‘Usual Care’ versus ‘Specialist Integrated Care’: A Study of Hospital Discharge Arrangements for Homeless People in England

This Data Sharing Agreement permits the retention of the data provided under previous iterations of this Agreement for an interim period. Permission to retain the data for the interim period is a practical step to enable the study to comply with the necessary legal and ethical requirements. If, for any reason, it is not possible for the study to meet the necessary requirements, this Agreement will be terminated and destruction of the data will be required.

The following information provides background information on the purpose of the original study:

The aim of this work is to evaluate the impact of specialist hospital discharge services developed as part of the Department of Health’s Section 64 (voluntary sector-led) ‘ten million pound cash boost’ to improve hospital discharge for homeless people compared to "usual care" and are funded to do this work. Specifically University College London (UCL) will evaluate evidence of differences in time-to-subsequent hospital admissions (re-admissions) and mortality between i) homeless people accessing care at discharge services delivered by participating study sites, ii) homeless people admitted to hospitals without specialist services and iii) hospitalised non-homeless people in the most deprived quintile. In addition, the study aims to quantify differences in the characteristics of people in each of the three groups that could drive differences in rates of readmission or mortality irrespective of the hospital care available. UCL will also present stratified data for the two dominant types of specialist hospital discharge schemes (housing-link and clinically-led services).

The principal research objectives are outlined as follows:

1. What are the rates of hospitalisation (overall admission rates, unscheduled admission rates and 28-day emergency readmission rates) for homeless people? Do these rates vary by type of specialist homeless hospital discharge service?

2. What are the mortality rates (including avoidable mortality) in homeless people and do these rates vary by type of specialist homeless hospital discharge service? How do mortality rates compare to people in the most deprived quintile who are not homeless?

3. What is the duration of hospital admission in homeless people accessing and not accessing specialist homeless hospital discharge services?

In addition UCL will present summary data for the characteristics of hospitalised individuals within each group (homeless accessing specialist services, homeless not accessing specialist services, deprived non-homeless).

The first work package seeks to gain an informed understanding of the ways in which specialist integrated homeless health and care services (SIHHC services) are being developed and implemented to facilitate hospital discharge in England and the impact this is having on quality of care and organisational outcomes such as the prevention of readmission to hospital. For this work package, local service providers will be asked to identify and nominate potential participants.

The second work package (WP2, for which support is requested for datasets 1, 3, 4, and 5) is a data linkage and health economic analysis work package that will work with twenty sites across England where homeless patients have been admitted to hospital. A cohort of homeless people who have used specialist discharge scheme will be compared to a cohort of homeless people who have not used such provision. The study will also compare patient’s hospitalisation history before and after engagement with specialist services. Analysis will also be undertaken to understand whether the outcomes are a factor of homelessness specifically or are tied to deprivation.

Data provided will not be shared with Kings College London.

Under this Agreement, the data may be securely stored and processed only for the purpose of pseudonymising the data. Processing of the data for any other purpose is not permitted under this Agreement. No new data will be provided by NHS Digital under this Agreement.

The study data, including data provided by NHS Digital under previous agreements, are currently held by University College London (UCL).

The following provides background on the processing activities undertaken for the original study:

Three groups of individuals admitted to hospital will be included in the study. The first group are homeless individuals admitted to hospital at any one of the 16 sites which offer a specialist discharge scheme. The second group are individuals seen by a community homeless service in London, Find and Treat. Find and Treat is a specialist outreach team that work alongside over 200 NHS and third sector front-line services to tackle TB among homeless people. The third group are a random sample of individuals equal in size to the Find and Treat group and are living in the lowest quintile of deprivation areas.

Three main datasets will be used for analysis:

• Unconsented data collected at the 16 sites that are part of this study

• Unconsented data from Find and Treat

• Linked HES and mortality data

Data flow from specialist hospital discharge services for homeless people, and from Find and Treat services for homeless people:

1) At each site the research team will compile identifiers (NHS number, forename, surname, aliases, date of birth, sex) for each patient accessing the service between November 2013 to November 2016 and create a unique study identifier for each record for the service provider.

2) The data requested for the study will then be securely uploaded and processed at University College London (UCL). The data will be stored and cleaned.

3) Identifiable information (NHS number, forename, surname, aliases, date of birth, sex,) required by NHS Digital for the linkage to Hospital Episode Statistics/mortality will at this point be transferred to NHS Digital with the unique study identifier.

4) NHS Digital will use the Personal Demographics Service (PDS) to add NHS number (where missing) to the identifiable data from homeless healthcare users.

5) When NHS Digital have confirmed that the list is clean, and linkage to HES has been completed, the researchers will de-identify all data held by the researchers at UCL (i.e. all identifiers except the unique study identifier will be destroyed).

6) The data requested for the study - including the unique study identifier - will then be securely uploaded and processed on the data safe haven at UCL in line with the published study protocol.

Dataset 1 will consist of data from homeless healthcare users and include forename, surname, aliases, date of birth, sex, address, contact numbers, hospital of admission, date of hospital admission, nationality, ethnicity, and NHS number. This data will be collected from study fieldwork sites.

Dataset 3 will consist of data from homeless healthcare users and include forename, surname, aliases, sex, address, land contact number from Find and Treat Service.

Dataset 4 Personal Demographics Service data from homeless healthcare users, including date of hospital admission, date of hospital discharge, date of hospital appointment and date of death. The data within PDS will be used to provide missing NHS numbers for Dataset 1 and Dataset 3. The research team will not at any point have access to these NHS Numbers, which will be used to improve the linkage of data to HES data.

Dataset 5: HES-mortality data from homeless healthcare users and a geographically comparable and representative sample of lowest quintile of deprivation population in HES equal in size to the Find and Treat dataset. This data will be de-identified by NHS Digital.

Outputs will contain only aggregate level data with small numbers suppressed in line with HES analysis guide.

No new outputs will be produced under this Data Sharing Agreement.

UCL have completed analysis on all primary outcomes for the study, but have not yet undertaken analyses on several secondary outcomes and some mortality outcomes as these data were not all included in the initial linked dataset. The extension will, therefore, allow UCL to complete these analyses and complete a number of reports, detailed as follows:

UCL are still working on a report for the funders (The National Institute for Health Research (September 2020)), including a Health Technology Assessment. This document will outline the results from the objectives and analyses outlined in the study protocol and include a "roadmap" for commissioners (see Benefits section).

- Aggregated, with small numbers suppressed in line with the HES analyse guide, site-specific summary of readmissions and mortality for each of the sites participating in the study (September 2020). This information will help sites better understand the care pathways of patients accessing their services.

To assist with development of policy from the findings a series of planned feedback events across the country. These events will be attended by local stakeholders - including the homeless health charity Pathway, homeless service users, health and social care commissioners and service providers - who are well placed to help the researcher disseminate the findings in an effective way. These events will aid translation of the results into a "roadmap" against which commissioners can explore the strengths and weaknesses of their local provision. A final version of the roapmap will be published as part of a Health Technology Assessment paper, for use by policy developers such as NICE.

The findings of this study are intended to feed into policy development for care pathways for homeless people accessing hospital and housing services. Policy responses are expected within 5-10 years, i.e. 2023-2028.

In addition the outputs from this study will enable Commissioners to make better informed decisions in relation to the specialist services within this research.

The findings from this study will enable Commissioners to ensure specialist services offered within their area are better targeted to suit the needs of the local population.

As a direct result of this research, subsequent policy development and better commissioning, UCL expect that this study will directly benefit patients the aim is to identify and improve:

- How hospital readmissions can be prevented through the provision of specialist services for people with experience of homelessness

- How to help prevent people with experience of homelessness having to visit emergency departments after a hospital admission

- How to provide more appropriate hospital treatment to people with experience of homelessness

- How to avoid deaths in people with experience of homelessness through the provision of better services and treatment whilst in hospital

In any future application, the applicant will be required to provide details of the expected benefits resulting from the study.

UCL have completed analysis on all primary outcomes for the study, but have not yet undertaken analyses on several secondary outcomes and some mortality outcomes. Aggregated results of the primary outcome analysis completed thus far has enabled UCL to use the data to complete an economic analysis of the hospital discharge schemes.