NHS Digital Data Release Register - reformatted

Public Health Scotland projects

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


Quarterly HES data request - Public Health Scotland — DARS-NIC-402414-Q5R7Y

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

Legal basis: Health and Social Care Act 2012 - s261 - 'Other dissemination of information'

Purposes: No (Agency/Public Body)

Sensitive: Non-Sensitive

When:DSA runs 2021-11-01 — 2024-10-31 2022.05 — 2022.08.

Access method: Ongoing

Data-controller type: PUBLIC HEALTH SCOTLAND

Sublicensing allowed: No

Datasets:

  1. Emergency Care Data Set (ECDS)
  2. Hospital Episode Statistics Accident and Emergency
  3. Hospital Episode Statistics Admitted Patient Care
  4. Hospital Episode Statistics Outpatients

Objectives:

Discovery is a web based information system that provides approved users with access to a range of comparative healthcare information to support performance and quality improvement in Health Boards across Scotland. It is an ongoing collaboration between NHS Boards, the Scottish Government, and Public Health Scotland (formerly National Services Scotland). Data is presented as a series of Tableau Dashboards that are updated regularly (timescales depend on the indicator) to help Scottish NHS Territorial health boards review, monitor and plan services to support and meet their quality improvement ambitions. The English Peer analytical dashboards are only accessible via an N4 / SWAN (Scottish Wide Area Network) internet connection. This means that Discovery users need to be remotely connected via their organisation before they can access this Discovery content. This provides additional security protection to this data. Discovery users also need to be authorised via their organisation Caldicott Guardian for the level of access most appropriate to their role. Regular user access reviews are also maintained via a User Access System.

Public Health Scotland came into being on the 1st April 2020. It is jointly accountable to both the Scottish Government and the Convention of Scottish Local Authorities (COSLA). It brings the functions of Health Protection Scotland and Information Services Division (ISD) formally within NHS National Services Scotland) together with NHS Health Scotland.

The Discovery Team was part of ISD which is one of the functions that have been transferred to Public Health Scotland from NHS National Services Scotland (NSS). Public Health Scotland have the overall responsibility and determine the purpose for processing. However, NSS still provide a number of shared services to PHS and is still the data processor.

Some NHS Boards in Scotland have no natural NHS peer comparisons from within Scotland for certain services and so require peers from outside Scotland. The aim of this Agreement is to continue to provide some of the NHS Health Boards in Scotland, (and their hospitals), with appropriate peer locations for benchmarking activity and performance across a range of measures and to support quality improvement by helping to identify what good performance could look like and by doing so helping to underpin service planning, service improvement and delivery.

Examples of those Scottish NHS Boards with no natural Scottish peers include the two largest boards (NHS Greater Glasgow and Clyde and NHS Lothian) and a large national elective centre (the Golden Jubilee hospital). The aggregated English data provides these NHS Boards with appropriate peer comparisons. Similar arrangements are in place with NWIS in Wales to provide additional rural comparisons for the three small island Boards that have no natural peers in Scotland. Providing Public Health Scotland with this information allows the Discovery users to better identify potential areas for improvement, and to understand where best practice is happening. It improves the ability of Health Boards to identify service improvements, leading to better outcomes for patients as well as the chance to consider new sustainable models for productive opportunities and efficiency savings.

The GDPR basis for processing this data is Article 6(1)(e): - “Processing is necessary for the performance of a task carried out in the public interest or in the exercise of official authority vested in the controller. This links to article 9 (2) (j) processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1).

PHS have requested access to pseudonymised HES Admitted Patient Care, HES Outpatients and the Emergency Care Data Set as this information allows PHS to provide benchmarking across a range of indicators including A&E Waits, A&E % Admitted, Length of Stay Analysis, BADs Daycase Rates, Pre-op stay rates, Outpatient DNA rates, Return to New Outpatient Ratios, Gestation at Booking.

Receiving data on all English NHS hospitals allows PHS to select the most appropriate peers for the hospitals based on the latest data, and to be flexible when service changes take place.
The data requested is limited to NHS Trusts and NHS Foundation Trusts only e.g. no independents, care trusts etc.

Discovery access is password protected and users must be individually authorised by a Health Boards Caldicott Guardian. Due to this the likelihood of an attempt to disclose data and the impact of any disclosure is felt to be low.

The information in Discovery is presented using Tableau Dashboards to allow the data to be visualized in an easily accessible way.

The list of benchmarking indicators available in NSS Discovery is agreed nationally and is under continuous development (as guided by national governance groups), and, therefore, it is anticipated the number of fields needed to calculate the indicators may gradually increase as well. In addition to this the Wrap Around Service that supports NSS Discovery provides NHS Boards, when requested, with additional more detailed ad hoc analysis for specific comparators, still at an aggregate level. These ad hoc requests would be produced as management information only in the form of excel tables/charts/presentations etc. All outputs will contain only data that is aggregated with small numbers suppressed in line with the HES Analysis Guide. The Discovery tool includes information for up to 4 years to allow longer term trend analysis and to monitor improvements over time that may take place following service changes/improvements. The Discovery Team will arrange for data outwith this 4 year period to be deleted and removed from all sources.

Yielded Benefits:

For some NHS Boards benchmarking information from Scottish peers is insufficient and they particularly value the ability to compare with English peers. This allows them to make more appropriate comparisons, which will support better decision making. Working with these Health Boards PHS have developed specific Discovery Dashboards focusing on key indicators that include specified English peer locations which provide the breadth of peer data that these health boards required. Indicators that have been developed using English data and English Peer locations include • A&E Waits, A&E % Admitted, Length of Stay Analysis, BADS Day Case Rates, Pre-operative stay rates, Outpatient DNA rates, Return to New Outpatient Ratios, Gestation at Booking. • Day of Surgery Admissions is another indicator that has recently been requested and it will provide focussed procedure level analysis into proportion of patients that have surgery on the day of admission. This will allow health boards to identify variations across the UK when it comes to comparing and planning patient management for elective procedures. This will lead to the ability for focussed service improvements in areas highlighted within the benchmarking analysis. In addition to the indicators that have been developed in the Discovery Tool having access to the wider range of the English Data that PHS have requested has allowed a number of bespoke analytical projects to be undertaken including the Bed Modelling projects identified above. Health Boards have utilised Discovery information in a number of ways. This ability to identify both differences in performance in relation to peer groups (including English Hospital peers) and deterioration in performance via trend analysis (when compared to Peer Groups), with the added ability to drill into more detail when required has provided both service assurance and also identified areas for service improvement. Some examples of how Discovery data has been used are shown below: • Discovery data is regularly included in Health Board’s routine performance reporting processes and board management papers. • Using the peer analysis functionality for specialty reviews in order to identify service improvements. • A number of Health Boards have established "Impact Huddle" projects which identify service improvement opportunities for efficiencies through performance benchmarking across peer locations • Benchmarking various metrics for a range of governance meetings and improvement programmes to look at and highlight unwarranted variation and the potential to drive service improvements and patient improvement within their respective organisations • Working with Unscheduled Care leads on where Discovery can support the redesign of Urgent Care Programme. • Discovery used within Health Boards Integrated Performance report as a valuable source of national comparator data. • Length of Stay analysis for Whole Systems Modelling Project • Support of Bespoke Bed Modelling Projects at a Specialty Level (using bespoke features) • This has led to o Improvements in BADS Day Case rates following benchmarked review, o Reduction of Pre-operative stays due to a review of peer performance. o Detailed analysis into ‘Respiratory’ Diseases and its acute management o Day Case rate analysis to review procedures that could be moved away from acute sites o Improvements in Length of Stay for certain conditions / procedures o As part of some Health Boards Financial Improvement Programme the identification of potential efficiencies, and monitoring of trajectories towards this. o Identification of optimal bed configurations for specific specialties and hospitals to help support service change. o Discovery becoming a trusted partner as the Scottish National Benchmarking tool of choice, leading to a significant reduction in Health Board dependence on external third party expensive benchmarking tools and systems. All of these examples of yielded benefits have led to improved efficiency in the way hospital services have been managed which leads to an improved experience for patients accessing these services. For example, not being admitted unnecessarily the night before an operation, not staying in hospital for longer than is required (reducing length of stay). These types of service improvements also help improve patient flow through the hospital by reducing bottlenecks due to bed pressures. Being able to provide the type of information requested by Health Boards from within the Discovery System and through Public Health Scotland means that Health Boards are able to quality assure their performance by benchmarking across locations throughout the UK and make and monitor changes both as required and due to service improvement priorities. Being able to drill down to a detailed level of data provides the level of analysis that is required for detailed service re-design and being able to update English peer groups within the Discovery Tool and also to support bespoke peer analysis has been cited by a number of Health Boards as one of the great successes of Discovery, and a main reason as to why they no longer utilise external third party expensive products to access English Data to respond to these types of requests, (as these Health Boards didn’t have any natural NHS peer comparisons from within Scotland). By having access to this level of data within the Discovery Team PHSknow that these Health Boards no longer utilise these third party products and that these resources are available to invest in improving patient care.

Expected Benefits:

Discovery has a broad user base which extends across the following staff groups within NHS Scotland, Managers, Planners, Analysts, Clinicians, Accountants and Improvement Advisors. They will use the comparative and benchmarking information to underpin service planning and delivery.

Discovery provides benchmarking visualisations which allow NHS Boards to quickly assess and understand how their performance compares to their peers. Impact Analysis information is also provided which helps to quickly identify where there are potential productive opportunities and quantifies what the savings could be if these improvement prospects were realised. For example if a location met their Peer UQ rate or a specific target for that indicator the Impact analysis identifies what the potential reduction in Bed days or the increases in daycase surgery or the reduction in re-admissions would have been.

The list of benchmarking indicators available in Discovery is agreed nationally and is under continuous development (as guided by national governance groups that have representatives from each of the Scottish Health Boards and the Scottish Government). Therefore, it is anticipated the number of fields needed to calculate the additional indicators will increase as well, and this is one of the reasons for why we have requested additional English Data to what is currently used within the Discovery Tool.

Indicators that are currently available within the Discovery Tool using English data and English Peer locations include
• A&E Waits, A&E % Admitted, Length of Stay Analysis, BADS Day Case Rates, Pre-operative stay rates, Outpatient DNA rates, Return to New Outpatient Ratios, Gestation at Booking.
• Day of Surgery Admissions is another indicator that has recently been requested and it will provide focussed procedure level analysis into proportion of patients that have surgery on the day of admission. This will allow Health Boards to identify variations across the UK when it comes to comparing patient management for elective procedures, and lead to the ability for focussed service improvements in areas highlighted within the benchmarking analysis.

Within the last renewal period our national Elective Care Centre (Golden Jubile) requested that we developed additional specific indicators. This development included the ability to analysis average length of stay and pre-operative stay information at a procedure level. As part of this development they identified additional English Peer locations that they needed to compare their performance against for specific conditions. At the time of the renewal request we were unaware of this development or the fact that additional peers were required.

• Having access to all of the data that we have requested allows us to evolve the Discovery offering as directed by the Health Boards across Scotland. In addition to this as this development progressed additional requirements were requested that we were able to respond to timeously and to develop the offering in a co-creational manner to ensure that the developments were as useful as possible.
• If we hadn’t have had access to the additional English Data this development may not have been possible.

NHS Boards can use Discovery to identify and learn from better performing peers about how they run their service and to consider if adopting these approaches could improve patient outcomes, drive efficiencies and reduce harm. The Discovery Service has worked with service users to identify these opportunities in and are assisting the boards to make transformational change within their organisations.

For some NHS Boards benchmarking information from Scottish peers is insufficient and they particularly value the ability to compare with English peers. This allows them to make more appropriate comparisons, which will support better decision making.

Processing:

The Discovery tool includes data from various sources including Scottish Health Boards and Health & Social Care, and also inpatient, outpatient, A&E and maternity data from England and Wales. Data is transferred using various secure file transfer methods including the (English) SEFT service.

The pseudonymised HES data is provided in a flat-file format. The files are uploaded onto the secure server at NSS and only records from hospitals that are current peers for the relevant hospitals and fields that are required to calculate the current set of performance indicators are transferred to the Discovery data mart. The original files are retained and are reprocessed whenever the peer selection for a hospital changes (which, has typically in previous years been between two and three times a year at most, but depending on evolving customer requirements and emerging service redesigns created as a result of COVID-19 remobilisation planning, this could increase).
The data we hold securely in our data mart is then aggregated to location and specialty levels, and rates are calculated, and the resulting data extracts drive the visualisations in Tableau. In a Level 2 Discovery dashboard average length of stay indicators and pre-operative stay information is available by recorded procedure, with small numbers suppressed in line with the HES Analysis guide.

The range of benchmarking indicators available in Discovery is agreed nationally and is under continuous evolution and development (as guided by national governance groups which has representatives from each of the Scottish Health Boards and the Scottish Government). Based on our previous development cycles, we know that it is essential to have access to the wide range of data variables in order to derive the existing and any prospective indicators that may be requested. If existing methodologies change or new definitions are required it is essential to have the data to enable these to be implemented. These are some of the key reasons why we have requested additional English Data, along with the need to maintain a high development velocity whilst avoiding having to request regular and multiple minor amendments to the DSA with NHS Digital.

Receiving data on all English NHS hospitals also allows PHS to select the most appropriate peers for the hospitals based on the latest data and NHS Health Board requirements, and to be flexible when service changes take place.

As services across hospitals and Health Boards are reconfigured we are often asked to make changes to Hospital Peer Groups. In addition to this five new Elective Care Centres are planned as part of the Scottish Government’s National Elective Centre Programme to come online within the next 3 to 5 years. Having access to a wide range of English data allows us to respond to these changes and developments in a timely fashion without having to request amendments to this DSA.

Currently the indicators developed include A&E waits, A&E % admitted, Length of Stay analysis, BADS Day Case rates, Pre-operative stay rates, Outpatient DNA rates, Return to New Outpatient Ratios, Gestation at Booking.

Within the last renewal period, our national Elective Care Centre (Golden Jubilee) requested that we develop additional specific indicators. This development included the ability to analysis average length of stay and pre-operative stay information at a procedure level. As part of this development they identified additional English Peer locations that they needed to compare against for specific conditions. At the time of the renewal request, we were unaware of this development or the fact that additional peers were required.
• Having access to all of the requested data allows us to evolve the Discovery offering as directed by the Health Boards across Scotland. In addition to this, as this development progressed further requirements were identified that we were able to respond to timeously and to develop the offering in a co-creational manner to ensure that the developments were as useful as possible.
• If we hadn’t have had access to the additional English Data this development may not have been possible.
• Previously Health Boards have paid for external third party providers products to respond to these types of requests. Being able to develop the tools that respond to specific requests quickly and safely by having access to the level of data that has been requested ensures resources that would otherwise be spent on external third party products can be invested in improving patient care.

The Discovery tool is complemented with a Wraparound Service (WAS) that provides support to Discovery users including bespoke analysis and reports. The WAS outputs may include figures from English and Welsh peers as defined by the Boards themselves to enhance their benchmarking; for the same or similar indicators, and at the same granularity (small numbers suppressed in line with the HES Analysis Guide) as available in the Discovery tool. Some examples of this bespoke analysis using the English Data include:

• Development of Bed Modelling analyses for a number of our larger NHS Boards and hospitals that have no natural peers in Scotland. This analysis helped to support a comprehensive review of acute services and helped to provide insight into future bed capacity requirements based on information such as benchmarked lengths of stay, day case and occupancy rates.
• Individual specialty and service reviews using tailored and bespoke peer comparisons in support of re-design projects which focussed on the improvement of patient care and delivery. Specific outcomes included reductions in pre-operative stay rates, increased same day surgery rates and reductions in inpatient lengths of stay
• Focussed comparative analyses of specific conditions and procedures in order to develop new Discovery dashboards tailored to the needs of our NHS Boards for the purposes of service and capacity planning.
• Being able to provide these types of analyses would not have been possible without access to the level of data that we have requested.
• In the past NHS Boards in Scotland needed to engage expensive external third party commercial consultancy for this type of expert analysis as opposed to Public Health Scotland now being able to provide this analysis at no extra cost to the NHS Board.

Discovery is an NHS Scotland Management System built using Tableau software. Access to the English data can only be accessed by approved users within NHS Scotland health boards and the Scottish Government via a secure log in. Users requesting access to Discovery must be approved by that organisation Caldicott Guardian for the level of access most appropriate to their role. Due to this the likelihood of an attempt to disclose data and the impact of any disclosure is felt to be low.
The Discovery service is funded by the NHS Scotland Territorial Health Boards directly to PHS with money top sliced from the Scottish Government.

The network data storage devices, including Tableau hardware, are located within a secure off-site location at ATOS in Livingston, which is managed under an existing NHS Scotland-wide service contract. Maintenance of the hardware is handled by NSS staff. ATOS will be responsible for the building, location and server room security. All access to the service from the Internet will be via Atos Origin Alliance (AOA) Internet security gateway, a service that provides reverse proxy and Intrusion Prevention System (IPS) functionality.

The HES data extracts are shown alongside the Scottish Morbidity Record (SMR) data and the Welsh data, trusts and locations and are shown within peer groups to be used by the NHS Scotland Boards in benchmarking comparisons. Trend analysis across all time points for up to 4 years is available in the Discovery Tool.

Discovery is an NHS Scotland Management System which can only be accessed by approved users within NHS Scotland health boards and the Scottish Government via a secure log in.

The Discovery service is funded by the NHS Scotland Territorial Health Boards directly to PHS with money top sliced from the Scottish Government.

Discovery benchmarking Indicators (outputs) are agreed nationally and are updated to agreed guidelines via appropriate national governance groups.

No data from Discovery will be publicly available and data contained within it will not be used for sales and marketing purposes.

Only substantive employees of Public Health Scotland can access the record-level data. Third parties will only have access to data that is aggregated (with small numbers suppressed in line with the HES Analysis Guide).


Evaluating the impact of minimum unit pricing on alcohol attributable hospital admissions and deaths in Scotland — DARS-NIC-250023-M6T9H

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

Legal basis: Health and Social Care Act 2012 - s261 - 'Other dissemination of information'

Purposes: No (Agency/Public Body)

Sensitive: Non-Sensitive

When:DSA runs 2022-01-31 — 2025-01-30 2022.08 — 2022.08.

Access method: One-Off

Data-controller type: PUBLIC HEALTH SCOTLAND

Sublicensing allowed: No

Datasets:

  1. Hospital Episode Statistics Admitted Patient Care

Objectives:

Public Health Scotland (previously NHS Health Scotland) has been commissioned by the Scottish Government to lead the evaluation of minimum unit pricing (MUP) for alcohol, which was implemented in Scotland on 1st May 2018. A portfolio of studies has been developed by Public Health Scotland to evaluate MUP, which are summarised on the Public Health Scotland website: http://www.healthscotland.scot/health-topics/alcohol/evaluation-of-minimum-unit-pricing/mup-evaluation-overview.

Understanding the impact of introducing MUP in Scotland on the harm to health that alcohol can cause is a key outcome of the evaluation. To that end the evaluation includes a package of studies concerned with the impact of MUP on alcohol-attributable health harms, including hospital admissions and deaths. While the evaluation programme will assess a wide range of outcomes, the importance of a robust and credible assessment of the impact of MUP on these health outcomes has been emphasised by senior government officials and members of the MUP Governance Board. Indeed, much of the evidence that informed the legislation was focused on the potential impacts on hospital admissions and deaths caused by alcohol.

An important aspect in achieving a robust evaluation of the impact of MUP on alcohol-attributable health harms, is the inclusion of a concurrent geographical control. The purpose of this application is therefore to request alcohol-attributable hospital admissions data for England. England makes an ideal candidate as a control for Scotland in this study due to the geographical proximity, similarity in demography, culture and behaviours, and the fact that MUP was not implemented there.

The study will examine trends and patterns in alcohol-attributable hospital admissions in Scotland, making comparisons with England and two large, sub-national regions of England. The study will use a natural experimental design to assess the impact of MUP on hospital admissions and deaths caused wholly or partially by alcohol in Scotland, using routine administrative data.

Research Questions include:
• What is the impact of the introduction of MUP on alcohol-attributable hospital admissions in Scotland?
• What is the impact of the introduction of MUP on alcohol-attributable deaths in Scotland?
• To what extent does any impact of the introduction of MUP on alcohol-attributable hospital admissions and deaths vary by sex, age group and socioeconomic deprivation?

It is planned that data for England will be used as the geographical control group (head count of population, not a physical geographical area); data for sub-national English regions (North East and North West) will be used in supplementary analyses. The impact of MUP on overall admissions and separately for a range of demographic groups (sex, age group, area deprivation decile) will be assessed. Statistical models will be adjusted for sociodemographic characteristics (age group, area deprivation decile), seasonality and underlying trend.

The main outcome measures will be:
• All wholly alcohol-attributable deaths/admissions
• Acute wholly alcohol-attributable deaths/admissions
• Chronic wholly alcohol-attributable deaths/admissions
• All alcohol-attributable deaths/admissions (those wholly and partially caused by alcohol)
• All acute alcohol-attributable deaths/admissions
• All chronic alcohol-attributable deaths/admissions
• A selection of condition-specific outcomes.

To minimise the request, ICD10 codes pertaining to alcohol related conditions only are being used.

The ICD10 codes included in the request are limited to those defined as being either wholly or partially attributable to alcohol based on the latest available evidence (Sherk et al, 2017, Tod et al, 2018, Webster et al, 2018). In wholly attributable conditions, such as alcoholic liver disease, alcohol is the sole cause. In partially attributable conditions alcohol may be one of several factors that cause the disease. For these conditions alcohol-attributable fractions are used to quantify the proportion of those conditions that are caused by alcohol. Acute conditions are those that come on suddenly, have immediate symptoms and are limited in their duration. Chronic conditions are long lasting and can worsen over time.

To assess the impact of MUP on alcohol-attributable hospital admissions in Scotland, the Scottish Morbidity Record, a national data scheme that records comprehensive information relating to all inpatients and day cases admitted to either general acute or psychiatric hospitals in Scotland, will be used. Monthly data on the number of person-specific admissions by sex, age group, socioeconomic deprivation and condition group will be obtained by a request to the relevant department within Public Health Scotland.

Obtaining equivalent data for England (including sub-national regions) is the subject of this request. The inclusion of a concurrent geographical control, one which has not been exposed to the intervention in question, is considered good practice in natural experimental studies and is key in attributing any observed effect to the intervention (Craig et al, 2012, 2017; Leatherdale, 2018). The use of England or England & Wales (combined) as a concurrent geographical control is consistent with the approach taken as part of the wider evaluation of Scotland’s alcohol strategy that has been undertaken since 2009 through the well-established and highly regarded Monitoring and Evaluating Scotland’s Alcohol Strategy (MESAS) work programme. Work examining the impact of MUP on alcohol sales in Scotland published earlier this year used England & Wales as a geographical control in primary analyses (Robinson et al, 2020). Similarly, the proposed approach of using data for the whole of England is consistent with previous natural experimental studies to evaluate impact of the Alcohol Act legislation (including the multi-buy discount ban) on alcohol-related hospital admissions and deaths (Robinson et al, 2017) and alcohol sales (Robinson et al, 2014) in Scotland, as well as to evaluate the impact of lowering the drink driving alcohol limit (Haghpanahan et al, 2018).

While England represents a large geographical control area it is appropriate for the purposes of this study due to external factors that could potentially have an impact on both the Scottish and comparator population. Using data for the whole of England will reduce the impact of local policies and strategies that may impact on alcohol-related hospital admissions in specific areas of England. Data at national and government office regional level will be less susceptible to short-term change and random variation, thus strengthening the case for using a larger geographical control area.

It has been suggested that Northern England is a more appropriate control group for Scotland than the whole of England due to a more similar socio-demographic make-up and industrial and cultural history. Data for these regions are therefore being requested for supplementary analyses to test the robustness of our main results, where the whole of England will be used as the control. This is consistent with previous studies both within the MESAS programme (Robinson et al, 2014, 2017, 2020) and of other researchers in the area (O’Donnell et al, 2019).

The use of England or England & Wales (combined) as a geographical control is consistent with the approach taken as part of the wider evaluation of Scotland’s alcohol strategy that has been undertaken since 2009 through the MESAS work programme. The availability of data for England as the primary geographical control group (head count of population, not a physical geographical area) is therefore a key part of the proposed natural experimental study. There is no single perfect control area in this instance; the application therefore includes a request for data for the north of England. Analysis of both data for the whole of England and the northern regions are of equal importance in this study; the former allow us to address the issue of local strategic variation while the latter provide us with a closer and more demographically similar control area. The analysis of both areas provide the opportunity for triangulation of results and strengthening any potential causal inference. This is the approach taken in our recent assessment of the impact of MUP on sales-based consumption (Robinson et al, 2020).

Obtaining unsuppressed aggregated data for the whole of England is therefore necessary to ensure comparability with Scotland and to ensure that the impact of MUP is evaluated based on complete data. It is essential that unsuppressed data is obtained as a key part of the analytical process is the application of appropriate alcohol-attributable fractions. Using unsuppressed data will allow accurate calculation of the true burden of alcohol in relation to hospital admissions, both pre and post MUP-implementation. It will also allow examination of the impact of MUP on certain condition-specific causes as detailed in the research questions.

Three data extracts will be required based on the following definitions:
1. Admissions to hospital where the primary diagnosis is a code wholly attributable to alcohol.
2. Admissions to hospital where the primary diagnosis is any alcohol-attributable code or a secondary diagnosis is an alcohol-attributable external cause code
3. Admissions to hospital where the primary diagnosis or any of the secondary diagnoses are an alcohol-attributable code. Where there is more than one alcohol-attributable ICD10 code among the 20 possible diagnostic codes the code(s), the one from the lowest diagnostic position is selected.

Altogether, data from January 2012 to April 2021 are required and the data will be requested in two waves:
Wave 1 – up to and including the most recent available data
Wave 2 – an update to Wave including everything up to and including the end of April 2021.


In total this will provide data for over six years before, and three full years after the implementation of MUP.
The rate of each outcome measure will be calculated during each calendar month in each population subgroup. Monthly population counts for each subgroup will be estimated using interpolation of mid-year estimates. Data for the outcome measures will first be analysed descriptively to enable trends and other key information to be presented in tables and charts. In addition, the time series for each outcome will be separated to show trend and seasonal components separately which will aid interpretation of the trends.

Multiple regression (statistical technique used to analyse the relationship between variables) will be used to evaluate the impact of MUP on alcohol-attributable hospital admissions and deaths in Scotland. Both immediate and lagged effects will be assessed and a range of additional sensitivity analyses will be performed to test the robustness of the results.

Data will be processed by Public Health Scotland and the University of Glasgow on behalf of Public Health Scotland. In addition to the existing Service Level Agreement, a Data Sharing Agreement and Data Processing Agreement will be established between Public Health Scotland and the University of Glasgow for the purposes of this specific study. To that end Public Health Scotland will be the data controller and processor, while the University of Glasgow will be a data processor.

While the Scottish Government has tasked Public Health Scotland with leading the MUP evaluation and is partially funding the evaluation, Public Health Scotland remains the decision making authority in relation to the design and delivery of this study including the data being requested and how it is processed, therefore the Scottish Government are not considered to be a data controller for the purposes of this Agreement.

As the data will be aggregated and calculated as rates, there is no risk of anonymity being jeopardised or the potential for stigmatisation of individuals or groups. In addition, the study is overseen by an Evaluation Advisory Group which serves to provide advice and expertise and to provide assurance that will maximise the quality and relevance of the study.

The proposed research is therefore in accordance with Article 6(1)(e) of the GDPR which gives a lawful basis for processing personal data where:
“processing is necessary for the performance of a task carried out in the public interest or in the exercise of official authority vested in the controller”
Data on health is considered special category data by the GDPR. The purpose of processing NHS Digital Hospital Episode Statistics meets the condition set out in Article 9(2)(j) of the GDPR:
(j) 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.

Expected Benefits:

Within Scotland, understanding the impact of minimum unit pricing for alcohol on alcohol-attributable health harms is a vital part of the evaluation, and arguably the most important in the chain of expected outcomes. It is hypothesised that MUP may reduce population consumption, particularly among harmful drinkers; it would be expected that reduced alcohol consumption would result in a reduction of alcohol-related health and social harms and, in turn, the demand on health and social services. Data on alcohol-related hospital admissions is therefore a key indicator of alcohol-related harms and, if MUP achieves its aim, would also indicate the potential to release capacity to meet unmet need and/or enhance quality, in health and social care services.

This evaluation is a legislative requirement and the findings from this project could inform the decision of the Scottish Parliament on whether the legislation should continue after six years of implementation. The importance of a robust and credible evaluation of its impact on health outcomes has been emphasised by senior government officials and members of the MUP Governance Board overseeing the overall evaluation. Indeed, much of the evidence that informed the legislation was focused on the potential impacts on hospital admissions and deaths caused by alcohol (Holmes et al, 2018; United Kingdom Supreme Court, 2017). The public benefit of this work to Scotland is therefore that it may be key in informing the decision as to whether MUP continues in Scotland beyond the 6th year of implementation.

The evaluation as a whole, and specifically understanding the impact of MUP on alcohol-attributable health harms, offers significant benefit to a much wider health and social care audience, including those in England. Broadly, the work serves to benefit the public interest by:
• providing an evidence base for public policy decision-making;
• providing an evidence base, nationally and internationally, for decisions which may impact significantly on population health
• significantly extending researchers' understanding of the impact of social policy on health.

This is of specific importance to the population of England as the potential introduction of minimum unit pricing in England remains under consideration: in July 2019, the UK Government stated that "There are currently no plans to implement minimum unit pricing in England. However, this will be kept under review as evidence emerges from Scotland" (House of Commons, 2019). The results of the proposed study are therefore directly relevant to policy development and decisions in England. In particular, if the evaluation of minimum unit pricing in Scotland is more robust due to the availability of sufficient and stable comparison population data (as is being requested here), this is hoped to provide better quality evidence to inform policy decision-making in England. Furthermore, the evidence is more likely to be generalisable to England if the comparison population consists of the entire English population because it would take into account the entirety of current alcohol policy there and examine the ‘added value’ of minimum unit pricing. It is evident through our regular MESAS Monitoring Reports that, since 2013, alcohol sales through the off-trade (supermarkets and off-licences) have risen steadily in England & Wales (Giles et al, 2020). Coupled with the increasing burden of alcohol attributable disease since the early 1990’s throughout the whole of the UK (Global Burden of Disease, 2016), understanding the impact of alcohol policy such as MUP on alcohol-attributable harm to health remains as important to the English policy audience, as it does globally.

The MUP legislation includes a review and sunset clause meaning that the findings from this project, alongside findings from a range of other projects, hope to inform the decision of the Scottish Parliament on whether the legislation should continue after six years of its implementation. Indeed, the UK Supreme Court considered the experimental nature of the legislation to be a key factor in their decision: “The system will be experimental, but that is a factor catered for by its provisions for review and sunset clause. It is a significant factor in favour of upholding the proposed minimum pricing regime” (UK Supreme Court, 2017). It is therefore crucial that the most robust study design possible is adopted; we believe that to be through the use of a concurrent geographical control.

It is hoped the findings from this study may be published in an individual report on the Public Health Scotland’s website no later than spring 2023. The findings may be synthesised alongside all other studies and evidence generated throughout the evaluation, into a final report to be presented to the Scottish Parliament no later than November 2023; it is hoped, this may form the basis of the decision-making process as to whether MUP will be continued beyond 6 years of implementation in Scotland. It is hoped the findings are submitted for publication in an international peer-reviewed journal and opportunities to present at international conferences will be sought, so as to make the results available to a global audience.

The data from NHS Digital will not be used for any other purpose other than that outlined in this Agreement.

Outputs:

MUP as implemented in Scotland is unique and so this high-profile project will provide the first assessment of its effectiveness on alcohol-attributable health harms. The findings will be of interest to politicians, researchers and advocacy organisations globally. The results will be made available in a stand-alone Public Health Scotland research report. They will also be included in the final MUP Evaluation report that will inform the review report being laid before the Scottish Parliament. Both of these will be published on the Public Health Scotland website. All outputs will only contain results in highly aggregated format and as statistical summaries and measures of association. Statistical disclosure control will be applied where necessary; specifically, where numbers for a particular group are between 1 and 5, or other statistics derived from numbers between 1 and 5, these will be suppressed so as to avoid any potential confidentiality breach. Record level information will not be released to any third party.

Public Health Scotland is registered as a producer of official statistics with the UK Statistics Authority. As required under the code for producing official statistics, Public Health Scotland adheres to strict information governance protocols including that around statistical disclosure control.

Publication for the individual report is expected to be by spring 2023 and for the full evaluation report, November 2023. Following publication of the Public Health Scotland research report, the findings will be submitted for publication in a high-impact peer-reviewed journal. Opportunities to present at local, national and international fora will also be sought, so as to make the results available to a wide-reaching and global audience.

The findings will be used by local, national and international policymakers, public health practitioners & advocacy groups with whom the team already have strong, long-standing links. Consistent with the MUP Evaluation Communication and Engagement Strategy (available upon request) Public Health Scotland will: (i) involve key stakeholders throughout the project including via a study advisory group (ii) disseminate findings via social media, prepare a lay summary, and issue a press release (iii) send findings directly to MSPs & MPs on health committees/cross-party groups; (iv) present findings to alcohol policy and academic communities (e.g. Faculty of Public Health; Global Alcohol Policy Alliance; Scottish Parliament Health and Sport Committee; Kettil-Bruun Society).

The data will not be used for commercial purposes, will not be provided to any third parties, and will not be used for direct marketing.

Processing:

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).

No data will flow from Public Health Scotland to NHS Digital. The following data from HES APC will flow from NHS Digital to PHS:
Year
Month
Condition (ICD-10)
Sex
Age group
Government Office Region
Index of Multiple Deprivation (IMD) decile
Admission count

Aggregate data (which will include small numbers) received by Public Health Scotland will be used to calculate the count of alcohol attributable hospital admissions, by condition, in each population subgroup (age group, sex, IMD decile) by applying alcohol attributable fractions (AAFs). These data will then be shared with the University of Glasgow using secure encrypted email. Alcohol attributable admissions will be compared with those in Scotland, but there will be no data linkage performed as part of this project.

The researchers at the University of Glasgow will apply statistical analysis methods (controlled interrupted time series analysis) to the data. The team providing the processing service for Public Health Scotland have extensive experience in analysing hospital and mortality data (including highly sensitive linked data). The team regularly update their knowledge regarding data security and confidentiality via regular training sessions available at the University of Glasgow and have completed the MRC Research Data and Confidentiality course.

Both Public Health Scotland and the University of Glasgow will access data via a secure organisational network, requiring passwords to access. Any transfer of data will be via secure encrypted email.

The data will be stored by Public Health Scotland (data controller and processor) on a Storage Area Network (SAN) located at ATOS Data centre. ATOS provides a warehousing facility for Public Health Scotland’s IT hardware. This physical location provides multi-layered security access procedures to ensure the integrity of access to the physical systems. No staff member of ATOS has direct access to Public Health Scotland’s hardware or IT systems/networks.

ATOS provide storage for Public Health Scotland but do not access data held under this Agreement and are not listed as a data processor as they only supply the building. Therefore, any access to the data held under this Agreement would be considered a breach of the Agreement. This includes granting access to the database[s] containing the data.

There are no subsequent flows of data.