Assessing the Impact of Service Models Separating Adult Elective and Emergency Surgical Care on Health Inequalities in England

Imperial College London (Imperial) requires access to NHS England data for the purpose of the following research project:

Assessing the Impact of Service Models Separating Adult Elective and Emergency Surgical Care on Health Inequalities in England

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

The overall aim of the research project is to understand the impact of service models separating adult elective and emergency surgical care on health inequalities in England. This is a mixed-methods PhD project to be conducted by the applicant at Imperial. This research project is conducted as part of a programme of work at the Institute for Global Health Innovation at Imperial entitled “Evaluating and integrating patient safety in the design of new service models.

The project will be divided into two studies:

1. Mapping GP referrals for elective adult surgical care in England

2. Analysing the impact of surgical hubs on equity of access to elective surgery in England

The following NHS England data will be accessed:

• HES admitted patient care, emergency care dataset and outpatient datasets – this is required to be able to identify regional variation in the data/ pathways across England, allow the identification of any geographical inequalities which may be present in elective surgical care provision and help identify pseudonymised patients who have had elective surgeries and endoscopies.

The level of the Data will be Pseudonymised

The Data will be minimised as follows by NHS England:

• Limited to data between 01/04/2022 and 31/03/2024.

• Limited patients over 18 years of age.

Imperial College London will further minimise the data to:

• Limited to patients admitted for, or had, an elective surgery/endoscopy procedure between 01/04/2022 and 31/03/2024.

• Patients who have chosen for an elective caesarean section to be excluded.

Imperial 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.

The research is lawful because it is in the public interest to know what the impact of health service models separating emergency and elective surgical care is for the population as a whole, different population groups and for various surgical specialities. Understanding the contemporary impact of this health service design will facilitate development of the service to greater benefit the English population.

The funding is provided by the National Institute for Health and Care Research (NIHR). Funding is in place until March 2028.

The funder will have no ability to suppress or otherwise limit the publication of findings.

The Royal College of Surgeons and NHS England will support Imperial in an advisory manner only and will not be accessing the data.

The data will only be accessed by substantive employees of Imperial.

The project has been presented to the Imperial Research Partners Group who found the project interesting and changes in the study design were implemented from their feedback. Outcomes from this study will utilize PPIE groups in disseminating the findings to the public.

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 HES APC, HES OP and ECDS datasets via NHS England Secure Data Environment (SDE). The Data will contain no direct identifying data items. The Data will be pseudonymised and individuals cannot be reidentified through linkage with other data in the possession of the recipient.

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.

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.

Users must identify themselves via a multi-factor authentication mechanism and are only able to access the datasets 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.

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

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

For remote access:

- Remote access will only be from secure locations situated within the territory of use (as further restricted elsewhere within the DSA if so done) stated within this DSA;

- Access controls granting users the minimum level of access required are in place;

- Remote access is only via secure connections (e.g., VPNs or secure protocols) to protect data;

- Multifactor authentication (MFA) is required for remote access;

- Device security, including up-to-date software and operating systems, antivirus software, and enabled firewalls are utilised for the remote access;

- All remote access is undertaken within the scope of the organisation’s DSPT (or other security arrangements as per this DSA) and complies with the organisation’s remote access policy.

The above applies in addition to any condition set out elsewhere within the DSA (e.g. who may carry out processing, and for what purpose).

The Data will not leave England/Wales at any time.

All data are accessed by a substantive employee of Imperial in the Secure Data Environment (SDE) within NHS England.

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

The applicant will process and analyse the Data for the purposes described above.

The outputs from this work will only contain aggregated information with small numbers suppressed.

The work from all studies will be reported in the applicant’s final PhD thesis which will be submitted in October 2026.

HES data processing will result in multiple outputs, for both the scientific community and wider public. HES data will be used to directly produce outputs and to hopefully inform planned qualitative research also. The outputs will include, but are not limited, to:

1. Conferences

The outputs from this study will hopefully be submitted to appropriate conferences in order to share the new knowledge will key stakeholders. Conferences to be targeted include those with a focus on surgery and health inequalities (e.g Academic Surgical Congress meeting, Association of Surgeons Great Britain and Ireland [ASGBI], UKHSA conference etc)

2. Reports

Updates on the study progress, and study results, will be processed into reports which will be circulated amongst the Department of Surgery and Cancer at Imperial. These reports will also be used by the Patient Safety Research Collaborative to feedback to the NIHR on the progression of funded projects. Reports summarising key findings from each study will be developed and shared with the Centre for Health Policy at Imperial. Collaborative working with this centre will aid in the production of appropriate reports to be shared with the Department of Health and Social Care along with key recommendations for policy which could foster further inclusive development of this care model.

3. Peer Reviewed Publications

Study 1 – Mapping GP referrals for elective surgical care in England

It is hoped that the outputs from this study to be submitted to appropriate journals (e.g. International Journal for Equity in Health, The Lancet Public Health, Journal of Public Health, British Journal of Surgery, JAMA Surgery) in January/ February 2025 (depending on when the data from NHS England is received). Materials for conferences will be prepared alongside the preparation of scientific articles and will be submitted to appropriate events when the call for abstracts open.

Study 2: Cluster analysis of surgical hubs to determine their impact on health inequalities in elective surgery

Imperial plan for the outputs from this study to be submitted to appropriate journals in Spring/Summer 2025 (depending on when the data from NHS England is received). Materials for conferences will be prepared alongside the preparation of scientific articles and will be submitted to appropriate events when the call for abstracts open.

This study hopes to demonstrate the impact of surgical hub creation on timeliness of care provision, patient outcomes and location of care according to markers of inequality. Imperial believe this will be the first study to determine this and will complement any outputs from the recently set up NIHR MEASURE study at the University of York. Imperial hope that the results from this study will result in the submission of a peer-reviewed article to an appropriate journal.

A report for submission to the Royal College of Surgeons and the Get It Right First Time Team at NHS England will also be produced. This report will detail any positive or negative impacts from surgical hub creation which potientially will then be used to inform future hub development. Utilising contacts at Imperial and the Centre for Health Policy, this report is expected to be shared with the Department of Health and Social Care. As a key target of the new Labour government is to reduce waiting times and address health inequality, this report intends to identify policy level initiatives which could be deployed to facilitate further inclusive hub development.

Dissemination Activities

In addition to the above scientific dissemination activities, a range of other activities to engage key stakeholders, policy makers and the public will be undertaken across the 3-year PhD project.

1. Engagement with Policy Makers

In addition to the submission of formal reports and briefing documents to the Department of Health and Social Care as stated above, Imperial hopes to involve individual MPs by writing directly to them. Imperial will identify MPs potentially interested in this area by using the “theyworkforyou” website which provides a record of all discussions in parliament along with written statements and memos. Through the identification of MPs who are interested in elective surgery, waiting times and health inequalities, Imperial can directly engage these individuals with their research and the results/outputs of it. The same website and the gov.uk website can also be used to identify any select committees in this field of research. Imperial will then submit evidence to these committees to help inform their discussions and recommendations.

2. Engagement with Key Stakeholders

There are multiple key stakeholders for this project, ranging from the UK government and national healthcare bodies (NHS England, Royal Colleges etc) to Integrated Care Boards, individual hospital trusts, patients and the wider public.

Imperial is assembling a project advisory committee which will incorporate medical professionals, patients and administrative staff. The function of this committee will be for the study researchers to inform them of the project direction and outputs whilst also enabling the committee to inform future areas of research to be covered which are of importance. Imperial will plan that this committee will meet remotely 3 times a year and in the interim, key developments will be shared via email in plain English.

Imperial has already spoken directly with a member of staff at NHS England who works within the Health Inequalities Improvement Programme to inform the NHS England representative of this project. Whilst this project does not align with the Core20Plus5 initiative which the programme is currently focusing on, this project could potentially complement the work and assist the call of the Health Innovation Network to assess the impact of surgical hubs on inequalities. Imperial will utilise these, and further contacts, to maximise dissemination of the analysis to appropriate individuals.

The Royal College of Surgeons (RCS) is also a key stakeholder. Imperial has contacted the RCS to inform them of this research and will liaise with them throughout the project. If possible, Imperial are looking to recruit an RCS committee member to the project advisory group. The RCS have regular events throughout the year and Imperial hope to present the outcomes of this study at these events to show progress to date and to network with other interested individuals/ bodies which may influence the work. These may also provide opportunities for collaboration which would maximise the impact of these projects.

Imperial also hope to utilise the national Patient Safety Research Collaborative (PSRC) Network. Imperial has contacted all PSRCs across England to inform them of the projects and to discuss utilisation of their networks for dissemination of project findings to patients and under-served groups.

3. Patients and the Public

It is believed that the results from this work will be of importance to patients and the wider public. As such, specific materials detailing this work will be disseminated. These materials will take the form of social media updates, plain English summaries and infographics/ posters. These materials will be produced and publicised throughout the project as key findings emerge. Through discussion with the Patient and Public Involvement and Engagement team at Imperial College London, these materials will be disseminated across established mailing lists.

If the research identifies particular groups which are experiencing inequity due to this care model, then there will be specific outputs targeted directly to these groups. Utilising the established links at Imperial with under-served communities, Imperial will co-produce targeted patient/public materials to maximise their impact. Imperial will also disseminate these materials in high-traffic areas as discussed with the communities (e.g. libraries, community halls, places of worship etc).

In June each year, Imperial hosts the Great Exhibition Road Festival. This festival is open to the public and the study team intend to submit an application for a stand in June 2025 to publicise the project along with results. The study team would design their stand in a public-friendly manner with eye catching displays and activities in order to deliver the key messages effectively.

The expected benefits of this work to health and social care are multiple.

The projects will detail the demographics, geographic distribution and patient outcomes (including timeliness of care) of the contemporary elective surgical population in England. Through understanding the current patient demographics, influence of comorbidity and any variation in service, it is hoped policymakers will be better informed to understand the health needs of the population and plan appropriate surgical services from contemporary data. This potentially will complement the current government’s aim of addressing long waiting lists for elective care and will provide a richer dataset than just measuring waiting time alone. Using the results from the projects, it is the aim that policy briefs will be created and shared with appropriate policymakers in Spring 2026.

New knowledge, particularly regarding the prevalence of multimorbidity in the surgical population, will inform current practice guidelines for the utilisation of “cold” sites, especially surgical hubs. Current guidelines indicate that these centres should be used for low risk patients with low complexity procedures, but the “traditional” low risk patient may now represent a small proportion of patients waiting for surgery. The results will be shared with the Royal College of Surgeons (RCS) and the Get It Right First Time team at NHS England with the aim of fostering further research to determine consensus on patient characteristics which may be compatible with “cold” site care. Presentation of the results to the RCS is planned for Summer 2025. The presentation materials can also be shared with RCS Edinburgh and Ireland to facilitate their plans in creation and implementation of “hot” and “cold” surgical sites, thus potentially providing benefit to the Scottish and Irish populations also.

Through the influence of the research on policy and service design (as outlined above), patients will benefit too. There are also specific dissemination plans, however, to ensure that the results of the research directly reach patients and provide additional benefit also. Through the work examining the impact of multimorbidity on elective surgery, plain English materials will be co-produced demonstrating the impact of multimorbidity across the elective surgical pathway. Depending on the research results, and outcomes of discussions with the coproduction team, these materials can be targeted to specific communities. The production of these materials is scheduled for Autumn 2025. The public will also benefit from gaining further/ new understanding of what the current model of surgical care is in England and how it is delivered. Facilitating this transparency, particularly with under-served groups, may empower patients to seek care and improve trust in the healthcare system.

It is hoped that this work will add to the growing body of evidence about health inequalities in England. By further growing this evidence pool, medical professionals, the health system and the wider public can be better informed regarding the challenges faced and work collaboratively to address these issues. It is hoped that this work will also highlight areas for future research to be undertaken and will add to evidence calling for improvement in the recording of inequality measures such that we can progress to individual level measurements of inequality.

Yielded Benefits is not a requirement for new applications.