NHS Digital Data Release Register - reformatted
Competition and Markets Authority
Project 1 — DARS-NIC-32833-M3M9V
Opt outs honoured: No - data flow is not identifiable
Sensitive: Non Sensitive
When: 2016/12 — 2018/12.
Repeats: One-Off, Ongoing
Legal basis: Health and Social Care Act 2012, Health and Social Care Act 2012 – s261(1) and s261(2)(b)(ii)
Categories: Anonymised - ICO code compliant
- Hospital Episode Statistics Admitted Patient Care
- Hospital Episode Statistics Outpatients
- Hospital Episode Statistics Accident and Emergency
The Competition and Markets Authority (CMA) is required, under the Enterprise Act 2002 (EA02), to monitor, investigate and decide whether mergers may be expected to give rise to a substantial lessening of competition within any markets(s) in the UK for goods or services. If the CMA concludes that there is an anti-competitive outcome, it must decide whether action should be taken to remedy, mitigate, or prevent the identified substantial lessening of competition and/or any adverse effect which may be expected to result from the substantial lessening of competition. The Health and Social Care Act 2012 (HSCA12) confirms this duty with respect to the merger of NHS Foundation Trusts. The CMA will be conducting reviews of several NHS Trust and Foundation Trust mergers across England. The reviews seek to establish whether the mergers may result in adverse effects for patients by reducing choice and competition. If borne out, such a reduction in competition could have the consequence of removing or dampening the incentives that currently exist for the Trusts to maintain and improve quality for patients to retain patients, given that the hospitals currently may seek to attract patient referrals from each other. The CMA's objective for processing data is to analyse the closeness of competition between the specific merging Trusts at trust and site level to specifically understand: - the geographic distribution of patients attending Trusts in the merging areas - the overlap in services provided by the merging Trusts and other trusts in the surrounding area, to the extent that these Trusts provide similar or identical treatments at different levels of data aggregation to understand patients' options in the area, and - the substitutability of the Trusts, to the extent that the merging Trusts and other trusts in the surrounding area are alternative providers to patients at GP and GP Practice level.
The CMA has conducted extensive analysis using this data to fulfil their statutory function of 1) deciding whether mergers involving NHS Foundation Trusts would result in a substantial lessening of competition and, if so, 2) determining the scale and scope of the adverse effect from lessening of competition on patients and commissioners that must be outweighed by relevant patient benefits in order for the merger to be allowed. This benefits healthcare by helping to ensure that only mergers that are, on balance, beneficial to patients are allowed to occur. The NHS Digital data underpinned most of the analysis on the impact on patient choice of provider of two high-profile mergers: 1) the merger of Central Manchester University Hospitals NHS FT and University Hospital of South Manchester NHS FT, and 2) the merger of University Hospital Birmingham NHS FT and Heart of England NHS FT. The CMA used the data to analyse the merging Trusts and other local providers’ activity and revenue, and the pattern of referrals from GPs and other referrers. The CMA publishes the full reasoning and analysis behind their decisions on their case pages (https://www.gov.uk/cma-cases). For examples, see this link for CMFT/UHSM: https://www.gov.uk/cma-cases/central-manchester-university-hospitals-university-hospital-of-south-manchester-merger-inquiry and this link for UHB/HEFT: https://www.gov.uk/cma-cases/university-hospitals-birmingham-heart-of-england-merger-inquiry
Economic literature suggests competition between healthcare providers strengthens incentives for hospitals to innovate, therefore maintaining and improving standards of quality. Following a merger between NHS (Foundation) Trusts, if there is a reduction of choice and competition, then this could have the consequence of reducing quality for patients by removing the incentives that currently exist for the Trusts to attract patient referrals from each other. The CMA must therefore finally decide whether the merger would result in a substantial lessening of competition. If a substantial lessening of competition is found, the CMA needs to consider whether it should take action for the purpose of remedying, mitigating or preventing the substantial lessening of competition concerned. For these purposes the CMA will also have regard to any relevant patient (or consumer) benefits. The HES data requested may also be of material assistance in CMA's weighing up of the potential substantial lessening of competition against any relevant patient benefits put to us by the merging Trusts. Given that many tens of thousands of patients may be affected, the CMA’s decisions as to whether, or on what grounds to allow the Trusts to merge, must be well informed.
The CMA intends to: - compile a ranking of the relevant Trusts as service providers according to the GP referral analysis - compare the results to simple choice modelling - produce maps showing the location of GP practices, where the proposed merger may result in the largest restriction in choice, and - compile tables showing the extent to which hospitals in the area provide the same or similar treatments. - produce statistics to understand the distance over which patients in the area travel for care at specialty and provider level These will be used in CMA's internal decision making process and will inform CMA's internal working papers and reports for eventual publication. Raw data will not be published but instead aggregated to a level where patients are not identifiable, and all small numbers will be removed in line with the HES Analysis Guide. A disclosure room is likely to be required if there is a finding of an substantial lessening of competition.
The CMA considers the following data as necessary in performance of CMA's objectives: - patient level data with no small number suppression (to use procedure and diagnosis information to cross-check specialty coding in order to know which services both merging Trusts offer, as the merging Trusts have informed us that specialty coding practices can be inconsistent across Trusts) - pseudonymised data (in order to identify cases where patients have multiple episodes of treatment as part of their care pathway, which may lead to duplicates in the analysis) - data for only the CCGs proximate to the trusts, or with whom the merging Trusts are contracted to provide services (in order to undertake this analysis for the area over which the patients travel to the merging Trusts) - data covering several years (in order to increase the sample size in low-volume specialties and thus smooth out unrepresentative figures). The CMA will then process the data by means of a ‘GP Referral Analysis’ methodology and specifically: - produce a ranking of Trusts by their credibility as alternative providers of services - consider which alternative providers are credible for a patient attending a given hospital through examining other referrals at their GP practice - produce rankings at a GP practice level, which CMA will then aggregate to develop a picture for the whole Trust - calculate and map referral ratios to providers from individual GP practices and - tabulate numbers of patients treated by the merging trusts at specialty level. - compare the results to simple choice modelling. The CMA will combine the HES data with other publically available information in order to test the impact of specific factors and to adequately control for factors which might otherwise bias CMA's results. CMA plan to match the following publically available data with the postcodes in HES data (a) ODS characteristics for GP practices, Branch Surgeries, NHS Trusts and Trust Sites. (b) ONS postcode lookup information including rural/urban indicators and coordinates (for GP practices and care providers), in order to calculate approximations of travel distances, and to control for the impact of rurality on these (c) ONS population density measures by GP practice, provider postcode and output areas to control for the impact of rurality on willingness to travel (d) Hospital Estates and Facilities Statistics data by hospital to control for characteristics of each hospital (e) Hospital performance data from the CQC, NHS choices, NHS Digital, NHS England, and My NHS BETA to test the relationship between quality of hospitals and key variables of interest (f) Data from NHS Digital, NHS Improvement and the Department of Health in relation to provider tariffs. If the CMA’s proposed decision is adverse to the Trusts’ anticipated merger, the CMA is likely to use a disclosure room as a way of enabling parties’ external advisers to review the data so as to verify the analyses that the CMA has conducted, thus ensuring that the CMA acts in a procedurally fair way without compromising the security of very sensitive data. The parties’ external advisers who are admitted to the disclosure room will be required to give strict, written and legally enforceable undertakings not to disclose any of the data more widely (including to their client(s)). Under the disclosure room rules, the data will only be accessible to external advisers for a limited period of time via computer terminals on the CMA’s premises, and the parties’ advisers will not be able to transmit or otherwise remove data from the data room other than in aggregated form with small numbers suppressed in line with the HES Analysis Guide. The CMA has operated such disclosure rooms in other cases and has found them to be an effective way of accommodating both procedural fairness and data security. Whilst there is a need to consult on the exact nature of the undertakings related to a disclosure room in this context, and the CMA cannot therefore upload the exact wording, the CMA have uploaded the undertakings from a recent market investigation which used similar pseudonymised data as an example. With the exception of the disclosure room scenario, access to data will be restricted to authorised substantive CMA employees (with system permissions granted by the Data Access Team within the Corporate Services Department) and will only be used for the fulfilment of the project’s objectives as described above. The Data Access Team within CMA grant permissions to CMA employees only when access is required and approved by the Deputy Chief Economic Adviser at CMA. The CMA Data Access Team are only involved in facilitating access and not in analysing the data. The CMA Deputy Chief Economic Adviser (the data recipient) must authorise any person using the data, and the Data Access Team in IT (also authorised by Deputy Chief Economic Advisor) facilitate giving that person access. If the CMA uses a disclosure room, access – subject to specific controls - may be given to external parties who have signed written undertakings, within the secure environment of the disclosure room.