Waiting times in Emergency Departments: Inequalities and impact on health outcomes

The University of Oxford requires access to NHS England data for the purpose of the following research project:

Waiting times in Emergency Departments: Inequalities and impact on health outcomes.

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

The work in the project for which the University of Oxford will use the data in this Data Sharing Agreement seeks to answer the following questions:

Q1) Are there inequalities in Emergency Department (ED) waiting times by socioeconomic status, between and within hospitals, allowing for severity of the patient’s presenting condition?

Q2) Do longer waits translate into worse patient health outcomes, by severity of condition?

There is a further work package (WP2) in the overall project which will use qualitative research methods (and none of the data in this application) which seeks to answer:

Q3) Are there differences in professional behaviour and organisational cultures in EDs that influence waiting times? Are these patterned by socioeconomic status and other patient characteristics?

Building on existing evidence about health inequalities and the use of ED care, the project will consider all health conditions, controlling for severity, and will then focus on a set of specific health conditions known to be more prevalent in deprived areas:

1. Heart failure, a common ambulatory care sensitive condition (that can be managed in the community) for which there is a known association between deprivation and adverse outcomes.

2. Chronic obstructive pulmonary disease (COPD), which has a known association with socioeconomic disadvantage and frequent ED attendances.

3. Asthma among children and adults. There is evidence that children in inner cities make heavy use of EDs.

The main objectives are to:

1. Understand waiting time variation in EDs by socioeconomic status, age, gender, ethnicity, attendance mode (ambulance, walk-in) and referral mode (by GP or 111), controlling for patient case-mix and severity (Q1), and other factors.

2. Provide evidence showing if/how differences in waiting times affect health outcomes for patients (Q2) and explore if this is patterned by socioeconomic deprivation (Q2).

The following NHS England Data will be accessed:

• Hospital Episode Statistics

o Admitted Patient Care

o Accident & Emergency

o Critical Care

o Outpatients

• Uncurated Low Latency Hospital Data Sets - Emergency Care

• Civil Registration Mortality

These datasets are necessary for the research team at the University of Oxford to identify whether patients that attend ED are discharged or admitted, classify the cause of attendance, understand whether the diagnosis, procedure and length of stay if the patient was admitted, and ascertain whether the patient subsequently died. Emergency Care data linked to HESA&E, HESOP, HESAPC, and HESCC data will make it possible to:

1. Follow patients that attend ED through any stage of health care (i.e., inpatient / outpatient / discharged),

2. Record their process of admission and outcome (e.g., length of stay and clinical health outcome);

3. Control for the utilisation of hospital care before and after an acute illness that required ED attendance.

Civil Registrations of Death data will allow the research team to link ED attendances with out-of-hospital mortality outcomes.

The level of the Data will be:

• Pseudonymised

The Data will be minimised as follows :

• Limited to data between 2016/17 and 2023/24 latest available (as a one-off drop of data);

The University of Oxford 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.

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 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, which protects and promotes the interests of patients, service users and the public, and aims to produce generalisable and publicly available information to inform future decisions over patients’ treatments or care.

The funding is provided by the NIHR Health and Social Care Delivery Research (HS&DR). The funding is specifically for the study described. Funding is in place until July 2025.

The University of Oxford is working alongside a PPIE group in relation to this study. The group were able to advise and contributed to the study design. The University of Oxford has made a commitment to share the results of this study (after it has been sufficiently anonymised with small number suppression rules upheld). The group have expressed a positive outcome of the need of this study.

No data will flow to NHS England for the purposes of this Data Sharing Agreement (DSA).

NHS England will grant access to the Data via the Secure Data Environment (SDE). The SDE is a secure data and research analysis platform. It allows approved researchers with approved projects access to pseudonymised data and industry-leading analytics tools.

NHS England will provide access to the relevant records from the HES, mortality, and Emergency Care Data to the University of Oxford. The Data will:

• Contain special categories of personal data but with 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.

SDE users can request exportation of aggregated analysis results (suppressed and summarised according to the NHSE SDE Disclosure Control rules) subject to review and approval by the NHS England SDE Output Checking team. The SDE Output Checking team will ensure that no output contains information which could be used either on its own or in conjunction with other data to breach an individual's privacy.

Access to the SDE is controlled via a multi-factor authentication mechanism and access is restricted to the datasets and periods detailed within this DSA. The access and use of the system is fully auditable, and all users must comply with the use of the Data as specified in this DSA.

Users are only authorised to access the Data specified in this DSA and can utilise a variety of analytical tools available within the SDE platform. Users are not permitted to export record-level data from the SDE.

The Data will be stored on servers at NHS England.

Remote processing will be from secure locations within the England.

The Data will not leave the England at any time.

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

The Data will be combined (for each individual) with freely available data such as the number of beds at the trust level, unemployment rates at the LSOA (Lower Layer Super Output Area) level, and the number of benefit claims at the LSOA level,

Analysts from the University of Oxford will analyse the Data for the purposes described above.

The expected outputs of the processing will be:

• A final report of findings available for everyone interested in this topic. [Month 17/18]

• Submissions to peer-reviewed journals [at months 6,12,18, 24]

• Presentations to academia at national and international conferences

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.

Dissemination of results/outputs

The research team will promote the dissemination of the research to stakeholders during the project and after its completion. The dissemination activities will target an audience of health care professionals, patient organisations, health care providers, national and local policy-makers, and researchers. The aim of the dissemination activities will be two-fold:

1. To enable engagement with scientific and policy-making communities,

2. To ensure that knowledge developed by the research can inform policy and practice and thus benefit patients, their families and communities.

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

• Journals

• Workshops involving stakeholders and researchers

• Social media

• Public reports

• Press/media engagement

• Participant newsletters

The research team will disseminate the research findings to patients, clinicians, professional bodies and policymakers, as well as publish in academic journals. The evidence produced by this research will be directly relevant to:

1. Policymakers, planners and decision-makers,

2. Health care providers, managers, practitioners,

3. Patients and their families.

The dissemination activities are designed to inform and support health and care policy through developing evidence that is crafted and presented with the policy user in mind, rigorous and authoritative, and timely.

The dissemination activities will include a one-day conference for key stakeholders at the end of the project, seeking their responses to the study’s results. The research team will ensure that a range of relevant organisations are included at the conference, such as professional organisations, patient organisations, health care providers, ICSs, DHSC and NHS England. This event will be press released.

The project will inform practice at local and national levels, drawing on the roles and contacts of the co-applicants and collaborators to ensure wide dissemination to policymakers, professional societies, health care providers and relevant research centres.

The project will raise public awareness by producing lay summaries of the results in accessible formats, including through webinars and blog entries, which will ensure broad dissemination through the extensive networks of the stakeholders which are collaborators in the project or with which the research team have contacts.

Communication of results/outputs - Active communication activities will ensure that: information about the project and its results reaches interested groups and civil society. Communication channels: website and newsletters, open lectures and talks, exhibition at public events, posters, press/media engagement and other public promotion of the research, stakeholder mailing list, etc.

The research team at the University of Oxford will draw on the roles and contacts of the co-applicants, collaborators, and funder to ensure wide dissemination of the outputs of the research to policymakers such as Getting It Right First Time, DHSC, NHS England and other NHS bodies among others.

The research team will ensure that the research findings are synthesised and communicated in a meaningful and clear way, such that the results of this study can be employed by all beneficiaries in practice to deliver real healthcare benefits.

The findings of this research study are expected to contribute to evidence-based decision-making for policy-makers, local decision-makers such as doctors, and patients to inform best practice to improve the care, treatment and experience of health care users relevant to the subject matter of the study.

The evidence produced by this research will be directly relevant to:

a) NHS patients and NHS organisations,

b) policymakers, planners and decision-makers, and

c) health care providers, managers and practitioners.

The study has considerable potential for positive health care, societal and economic impacts. As an important objective of the NHS Constitution is equality of access to health care, it is hoped that the NHS would be keen to address any inequalities in ED waiting times with the support of new evidence. Understanding and tackling inequalities should improve public confidence in the NHS, especially among disadvantaged groups. This is likely to benefit society by increasing social solidarity. Addressing inequalities can also lead to more efficient use of resources, if, as is likely, inequalities mean that decisions on prioritisation of patients in ED are currently less than optimal. This would be a valuable economic benefit.

This research will have impact for health care services policy and research. It will provide new evidence to help policy makers and healthcare professionals consider how best to address any inequalities in waiting times. This will benefit policy makers who are currently interested in issues of inequality in the context of the Government priority on ‘levelling up’. The research team will use collaborative networks established through previous work for DHSC and NHS England to convey our findings to them.

It is intended that this study will provide evidence and recommendations that will lead to reduction and ultimately elimination of any socioeconomic inequalities in waiting times in EDs. It will in this way benefit NHS patients, especially patients from disadvantaged communities. Achieving this aim will require promoting impact among NHS decision-makers. The research team will therefore seek opportunities to give seminars or hold discussions with DHSC, NHS England, NHS agencies and professional organisations, as well as patient networks and voluntary organisations.

Researchers’ links, and those of the project advisers and colleagues, with PPI networks, Royal Colleges, NHS and voluntary organisations and DHSC will be used to promote impact of our study.

The use of the data could:

• help the system to better understand the health and care needs of populations.

• advance understanding of regional and national trends in health and social care needs.

• inform planning health services and programmes to improve equity of access.

• inform decisions on how to effectively allocate and evaluate funding according to health needs.

To maximise the impact on academia and implementation, three papers will be submitted to leading economic, health policy and health services journals and our research will be presented at conferences and seminars, including the BSA Medical Sociology Group and UK Health Economists’ Study Group meetings. This multi-professional study will provide scope for learning between researchers and for new collaborations to develop further proposals.

Regular meetings with PPI groups and the advisory group will be held every 6 months.

Two members of the qualitative research team and 2 members from the quantitative research team will attend conferences in late summer 2024 to share findings.

A workshop will bring together stakeholders from different backgrounds to discuss the work.

This study could potentially lead to several benefits for patients. Here are some potential benefits that could be expected based on the findings:

• Improved access and reduced wait times: If the study identifies factors contributing to longer wait times for certain patient groups, such as those from disadvantaged backgrounds or minority populations, the findings could inform strategies to address these disparities. Implementing measures to reduce wait times for these groups could lead to more equitable access to emergency care.

• Enhanced patient experience: Prolonged waiting times in emergency departments can contribute to patient dissatisfaction, anxiety, and frustration. By addressing systemic factors that lead to longer wait times for specific patient populations, the overall patient experience could be improved, leading to greater satisfaction and better health 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 care practitioners charged with making policy decisions for or within the NHS or treatment decisions in relation to specific patients.

These are the actions that we will take to optimise the potential public benefits from the use of these data:

Publish the findings in peer-reviewed medical journals and make them open access to reach a wide academic audience.

Present the research at relevant healthcare conferences and seminars to share the findings with medical professionals, administrators, and policymakers.

Issue press releases and conduct media outreach to raise awareness among the general public through news outlets and online channels.

Stakeholder engagement:

Reach out to patient advocacy groups, charities, and societies focused on healthcare access, equity, and patient rights to share the findings and seek their support in amplifying the message.

Collaborate with professional medical associations and healthcare provider organizations to disseminate the findings among their members and encourage implementation of recommended changes.

Engage with policymakers, legislators, and government agencies responsible for healthcare regulations and policies to advocate for systemic changes based on the findings.

Public awareness campaigns (if findings warrant significant attention):

Develop educational materials (brochures, infographics, videos) that explain the findings in an accessible manner for the general public.

Utilize social media platforms and online channels to reach broader audiences with the findings and raise awareness.

Partner with community organizations, local governments, and grassroots movements to amplify the message within various communities.

Continuous engagement and updates:

Host regular meetings, forums, or webinars to discuss the findings, gather feedback, and provide updates on the implementation of recommendations.

Establish advisory committees or working groups with relevant stakeholders to guide the implementation process and track progress.

Provide periodic progress reports or updates to maintain transparency and accountability.

The benefits of this project are yet to be fully exploited because we have only had data for a few months. However, the study has considerable potential for positive health care, societal and economic impacts.

Preliminary results were presented to DHSC and NHS. Their feedback will be used to improve the research questions and to implement the analysis and interpretation of future results. Eventually, this will help to shape policies that will be designed to address inequalities in ED waiting times.