NHS Digital Data Release Register - reformatted

NHS Improvement

Project 1 — DARS-NIC-213403-P3R8Q

Opt outs honoured: No - data flow is not identifiable (Does not include the flow of confidential data)

Sensitive: Non Sensitive

When: 2020/06 — 2021/05.

Repeats: One-Off, Ongoing

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

Categories: Anonymised - ICO code compliant


  • NCIP Theatre Data Set Discovery Project
  • NCIP Theatre Data Set Discovery Project Bridging File
  • Secondary Uses Service Payment By Results Outpatients
  • Secondary Uses Service Payment By Results Episodes
  • Secondary Uses Service Payment By Results Accident & Emergency
  • Secondary Uses Service Payment By Results Spells


NHS Improvement (NHSI) was launched on 1 April 2016 and is the operational name for the organisation that brings together Monitor and the NHS Trust Development Authority (TDA) plus a number of other teams. NHS Improvement operates as a single organisation, with a joint board and single leadership and operating model although the TDA and Monitor continue to exist as distinct legal entities with their continuing statutory functions, legal powers and staff. This application seeks to request data for both the TDA and Monitor as joint Data controllers. The TDA is a Special Health Authority established by Article 2 of the TDA (Establishment and Constitution) Order 2012. The NHS TDA is also made up of the Patient Safety, the National Reporting and Learning System, the Advancing Change and the Intensive Support Teams. Under the NHS DA (Directions and Miscellaneous Amendments etc.) Regulations 2016 it has a general power to take such steps as it considers necessary and appropriate to assist and support persons providing NHS services to ensure continuous improvement in the quality of the provision and the financial sustainability of NHS services. Monitor is a statutory body. Under the Health and Social Care Act 2012. It has a duty when exercising its functions to protect and promote patient interests by promoting economic, efficient and effective health care services whilst maintaining or improving quality. Monitor must co-operate with Special Health Authorities including the NHS TDA. Monitor and the NHS Trust Development Authority (TDA) have come together under the operational name NHS Improvement, combining the functions and responsibilities of the two statutory bodies in a single integrated organisation. Article 6(1)(e) is being used as the GDPR legal basis for processing. Monitor, The TDA and NHSE are public authorities. The Data Protection Act 2018 s7(1)(a) defines ‘public bodies’ for the purpose of the GDPR as “a public authority as defined by the Freedom of Information Act 2000”. The FOI Act 2000 Part 1, section 3 (1)(a)(i) specifies that a public authority means any body which is listed in Schedule 1. Schedule 1 of the FOI Act 2000 lists special health authorities as public authorities (TDA) and Monitor is a statutory body. Under the Health and Social Care Act 2012. Article 9(2)(j) is also being used as 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). As such, NHS Improvement is responsible, among other things, for the oversight of NHS trusts, NHS foundation trusts and independent providers. Monitor require access to the following data sets as part of this request; *Hospital Episode Statistics (HES) including Consultant code *Patient Reported Outcome Measures (PROMS) *ONS-HES linked data *Civil registration of deaths data *Theatre data set (discovery collection) The National Clinical Improvement Programme (NCIP) aims to support clinicians with learning and continuous self-development with respect to the services they deliver. The programme will provide both team and clinical-level activity and metrics about the whole of a clinician's practice, and links to relevant service delivery research and other evidence, delivered through a secure online portal hosted by NHS Improvement. NCIP will be a digital product that NHS consultants and speciality grade doctors in England will use to source their personal and unit-level outcome data in the context of national benchmarks. This information will support quality improvement activities, with the ultimate aim of delivering improved patient care. NCIP is a Getting It Right First Time (GIRFT) Programme, operating under the statutory improvement functions of NHS Improvement, which is a central part of the NHS Long Term Plan. The NCIP product will feature a series of activity-specific dashboards and metrics. Those with access will be able to drill through the dashboards to the underlying pseudonymised record level data. Consultants and speciality grade doctors will have access to dashboards that describe their personal activity and the unit level activity of their designated organisation (where the designated organisation is an NHS Trust). A Consultant’s or speciality grade doctor’s access to the product will be subject to the approval of the Medical Director (or persons working on their behalf) at their NHS Designated Organisation. Specific to the theatre data set discovery this data is being collected under a Mandatory Request to NHS Digital. The request is for NHS Digital to establish and operate an information system for the collection and analysis of theatre data from between five and seven NHS Foundation Trusts (discovery sites) in support of the NCIP. The purpose of requesting NHS Digital to establish the NCIP Theatre Data Set Discovery Information System is to enable NHSI/E to assess the potential of theatre data to enhance the attribution of surgical activity to consultants, as recorded in Hospital Episode Statistics (HES) Admitted Patient Care (APC) data, and to explore potential other uses of the data (e.g. unit-level productivity measurement) with a view to developing a national theatre data set. Inaccurate attribution of existing activity data to consultants is a risk to the success of NCIP. The data will be collected in a form which identifies individual patients and associated information about their health care. This will therefore be patient level data sourced from local theatre systems within NHS trusts. The data will be disseminated to NHSI once it has been collected by NHSD as part of the data set discovery project. The flow of data will be limited by the duration of the Discovery project; i.e. the Discovery project will not support an on-going flow of theatre data. This information is necessary to enable data linkage to HES APC data at procedure level and for NHSI to share the relevant activity data with the consultants concerned. The collection also identifies the surgeons and anaesthetists involved. Clinicians will be identified in Theatre data using a combination of GMC number, local identifier and name. There are no intended publications of the Theatre Data Set Discovery collection. The data sourced from NHS Digital under this agreement will also be used by the NCIP development team for validation and development of NCIP algorithms. This will involve a trust consultant (involved in the development of NCIP) sharing with NHSI analysts a sub set of trust held data related to a specific procedure, this will be cross referenced to HES data and any inaccuracies shared back with the consultant who is directly involved in the delivery of the patient’s direct care. This will generally include aggregate level figures with small numbers suppressed but could include a set of procedure codes. This activity is critical to developing accurate content, be it aggregations of activity or metrics that are applied to those activities.

Yielded Benefits:

There are currently no yielded benefits due to the sub-license being in place for less than 12 months.

Expected Benefits:

The benefits that the NCIP product will provide is to improve patient care through learning generated from the provision of individual and unit level activity and outcomes data to NHS consultants and speciality grade doctors in England. The product will provide data to individual consultants and speciality grade doctors for personal development, professional appraisal and improvements/learning. Support the Responsible Officer to discharge statutory duties for having oversight of a Consultant’s and speciality grade doctor whole practice. Ensure trust Medical Director has a view of all activity within their trust and identity areas of required improvements.


Example outputs that will form part of the core functions set out in the purpose section are: Developing the Carter Model Hospital, GIRFT and NCIP product. Developing the Carter Programme and the Model Hospital dashboard and metrics in a nationally available online information system, with a series of themed compartments which present key performance metrics for different area across the hospital, community services, mental health services and ambulance services. Enabling providers to compare performance against their peers and national benchmarks and identify areas where they need to improve and develop products to help support service improvements and operational productivity. Providing Consultant and speciality grade doctor level activity data to individual Consultants and speciality grade doctors. The rationale of sharing at this level is to support Consultant and speciality grade doctor appraisals and clinical improvements/outcomes.


The NCIP product will be securely provided over the web, where users will require username and password to access. All patient level pseudonymised HES data will be held within NHSI secure servers, whereas aggregate activity data (e.g. number of procedures, number of re admission within 30 days) at consultant and speciality grade doctor level will be held in the Azure Cloud under contract with NHSI. Only Aggregated data with small number suppression will be held in the Azure Cloud. Data presented via the NCIP product will include pseudonymised record level data as well as aggregate data (without small numbers suppression in line with the exception agreed for GIRFT). Access to data held in the NCIP product will be provided in accordance with sign up to terms of conditions of use for accessing NCIP (flow down NHSD requirements) and under a sub licence arrangement with trusts. Access levels of data will be in accordance with the sub licence each Trust signs up to; Consultants and speciality grade doctors will have access to Trust level dashboards (where their Designated Body is the subject) in addition to their personal dashboards, where the Consultant and speciality grade doctor is the subject. Consultants and speciality grade doctors will not be able to access other Consultants and speciality grade doctor dashboards. Consultants and speciality grade doctors will be able to access pseudonymised patient data related to the numerator and denominator values displayed in their own Consultant and speciality grade doctor dashboards. Consultants and speciality grade doctors will be able to access pseudonymised patient data related to the numerator and denominator values displayed in the Unit level dashboards to which they have access. Consultants and speciality grade doctors will not be able to identify other consultants and speciality grade doctors in the dashboards. Consultants and speciality grade doctors will be able to identify other consultants and speciality grade doctor in the pseudonymised patient data only where there are other episodes in index spells attributed to the consultant and speciality grade doctor in question. For the purpose of this agreement Consultants and Specialty Doctors are defined as; A senior medical practitioner who is appointed to their role by an NHS Trust. A Medical Practitioner is; “Medical Practitioner” means a person who- - is included in the register of medical practitioners referred to in section 2 of the Medical Act 1983; - holds a licence to practise under that Act; and - is employed or otherwise engaged by the Trust to provide healthcare services under the NHS. GIRFT (including NCIP) and Model Hospital are keen to use the civil registration of death data to measure mortality following procedures. The key data fields for this purpose are date of death and cause of death. The GIRFT and Model Hospital programmes aim to improve cost efficiency of NHS services through reducing variation in cost and clinical quality. One of the key clinical quality metrics is death following surgical procedures. The programmes currently use HES data to calculate a number of clinical quality indicators, including in-hospital mortality. NHSI plan to switch from monitoring in hospital mortality to mortality (in any setting) over the next few months NHS Improvement will ensure that suitable controls are in place such that the data is used by the trust solely in line with the purposes set out within the agreement. Monitor will not use data for any commercial purpose. Monitor will retain the Intellectual Property Rights to any works derived from or including the production of the National Tariff, PLICS, GIRFT data packs, NCIP product and Model Hospital Dashboard outputs. For clarity, Monitor and NHS TDA will act as joint data controllers in common. All organisations party to this agreement must comply with the Data Sharing Framework Contract requirements, including those regarding the use (and purposes of that use) by ‘Personnel’ (as defined within the Data Sharing Framework Contract i.e. employees, agents and contractors of the Data Recipient who may have access to that data). Flow down terms of the DSFC will be included in the sub licence for NCIP. Under the Sub licence arrangements which this agreement will permit NHS trusts will have access to the following data; Consultants and speciality grade doctors will access to NCIP Product with role based access controls (RBAC) under a sub licencing arrangement. *HES pseudonymised patient level- including Consultant code *Patient Reported Outcome Measures (PROMS) *HES-Civil registration data *Sus PBR *DIDS *PLICS *Theatres data Only data for care and treatment in English hospitals is provided under this agreement.