SkillMix-ED Study (Phase Two)

Kingston University London requires access to NHS England data for the purpose of the following research project: SkillMix-ED Study (Phase Two)

The following is a summary of the aims of the research project provided by Kingston University:

“The purpose of the project under this Data Sharing Agreement is to explore how non-medical practitioners, as part of the clinical workforce, are being deployed and the impact of different skill-mix including non-medical practitioners in emergency departments and urgent treatment centres on patient experience, quality of care, clinical outcomes, activity, staff experience and costs in acute NHS trusts in England, in order to inform workforce decisions of clinicians, managers and commissioners. The data requested are required to provide patient-level clinical outcomes, activity, and cost. The requested data provide national data on patient processes and outcomes of their emergency department (ED) or urgent treatment centres (UTC) attendance. These individual-level data are required to construct a NHS trust-level description of the patient group, to which publicly-available variables may be added and outcomes at trust-level be considered, month-by-month over a five-year period. This analysis will allow Kingston University to have statistical power and to be able to generalise from results.

“National data are requested in order to provide a comprehensive picture of the impact of different skill-mixes including non-medical practitioners in England.

The data are required to answer the following research question considered to be of national importance:

What is the impact of different non-medical practitioner skill-mix in EDs and UTCs in NHS acute hospitals on patient and service processes and outcomes?

The request is made for a standalone research project, which is not currently part of any project, collaboration, associated work or follow up.

The Primary outcome will be the rate of unplanned return to the ED within 7-days; a proxy for clinical safety.

The secondary outcomes are the five nationally collected indicators of ED/UTC health system quality

- Left department before being seen for treatment rate

- Time to initial assessment

- Time to treatment

- Total time in A&E

- Onward referral /treatment complete time

Patient-level data will allow Kingston University to create organisation-level descriptions of patient demographics, as well as episode, clinical, injury and referral/discharge information, enabling the measurement of outcomes with knowledge of the patient case-mix."

Analyses will be adjusted based on ethnicity, age and gender to ensure the analysis is representative.

The following NHS England data will be accessed:

• Emergency Care Data Set (ECDS)

• Hospital Episode Statistics Accident & Emergency (HES A&E)

These datasets are both necessary because the research question on the impact of skill-mix on patient outcomes requires access to patient-level episode data. HES A&E provide these data in the early years of data period (2017-2019) and ECDS from 2019-2023. ECDS 2019-2020 is necessary for Kingston University to collect for descriptive analysis of pseudonymised patient records to understand whether that year differs in patient attendance type, volume, or outcomes (other than the primary outcome of reattendance as patients cannot be linked).

The level of the data will be:

• Pseudonymised

The data will be minimised as follows:

• Limited to all patients with a recorded attendance episode at an emergency department or urgent treatment centre

• Limited to data from March 2017 to the latest data available.

Kingston University is the research sponsor and the controller as the organisation responsible for ensuring that the data will only be processed for the purpose described above.

Microsoft Limited are a processors acting under the instructions of Kingston University. Microsoft Limited's role is vendor agnostic and Kingston University will use the most appropriate vendor for the processing needed.

Computer Systems Integration (CSI) Limited, under the instruction of Kingston University, provide a managed service for Kingston University’s backup environments - this involves monitoring backups, maintaining the system, performing restores and running disaster recovery scenarios. As CSI have the ability to have sight of the data, CSI are therefore listed as a processor.

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

Article 6(1)(e) - processing is necessary for the performance of a task carried out in the public interest or in the exercise of official authority vested in the controller; the research is funded by the National Institute of Health and Social Care Research to inform health services.

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

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

This processing is in the public interest because it adheres to the UK Policy Framework for Health and Social Care Research and aims to explore how non-medical practitioners are being deployed and the impact of different skill-mix including non-medical practitioners in emergency departments and urgent treatment centres on patient experience, quality of care, clinical outcomes, activity, staff experience and costs in acute NHS trusts in England, in order to inform workforce decisions of clinicians, managers and commissioners.

The funding is provided by National Institute for Health Research (NIHR). The funding is specifically for the study described.

Kingston University is the sole organisation who will access the the data. No other organisation will process the data

Research co-applicants include members of the following other organisations: Royal Holloway University of London; University of Surrey; St George’s University Hospitals NHS Trust and Surrey and Sussex NHS Healthcare Trust. The co-applicants provide expert advice and guidance to the core research team at Kingston University, via bi-monthly study management meetings, and expert input (e.g., sociological, clinical and health economic) to the planning of the conduct of the study and interpretation of its findings. The study management group will see outputs of data analyses associated with the data under this Data Sharing Agreement but will have no access to the data. Specific data analysis outputs will be shared with co-applicant from the University of Surrey for health economic analysis. For the avoidance of doubt, the data analysis outputs shared with co-applicants will be aggregated with small number suppression rules applied.

A Public and Patient Involvement (PPI) and Engagement group helped refine the purpose of the research. The group supported the collection of the data for the purposes described above. The PPI group under the leadership of the study PPI co-applicant has commented on the study design and data collection, being specifically asked about the collection of routine patient information; they understood the benefits of national data and that this would be de-identified. The PPI panel will receive selected excerpts of data analysis to inform their contribution to interpretation of the study but will have no access to data. Engagement with the PPI panel will continue throughout the lifecycle of this study.

No data will flow to NHS England for the purposes of this Agreement.

NHS England will provide the relevant records from the HES A&E and ECDS dataset to Kingston University. The data will contain no direct identifying data items. The data will be pseudonymised and individuals cannot be reidentified through linkage with other data in the possession of the recipient.

The data will not be transferred to any other location.

The data will be stored on servers at Kingston University.

Kingston University stores Data on the Cloud provided by Microsoft Azure

Kingston University uses offsite back-up services provided by the University’s backup partner CSI Limited

The Data will be accessed by authorised personnel via remote access.

The Controller(s) must confirm and provide evidence upon audit by NHS England that access via any remote device complies with the data security obligations within this DSA and the Data Sharing Framework Contract.

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).

The data will not leave England any time.

Data will be accessed by substantive employees of Kingston University.

All personnel accessing the data have been appropriately trained in data protection and confidentiality.

The data will not be linked with any other data.

There will be no requirement and no attempt to reidentify individuals when using the data.

Analysts/researchers with a specific role are employed to undertake the study will process and analyse the data for the purposes described above.

The expected outputs of the processing will be:

• Article submissions to peer-reviewed journals, including, but not limited to the NIHR Health and Social Care Delivery Research Journal through an agreed threaded publication protocol.

• National conference presentations and presentations within Kingston University (free online seminars) to manager forums and emergency service or health services research-focused conferences

• Short briefings and vignettes targeted at NHS managers, clinicians, and commissioners.

• Blogs hosted on the SkillMix-ED webpages.

• Social media and industry publications

• Press releases

• Other activities such as workshops involving health service managers and clinicians and/ or policy makers; webinars open to interested parties in health services, policy and research; direct bilateral engagement with health service managers and clinicians and/ or policy makers; or engagement in other public events will be determined by the study results and interest in their publication.

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

The findings of this research study are expected to contribute to evidence-based decision-making for policy-makers, local decision-makers such as senior clinicians and managers, and patient and public engagement groups to inform best practice to improve the care, treatment and experience of health care workforce and service users relevant to the subject matter of the study.

The use of the data could:

• lead to the identification or improvement of health and care system design to improve health and care outcomes or experience.

• inform planning health services and programmes, for example to improve equity of access, experience and outcomes.

• inform decisions on how to effectively allocate and evaluate funding for workforce.

• provide a mechanism for checking the quality of care. This could include identifying areas of good practice to learn from, or areas of poorer practice which need to be addressed.

• support knowledge creation or exploratory research (and the innovations and developments that might result from that exploratory work).

Benefits to patients are dependent on study results and are not expected to be direct. These data contribute to an analysis of patient outcomes according to the skill-mix composition of the workforce. If skill-mix differences are found to contribute to patient outcomes, the study may be able to recommend an optimal (or parameters for improved) skill-mix for patient outcomes.

It is hoped that through publication of findings in appropriate media, the findings of this research will add to the body of evidence that is considered by the bodies, organisations and individual health service managers and clinicians charged with making policy decisions for or within the NHS or staffing decisions in relation to sector of the workforce.

An NHS trust might give consideration to its staffing models if they differed from those potentially identified as producing improved patient, staff or organisational outcomes, they would do this based on the information provided to them in order to realise the potential improvement opportunities.

The channels described in the outputs dissemination sections will be utilised initially, with a view to wider public dissemination if considered appropriate. The study topic does not align to particular charities; engagement with public bodies such as Healthwatch will however be sought.

The data supplied in the current DSA (HES A&E 2017, 2018, 2019 and ECDS 2023) are currently being analysed against the study's primary outcome and early analytical steps indicate where changes in skill-mix ratios in Emergency Departments have and have not bene associated with patient and service outcomes. This evidence will be helpful for workforce decision makers once analysis completes this year.