do not determine the purposes and means for the processing of the data. The report and interactive dashboard will be are made publicly available. The PHE OHID analytical team will continue to work closely with the CVDPREVENT clinical lead and the incoming audit partner NHS Benchmarking to ensure data outputs have a suitable and sensitive narrative. Future analytical work will be guided by an expert reference group to ensure the audit supports system priorities. [6 paragraphs unchanged] In the future CVDPREVENT may wish to link the primary care general practice data with secondary care Hospital Episode Statistics (HES) data and/or mortality data, in order to track the monitoring and evaluation of national programme delivery across the life course and care pathway, and to determine impact on outcomes and health inequalities. This will be subject to approval by NHS Digital and an amendment to this agreement.

Expected measurable benefits

The audit will continue to provide information on a national and local level that has not previously [89 words unchanged] of the extent to which CVD related comorbidities occur within the population. [2 paragraphs unchanged] This cohort will support clinicians to identify patients who require further assessment and who may have a further undiagnosed high-risk condition however the outputs will support clinicians to only identify the features of at risk patients, not actual individual patients. patients who require further assessment and who may have a further undiagnosed high-risk conditions. Cohort 2 of the extract will support audit prevention of subsequent cardiovascular events in people with pre-existing cardiovascular disease [71 words unchanged] (including both over and under treatment) to inform professionally led quality improvement. This cohort will also identify people who may have CVD already but [60 words unchanged] hidden from view over time. This data will support clinicians to identify the features of at risk patients, not actual individual patients who require further assessment and who may have a further undiagnosed high-risk condition. A final cohort will support audit diagnosis of the high-risk conditions for CVD (as listed in cohort [68 words unchanged] hidden from view over time. This cohort will support clinicians to identify the features of at risk patients, not actual individual patients who require further assessment and who may have an undiagnosed high-risk condition. [4 paragraphs unchanged] • Objective 4 – contributing to a step change in the NHS [20 words unchanged] implementing identified preventative interventions at scale in collaboration with health and care partners partners. [4 paragraphs unchanged] NHS RightCare CVD prevention pathway is also now being implemented across CCGs ICBs and STPs. A paper has been developed with strategic partners (NHS England, Public Health England (now DHSC) and the British Heart Foundation) to develop a world leading plan to [14 words unchanged] continue on embedding this vision within the developing NHS Long Term Plan. [1 paragraph unchanged] The additional linkage of CVDPREVENT audit data and HES along with ONS mortality will further allow the measurement of progress and the burden of disease of prevention measures in secondary care.

Benefits reported

Yielded Benefits is not a requirement for new applications. The audit has provided information on a national and local level that has not previously been available - for example breakdowns of indicators by age, ethnicity and gender. These newly published data of primary care data go beyond that currently published as part of the QOF enabling the reporting of familiar indicators but with greater detail which enables and informs improvements in service delivery and to reduce inequalities. While not all of the expected benefits described previously have occurred, it is hoped that these will be achieved during this version of the agreement.