Access to Civil Registration Data

The births and deaths data is of significant value to the Local Authority in enabling analysts to respond to local public health needs. Evaluations of births and deaths in their local area allows local authorities to perform the following:

a) Measuring the health, mortality or care needs of the population, for specific geographical area or population group;

b) Planning, evaluating or monitoring health and social care policies, services or interventions; and,

c) Protecting or improving the public health, including such subjects as the incidence of disease, the characteristics (e.g. age, gender, occupation) of persons with disease, the risk factors pertaining to sections of the population, investigating specific areas of local concern relating to the health of the local population, or the effectiveness of medical treatments.

The births and deaths data both contain identifiable data which is required when linking into other datasets to enhance and verify the statistics produced, or to investigate specific areas of local concern relating to the health of the local population, e.g. deaths data is used to produce suicide audits by linking into hospital / GP / social care data and births data can be linked into child care / social care systems when infant deaths are investigated usually as part of local “Safeguarding Children” projects.

Such local investigations will reflect local need and thus vary in relation to the specific local authority, but the detail below provides specific examples of such local investigations which provide evidence on why identifiable data is needed in order to carry out the purposes stated within a), b) and c) above.

Each Local Authority will only be permitted to process the data in the way outlined in this application. Processing outside the terms of this application will require a separate application as an amendment to this agreement

In relation to mortality data :

Suicide Audit – As part of on-going (or the introduction of) suicide audit processes identifiable information will be required to support this work. Such audits require specific identifiable fields, including postcode of usual residence and postcode of place of death (further refined using the place of death text) to analyse and investigate of deaths in public places to support work on accident prevention strategies and the identification of hotspots and locational characteristics for accidental harm and suicide. For example, exact postcode is used to calculate distance from home address to identify suicide hotspots which are a distance from place of resident as a further means of classifying risk. NHS number, date of death and date of registration fields are used when conducting local audits at the coroner’s office, to match their records with the death record in order to supplement information which is subsequently aggregated within the final internal report.

To expand on what is noted above, postcode of residence and place of death (further refined using the place of death text) is used for hotspot mapping and in particular is used to inform suicide prevention work through target hotspot areas of location types within the county and undertake specific preventative work. Pseudonymised data would be insufficient as lower super output areas or partial postcode) cover too large an area to identify exact locations and features or calculate distance from home, especially in more dispersed rural areas, where locations may be many miles apart. This granularity of data is required since the local authorities are where appropriate taking specific locally based action rather than just authority wide activity. The suicide audit process involves collecting information from services such as police, healthcare providers and GP practices of the factors involved in the suicide and NHS number, date of death and other identifiable data will be essential for doing this. As with the hotspot work this is about understanding risk, detecting local issues to inform evidence-based interventions addressing known local factors.

Accidental/Preventable Deaths – Postcode of usual residence and postcode of place of death (further refined using the place of death text) are used for the analysis and investigation of deaths in public places to support work the identification of hotspots and locational characteristics for accident – with identification of types of areas (e.g. parks, railway lines, pavements) as well as particular locations. This level of analysis enables preventative work to be targeted to high risk areas (both in terms of residence as well as occurrence). As a specific example relating to one Local Authority, it carried out work that identified a number of suicides at a particular railway location, and hence facilitated suicide prevention training with staff members at their local Railway Station.

In conjunction with postcode of usual residence and postcode of place of death, detailed analysis of cause of death allows the monitoring of patterns of preventable or amenable disease, particularly avoidable deaths including the major killers, i.e. circulatory, cancer and respiratory disease.

Seasonal monitoring of deaths – Date of death is used both to establish seasonal patterns of mortality (such as excess winter deaths) and the correlation of this with data on weather conditions and local health and social care system pressures, and in the case of any deaths going to coroner to track the length of time between death and registration.

In relation to local population health needs:

Bespoke geography analysis – The postcode also enables analysis by non-coterminous geographies such as highly trafficked roads so the Local Authority can complete aggregate analysis of areas with particular risk factors – for example to see if people living on main roads have high risks of respiratory disease than people who live on cul-de-sacs.

The postcode and place of death text also enables Local Authorities to identify locations of particular types such as care homes or other residential institutions, analysis of deaths by homes enables targeted prevention work (such as control of infection or falls prevention).

Further, bespoke geographies created by postcodes support the assessment of environmental risks to health. For example, a Local Authority may be required to investigate a number of residential streets which have been built on potentially contaminated ground to see if there are any unusual disease patterns. One specific Local Authority needed to identify deaths where the person was resident in particular streets, in the case of a previous cancer cluster possibly relating to chemicals in soil.

Postcodes are used to identify births along these roads to see if there are increased risks of low birth-weight or stillbirths.

Deprivation and inequalities – Postcode is also used to sum data to aggregate geographies that are not based on LSOAs, to facilitate partnership working and to look at small area clusters such as pockets of deprivation, poor quality housing and inequalities in healthcare provision which are all found to be smaller than an LSOA level, identifying the conditions contributing to the greatest levels of premature and preventable deaths, and identifying areas for further investigation.

Child deaths and stillbirths – Identifiable data is also required to provide any data needed to fulfil our duties for audit under the Child Overview Death Panel and other Safeguarding investigations – using NHS numbers to identify these cases and look for patterns, date of birth of mother/postcode of mother to investigate trends based on mother’s location or age.

Audit of medical professionals – there is a requirement for NHS number to facilitate clinical audits by medical professionals into unusual patterns of death; this is part of the Local Authority’s statutory duty to protect the health of the population from risks to Public Health, from both medical conditions and also from clinical practice. Some recent specific examples include :-

• An unusually high number of deaths from epilepsy were noted from the data, and these were audited against GP practice data having had access to identifiable data to identify records.

• GP practices raised concerns about health in their practices, having noticed clusters of cases that they request the Local Authority to investigate.

• Following the Shipman Enquiry recommendations, Local Authorities are required to investigate any concerns raised about clinical practitioners. This duty was given to PCTs in 2007, but information source is the PCMD and is part of the PH duty to provide analysis and evidence to CCGs.

Seasonal monitoring of births – A Local Authorities have a requirement for the inclusion of date of birth of child as it is used to monitor seasonal patterns of births. Postcode of usual residence of mother and postcode of place of birth of child are also used to establish and monitor distance from home to place of birth and monitor catchment areas for different providers for future service planning covering areas based on postcodes rather than LSOA. This will not include any data sharing with providers or other third parties.

Age of mother is required to investigate trends in both young mothers (to support teenage conception and Family Nurse Partnership programmes) and older mothers (to support service planning for higher risk pregnancies). This will not include any data sharing with providers or other third parties.

A mixture of regular annual projects and ad hoc projects triggered by local conditions will require the use of births and deaths data that will result in published summary statistics for public health projects, and these may be used internally or externally with partners in the project.

Typical uses of deaths data are for the following:

a) Joint Strategic Needs Assessments (JSNAs);

b) Joint Health and Wellbeing Strategies;

c) the annual report of the Director of Public Health;

d) reports commissioned by the Health and Wellbeing Board;

e) public health and wider Local Authority health and wellbeing commissioning strategies and plans;

f) public health advice to NHS commissioners;

g) local health profiles;

h) health impact assessments

i) Suicide audits (this specifically requires NHS number)

j) End of life care projects

k) Abdominal Aortic Aneurysm (AAA) screening programme

l) responses to internal and external requests for information and intelligence on the health and wellbeing of the population.

Typical uses of births data are for the following:

a) Joint Strategic Needs Assessments (JSNAs);

b) Joint Health and Wellbeing Strategies;

c) the annual report of the Director of Public Health;

d) reports commissioned by the Health and Wellbeing Board;

e) public health and wider Local Authority health and wellbeing commissioning strategies and plans;

f) public health advice to NHS commissioners;

g) local health profiles;

h) health impact assessments

i) responses to internal and external requests for information and intelligence on the health and wellbeing of the population.

The specific content and target dates for these outputs will be for the Local Authority to determine, although it is required to comply with national guidance published by the Department of Health, Public Health England and others as appropriate, for example on the timetable for publishing refreshed JSNAs.

All outputs will be of aggregated data (with small numbers suppressed).

The overall benefits are as set out in the expected measurable benefits section. Analyses can be undertaken to enable the Local Authority to support the discharge of its statutory duties in relation to public health, and wider public health responsibilities, by producing ad-hoc and routine outputs such as the Joint Strategic Needs Assessments or by informing the Joint Health and Wellbeing Strategies. Access to the data has allowed the Local Authority to undertake locally-focused and locally-responsive analyses of health status and health outcomes, which include analyses of health inequalities to help ensure that the health challenges facing the local population and communities are identified and responded to appropriately by the Local Authority and its partners.

Due to the current COVID-19 Pandemic Royal Borough of Greenwich have not undertaken as much analysis using this data as previous years. Specific yielded benefits up until May 2021 include:

Royal Borough of Greenwich have used the data to explore how the number and pattern of deaths has changed in 2020 compared to 2019, the impact of COVID 19 on residents, including inequalities, and underlying health conditions. This is an ongoing area of work.

In Greenwich there have been recent increases in the rate of stillbirths and child mortality which Royal Borough of Greenwich are seeking to understand and address. The Local Authority have worked with its PH Medical Associate to undertake this work, also providing contextual statistics for the PH Medial Associate’s work as Chair of the Child Deaths Overview Panel. Reports provided to the Children Strategic Services Partnership Board maintain a focus on this area and it is included in the Start Well section of Greenwich’s forthcoming JSNA.

A maternity review commenced in March 2020 which has also examined these concerns in addition to maternal mortality in Greenwich, and the impact of prematurity and low birth weight births, including whether there is any evidence of health inequalities in Greenwich which can be addressed (for example based on average age of mother, age of mother, country of birth of mother, level of deprivation, etc). This piece was paused due to the COVID pandemic and will resume when capacity allows. The results will provide context, identify areas of need and change, and any challenges to inform commissioning process and priorities for the next period of work

Births data is used to examine trends in the number of births to teenage mothers for the Sexual Health Monitoring Report and Action Plan

Births data is used within Royal Borough of Greenwich’s children's centre datapacks. These packs are provided to children's centres in Royal Borough of Greenwich to inform them of health and well-being issues within their patch (where possible, depending on necessary suppression) and the wider borough, to identify if they are reaching all and especially vulnerable parents and their children, and to support the centres in choosing priorities to take action on each year. They include information about the number of births in the area, the number of births to teenage mothers, likelihood of low birth weight birth in their area.

Royal Borough of Greenwich updates the suicide audit annually and identifying progress against the Greenwich suicide prevention plan. RBG continues to build joint work across SE London, included renewing joint efforts to work more closely with the coroner’s office to reduce suicides (as well as deaths from substance misuse and child mortality), and since 2019 to the development of the London wide suicide prevention project.

Royal Borough of Greenwich have continued to undertake analysis of trends and patterns of mortality in Greenwich in general for the JSNA and APHR, for example reviewing the overview of causes of death in Greenwich over the most recent 5 year period, examining factors contributing to recent stalling/ drops in life expectancy, or tackling preventable mortality (for example from lung cancer or ischaemic heart disease).

The births and deaths data is of significant value to the Local Authority in enabling analysts to respond to local public health needs. Evaluations of births and deaths in their local area allows local authorities to perform the following:

a) Measuring the health, mortality or care needs of the population, for specific geographical area or population group;

b) Planning, evaluating or monitoring health and social care policies, services or interventions; and,

c) Protecting or improving the public health, including such subjects as the incidence of disease, the characteristics (e.g. age, gender, occupation) of persons with disease, the risk factors pertaining to sections of the population, investigating specific areas of local concern relating to the health of the local population, or the effectiveness of medical treatments.

The births and deaths data both contain identifiable data which is required when linking into other datasets to enhance and verify the statistics produced, or to investigate specific areas of local concern relating to the health of the local population, e.g. deaths data is used to produce suicide audits by linking into hospital / GP / social care data and births data can be linked into child care / social care systems when infant deaths are investigated usually as part of local “Safeguarding Children” projects.

Such local investigations will reflect local need and thus vary in relation to the specific local authority, but the detail below provides specific examples of such local investigations which provide evidence on why identifiable data is needed in order to carry out the purposes stated within a), b) and c) above.

Each Local Authority will only be permitted to process the data in the way outlined in this application. Processing outside the terms of this application will require a separate application as an amendment to this agreement

In relation to mortality data :

Suicide Audit – As part of on-going (or the introduction of) suicide audit processes identifiable information will be required to support this work. Such audits require specific identifiable fields, including postcode of usual residence and postcode of place of death (further refined using the place of death text) to analyse and investigate of deaths in public places to support work on accident prevention strategies and the identification of hotspots and locational characteristics for accidental harm and suicide. For example, exact postcode is used to calculate distance from home address to identify suicide hotspots which are a distance from place of resident as a further means of classifying risk. NHS number, date of death and date of registration fields are used when conducting local audits at the coroner’s office, to match their records with the death record in order to supplement information which is subsequently aggregated within the final internal report.

To expand on what is noted above, postcode of residence and place of death (further refined using the place of death text) is used for hotspot mapping and in particular is used to inform suicide prevention work through target hotspot areas of location types within the county and undertake specific preventative work. Pseudonymised data would be insufficient as lower super output areas or partial postcode) cover too large an area to identify exact locations and features or calculate distance from home, especially in more dispersed rural areas, where locations may be many miles apart. This granularity of data is required since the local authorities are where appropriate taking specific locally based action rather than just authority wide activity. The suicide audit process involves collecting information from services such as police, healthcare providers and GP practices of the factors involved in the suicide and NHS number, date of death and other identifiable data will be essential for doing this. As with the hotspot work this is about understanding risk, detecting local issues to inform evidence-based interventions addressing known local factors.

Accidental/Preventable Deaths – Postcode of usual residence and postcode of place of death (further refined using the place of death text) are used for the analysis and investigation of deaths in public places to support work the identification of hotspots and locational characteristics for accident – with identification of types of areas (e.g. parks, railway lines, pavements) as well as particular locations. This level of analysis enables preventative work to be targeted to high risk areas (both in terms of residence as well as occurrence). As a specific example relating to one Local Authority, it carried out work that identified a number of suicides at a particular railway location, and hence facilitated suicide prevention training with staff members at their local Railway Station.

In conjunction with postcode of usual residence and postcode of place of death, detailed analysis of cause of death allows the monitoring of patterns of preventable or amenable disease, particularly avoidable deaths including the major killers, i.e. circulatory, cancer and respiratory disease.

Seasonal monitoring of deaths – Date of death is used both to establish seasonal patterns of mortality (such as excess winter deaths) and the correlation of this with data on weather conditions and local health and social care system pressures, and in the case of any deaths going to coroner to track the length of time between death and registration.

In relation to local population health needs:

Bespoke geography analysis – The postcode also enables analysis by non-coterminous geographies such as highly trafficked roads so the Local Authority can complete aggregate analysis of areas with particular risk factors – for example to see if people living on main roads have high risks of respiratory disease than people who live on cul-de-sacs.

The postcode and place of death text also enables Local Authorities to identify locations of particular types such as care homes or other residential institutions, analysis of deaths by homes enables targeted prevention work (such as control of infection or falls prevention).

Further, bespoke geographies created by postcodes support the assessment of environmental risks to health. For example, a Local Authority may be required to investigate a number of residential streets which have been built on potentially contaminated ground to see if there are any unusual disease patterns. One specific Local Authority needed to identify deaths where the person was resident in particular streets, in the case of a previous cancer cluster possibly relating to chemicals in soil.

Postcodes are used to identify births along these roads to see if there are increased risks of low birth-weight or stillbirths.

Deprivation and inequalities – Postcode is also used to sum data to aggregate geographies that are not based on LSOAs, to facilitate partnership working and to look at small area clusters such as pockets of deprivation, poor quality housing and inequalities in healthcare provision which are all found to be smaller than an LSOA level, identifying the conditions contributing to the greatest levels of premature and preventable deaths, and identifying areas for further investigation.

Child deaths and stillbirths – Identifiable data is also required to provide any data needed to fulfil our duties for audit under the Child Overview Death Panel and other Safeguarding investigations – using NHS numbers to identify these cases and look for patterns, date of birth of mother/postcode of mother to investigate trends based on mother’s location or age.

Audit of medical professionals – there is a requirement for NHS number to facilitate clinical audits by medical professionals into unusual patterns of death; this is part of the Local Authority’s statutory duty to protect the health of the population from risks to Public Health, from both medical conditions and also from clinical practice. Some recent specific examples include :-

• An unusually high number of deaths from epilepsy were noted from the data, and these were audited against GP practice data having had access to identifiable data to identify records.

• GP practices raised concerns about health in their practices, having noticed clusters of cases that they request the Local Authority to investigate.

• Following the Shipman Enquiry recommendations, Local Authorities are required to investigate any concerns raised about clinical practitioners. This duty was given to PCTs in 2007, but information source is the PCMD and is part of the PH duty to provide analysis and evidence to CCGs.

Seasonal monitoring of births – A Local Authorities have a requirement for the inclusion of date of birth of child as it is used to monitor seasonal patterns of births. Postcode of usual residence of mother and postcode of place of birth of child are also used to establish and monitor distance from home to place of birth and monitor catchment areas for different providers for future service planning covering areas based on postcodes rather than LSOA. This will not include any data sharing with providers or other third parties.

Age of mother is required to investigate trends in both young mothers (to support teenage conception and Family Nurse Partnership programmes) and older mothers (to support service planning for higher risk pregnancies). This will not include any data sharing with providers or other third parties.

A mixture of regular annual projects and ad hoc projects triggered by local conditions will require the use of births and deaths data that will result in published summary statistics for public health projects, and these may be used internally or externally with partners in the project.

Typical uses of deaths data are for the following:

a) Joint Strategic Needs Assessments (JSNAs);

b) Joint Health and Wellbeing Strategies;

c) the annual report of the Director of Public Health;

d) reports commissioned by the Health and Wellbeing Board;

e) public health and wider Local Authority health and wellbeing commissioning strategies and plans;

f) public health advice to NHS commissioners;

g) local health profiles;

h) health impact assessments

i) Suicide audits (this specifically requires NHS number)

j) End of life care projects

k) Abdominal Aortic Aneurysm (AAA) screening programme

l) responses to internal and external requests for information and intelligence on the health and wellbeing of the population.

Typical uses of births data are for the following:

a) Joint Strategic Needs Assessments (JSNAs);

b) Joint Health and Wellbeing Strategies;

c) the annual report of the Director of Public Health;

d) reports commissioned by the Health and Wellbeing Board;

e) public health and wider Local Authority health and wellbeing commissioning strategies and plans;

f) public health advice to NHS commissioners;

g) local health profiles;

h) health impact assessments

i) responses to internal and external requests for information and intelligence on the health and wellbeing of the population.

The specific content and target dates for these outputs will be for the Local Authority to determine, although it is required to comply with national guidance published by the Department of Health, Public Health England and others as appropriate, for example on the timetable for publishing refreshed JSNAs.

All outputs will be of aggregated data (with small numbers suppressed).

The overall benefits are as set out in the expected measurable benefits section. Analyses can be undertaken to enable the Local Authority to support the discharge of its statutory duties in relation to public health, and wider public health responsibilities, by producing ad-hoc and routine outputs such as the Joint Strategic Needs Assessments or by informing the Joint Health and Wellbeing Strategies. Access to the data has allowed the Local Authority to undertake locally-focused and locally-responsive analyses of health status and health outcomes, which include analyses of health inequalities to help ensure that the health challenges facing the local population and communities are identified and responded to appropriately by the Local Authority and its partners.

Specific yielded benefits up until May 2020 include:

1) Royal Borough of Greenwich are undertaking work with Greenwich CCG to explore any inequalities in end of life care and the ability of the Local Authorities residents to have a death at home (or where they choose), including any variation in the ability of care homes to provide end of life care successfully, and considering how this relates to cause of death. This will support the CCG and adult and social care to develop their commissioning plans for preventative services, care of older people and palliative care.

2) Importantly, Royal Borough of Greenwich have recently used the data to explore how the number and pattern of deaths has changed in the first weeks of 2020 compared to 2019, the impact of COVID 19 on residents, including residents in care homes, and the success or not of measures that Greenwich has sought to put in place (in addition to regional and national efforts). This is going to be a vital area of Royal Borough of Greenwich’s work as the COVID outbreak continues in 2020 and possibly beyond.

3) Royal Borough of Greenwich have also undertaken work with the CCG examining numbers and patterns of admissions and mortality related to frailty and falls. This work builds on an earlier investigation examining the high rates of morbidity and mortality due to falls and fracture of neck of femur and subsequent reinvestment in falls prevention by the CCG. This work will also support Adult and Social Care as they seek to build increased capacity in the population for healthy independent living in order to focus on their most vulnerable clients. Being sure that measures taken are working well and that negative impacts are avoided will remain a priority for Greenwich, and morbidity and mortality related to falls and fracture of femur forms is kept under review by Health Services and Adult Social Care Scrutiny Panel.

4) In Greenwich there have been recent increases in the rate of stillbirths and child mortality which Royal Borough of Greenwich are seeking to understand and address. The Local Authority have worked with its PH Medical Associate to undertake this work, also providing contextual statistics for the PH Medial Associate’s work as Chair of the Child Deaths Overview Panel. Reports provided to the Children Strategic Services Partnership Board maintain a focus on this area and it is included in the Start Well section of Greenwich’s forthcoming JSNA.

5) A maternity review is being undertaken which has also examined these concerns in addition to maternal mortality in Greenwich, and the impact of prematurity and low birth weight births, including whether there is any evidence of health inequalities in Greenwich which can be addressed (for example based on average age of mother, age of mother, country of birth of mother, level of deprivation, etc). The results will provide context, identify areas of need and change, and any challenges to inform commissioning process and priorities for the next period of work

6) Births data is also used to examine trends in the number of births to teenage mothers for the Sexual Health Monitoring Report and Action Plan

7) Births data is also used within Royal Borough of Greenwich’s children's centre datapacks. These packs are provided to children's centres in Royal Borough of Greenwich to inform them of health and well-being issues within their patch (where possible, depending on necessary suppression) and the wider borough, to identify if they are reaching all and especially vulnerable parents and their children, and to support the centres in choosing priorities to take action on each year. They include information about the number of births in the area, the number of births to teenage mothers, likelihood of low birth weight birth in their area.

8) Statistics on child mortality and stillbirths have also contributed to a Special Educational Needs and Disabilities in Children (SEND) Needs Assessment which was finalised in 2019-20. Other data examined for these purposes (from the Civil Registration datasets) included low and high birth weight and gestation length. This report was signed off by the RBG Strategic SEND group and feeds into the RB Greenwich Children and Young Peoples Plan and contributes to recommissioning of universal childrens services.

9) Once again Royal Borough of Greenwich are updating its suicide audit and identifying progress against the Greenwich suicide prevention plan. RBG continues to build joint work across SE London, included renewing joint efforts to work more closely with the coroners office to reduce suicides (as well as deaths from substance misuse and child mortality), and since 2019 to the development of the London wide suicide prevention project.

10) Related to this, RBG has worked with the Metropolitan Police to examine whether there is any information available about deaths due to drowning or connected to the river (including suicide) that would support a funding application for a preventative project.

11) Royal Borough of Greenwich have continued to undertake analysis of trends and patterns of mortality in Greenwich in general for the JSNA and APHR, for example reviewing the overview of causes of death in Greenwich between 2014 and 2018, examining factors contributing to recent stalling/ drops in life expectancy, or tackling preventable mortality (for example from lung cancer or ischaemic heart disease).

12) A specific theme included in the forthcoming JSNA is a review of patterns of morbidity and mortality from causes related to air pollution such as respiratory illness and CVD. This is a matter of increased concern and more needs to be known about the specific impact in Greenwich and the extent to which other factors such as smoking might impact on the population’s health.

13) This information (along with other relevant health data) has been shared with Environmental Health and the Transport planning teams as part of their evidence base when monitoring emissions and to plan location of low traffic neighbourhoods (to increase levels of physical activity and improve quality).

The births and deaths data is of significant value to the Local Authority in enabling analysts to respond to local public health needs. Evaluations of births and deaths in their local area allows local authorities to perform the following:

a) Measuring the health, mortality or care needs of the population, for specific geographical area or population group;

b) Planning, evaluating or monitoring health and social care policies, services or interventions; and,

c) Protecting or improving the public health, including such subjects as the incidence of disease, the characteristics (e.g. age, gender, occupation) of persons with disease, the risk factors pertaining to sections of the population, investigating specific areas of local concern relating to the health of the local population, or the effectiveness of medical treatments.

The births and deaths data both contain identifiable data which is required when linking into other datasets to enhance and verify the statistics produced, or to investigate specific areas of local concern relating to the health of the local population, e.g. deaths data is used to produce suicide audits by linking into hospital / GP / social care data and births data can be linked into child care / social care systems when infant deaths are investigated usually as part of local “Safeguarding Children” projects.

Such local investigations will reflect local need and thus vary in relation to the specific local authority, but the detail below provides specific examples of such local investigations which provide evidence on why identifiable data is needed in order to carry out the purposes stated within a), b) and c) above.

Each Local Authority will only be permitted to process the data in the way outlined in this application. Processing outside the terms of this application will require a separate application as an amendment to this agreement

In relation to mortality data :

Suicide Audit – As part of on-going (or the introduction of) suicide audit processes identifiable information will be required to support this work. Such audits require specific identifiable fields, including postcode of usual residence and postcode of place of death (further refined using the place of death text) to analyse and investigate of deaths in public places to support work on accident prevention strategies and the identification of hotspots and locational characteristics for accidental harm and suicide. For example, exact postcode is used to calculate distance from home address to identify suicide hotspots which are a distance from place of resident as a further means of classifying risk. NHS number, date of death and date of registration fields are used when conducting local audits at the coroner’s office, to match their records with the death record in order to supplement information which is subsequently aggregated within the final internal report.

To expand on what is noted above, postcode of residence and place of death (further refined using the place of death text) is used for hotspot mapping and in particular is used to inform suicide prevention work through target hotspot areas of location types within the county and undertake specific preventative work. Pseudonymised data would be insufficient as lower super output areas or partial postcode) cover too large an area to identify exact locations and features or calculate distance from home, especially in more dispersed rural areas, where locations may be many miles apart. This granularity of data is required since the local authorities are where appropriate taking specific locally based action rather than just authority wide activity. The suicide audit process involves collecting information from services such as police, healthcare providers and GP practices of the factors involved in the suicide and NHS number, date of death and other identifiable data will be essential for doing this. As with the hotspot work this is about understanding risk, detecting local issues to inform evidence-based interventions addressing known local factors.

Accidental/Preventable Deaths – Postcode of usual residence and postcode of place of death (further refined using the place of death text) are used for the analysis and investigation of deaths in public places to support work the identification of hotspots and locational characteristics for accident – with identification of types of areas (e.g. parks, railway lines, pavements) as well as particular locations. This level of analysis enables preventative work to be targeted to high risk areas (both in terms of residence as well as occurrence). As a specific example relating to one Local Authority, it carried out work that identified a number of suicides at a particular railway location, and hence facilitated suicide prevention training with staff members at their local Railway Station.

In conjunction with postcode of usual residence and postcode of place of death, detailed analysis of cause of death allows the monitoring of patterns of preventable or amenable disease, particularly avoidable deaths including the major killers, i.e. circulatory, cancer and respiratory disease.

Seasonal monitoring of deaths – Date of death is used both to establish seasonal patterns of mortality (such as excess winter deaths) and the correlation of this with data on weather conditions and local health and social care system pressures, and in the case of any deaths going to coroner to track the length of time between death and registration.

In relation to local population health needs:

Bespoke geography analysis – The postcode also enables analysis by non-coterminous geographies such as highly trafficked roads so the Local Authority can complete aggregate analysis of areas with particular risk factors – for example to see if people living on main roads have high risks of respiratory disease than people who live on cul-de-sacs.

The postcode and place of death text also enables Local Authorities to identify locations of particular types such as care homes or other residential institutions, analysis of deaths by homes enables targeted prevention work (such as control of infection or falls prevention).

Further, bespoke geographies created by postcodes support the assessment of environmental risks to health. For example, a Local Authority may be required to investigate a number of residential streets which have been built on potentially contaminated ground to see if there are any unusual disease patterns. One specific Local Authority needed to identify deaths where the person was resident in particular streets, in the case of a previous cancer cluster possibly relating to chemicals in soil.

Postcodes are used to identify births along these roads to see if there are increased risks of low birth-weight or stillbirths.

Deprivation and inequalities – Postcode is also used to sum data to aggregate geographies that are not based on LSOAs, to facilitate partnership working and to look at small area clusters such as pockets of deprivation, poor quality housing and inequalities in healthcare provision which are all found to be smaller than an LSOA level, identifying the conditions contributing to the greatest levels of premature and preventable deaths, and identifying areas for further investigation.

Child deaths and stillbirths – Identifiable data is also required to provide any data needed to fulfil our duties for audit under the Child Overview Death Panel and other Safeguarding investigations – using NHS numbers to identify these cases and look for patterns, date of birth of mother/postcode of mother to investigate trends based on mother’s location or age.

Audit of medical professionals – there is a requirement for NHS number to facilitate clinical audits by medical professionals into unusual patterns of death; this is part of the Local Authority’s statutory duty to protect the health of the population from risks to Public Health, from both medical conditions and also from clinical practice. Some recent specific examples include :-

• An unusually high number of deaths from epilepsy were noted from the data, and these were audited against GP practice data having had access to identifiable data to identify records.

• GP practices raised concerns about health in their practices, having noticed clusters of cases that they request the Local Authority to investigate.

• Following the Shipman Enquiry recommendations, Local Authorities are required to investigate any concerns raised about clinical practitioners. This duty was given to PCTs in 2007, but information source is the PCMD and is part of the PH duty to provide analysis and evidence to CCGs.

Seasonal monitoring of births – A Local Authorities have a requirement for the inclusion of date of birth of child as it is used to monitor seasonal patterns of births. Postcode of usual residence of mother and postcode of place of birth of child are also used to establish and monitor distance from home to place of birth and monitor catchment areas for different providers for future service planning covering areas based on postcodes rather than LSOA. This will not include any data sharing with providers or other third parties.

Age of mother is required to investigate trends in both young mothers (to support teenage conception and Family Nurse Partnership programmes) and older mothers (to support service planning for higher risk pregnancies). This will not include any data sharing with providers or other third parties.

A mixture of regular annual projects and ad hoc projects triggered by local conditions will require the use of births and deaths data that will result in published summary statistics for public health projects, and these may be used internally or externally with partners in the project.

Typical uses of deaths data are for the following:

a) Joint Strategic Needs Assessments (JSNAs);

b) Joint Health and Wellbeing Strategies;

c) the annual report of the Director of Public Health;

d) reports commissioned by the Health and Wellbeing Board;

e) public health and wider Local Authority health and wellbeing commissioning strategies and plans;

f) public health advice to NHS commissioners;

g) local health profiles;

h) health impact assessments

i) Suicide audits (this specifically requires NHS number)

j) End of life care projects

k) Abdominal Aortic Aneurysm (AAA) screening programme

l) responses to internal and external requests for information and intelligence on the health and wellbeing of the population.

Typical uses of births data are for the following:

a) Joint Strategic Needs Assessments (JSNAs);

b) Joint Health and Wellbeing Strategies;

c) the annual report of the Director of Public Health;

d) reports commissioned by the Health and Wellbeing Board;

e) public health and wider Local Authority health and wellbeing commissioning strategies and plans;

f) public health advice to NHS commissioners;

g) local health profiles;

h) health impact assessments

i) responses to internal and external requests for information and intelligence on the health and wellbeing of the population.

The specific content and target dates for these outputs will be for the Local Authority to determine, although it is required to comply with national guidance published by the Department of Health, Public Health England and others as appropriate, for example on the timetable for publishing refreshed JSNAs.

All outputs will be of aggregated data (with small numbers suppressed).

The overall benefits are as set out in the expected measurable benefits section. Analyses can be undertaken to enable the Local Authority to support the discharge of its statutory duties in relation to public health, and wider public health responsibilities, by producing ad-hoc and routine outputs such as the Joint Strategic Needs Assessments or by informing the Joint Health and Wellbeing Strategies. Access to the data has allowed the Local Authority to undertake locally-focused and locally-responsive analyses of health status and health outcomes, which include analyses of health inequalities to help ensure that the health challenges facing the local population and communities are identified and responded to appropriately by the Local Authority and its partners.

Specific yielded benefits up until May 2020 include:

1) London Borough of Greenwich are undertaking work with Greenwich CCG to explore any inequalities in end of life care and the ability of the Local Authorities residents to have a death at home (or where they choose), including any variation in the ability of care homes to provide end of life care successfully, and considering how this relates to cause of death. This will support the CCG and adult and social care to develop their commissioning plans for preventative services, care of older people and palliative care.

2) Importantly, London Borough of Greenwich have recently used the data to explore how the number and pattern of deaths has changed in the first weeks of 2020 compared to 2019, the impact of COVID 19 on residents, including residents in care homes, and the success or not of measures that Greenwich has sought to put in place (in addition to regional and national efforts). This is going to be a vital area of London Borough of Greenwich’s work as the COVID outbreak continues in 2020 and possibly beyond.

3) London Borough of Greenwich have also undertaken work with the CCG examining numbers and patterns of admissions and mortality related to frailty and falls. This work builds on an earlier investigation examining the high rates of morbidity and mortality due to falls and fracture of neck of femur and subsequent reinvestment in falls prevention by the CCG. This work will also support Adult and Social Care as they seek to build increased capacity in the population for healthy independent living in order to focus on their most vulnerable clients. Being sure that measures taken are working well and that negative impacts are avoided will remain a priority for Greenwich, and morbidity and mortality related to falls and fracture of femur forms is kept under review by Health Services and Adult Social Care Scrutiny Panel.

4) In Greenwich there have been recent increases in the rate of stillbirths and child mortality which London Borough of Greenwich are seeking to understand and address. The Local Authority have worked with its PH Medical Associate to undertake this work, also providing contextual statistics for the PH Medial Associate’s work as Chair of the Child Deaths Overview Panel. Reports provided to the Children Strategic Services Partnership Board maintain a focus on this area and it is included in the Start Well section of Greenwich’s forthcoming JSNA.

5) A maternity review is being undertaken which has also examined these concerns in addition to maternal mortality in Greenwich, and the impact of prematurity and low birth weight births, including whether there is any evidence of health inequalities in Greenwich which can be addressed (for example based on average age of mother, age of mother, country of birth of mother, level of deprivation, etc). The results will provide context, identify areas of need and change, and any challenges to inform commissioning process and priorities for the next period of work

6) Births data is also used to examine trends in the number of births to teenage mothers for the Sexual Health Monitoring Report and Action Plan

7) Births data is also used within London Borough of Greenwich’s children's centre datapacks. These packs are provided to children's centres in Royal Borough of Greenwich to inform them of health and well-being issues within their patch (where possible, depending on necessary suppression) and the wider borough, to identify if they are reaching all and especially vulnerable parents and their children, and to support the centres in choosing priorities to take action on each year. They include information about the number of births in the area, the number of births to teenage mothers, likelihood of low birth weight birth in their area.

8) Statistics on child mortality and stillbirths have also contributed to a Special Educational Needs and Disabilities in Children (SEND) Needs Assessment which was finalised in 2019-20. Other data examined for these purposes (from the Civil Registration datasets) included low and high birth weight and gestation length. This report was signed off by the RBG Strategic SEND group and feeds into the RB Greenwich Children and Young Peoples Plan and contributes to recommissioning of universal childrens services.

9) Once again London Borough of Greenwich are updating its suicide audit and identifying progress against the Greenwich suicide prevention plan. RBG continues to build joint work across SE London, included renewing joint efforts to work more closely with the coroners office to reduce suicides (as well as deaths from substance misuse and child mortality), and since 2019 to the development of the London wide suicide prevention project.

10) Related to this, RBG has worked with the Metropolitan Police to examine whether there is any information available about deaths due to drowning or connected to the river (including suicide) that would support a funding application for a preventative project.

11) London Borough of Greenwich have continued to undertake analysis of trends and patterns of mortality in Greenwich in general for the JSNA and APHR, for example reviewing the overview of causes of death in Greenwich between 2014 and 2018, examining factors contributing to recent stalling/ drops in life expectancy, or tackling preventable mortality (for example from lung cancer or ischaemic heart disease).

12) A specific theme included in the forthcoming JSNA is a review of patterns of morbidity and mortality from causes related to air pollution such as respiratory illness and CVD. This is a matter of increased concern and more needs to be known about the specific impact in Greenwich and the extent to which other factors such as smoking might impact on the population’s health.

13) This information (along with other relevant health data) has been shared with Environmental Health and the Transport planning teams as part of their evidence base when monitoring emissions and to plan location of low traffic neighbourhoods (to increase levels of physical activity and improve quality).

The births and deaths data is of significant value to the Local Authority in enabling analysts to respond to local public health needs. Evaluations of births and deaths in their local area allows local authorities to perform the following:

a) Measuring the health, mortality or care needs of the population, for specific geographical area or population group;

b) Planning, evaluating or monitoring health and social care policies, services or interventions; and,

c) Protecting or improving the public health, including such subjects as the incidence of disease, the characteristics (e.g. age, gender, occupation) of persons with disease, the risk factors pertaining to sections of the population, investigating specific areas of local concern relating to the health of the local population, or the effectiveness of medical treatments.

The births and deaths data both contain identifiable data which is required when linking into other datasets to enhance and verify the statistics produced, or to investigate specific areas of local concern relating to the health of the local population, e.g. deaths data is used to produce suicide audits by linking into hospital / GP / social care data and births data can be linked into child care / social care systems when infant deaths are investigated usually as part of local “Safeguarding Children” projects.

Such local investigations will reflect local need and thus vary in relation to the specific local authority, but the detail below provides specific examples of such local investigations which provide evidence on why identifiable data is needed in order to carry out the purposes stated within a), b) and c) above.

Each Local Authority will only be permitted to process the data in the way outlined in this application. Processing outside the terms of this application will require a separate application as an amendment to this agreement

In relation to mortality data :

Suicide Audit – As part of on-going (or the introduction of) suicide audit processes identifiable information will be required to support this work. Such audits require specific identifiable fields, including postcode of usual residence and postcode of place of death (further refined using the place of death text) to analyse and investigate of deaths in public places to support work on accident prevention strategies and the identification of hotspots and locational characteristics for accidental harm and suicide. For example, exact postcode is used to calculate distance from home address to identify suicide hotspots which are a distance from place of resident as a further means of classifying risk. NHS number, date of death and date of registration fields are used when conducting local audits at the coroner’s office, to match their records with the death record in order to supplement information which is subsequently aggregated within the final internal report.

To expand on what is noted above, postcode of residence and place of death (further refined using the place of death text) is used for hotspot mapping and in particular is used to inform suicide prevention work through target hotspot areas of location types within the county and undertake specific preventative work. Pseudonymised data would be insufficient as lower super output areas or partial postcode) cover too large an area to identify exact locations and features or calculate distance from home, especially in more dispersed rural areas, where locations may be many miles apart. This granularity of data is required since the local authorities are where appropriate taking specific locally based action rather than just authority wide activity. The suicide audit process involves collecting information from services such as police, healthcare providers and GP practices of the factors involved in the suicide and NHS number, date of death and other identifiable data will be essential for doing this. As with the hotspot work this is about understanding risk, detecting local issues to inform evidence-based interventions addressing known local factors.

Accidental/Preventable Deaths – Postcode of usual residence and postcode of place of death (further refined using the place of death text) are used for the analysis and investigation of deaths in public places to support work the identification of hotspots and locational characteristics for accident – with identification of types of areas (e.g. parks, railway lines, pavements) as well as particular locations. This level of analysis enables preventative work to be targeted to high risk areas (both in terms of residence as well as occurrence). As a specific example relating to one Local Authority, it carried out work that identified a number of suicides at a particular railway location, and hence facilitated suicide prevention training with staff members at their local Railway Station.

In conjunction with postcode of usual residence and postcode of place of death, detailed analysis of cause of death allows the monitoring of patterns of preventable or amenable disease, particularly avoidable deaths including the major killers, i.e. circulatory, cancer and respiratory disease.

Seasonal monitoring of deaths – Date of death is used both to establish seasonal patterns of mortality (such as excess winter deaths) and the correlation of this with data on weather conditions and local health and social care system pressures, and in the case of any deaths going to coroner to track the length of time between death and registration.

In relation to local population health needs:

Bespoke geography analysis – The postcode also enables analysis by non-coterminous geographies such as highly trafficked roads so the Local Authority can complete aggregate analysis of areas with particular risk factors – for example to see if people living on main roads have high risks of respiratory disease than people who live on cul-de-sacs.

The postcode and place of death text also enables Local Authorities to identify locations of particular types such as care homes or other residential institutions, analysis of deaths by homes enables targeted prevention work (such as control of infection or falls prevention).

Further, bespoke geographies created by postcodes support the assessment of environmental risks to health. For example, a Local Authority may be required to investigate a number of residential streets which have been built on potentially contaminated ground to see if there are any unusual disease patterns. One specific Local Authority needed to identify deaths where the person was resident in particular streets, in the case of a previous cancer cluster possibly relating to chemicals in soil.

Postcodes are used to identify births along these roads to see if there are increased risks of low birth-weight or stillbirths.

Deprivation and inequalities – Postcode is also used to sum data to aggregate geographies that are not based on LSOAs, to facilitate partnership working and to look at small area clusters such as pockets of deprivation, poor quality housing and inequalities in healthcare provision which are all found to be smaller than an LSOA level, identifying the conditions contributing to the greatest levels of premature and preventable deaths, and identifying areas for further investigation.

Child deaths and stillbirths – Identifiable data is also required to provide any data needed to fulfil our duties for audit under the Child Overview Death Panel and other Safeguarding investigations – using NHS numbers to identify these cases and look for patterns, date of birth of mother/postcode of mother to investigate trends based on mother’s location or age.

Audit of medical professionals – there is a requirement for NHS number to facilitate clinical audits by medical professionals into unusual patterns of death; this is part of the Local Authority’s statutory duty to protect the health of the population from risks to Public Health, from both medical conditions and also from clinical practice. Some recent specific examples include :-

• An unusually high number of deaths from epilepsy were noted from the data, and these were audited against GP practice data having had access to identifiable data to identify records.

• GP practices raised concerns about health in their practices, having noticed clusters of cases that they request the Local Authority to investigate.

• Following the Shipman Enquiry recommendations, Local Authorities are required to investigate any concerns raised about clinical practitioners. This duty was given to PCTs in 2007, but information source is the PCMD and is part of the PH duty to provide analysis and evidence to CCGs.

Seasonal monitoring of births – A Local Authorities have a requirement for the inclusion of date of birth of child as it is used to monitor seasonal patterns of births. Postcode of usual residence of mother and postcode of place of birth of child are also used to establish and monitor distance from home to place of birth and monitor catchment areas for different providers for future service planning covering areas based on postcodes rather than LSOA. This will not include any data sharing with providers or other third parties.

Age of mother is required to investigate trends in both young mothers (to support teenage conception and Family Nurse Partnership programmes) and older mothers (to support service planning for higher risk pregnancies). This will not include any data sharing with providers or other third parties.

A mixture of regular annual projects and ad hoc projects triggered by local conditions will require the use of births and deaths data that will result in published summary statistics for public health projects, and these may be used internally or externally with partners in the project.

Typical uses of deaths data are for the following:

a) Joint Strategic Needs Assessments (JSNAs);

b) Joint Health and Wellbeing Strategies;

c) the annual report of the Director of Public Health;

d) reports commissioned by the Health and Wellbeing Board;

e) public health and wider Local Authority health and wellbeing commissioning strategies and plans;

f) public health advice to NHS commissioners;

g) local health profiles;

h) health impact assessments

i) Suicide audits (this specifically requires NHS number)

j) End of life care projects

k) Abdominal Aortic Aneurysm (AAA) screening programme

l) responses to internal and external requests for information and intelligence on the health and wellbeing of the population.

Typical uses of births data are for the following:

a) Joint Strategic Needs Assessments (JSNAs);

b) Joint Health and Wellbeing Strategies;

c) the annual report of the Director of Public Health;

d) reports commissioned by the Health and Wellbeing Board;

e) public health and wider Local Authority health and wellbeing commissioning strategies and plans;

f) public health advice to NHS commissioners;

g) local health profiles;

h) health impact assessments

i) responses to internal and external requests for information and intelligence on the health and wellbeing of the population.

The specific content and target dates for these outputs will be for the Local Authority to determine, although it is required to comply with national guidance published by the Department of Health, Public Health England and others as appropriate, for example on the timetable for publishing refreshed JSNAs.

All outputs will be of aggregated data (with small numbers suppressed).

The overall benefits are as set out in the expected measurable benefits section. Analyses can be undertaken to enable the Local Authority to support the discharge of its statutory duties in relation to public health, and wider public health responsibilities, by producing ad-hoc and routine outputs such as the Joint Strategic Needs Assessments or by informing the Joint Health and Wellbeing Strategies.

Specific yielded benefits up until May 2019 include:

1) Continued to undertake analysis of trends and patterns of mortality in Greenwich – the latest results will be included in the JSNA which will be published in 2019-20

2) A specific theme that will be included in the forthcoming JSNA is a review of patterns of morbidity and mortality from causes related to air pollution such as respiratory illness and CVD. Results are currently being prepared. This is a matter of increased concern and more needs to be known about the impact in Greenwich, the extent to which other factors such as smoking impact on our population’s health, and any changes which might result from developments such as the Low Emission Zones in Central London.

3) Analysis of the data has contributed to an update of the council's suicide audit. This will contribute to identifying progress against the Greenwich suicide prevention plan which was agreed in 2017-18 in September 2019, and feed into joint work around suicide prevention being undertaken with the South East London STP.

4) In updating the local Food Poverty Needs Assessment (and in response to concerns raised in national media), the local authority investigated whether there had been any hospital admissions or deaths where malnutrition was identified as a cause, and whether any groups in the population were especially affected. The results showed there were few admissions of Greenwich residents where this was identified as a diagnosis, and this had generally not changed in recent periods. Further analysis would be required once additional data became available because of the small numbers involved. This is to be revisited in summer 2019.

5) There have been recent increases in the rate of stillbirths and child mortality in Greenwich which the Local Authority are seeking to understand and address. They have worked with a PH Medical Associate to undertake this work, providing contextual statistics for his work as Chair of the Child Deaths Overview Panel and his investigations at the maternity unit at the local hospital.

6) Levels of infant mortality and stillbirths are also included in reports provided to the Children Strategic Services Partnership Board and are going to be included in the Start Well section of the forthcoming JSNA.

7) Statistics on child mortality and stillbirths contributed to a Special Educational Needs and Disabilities in Children (SEND) Needs Assessment, as well as the RB Greenwich Children and Young People’s Plan. Other data examined for these purposes (from the Civil Registration datasets) included low and high birth weight and gestation length.

8) Greenwich have continued to monitor the level of hospital admissions and mortality related to the misuse of alcohol against targets in the Alcohol Strategy 2016-2020. The harmful drinking section of the JSNA will be updated in 2019-20 to contribute to the next borough strategy and action plan. The results provided will contribute to recommendations and plans for the prevention of alcohol misuse in Greenwich and targeting of the treatment services. This information will also support the local authority to fulfil their statutory function in providing PH input to related licensing applications.

9) Greenwich have also used the datasets to identify whether mortality as a result of substance misuse and poisonings have increased in Greenwich, as they have elsewhere in the UK, especially in light of request by PH England that they investigate the high rate of mental health admissions to hospital as a result of substance misuse in Greenwich. These analyses have supported our local authority substance misuse commissioning team to identify how successful current referral pathways to their treatment services have been and whether more could be done to direct substance users to addiction services and reduce admissions to hospital and mortality. The yielded benefits so far (of this wider piece of work) have included providing reports to the SM commissioning team, Oxleas NHS Trust and Greenwich CCG to improve the health of this client group and reduce admissions to hospital.

10) The PH Outcomes Framework has indicated that both the rate of admissions to hospital as a result of falls and the rate of admissions as a result of neck of femur fractures has increased in Greenwich. Examination of the mortality data suggests that there has also been an increase in the number of deaths which mention these causes. A report was prepared for the PHWB board and as a result GCCG are re-investing in falls prevention. The report helped focus where new services should be targeted. These indicators will continue to be monitored and have now been added to the PH report which is presented to the RBG Health Services and Adult Social Care Scrutiny Panel. The issue was highlighted in the 2017/18 APHR and further analysis will be included in the next APHR to ensure that it remains a focus for the Borough.

11) Births data is used to examine trends in the number of births to teenage mothers for the Sexual Health Monitoring Report and Action Plan. Information about overall number of births as well as the number of teenage mothers estimated to live in the borough is provided to children's centres as part of data packs helping them to identify the local population and identify neighbourhood priorities for action.

12) Greenwich have provided statistics to the Greenwich Clinical Commissioning Group identifying the most frequent causes of death in the borough and of these, the causes of death most frequently mentioned in the first line of the death certificates. This was requested to support them developing their commissioning plans for preventative services and palliative care.