Investigating the relationship between Quality of Primary Care and Hospitalisation: A spatial whole population study for England

The University of Manchester requires unsuppressed aggregated HES Admitted Patient Care data from NHS Digital for a study that aims to investigate and quantify the relationships between recorded general practice performance. This performance is as measured in the Quality and Outcomes Framework (QOF), at population level in England and cause-specific hospitalisations. The purpose of this project is to investigate the effects of one of the largest Pay-for-performance (P4P) programmes worldwide which has attracted substantial attention from media, policy makers and the public. Furthermore, this study will analyse the relationship between area-based measures such as deprivation and social fragmentation with hospital admissions. There is public interest to process the data due to the increased numbers of admissions which may be preventable through high quality primary care and there is limited evidence to support this statement. Therefore, the data will be processed under Article 6 (1) (e) and Article 9 (2) (j) of the GDPR. The study will not use personal identifying data as the tabulation refers to aggregated data therefore the privacy impact is minimal.

This study is in the interests of the public as this study will explore whether there has been any effect on all cause and cause-specific hospitalisations (reductions/increases) due to financial incentives, targeted to improve the quality of services in Primary Care in the UK between 2006 and 2019. This analysis will be conducted longitudinally as well as cross-sectionally while controlling for factors that are known to have an effect on hospitalisations. The study will utilise HES Admitted Patient care data as it is deemed it to be the most robust and high-quality data on hospitalisations for the UK, which are available at the level of Lower Super Output Area (LSOA).

The QOF is one of the most comprehensive P4P schemes of its kind and it was introduced in 2004 to improve quality of Primary Care in the UK. However, doubts on its impact and value mean that the UK is now retreating from using incentives in primary care. The impact of the QOF on hospital admissions has been a matter of continuous debate among policy makers and the public and its effects are largely unknown. Furthermore, the QOF comes with large costs and there exist questions on whether this budget is spent efficiently. The NHS has published several reports on the QOF and there exists substantial public interest on the future of the scheme and the whether the QOF can be integrated in the modern English Primary Care. There is a large amount of literature, which investigated the effects of the QOF in the UK but all research up to date was subject to methodological limitations which this research aims to overcome. The present analysis will be conducted at a low geographical level (LSOA) and will use geographically defined statistical models to avoid aggregation of data at bigger heterogeneous areas and populations. In relation to this, the University of Manchester has obtained relevant publicly available aggregate data on general practice quality of care and prevalence of relevant chronic diseases from NHS Digital. In addition HES data will be combined with publicly available aggregate information on deprivation (IMD score) and rurality sourced from the Office for National Statistics and which are available at the LSOA level.

This is a tabulation request with an unsuppressed small numbers specification which will support the validity of the findings. If suppression according to the standards and regulations of NHS Digital is applied, it will result in significantly large numbers of unused cells which will be treated as missing values thus rendering this analysis unreliable.

The University of Manchester is the data controller and also processes the data for this study. No other organisations process the data for this purpose.

The research is a continuation from a previous request which looked at the relationships between financially incentivised quality of care and patient outcomes under a national P4P scheme in English primary care. The outcomes mentioned in this instance include hospitalisations, suicides and alcohol related deaths. These outcomes and the respective (i.e. Office for National Statistics (ONS) suicide and alcohol related deaths) datasets will not be linked, analysed or investigated together. There will be three different analyses that will constitute individual pieces of work and will be organised apart. These data will be aggregated with small numbers suppressed.

The data will be stored in a locked encrypted server at the storage address specified at the University of Manchester. The data will only be accessed by the authorised researcher, however responsibility for the processing of the data and outputs resulting from this remain with the University of Manchester. The data will be accessed locally at the Centre for Primary Care only and no remote access or transfer of the data to other locations (inside or outside England) will be possible.

The outputs produced from this project will be presented as aggregated information at a larger geographical level than the one used for the analysis. The data obtained from HES will be presented as aggregated at regional level, which constitutes a much larger unit of the English geography, in order to eliminate any risk for identification. More specifically, the analysis will be conducted at the LSOA level but all outputs that refer to hospitalisation data will be presented at Regional level.

All organisations party to this agreement must comply with the Data Sharing Framework Contract requirements, including those regarding the use (and purposes of that use) by “Personnel” (as defined within the Data Sharing Framework Contract ie: employees, agents and contractors of the Data Recipient who may have access to that data).

Outputs related to this project will be submitted in the form of an original research study for international peer reviewed journals. This project has the possibility, of informing policy regarding the successes, failures and future of Pay-for-Performance implemented in Primary Care in the UK and worldwide. Potential journals for submission, but not limited to are: The British Medical Journal, The BMJ Quality and Safety and/or the British Journal of General Practice as these feature articles related to this research. Submission dates and subsequent publication will vary according to when the data will be obtained but submission is likely to occur between 3 to 4 months after the data is provided. The outputs from this research will be publicly available via any publication that might occur from this project.

The outputs related to HES data, in the form of an original study, will be initially seen by the research team. They will assess the validity of the results and there will be extended discussions about this research project throughout the duration of the project. Reviewers of the international peer reviewed journals mentioned previously will be able to see the outputs when the study is submitted (potentially in June-July 2020). Furthermore, there is increased interest for studies that look at the relationship between quality of care and patient outcomes such as hospitalisations.

Finally, when publication to a peer reviewed journal is achieved the outputs will be accessed by the public as well as clinicians and academics and will be disseminated to decision makers via the NIHR School for Primary Care Research (SPCR), the University of Manchester and the Centre for Primary Care research and dissemination networks. The NIHR SPCR collects annual data on publications from all students and trainees associated with the School and advertises the respective publications on the SPCR website (wwww.spcr.nihr.ac.uk) although there are no publication requirements imposed by the SPCR. The outputs generated from this research will also be advertised at the University of Manchester website, where each of co-authors will include links of the HES relevant publications on their personal University of Manchester webpage (including the researcher of this agreement). Finally, the outputs will be presented to the public via Personal and Public Involvement (PPI) groups such as the PRIMER patient and public involvement group based at the Centre for Primary Care at the University of Manchester and PPI activities incentivised and required from the NIHR SPCR.

All outputs will aggregated to small numbers suppressed in line with the HES analysis guidelines.

The benefits derived from the outputs will be related to policy and will be immediately available to the NHS, policy makers and academics. The themes that are challenged within this project are of direct interest to the NHS as increased spending that has occurred during the implementation of Pay-for-Performance (P4P) programmes in English primary care in conjunction with the ineffectiveness of these programmes have attracted substantial criticism for the NHS. The channel through which the outputs from this research will inform the NHS is the NIHR SPCR and the Centre for Primary Care in the University of Manchester.

The outputs from this research (except for peer reviewed accessible publications or oral/poster presentations in conferences) will inform the NIHR SPCR in the form of an annual report. The outputs from this project will be presented at the NIHR SPCR Annual Trainees Event and the Annual NIHR Trainees Meeting which attracts academics, clinicians and policy makers from the UK and is funded by the NHS. Considering that the QOF is a programme that has been running for more than 10 years and is perhaps considered the largest programme of its kind, with specific targets set for prevention and monitoring of patients, the investigation of its effects are of substantial importance as it may be the best example of financial incentivisation in a large scale that has been implemented worldwide to improve population health.

Improvements in the quality of care lead directly to improvements in the health of the population, as higher quality of care means better treatment, improved prevention and better monitoring. The research findings, available in the form of a journal article, will inform Health and Social care on the effectiveness of the QOF while the aim of this output will be to provide robust and reliable information to understand how resources can best be used to achieve high quality of primary care services and improved patient outcomes for the population. If such incentives fail to improve quality of care, then valuable resources will be allocated to activities that may not have the desirable effects whilst the same resources could be allocated to other more effective activities or programmes. To put things into context, the amount of money invested in the QOF has exceeded £1 billion a year in the first years of the scheme and still it is unclear whether these amounts were invested in an optimal way and whether they can be allocated more efficiently. If these investments in the QOF have been made efficiently and the scheme has improved population health then the University of Manchester’s results will support this. The QOF is a nationwide programme and as such it is an extremely complex programme with the people involved, ranging from clinicians to policy makers, and PhD students. The outputs from this study will inform the NHS and the NIHR SPCR of the effects of the largest P4P scheme implemented in the world and will be available freely to them to utilise in order to pursue improvements in the current care pathways.

Not stated in the register.