Good TREs work

Royal National Orthopaedic Hospital NHS Trust projects

46 data files in total were disseminated unsafely (information about files used safely is missing for TRE/"system access" projects).

Client Health Data - GIRFT extension program at the Royal National Orthopaedic Hospital (RNOH) NHS Trust — DARS-NIC-759654-D8H5M

Type of data: information not disclosed for TRE projects

Opt outs honoured: Anonymised - ICO Code Compliant (Does not include the flow of confidential data)

Legal basis: Health and Social Care Act 2012 – s261(2)(a)

Purposes: Yes (NHS Trust)

Sensitive: Non-Sensitive

When:DSA runs 2024-08-16 — 2027-08-15 2024.08 — 2024.09.

Access method: System Access
(System access exclusively means data was not disseminated, but was accessed under supervision on NHS Digital's systems)

Data-controller type: ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST

Sublicensing allowed: No

Datasets:

  1. Diagnostic Imaging Data Set (DID)
  2. Emergency Care Data Set (ECDS)
  3. Hospital Episode Statistics Admitted Patient Care (HES APC)
  4. Hospital Episode Statistics Outpatients (HES OP)

Expected Benefits:

NHS England has considered the public benefit associated with this work based on relevant criteria set out in the National Data Guardian Guidance and believes there is a sufficient case to justify sharing data as proposed. Key points in relation to this are summarised below:

1. Firstly, the GIRFT work carried out by RNOH provides independent sector or devolved clients with a clear, benchmarked mechanism for checking the quality of care, identifying good practice to learn from and areas of poorer practice which need to be addressed. This represents a direct benefit to the public.

2. Independent sector providers deliver services for a significant proportion of the England population and therefore improvements in the quality of NHS or private healthcare services provided for this group of patients will benefit the public directly.

3. In addition to the direct benefits to patients identified above, there are indirect benefits to the NHS since better outcomes from these providers can reduce the burden on the NHS e.g. reducing emergency admissions or subsequent elective admissions following
complications after surgery; reducing the need for follow up and support services etc.

4. Similar benefits can be seen where the RNOH GIRFT work assists the NHS in devolved nations to improve, as there is considerable overlap in the populations served near borders (e.g. England and Wales) and hospitals in the devolved nations also deliver
services for many patients that live in England (e.g. when on holiday) with follow up care provided once back at home in England.

5. However perhaps the key area for NHS England is the indirect benefit of capturing learning for the NHS. It is agreed with RNOH that the learning from all GIRFT Extension Programme projects must be shared with NHS England. Principally this is concerned
with identification or improvement of treatments or intervention, or health and care system design, to improve health and care outcomes or experience. The work carried out by RNOH provides NHS England with a significant opportunity to access
intelligence and examples of good practice from services that are not normally under its remit and to share this with the wider NHS.

Outputs:

NHS England, acting as processor for RNOH, calculates GIRFT metrics from client data so they can be presented against the England NHS providers for benchmarking.

The outputs are Data Packs, which include reports containing descriptive statistics, graphs and an explanation of the outputs.

Processing:

NHS England will grant access to RNOH via the Unified Data Access Layer (UDAL) – a secure data management system within NHS England that enables patient data to be processed and made available for analytical purposes.

UDAL accommodates a series of tools, which enable users to explore patient or aggregate data, to create standardised reports and dashboards, and create statistical models.

NHS England, acting as a processor for RNOH, allows RNOH client data to be uploaded to UDAL so that GIRFT metrics can be applied accurately and consistently

NHS England, acting as processor for RNOH, calculates GIRFT metrics from client data so they can be presented against the England NHS providers for benchmarking.

All processing is carried out by Edge Health Ltd in the UDAL secure environment and RNOH covers all costs associated with the work.

For each RNOH client, Edge Health Ltd undertakes two sets of analysis in parallel:
- Preparation of relevant GIRFT benchmarking metrics for England NHS providers using NHS England GIRFT datasets. This includes any England NHS data associated with RNOH clients where this is submitted to national datasets (e.g. NHS services provided by independent sector clients).
- Preparation of any RNOH client data required for benchmarking comparison, using NHS England GIRFT metric coding recipes. All metrics are presented as aggregate data.

The NHS England and RNOH client datasets are not linked in any way but once analysis is complete, aggregate data results are presented together for benchmarking comparison.

Some metric values for the RNOH client being reviewed may not have small numbers suppressed (where this is necessary to understand the service) but are only shared with the client. However, comparative benchmarking data for England NHS providers are always presented with small numbers suppressed.

The aggregate outputs as described above are shared with the RNOH client, and are the only data that leaves the NHS England UDAL environment.

NHS England does not access the RNOH client data for any purpose other than in its capacity as processor for RNOH.

The Data will not be transferred to any other location.

The Data will be stored on servers at NHS England (UDAL).

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 at any time.

Access is restricted to employees of RNOH or Edge Health.

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

Getting It Right First Time programme - hosted by the Royal National Orthopaedic Hospital — DARS-NIC-14440-Q2G4W

Type of data: information not disclosed for TRE projects

Opt outs honoured: No - data flow is not identifiable, N, Anonymised - ICO Code Compliant, No (Does not include the flow of confidential data)

Legal basis: Health and Social Care Act 2012 – s261(1) and s261(2)(b)(ii), 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 - 'Other dissemination of information', Health and Social Care Act 2012 – s261(2)(b)(ii)

Purposes: No (NHS Trust)

Sensitive: Non Sensitive, and Non-Sensitive

When:DSA runs 2018-09-20 — 2021-09-19 2019.07 — 2019.07.

Access method: One-Off, Ongoing

Data-controller type: ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST

Sublicensing allowed: No

Datasets:

  1. Hospital Episode Statistics Admitted Patient Care
  2. Hospital Episode Statistics Critical Care
  3. Hospital Episode Statistics Admitted Patient Care (HES APC)
  4. Hospital Episode Statistics Critical Care (HES Critical Care)

Objectives:

The Getting It Right First Time (GIRFT) programme has been extended from a pilot (for orthopaedic surgical activity only) to a programme supporting improvements in clinical efficiency for 10 surgical and 19 medical specialties. Both the GIRFT and the Clinically-Led Quality and Efficiency programmes now report to the NHS Procurement and Efficiency Board within NHS Improvement.

The GIRFT methodology include two main features: (1) peer-to-peer meetings between a clinical lead and clinicians and senior managers from acute NHS hospitals to review clinical practice and surgical performance; (2) these meetings are supported by a broad selection of clinical, quality, cost and performance metrics. The metrics are used not to judge, but to encourage further investigation and understanding of clinical practice and the service delivered by hospitals.

The requested HES data will be used to calculate some of the metrics that are used to support the peer-to-peer discussions. The HES data will be used to calculate a range of activity and quality metrics for the 10 surgical and 19 medical specialties at hospital and CCG summary level. The calculated metrics will be stored in the GIRFT performance dashboard (along with metrics calculated using other data sources). The dashboard will hold data for individual years and trend data.

Hospital and CCG summary level values will be taken from this dashboard and reported in hospital, regional and national data packs and reports. The GIRFT metrics calculated from HES data will be published publically in the Model Hospitals dashboard (the web-based dashboard developed by the Clinically-Led Quality and Efficiency programme and sitting within NHS Improvement) adhering to small number suppression requirements in HES analysis guidance).

As part of the GIRFT programme, we are also undertaking research to evaluate and assess the GIRFT methodology. The analysis will help inform improvements in the GIRFT methodology and will model how those improvements in outcomes translate into broader macroeconomic benefits – such as reduced disability leading to faster return to work, less reliance on health and care services, and less expenditure on social security benefits. Analysis and evaluation based on HES data may be submitted for peer-review publications.

HES data will also be used to benchmark coding quality. Information about the ICD10 and OPCS code combinations used to identify specific procedures will be examined and reported back to Acute Trusts. This analysis may include record-level reporting to Trusts; however, only ICD10 and OPCS coding will be returned - no person identifiable or date fields will be included.

Yielded Benefits:

Since the GIRFT programme began, changes in clinical practice have taken place within hospitals. As an example, for orthopaedic surgery services, GIRFT have measured reductions in length of stay, reductions in readmission rates, reductions in litigation in orthopaedics (bucking the trend for other specialties), and reductions in number of centres carrying out low volume of interventions. There are similar examples of changes in neurosurgery, paediatric surgery, and cardiothoracic surgery. One specific example for vascular Abdominal Aortic Aneurysm (AAA) surgery – when AAA surgery is performed in centres of excellence you get a significantly reduced mortality rate and reduced length of stay. In low volume (non centre of excellence) centres mortality can be as high as 25%. In addition to the improvements in clinical quality from the changes described, the GIRFT Team have measured the financial opportunity that has been realised as a result of the GIRFT programme. The GIRFT Team's current estimate is that this value was over £70 million in 2016/17, over £280 million in 2017/18, and over £240 million in Quarters 1 and 2 of 2018/19. The realised financial opportunity from the reduction in litigation costs for orthopaedic surgery alone over the last three years is estimated at over £79 million.

Expected Benefits:

An opportunity assessment of the GIRFT orthopaedics pilot identified £400 million of efficiency savings per annum, representing nearly 4% of total orthopaedic pathway cost and in excess of 7% musculoskeletal orthopaedic pathway cost. These savings relate to the opportunity to tackle variation in surgical practice across England. In particular to drive short, medium and longer-term improvements in quality of delivery (through adopting best practice), lower supplier costs (for example of implants) and lower readmission, re-operation and litigation rates.

It is recognised that the same scope for efficiency may not exist for all specialties, but drawing on the experience of the GIRFT pilot project and other clinical insights, a conservative 2% annual saving opportunity was assessed to be achievable through the application of GIRFT principles. A comparison of the headline potential savings for the 3-year delivery programme is shown in the table below:

3 year Delivery Programme
Total programme costs £2.45mn
Annual savings based on 2% efficiencies (once programme fully implemented) £0.99bn
Savings over 5 years based on 2% efficiencies £3.86bn
Number of clinical pathways 10
Return on Investment in first full year of savings realisation 404:1

It is anticipated that the annual saving should commence approximately one year after implementation of GIRFT recommendations for each specialty, approximately two years after publication of hospital reports. A breakdown of the expected annual savings by the specialty areas is illustrated below:
Clinical Pathway Annual savings target @ 2% (surgery only) Notes
Orthopaedics and spinal surgery £400 million Very significant savings have also been identified outside of the immediate surgical spend. Growth last year of 6.35% also makes this an important target.
Cardiothoracic £124million 7.76% growth last year and high readmission 7.61% and reoperation 8.8% rates.
General surgery £98million Elective general surgery grew by 5.93% last year and readmission rates are high.
Neurosurgery £91million 19.77% growth and high readmission 13.31% and reoperation 5.44% rates.
Oral & Maxillofacial £73million Relatively high cost specialty.
Urology & Renal £69million 7.51% for elective and 20.36% for non-elective for readmission and 5.13% for elective and 6.31% for non-elective for reoperation. 30.14% growth in non-elective.
ENT £68 million 3.95% readmissions and relatively high cost specialty.
Gynaecology £26million High volume specialty but with low growth last year and moderate readmissions.
Paediatric surgery £20million Relatively high readmissions at 5.51%.
Vascular £17million Very high growth last year of 15.59% and high readmissions at 6.6%.
Total £986 million per annum recurring

The evidence that these potential opportunities are achievable relies on evaluation of the GIRFT orthopaedic pilot programme. This programme gathered information during peer-to-peer meetings that demonstrated where implementation of good practice is already driving efficiency savings, and also examples where abandoning best practice has had the opposite effect. Some of these examples are listed below.


. Wound infection - Many studies demonstrate that ring-fenced beds have a significant impact on the incidence of wound infection and this has been one of the principle lines of enquiry for the GIRFT pilot. The GIRFT team visited hospitals where the primary hip and knee replacement deep wound infection rates varied between 0.5% and 4%, with one Trust for a short period having a rate of 15%. Three Trusts cited examples of infection rates escalating from 0.5% to 4% following the loss of ring- fenced elective orthopaedic beds. At one hospital, there was a particularly extreme example, where the loss of the orthopaedic ring-fenced beds in the face of winter bed pressures led to a 40% increase in infections.

Deep wound infection is traumatic and devastating for the individual patients, and is estimated conservatively to cost the NHS an additional £50k per patient (studies have quoted a range of between £50k and £100k). If a cost of £100k per patient is accepted then this equates to an extra £1,000 for each orthopaedic arthroplasty procedure to cover the costs of readmission, reoperation and medication for infected patients. At the national level, if Trusts achieved a 1% deep infection rate, this would equate to transforming the lives of 6,000 patients per year and saving the NHS £300m per year – a saving of £1.5 billion over five years.


. Procurement - Many of the orthopaedic teams that the GIRFT team met were unaware of their loan kit and prosthesis expenditure, or their rates of cemented vs un-cemented hip fixation. Loan kit - Trusts were encouraged to adopt a best practice methodology developed by GIRFT that could achieve a 90% reduction in loan kit costs within two years. With an average annual spend per hospital of £200,000, a saving of £108 million over the next five years is possible. Cost of implants - The NJR (National Joint Registry) procurement pilot demonstrated that adoption of the GIRFT procurement recommendations and a review of the NHS Supply Chain to reduce the large price variations that currently exist between Trusts could realise potential saving of £40 million per year. This equates to £200 million over five years. Fixation type - Published evidence indicates that a cemented fixation for hip replacement surgery is preferable in most over 65 year old patients – few patients require revision, and the prostheses are significantly less expensive. If all English hospitals delivered cemented hip replacement surgery to 75% of patients over 65 years, approximately £16 million per annum could be saved. These saving would increase in future years because the lower revision rate would lead to fewer readmissions.


. Litigation - A review of information released from the NHSLA (NHS Litigation Authority) databank by the GIRFT team identified a rapid rise in litigation claims in orthopaedic surgery. The GIRFT team is undertaking more detailed analysis, in association with leading law firms involved with orthopaedic clinical negligence, with a view to developing procedure specific guidelines to improve patient care and safety. The available data indicates a potential to reduce the cost of litigation claims for orthopaedic surgery by £50 million per annum. It has not been possible yet to assess the potential savings for other specialties.

Outputs:

Hospital and CCG summary level values will be taken from the GIRFT performance dashboard and reported in hospital, regional and national reports and data packs. Analysis and evaluation based on HES data may be submitted for peer-review publications. The GIRFT programme will publish metric values from the performance dashboard on the NHS Improvement Model Hospitals on-line dashboard. Summary level values may be released to other organisations as described below.

With reference to these publications, the following should be noted:
• No patient-level values will ever be published
• All data processors are aware of and will adhere to small number suppression requirements in HES analysis guidance
• Hospital data packs will only be released to the NHS Trust from which the data originated (under the agreed GIRFT-NHS Digital process).
• Data owners/processors will never release data other than in the publications described above. To be clear, data will never be used for sales or marketing purposes.


For the creation of the performance dashboard or publications, it may be necessary to share summary level values with other organisations (aggregated data with small numbers supressed). Below are the purposes for which GIRFT may be required to share summary level data:

• GIRFT works with various clinical associations and NHS national organisations to ensure that the quality metrics in the performance dashboard are the most appropriate for the GIRFT programme and the calculation methodology is the same for both organisations. GIRFT may share summary level values with organisations such as clinical association (e.g. British Orthopaedic Association, Association of Coloproctology of Great Britain and Ireland), national quality programmes (e.g. the National Spinal Taskforce, Arthritis Research UK, NEQOS (North East Quality Observatory System)), NHS England (e.g. Specialised Services Clinical Reference Groups, Quality Surveillance team), and other NHS organisations (e.g. RightCare) for this purpose.

• GIRFT is required to report to the NHS Procurement and Efficiency Board (NHS Improvement) and the Department of Health. We may need to share summary level values with this Board for this purpose.

• The national reports may include maps to show geographic distribution of access and performance. GIRFT may share summary level values from the performance dashboard to organisations who can produce these maps for us (e.g. SHAPE (Strategic Health Asset Planning and Evaluation; Public Health England, North West Commissioning Support Unit)).


There are two other organisations with whom we may need to share HES data:
. The main tables and graphs for some of the hospital, regional and national reports will be produced by Methods Analytics. GIRFT may need to share summary level values from the performance dashboard with this organisation for this purpose. This will need to include hospital or CCG values without small number suppression where these data are for hospital data packs. We are aware that Methods Analytics has agreement with NHS Digital that they can work with and report unsuppressed small numbers for the GIRFT programme only.

. It is likely that GIRFT will be working jointly with RightCare to produce some STP level products. GIRFT may need to share summary level HES data (with small number suppression) for inclusion in these products


The hospital, regional and national datapacks and reports for the 10 surgical and 19 medical specialties are expected to be published during 2016, 2017 and 2018, approximately one surgical specialty per month. In addition, refreshed versions of previously published hospital and regional reports may be published during 2017 and 2018. The only new hospital data pack publication that has been planned so far is for cardiothoracic surgery, in March 2017. Refresh versions of the existing orthopaedic surgery, general surgery and urology hospital data packs are planned for early 2017. National reports for general surgery, urology, neurosurgery and vascular surgery are likely to be published during the next 6 months.


Evaluation is likely to occur on a regular basis (to meet the timescale for NHS Procurement and Efficiency Board meetings), with a major annual report and other ad hoc reports as required. From the analysis for these Board meetings, peer-reviewed publications will be produced on an ad hoc basis (possibly starting during 2017/18).

Publication of metric values on the Model Hospital dashboard commenced with orthopaedic surgery metrics in December 2016. A rolling timetable for publication of metric values for other specialties (perhaps one specialty area per month) is planned during 2017.

Reports for orthopaedic surgery that include economic modelling and detail about clinical coding are expected during 2017. These are likely to be internal NHS documents, and will only include aggregated activity values.

Processing:

The GIRFT performance dashboard contains a wide range of metrics, some of which are calculated using HES data.

For the dashboard, HES data are processed in the following way:
• FCE (Finished Consultant Episode) records will be grouped to spells using the Local Payment Grouper software (www.hscic.gov.uk/article/3938/HRG4-201415-Payment-Grouper);
• National Tariff Payment System rules will be applied to the data (note: this will include linking the Inpatient HES dataset to the Critical Care HES dataset to ensure the correct calculation of excess bed day national tariffs);
• National and indicative tariffs will be applied to spells, including all National tariff adjustments;
• Various performance metrics will be calculated at Acute Trust and CCG level, and trend values will be calculated using HES data from different financial years
• Performance metrics will be stored in the GIRFT performance dashboard (see outputs section for publication details)


The performance metrics included in the performance dashboard will relate to:
• Original surgical specialties - orthopaedics and spinal surgery, cardiothoracic surgery, ENT, general surgery, gynaecology, neurosurgery, oral and maxillofacial surgery, paediatric surgery, urology, and vascular surgery.
• New medical & surgical specialties - dentistry, breast surgery, plastic surgery & burns, general medicine, emergency medicine, intensive care, imaging &radiology, cardiology, geriatric medicine, outpatients, respiratory, dermatology, neurology, rheumatology, gastroenterology, diabetes & endocrinology, pathology, renal.


HES data processing to populate the performance dashboard will occur at two sites (see data flow diagram below). These sites have different roles:
• RNOH and NA Wilson Associates calculate hospital and CCG level values for inclusion within the GIRFT performance dashboard;
• CLAHRC statistically analyses a selected group of metrics for the purpose of evaluating the success of the GIRFT programme. CLAHRC will use both HES pseudonymised patient-level HES data and hospital and CCG level values from the performance dashboard for its work.


HES data will never be linked with any other data (except the HES inpatient to HES critical care linkage discussed above).

Processing HES data for the evaluation and macroeconomic modelling work will include controlling for factors such as age and sex patients, and variations in individual pathways. This is only possible with pseudonymised patient level data.

The Specialist Orthopaedic Alliance (SOA; the organisation that originally hosted the GIRFT programme) used 2011/12 HES inpatient data to populate the SOA orthopaedic and spinal performance dashboard (Application reference RU738). This data has since been deleted in compliance with a HSCIC data destruction certificate. The SOA subsequently updated the SOA orthopaedic and spinal performance dashboard using the 2012/13 and 2013/14 HES data provided by application NIC-275445-L6X9T. The GIRFT programme applied for 2014/15 HES data under application NIC-393384-L9Z2J. The approval was subsequently changed (NIC-14440-Q2G4W) to allow access to the HES data for Methods Analytics (who undertook some analysis of HES data for the GIRFT programme).