Good TREs work
Cumbria, Northumberland, Tyne And Wear NHS Foundation Trust projects
86 data files in total were disseminated unsafely (information about files used safely is missing for TRE/"system access" projects).
Access to NHS Digital on-line portal — DARS-NIC-10328-S0H5J
Opt outs honoured: No - data flow is not identifiable, Anonymised - ICO Code Compliant (Does not include the flow of confidential data)
Legal basis: Health and Social Care Act 2012, Health and Social Care Act 2012 – s261(1) and s261(2)(b)(ii), Health and Social Care Act 2012 s261(1) and s261(2)(b)(ii), Health and Social Care Act 2012 - s261 - 'Other dissemination of information',
Purposes: Yes (NHS Trust)
Sensitive: Non Sensitive, and Non-Sensitive, and Sensitive
When:DSA runs 2019-08-02 — 2020-08-01 2017.06 — 2017.05.
Access method: Ongoing, System access, System Access
(System access exclusively means data was not disseminated, but was accessed under supervision on NHS Digital's systems)
Data-controller type: CUMBRIA, NORTHUMBERLAND, TYNE AND WEAR NHS FOUNDATION TRUST
Sublicensing allowed: No
- HES Data Interrogation System
- Hospital Episode Statistics Admitted Patient Care
- Hospital Episode Statistics Accident and Emergency
- Hospital Episode Statistics Outpatients
- Hospital Episode Statistics Critical Care
- Emergency Care Data Set (ECDS)
The HDIS system enables organisations to access HES data for a wide range of data analytical purposes. The system is an online analytical processing tool through which the users of this organisation data has access to a wide range of analytical, graphical, statistical and reporting functions. Access is provided to the entire HES dataset (non-identifiable) for the specific purposes as listed below.
The North East Quality Observatory Service (NEQOS) uses the system to support the measurement of quality of care, including care delivered in hospital. Access to HES data enables NEQOS to offer a comprehensive healthcare quality measurement service to the health economy in the North East and North Cumbria, and increasingly beyond. It is believed that the information provided is able to inform providers / clinicians, commissioners, regulators and others of improvements that are necessary and highlight best practice.
HES is the principal source of hospital data and underpins several NEQOS projects and products. It is one of the key resources used to get beneath the surface of quality in a provider organisation and ensure that the right things are being measured to support the quality improvement agenda. It provides data for the construction of a significant percentage of the indicators which have been developed to enable front line staff to effectively monitor, evaluate and improve their services.
Specific areas of work requiring NEQOS to use HES data are as follows:-
• Quality improvement work such as implementation of new pathways and service evaluation;
• Patient safety;
• Monitoring adherence to best practice including NICE Quality Standards;
• Understanding variation in the utilisation and cost of healthcare;
• Identifying priorities for action;
• Estimating the incidence of certain conditions and treatments, and allowing gaps in service provision to be identified.
Current clients include or have included:
• NHS organisations (both providers and commissioners) across the North East and North Cumbria region, and occasionally further afield (within England);
• The Academic Health Science Network (AHSN) in the North East and North Cumbria;
• Health Education England – North East and North Cumbia;
• NHS England;
• Orthopaedic Research UK.
An important advantage of having access to HES data is the benchmarking capability it offers. It also enables NEQOS to support the national agenda in a range of areas, by facilitating benchmarking and analysis on a national footprint for national bodies.
The inclusion of geographical identifiers in the HES dataset allows to analyse access to treatments according to geography and / or socio-demographic variables (e.g. deprivation).
The use of a pseudonymised patient Identifier enables the HES dataset to provide a longitudinal picture of what happens to patients, and it is aimed to use it to track over time, cohorts of patients meeting specific criteria (e.g. in terms of age, diagnosis, procedures), in order to better understand experience and utilisation of hospital services, pathways, and on-going healthcare needs.
Data accessed via the HDIS database will only ever be used for purposes related to healthcare or the promotion of health, in line with the Health and Social Care Act 2012 as amended by the Care Act 2014.
The analysis of HES data by NEQOS has had the following benefits: · The re-design of the national back pain pathway has been informed by robust data on the whole population of England using hospital services for back pain. It has been possible to quantify the extent to which treatments are being given which do not comply with best practice (e.g. NICE guidance) and this information has been used to design new pathways to ensure that appropriate treatments are available. · It is facilitating targeted action by the vascular and maternity workstreams of the national "Getting it Right First Time" Initiative, aimed at improving the quality and safety of care in trusts, whilst improving operation efficiencies in hospitals. The HES data identifies variation in care decisions, patient outcomes, and costs which GIRFT is working with individual trusts to address. · the submission of data to the National Joint Registry in relation to shoulder replacement surgery has improved for several of the North East trusts since NEQOS reported relatively poor submission rates in our first shoulder dashboard (by comparing the number of operations reported to the NJR was compared to the numbers reported in HES). This is important from a patient safety perspective. · Using the information reported in the NEQOS Hip and Knee Dashboard, 4 out of the 5 subscribing Trusts in the North East have reduced the mean length of stay in hospital following elective knee surgery, and 2 out of the 5 have reduced the length of stay following hip surgery. In relation to emergency readmissions within 30 days of discharge, 3 trusts have reduced their readmission rate following knee replacements and 4 following hip replacements. · The health and social care system in the North East now has firm evidence (as opposed to anecdotal evidence) that individuals with mental health problems have higher hospital admission and A&E attendance rates than the general population, and substantial differences in reasons for hospital admission. These findings, which emerged from using HES to track, over a 9 year period, a patient cohort admitted to a large North East mental health trust, are enabling the wider system in the North East (ICS) to tackle these issues. · Analysis of HES data is an important element of service evaluations. For example, HEs data has been an important data source enabling initiatives aimed at keeping people out of hospital to be evaluated. The analysis of HES data helps to answer the question as to whether hospital admissions / A&E attendances have reduced since a specific initiative (e.g. Falls reduction initiative) was put in place.
The use of HDIS mean that users and organisations have a secure access, remotely hosted software application for the analysis of HES data. The system is hosted and audited by NHS Digital meaning that large transfers of data to on-site servers is reduced and NHS Digital has the ability to audit the use and access to the data. The provision of a tool enables that rapid analysis can be performed to the latest version of the data where speedy analysis is required to react to either local public health, commissioning or research requirements.
NEQOS outputs are produced in response to clients’ needs and are made available to organisations which then use them to achieve benefits for patients and the health economy, such as for driving quality improvements, reducing costs and prioritising work programmes. So whilst NEQOS does not undertake health / healthcare improvement work directly, or commission healthcare, NEQOS analyses facilitate other organisations to do so. Access to HES data enables NEOQS to offer a valued benchmarking service to providers and commissioners across a wider geographical area than access to SUS allows. Regional, national and peer group comparisons are possible, enabling sub-optimal healthcare quality to be highlighted and best practice to be identified and celebrated. Commissioners, providers/clinicians have an increased awareness of quality issues, are better informed about the care being provided, and better engaged in improving its quality.
Some specific examples of the benefits that are being realised using the intelligence provided from HES data are as follows:
• Some of the information provided is used to re-design services and pathways for patients. For example, back pain profiles are being used to inform a national Pathfinder project designed to de-medicalise low back pain, improve the quality of patient care, provide community based alternatives to secondary care admissions for back pain and reduce secondary care expenditure. Low back pain is extremely common and is the largest single cause of loss of disability adjusted life years, and the largest single cause of years lived with disability in England. It accounts for 11% of the entire disability burden from all diseases in the UK and is increasing. The back pain pathway is a high value care pathway due to the very large number of patients involved. It crosses commissioning and health care boundaries, from general practice, through community services and into secondary care and sometimes specialised services. Difficulties in commissioning across boundaries, can cause interruptions in what should be a seamless care pathway. The pathfinder project, which NEQOS is supporting through the provision of intelligence based on HES data, is requiring all stakeholders to work collaboratively to examine in depth these health care interfaces and to develop commissioning structures to commission care across the whole pathway.
• Another of the projects, with which is supporting a client with intelligence drawn from HES, should lead to improvements in patient safety for children and young people within the North East and North Cumbrian region. The project aims to decrease Paediatric Intensive Care Unit admissions and cardiac arrests, decrease acute hospital emergency admissions, decrease Accident and Emergency attendences that do not lead to admission, and increase family health literacy for acute childhood illness. Reductions in readmissions and death are also some of the anticipated outcomes.
• An improved patient experience with faster recovery is one of the benefits that results from the use of the NEOQS hip and knee dashboard. This product, which utilises HES data, enables Trusts to monitor enhanced recovery pathways as it includes metrics measuring length of stay and emergency readmissions within 30 days of discharge.
• NEQOS is also using HES to highlight issues with data quality and completeness which may be putting the long-term safety of patients at risk. One area of focus for NEQOS Shoulder Surgery dashboard has been in highlighting low levels of reporting to the National Joint Registry (NJR). The NJR records data on shoulder replacements and analysis of this information provides the clinical evidence to surgeons and the wider healthcare community in order to improve patient safety and patient care. For example, the data are essential for deciding which prostheses and procedures are appropriate for which patients to ensure patient safety. Analysis by NEQOS, in which the number of operations reported to the NJR was compared to the numbers reported in HES, demonstrates an urgent need to rapidly improve data reporting to the NJR of shoulder replacements, which have much lower levels of reporting than hip and knee replacements.
• Analysis may sometimes demonstrate the need for educational materials to be developed to encourage patients, carers and the wider healthcare community to recognise the importance of using the correct pathway and services. For example, one of the projects is expected to show that there is a need for educational materials to be developed to direct patients with a specific condition to a specific unit for follow-up care as it is expected that this leads to better outcomes and less complications as well as financial savings to the NHS.
• HES is an important resource for the design and production of measures to support service evaluation and prioritisation activities. For example, HES data is used to help the AHSN Programme Leads to identify priorities and evaluate the impact of initiatives with respect to improvement in quality or clinical variation. Metrics based on the analysis of HES data will ultimately:
o Provide objective evidence of the current major strengths and challenges for the North East and North Cumbria AHSN in terms of population health and healthcare;
o Enable the AHSN to objectively monitor changes (improvements) in the region’s population health and healthcare processes/outcomes; and
o Enable the AHSN to monitor and evaluate the impact of its initiatives (measure success).
Users of HDIS are able to produce outputs from the system in a number of formats. The system has the ability to be able to produce small row count extracts for local analysis in Excel or other local analysis software. Users are also able to produce tabulations, aggregations, reports, charts, graphs and statistical outputs for viewing on screen or export to a local system. Any outputs that are produced from the system that are to be published or shared will be small number suppressed outputs in line with the HES analysis guide. Users are not permitted to link data extracted from the system to any other data items which make the data identifiable.
The outputs are made available to subscribers or those who commission work from the department. The precise nature of the outputs is determined by the clients’ requirements and so the outputs are continually evolving to meet clients’ needs. Some are ad hoc and others are produced routinely (monthly, quarterly, bi-annually, annually), as required to meet clients’ needs or in line with availability of the underlying data. Some of the outputs which are currently produced or are currently developing are listed below.
Example of NEQOS outputs
Product 1: National Hip and knee dashboard
Description: This dashboard provides a more detailed overview than that available elsewhere, of the quality of care for these elective procedures and enables Trusts to monitor enhanced recovery pathways by including length of stay and emergency readmissions within 30 days of discharge.
Several of the indicators in this dashboard are constructed using HES data.
Clients / Distribution Frequency: 1. NEQOS subscribing NHS Trusts in the North East - refreshed twice a year. 2. NHS England national initiative “Getting it Right First Time” - The most recent update, for all Trusts in England, will be included as part of the orthopaedic reports for the national DH funded Getting It Right First Time (GIRFT) initiative.
Reporting: Data is aggregated and reported at NHS trust level.
Product 2: National Shoulder Surgery Dashboard
Description: This dashboard, for all Trusts in England, highlights where a Trust is different from the national picture and there is a need for further investigation to ascertain if there is an issue with the quality of the data or the quality of patient care. The dashboard has been developed in collaboration with upper limb surgeons and several of the indicators are constructed using HES data.
Clients / Distribution Frequency: This dashboard which was funded by Orthopaedic Research UK is being included as part of the Getting It Right First Time (GIRFT) orthopaedic reports. During the development phase of the dashboard it was showcased at the British Elbow and Shoulder Society (BESS) Annual Conference in 2015. Produced once so far, but are hoping to secure funding to produce it on a regular basis.
Reporting: Data is aggregated and most of the indicators are reported at NHS trust level. One indicator is reported at CCG level.
Product 3: National Varicose vein dashboard
Description: A prototype dashboard monitoring variation in access to surgery across CCGs and compliance with the NICE Quality Standard, in relation to varicose vein surgery. The dashboard has been developed in collaboration with vascular surgeons and several of the indicators are constructed using HES data.
Clients: Initial development of the prototype was funded by one subscribers. NEQOS are currently trying to secure funding to roll out nationally. Two presentations based on the analysis undertaken for the dashboard were presented at the National Venous Forum in London in May 2015. A presentation based on the analysis was presented at a National PROMS summit in December 2015.
Distribution frequency: To be decided.
Reporting: Data is aggregated and most of the indicators are reported at NHS trust level. One indicator is reported at CCG level.
Product 4: National Back pain profiles
Description: These profiles aim to assist clinicians and commissioners to better understand variation in the volume, type and costs of secondary care activity, related to low back and radicular pain, across England. All of the indicators have been constructed, in collaboration with spinal surgeons, and using HES Inpatient data. NEQOS are currently in the process of producing regional profiles for every region in England.
Clients: The profiles are being used to inform the development of an NHS England National Pathfinder initiative: National Pathway of Care for Low Back and Radicular Pain and by the NHS England national initiative “Getting it Right First Time”
Two presentations based on the analysis undertaken for the dashboard were presented at the National Venous Forum in London in May 2015. A presentation based on the analysis was presented at a National PROMS summit in December 2015.
Distribution frequency: Produced once so far.
Reporting: Data is Aggregated and reported at Provider, CCG and GP Practice level, benchmarked against regional and national averages.
Product 5: AHSN Surveillance report
Description: This report contains indicators derived from HES in relation to (i) hospital utilisation rates for ambulatory care sensitive conditions and for A&E and outpatient attendances (ii) Review to New ratios for Outpatient attendances and (iii) length of stay statistics.
Indicators, produced using HES data, provide evidence of the current pressures on urgent care, and how specialist services are being used in the North East and North Cumbria compared with elsewhere.
Clients/: North East & North Cumbria Academic Health Science Network (AHSN)
Distribution Frequency: Refreshed twice per year.
Reporting: Aggregated data is reported by CCG, benchmarked against regional and national averages.
Product 6: Profiles of organisational performance against selected NICE Quality Standards (e.g. heart failure, diabetes)
Description: These profiles are produced using a variety of data sources, including HES.
Clients EQOS subscribing NHS Trusts in the North East.
Distribution Frequency: Determined by clients’ requirements.
Reporting: Aggregated data is reported by NHS Trust and/or CCG, with comparisons with regional and national averages.
Product 7: Tracking cohorts of patients
Description: In these projects NEQOS aim to identify a cohort of patients meeting specific criteria (e.g. have had a specific diagnosis or procedure) and then track the cohort. NEQOS do this for a number of reasons such as:
• to enable clients to better understand patient flows, patient experiences, the utilisation of hospital services either before or after the index admission, and
• to compare existing pathways against agreed best practice.
Clients: North East subscribing Trusts.
Distribution Frequency: One-off projects at present, but NEQOS may be commissioned to undertake routine monitoring in the future.
Reporting: Data will be reported as aggregated statistics.
The plan to make use of the pseudonymised patient Identifier in the HES datasets to track cohorts of patients meeting specific criteria (for example, with a specific diagnosis such as sepsis, admitted in a specific time period to a specific Trust) in order to better understand experiences, utilisation of hospital services and pathways, and in some cases, to compare pathways with established best practice, such as NICE guidelines. This will involve tracking patients across the Inpatient, A&E or Outpatient HES datasets in order to identify other admissions/re-admissions / attendances which they have had over a specified time period, which could be either before or after the index admission, depending on the purpose of the project. The outputs reported will be aggregated statistical data, for example, the number and proportion of admissions by Trust, specialty, primary diagnosis.
Another area of work where the use the pseudonymised patient Identifier in the HES dataset is when examining the quality of specific aspects of clinical care and there is a need to understand the sequencing of treatments patients have had. For example, the use of the pseudonymised patient Identifier in HES is to track, for one year, patients who have had a subacromial decompression, in order to see whether they have gone on to have a primary shoulder replacement with a year. Then report aggregated statistics by Trust such as the percentage of patients who have had a shoulder replacement at any provider within a year of the subacromial decompression. Having a high proportion may suggest that some patients with more severe pathology may be having an inappropriate initial procedure when they should be having a full shoulder replacement.
Please note that the above list is not an exhaustive one of outputs, but aims to demonstrate the nature and scope of the work undertaken using HES data. At the moment the majority of work is undertaken for subscribing organisations, whom have annual Service Level Agreements are held. Work is also undertaken for one-off bespoke projects for clients.
Any outputs produced will be limited to aggregate data with small numbers suppressed in line with the HES analysis guide.
HDIS is accessed via a two-factor secure authentication method to approved users who are in receipt of an encryption token ID. Users have to attend training before the account is set up and users are only permitted to access the datasets that are agreed within this agreement. Users log onto the HDIS system and are presented with a SAS software application called Enterprise Guide which presents the users with a list of available data sets and available reference data tables so that they can return appropriate descriptions to the coded data.
The access and use of the system is fully auditable and all users have to comply with the use of the data as specified in this agreement. The software tool also provides users with the ability to perform full data minimisation and filtering of the HES data as part of processing activities. Users are not permitted to upload data into the system.
HES data is used to:
1. Produce aggregated tables and charts displaying statistical data (for example by CCG, Local Authority, Region, NHS Trust, Independent Sector Provider, GP practice), which takes account of the need to suppress small numbers to prevent potential disclosure of identity, and in line with the HES analysis guide.
2. Benchmark organisations, for example against peers in the same region or elsewhere in the county, and against regional and national averages / best / worst.
3. Trend analysis which includes consideration of data over time to establish any relevant patterns. Trend analysis is most often conducted on a quarterly or annual basis.
4.Combine the outputs from HES (i.e. numbers) with other data (e.g. resident population figures produced by ONS, CCG populations produced by NHS Digital (formerly known as the Health and Social Care Information Centre)) to generate rates.
5. Create Continuous Inpatient (CIP) spells (i.e. superspells) using NHS Digital methodology, in order to calculate re-admission rates and better understand patient flows.
6. Track cohorts of patients meeting specific criteria over time in order to better understand patients experience and utilisation of hospital services, pathways, and on-going healthcare needs. This will sometimes involve tracking patients across the Inpatient, A&E and Outpatient HES datasets, and will make use of the pseudonymised patient Identifier in the HES datasets to do this.
The HES data will not be linked to any other datasets. For analysis purposes data will tracked at patient record level, there is no requirement within any project to present the data at this level.
For example it is required for the need to use the HES pseudonymised patient Identifier, in conjunction with the spell identifier, to track episodes or spells in order to identify re-admissions, re-operations within the same spell (but not necessarily the same episode) or the frequency with which a certain procedure is undertaken within a specified timeframe of a different procedure (e.g. % of primary shoulder replacements undertaken within one year of subacromial decompression and/or rotator cuff repair).
Only aggregated statistical data will be reported with small numbers supressed in line with the HES analysis guide.
7. Compare aggregated data from HES with data published by other organisations. For example, comparison is carried out with the number of Shoulder Joint replacement operations recorded in HES with the numbers reported by the National Joint Registry (NJR) in order to calculate data submission rates to the NJR for NHS Trusts. The number of operations are compared for Abominal Aortic Aneurysm recorded in HES with those reported by the National Vascular Database (NVD) to assure that the correct clinical codes have been used to identify the activity in HES for North East and North Cumbria trusts.
8. HES data would be useful to estimate the cost of secondary care activity, by combining it with NHS Reference Costs. Work has been undertaken on one of the projects, by downloading record level data via HDIS1 and then uploading it to the HRG Grouper software in order to add the Spell HRG, which is in turn mapped to the HRG Reference Cost data. Advice is being taken from NHS Digital as to whether and how it may be possible to undertake this work in the future using HDIS2.
NEQOS are only ever commissioned to undertake work on behalf of public sector organisations or charities. This application does not permit the HDIS database to be accessed and used for the purpose of work on behalf of commercial organisations/pharmaceutical companies.
Access to HDIS from South Tees Hospitals NHS FT is required to enable one of the analyst's based at South Tees to use the system without the need for travel to the Northumberland Tyne & Wear NHS FT site.