NHS Digital Data Release Register - reformatted
Project 1 — DARS-NIC-66034-M7B8W
Opt outs honoured: No - data flow is not identifiable (Consent (Reasonable Expectation))
Sensitive: Sensitive, and Non Sensitive
When: 2018/10 — 2020/01.
Legal basis: Health and Social Care Act 2012 – s261(1) and s261(2)(b)(ii)
Categories: Anonymised - ICO code compliant
- Mental Health and Learning Disabilities Data Set
- Mental Health Minimum Data Set
- Hospital Episode Statistics Accident and Emergency
- Mental Health Services Data Set
- Improving Access to Psychological Therapies Data Set
RAND Europe Community Interest Company (hereafter known as Rand Europe) has been commissioned by the Department of Health to undertake an evaluation of the National Model for Liaison and Diversion (L&D) services in England. This follows a previous evaluation of the implementation of the National Model undertaken by RAND Europe from April 2014 to August 2015. Liaison and Diversion (L&D) services aim to identify people experiencing mental health and substance misuse problems, and learning disabilities (among other vulnerabilities) as they pass through the criminal justice system (CJS) to ensure their health and other needs are known about and that they are referred to services to address their needs. L&D schemes aim to improve outcomes for their service user group and to save money through the provision of accurate, appropriate and timely information to inform the decisions of the CJS. The use of NHS Digital data will help RAND Europe in fulfilling its mission which is to improve health and health care systems, by providing policymakers with objective, empirically based research to inform their decision making. Developing the work undertaken in the first implementation evaluation, the Department of Health requires an outcome evaluation of the Liaison and Diversion (L&D) Trial scheme, which has been implemented in 25 areas of England. These 25 sites are made up of 10 ‘wave 1 roll-out’ sites (operating since April 2014) 15 ‘wave 2 roll-out’ sites (since April 2015). This application seeks data to support Work package 3: Health service utilisation. The objective of this work package is to understand whether the L&D service has an impact on health service utilisation by users. The study will use the same approach to generating the counterfactual as for the reconviction and diversion analysis – employing both a before-and-after design and a quasi experimental design using a matched comparison group. Importantly the answers to the research questions below will ascertain whether getting people who are in the criminal justice system signposted to the rights services will have a positive impact on their health and in turn have a knock on effect on the system as a whole. The aims of the evaluation are to address the following research questions: 1. What impact, if any, does the implementation of the National Model of L&D have on reconviction? 2. What impact, if any, does the implementation of the National Model of L&D have on health service utilisation? 3. If any impacts on offending and health care utilisation are found, what is the economic effect of those? 4. How have any impacts of the National Model of L&D been achieved? 5. What impact, if any, does the implementation of the National Model of L&D have on diversion from the criminal justice system? To answer some these questions, RAND Europe require HES A&E, MHMDS, IAPT data to understand whether the L&D service has had an impact on health service utilisation by service users. The study will employ both a before-and-after design (comparing outcomes between wave 1 and wave 2 sites) and a quasi-experimental design using a matched comparison group. The study intends to gather information about health service utilisation from the following datasets: • HES A&E dataset • MHMDS • IAPT RAND Europe is a not-for-profit research organisation that helps to improve policy and decision making through research and analysis. Whilst RAND Europe have offices based in England and the EU for the purposes of this application no data will be processed outside of England and Wales. 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 ie: employees, agents and contractors of the Data Recipient who may have access to that data).
To date, the study has produced three progress reports. The key benefits these reports is that, for the first time, the L&D Programme Board were provided with rigorous information about the criminal justice histories and health service utilisation of the cohort of service users targeted by the L&D service. For example, RAND's descriptive analysis provided evidence that this population are much higher users of A&E services than the general population - providing the possibility that L&D are targeting a costly group. It also could show that L&D service intervention comes at a point of 'crisis' - where drug use, self-reported offending and health service utilisation has peeked. Again, it is of benefit for the Programme Board to understand this, in order to realise the scheme's potential benefits. As yet, RAND do not have any health data relating to the time after RAND's cohort used the L&D service. RAND do have ‘after’ data from the national drug treatment data base. RAND's analysis of data collected about RAND's cohort from drug treatment services, show that self-rated psychological health and quality of life on average falls about 2 points on a 0-20 scale in the two years before L&D referral, recovering to about baseline levels after the referral. The descriptive analysis of the mental health data previously received from NHS Digital finds that service utilisation increases in the evaluation cohort in the years before L&D, reflecting that contact with L&D may occur at a point of crisis for many individuals. As yet RAND have only published preliminary results, so they have not been used to inform policy, as of yet.
The prevalence of mental health and other vulnerabilities among those in the criminal justice system (CJS) is a matter of concern to policymakers. L&D schemes aim to improve outcomes for offenders suffering from these difficulties and to save money through the provision of accurate, timely information to the CJS. The intended outcome of the research is evidence about whether or not the National L&D Model has any impact on reconviction, diversion and the use of health services. Currently, there is no evidence on this, so the evaluation could make an important contribution in this respect. These findings could have important impacts for those in NHS England responsible for deciding whether and how to roll-out the National Model to other areas of the country and as such, it is hoped that this research will lead to benefits for future L&D service users and stakeholders. The study has been timed to feed directly into Treasury and NHS England decision-making on funding and implementing further L&D roll-out. The key benefits are threefold, getting people who are in the criminal justice system signposted to the right services will have a positive impact on their own health and well being, thus benefiting their mental and physical health. With this there is more of a likelihood of these individuals leading a less chaotic lifestyle. With the better allocation and management of signposting people in this group to the right services there will be a benefit of a reduced burden on health and social care services, less movement of resources and better management of service. Getting people who are in the criminal justice system connected to the right services could divert the individuals fro re-conviction thus benefiting the CJS with fewer re-convictions entering the system. In summary getting people who are in the criminal justice system signposted to the right services will have a positive impact on their own health and a positive impact on the use of health and social care services. As such there is potential benefit to reduce burden on health and social care services for those people who are in the criminal justice system. These people are more likely to lead chaotic and complex lives if the L&D scheme can improve the outcomes for these people through better allocation of health services then the whole system will benefit.
The project has been commissioned and funded by the Department of Health, the final report will be submitted to the Department of Health. It will be subject to peer review and approval from the Department of Health. NHS England is involved as it is the provider of L&D services and will be a key user of the findings from the evaluation, which NHS England will use in putting a business case to Treasury regarding final roll-out of the L&D service. The research team are working closely with the NHS England team in the recruitment process (consent procedure etc.) and the timelines associated with the recruitment process etc. The final report will be used by NHS England to inform its business model for the national role out of the L&D service, which will be submitted to HM Treasury. The main output from the research will be a final report of findings produced for NHS England. This will be made publically available through the NHS England and RAND Europe website. It will have a short, clear executive summary and be written for policymaker and practitioner audiences. It will be approved by the DH peer review system, as well as the RAND Europe Community Interest Company quality assurance system, to ensure the results are reliable and the drafting clear. The distribution of this report would be supported by the NHS England programme board – who have cross departmental links with key policymakers nationally and regionally. The final report will be submitted in May 2019. Findings in relation to each of the aims outlined in the objectives for processing will be included in RAND Europe's final report May 2019. The timing of that report has been selected in order to provide evidence to feed into a business case for the national rollout of liaison and diversion scheme that NHS England will submit to HM Treasury at this time. Treasure will then make a decision about whether the L&D scheme should be rolled out to remaining parts of the county. The Treasury is expecting the evaluation report to be an important piece of evidence to information their decision. During the study RAND Europe will keep L&D service staff informed about progress/emerging findings through contributions to monthly L&D Bulletins produced by NHS England. Additional dissemination opportunities are being considered including: • Delivering a briefing on the final results to policy makers from interested departments. • Attendance at events or conferences to disseminate findings to practitioner, policy and/or academic audiences. • Writing blogs or short policy briefs. • Contributing on occasions to the L&D newsletter distributed monthly to practitioners. The research team has done this throughout phase 1, and could build on this. • Briefing cross-departmental meetings of the L&D programme board on evaluation progress, interim findings etc. The research team attended this meeting during Phase 1. This will be a key forum for engaging with health policy makers. The public and service users are a key audience for this work. RAND Europe Community Interest Company would investigate, at the time of publication, how RAND Europe can make use of the arrangements NHS England and/ or individual sites have in place for dissemination to service users, and intend to make use of those existing channels to disseminate tailored outputs for the public and service users. Examples of outputs could include providing updates on the progress of the findings in the L&D service newsletter (circulated to all L&D staff) as well as producing a short (two-page) research brief and posters which could be disseminated to staff and made available at L&D service sites. The final report will be shared with service staff, this will include a plain English summary which could be shared with service users if they see fit. When the time comes for dissemination RAND Europe will discuss with the DH what outputs would be most useful and valuable for the stakeholders involved. RAND Europe will also explore the possibility of dissemination to academic audiences via articles in peer-reviewed journals and conferences. All outputs will present data at aggregated level with small numbers suppressed inline with the HES analysis guide. The data is anonymised in accordance with the ICO Anonymisation: Managing data protection risk code of practice.’
RAND Europe have in place their own internal user agreements that staff working with data on projects must sign prior to being provided access to any data. These agreements are project specific and clearly set out the data use restrictions by which researchers must abide. NHS number, Date of Birth, Sex, and Study ID of RAND Europe's cohort (for which recruitment has now closed) to enable the matching, no other identifiable data will be transferred to NHS Digital Data set A. The raw unprocessed data (L&D Personal Data Sheet) will be stored on a dedicated area of RAND’s secure server, separate to all the other datasets created during the course of this project, including Dataset A. Dataset A will include the unique study ID but other identifiable data such as name and address will have been removed from this dataset. The unique study ID will be used to link the various datasets. Arrangements are in place so that research team members involved in analysis of Dataset B and Dataset C will not have access to the L&D Personal Data Sheet. Only two people at RAND Europe will have access to the Personal Data Sheet which links name, date of birth and gender to the unique study identifier. Only those 2 people will have the password for the Personal Datasheet file and access to that part of the server. The following description of the processing activity applies to the data set received from NHS Digital. Data Set B. Data cleaning and pre-processing will be conducted by the members of the RAND Europe research team. Pre-processing will include the following: linking episodes to create a dataset delineated by admissions. The Mental Health Minimum Data Set (MHMDS); Improving Access to Psychological Therapies (IAPT); and the Hospital Episode Statistics (HES) A&E dataset will be linked to data from the Police National Computer (PNC) and the National Drug Treatment Monitoring System (NDTMS) by RAND Europe based on a unique study identifier. This creates Data set C. Data Set A is the data from separate L&D sites combined and cleaned. Unique study identifier assigned to participating service users by RAND in preperation for sending to NHS Digital Dat Set B is the cohort date which has been linked to NHS Digital IAPT Mental Health and HES data by NHS Digital Dat Set C is data set B which has been linked to data from the Police National Computer (PNC) and the National Drug Treatment Monitoring System (NDTMS) by RAND Europe based on a unique study identifier. An initial analysis will be undertaken to describe the population of L&D service users. This population is poorly characterised at present, in terms of understanding of their previous health care utililsation and criminal justice history. This analysis will draw on historical data from April 2012. The evaluation will employ two analysis strategies to examine the outcomes from the L&D schemes. 1. Before and after comparison: This analysis will be undertaken for all of the study sample (service users in both wave 1 and wave 2 sites who have consented to their data being shared with the research team). Outcomes would be compared for the 12 monthsa period before entry into the service (back to 2012) and the 12 months after the date of entry of the service user into the L&D service. 2. Retrospective comparison group: A second form of analysis will be to compare L&D service users in the wave 1 sites (the treatment group) with a similar population of individuals who have not used the L&D service (the control group). The control group will be drawn from individuals in the wave 2 sites, but ONLY looking at the period BEFORE they entered the L&D service. Individuals who eventually end up in an L&D service in a wave 2 site are likely to share many characteristics with individuals using the L&D service in the wave 1 sites. This approach to constructing a comparison group is unusual, but was considered the best in the circumstances, and was signed off by independent academic reviewers of RAND’s application for funding for this study from the DH. The results of the analysis will be presented at an aggregated level and RAND Europe will suppress any small numbers in line with the HES analysis guide. RAND Europe will be the sole data controller and data processor. All data will be securely stored on a dedicated server at the RAND Europe offices in Cambridge (England). Access to the data is managed by the Information Controller; internal HES user agreements are in place and staff working on the project have to sign this agreement prior to being provided access to the data. These agreements are project specific and clearly set out the data use restrictions by which they must abide. NHS England will not have access to any of the unprocessed data, when findings are shared with NHS England these will be presented at an aggregated form. The data being disseminated back to Rand will be Pseudonymised and will stored and managed on a separate secure server to the L&D Personal Data. Rand will not make any attempts to re identify an individual. 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 ie: employees, agents and contractors of the Data Recipient who may have access to that data). All data will be handled in accordance with the specific NHS Digital Terms and Conditions associated with the data. Disclosure control rules (valid until superseded by disclosure controls published by NHS Digital): For data from the Mental Health (MHSDS, MHLDDS, MHMDS) data sets, and any Mental Health data linked to HES or SUS, the following disclosure control rules must be applied: • National-level figures only may be presented unrounded, without small number suppression • Suppress all numbers between 0 and 5 • Round all other numbers to the nearest 5 • Percentages can be calculated based on unrounded values, but need to be rounded to the nearest integer in any outputs • In addition for Learning Disability data in Mental Health (MHSDS, MHLDDS, MHMDS), the England-level data also must apply the suppression of all numbers between 0 and 5, and rounding of other numbers to the nearest 5. There will be no data linkage undertaken with NHS Digital data provided under this agreement that is not already noted in the agreement. 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 ie: employees, agents and contractors of the Data Recipient who may have access to that data).
Project 2 — DARS-NIC-07173-T8S5M
Opt outs honoured: N
Sensitive: Non Sensitive
When: 2016/12 — 2017/02.
Legal basis: Health and Social Care Act 2012
Categories: Anonymised - ICO code compliant
- Hospital Episode Statistics Admitted Patient Care
- Hospital Episode Statistics Accident and Emergency
- Hospital Episode Statistics Outpatients
RAND Europe and the Health Service Group at the University of Cambridge have been commissioned to undertake two research projects on behalf of NHS organisations. These are SLIC (Southwark and Lambeth's Integrated Care) and TELE-FIRST. No data will be shared with a third party. SLIC Southwark and Lambeth's Integrated Care (SLIC) focuses specifically on the Older Peoples' Programme (OPP). The project was commissioned by King's Health Partners (Guy's and St Thomas' NHS Foundation Trust & King's College Hospital NHS Foundation Trust) as part of the 'Evaluation of Lambeth and Southwark Integrated Care Pilot Scheme. The evaluation focuses on outcomes (hospital and nursing home utilisation) and cost effectiveness. The HES data is needed to understand the impact of the OPP on hospital utilisation (e.g. admissions, emergency admissions, outpatient attendance and A&E attendance). The study is a controlled before and after design and comparisons will be made with similar populations in south London and the rest of England. The study will compare results at the GP practice level - e.g. to compare responses for all over 65s or all over 75s in Lambeth and Southwark practices with matched practices in other parts of the country. Initiated in 2012, the SLIC OPP brings together health and social care providers and local people to help maximise the health and independence of older people, aged 65 years and older, through: - better identification and management of risk; - minimisation of inappropriate hospital use in times of crisis through faster access to special assessment, rapid support at home and improved discharge programmes. The programme focuses on holistic care for the population rather than a single disease, across physical and mental health, and social care in two boroughs. A formative and summative evaluation was commissioned to run in parallel to the programme from August 2012. The formative evaluation is to be undertaken while the programme activities are in progress to help monitor how well the aims and objectives are being implemented. The summative component focuses on outcomes to enable SLIC to understand whether the programme has achieved its aims and objectives at the end of the programme. The summative component will report in summer 2017. The evaluation consists of four components: -People's views; -Outcomes; -Cost effectiveness; -Change Process. TELE-FIRST The Tele-first study, is to reuse the data currently processed under the existing agreement. Tele-first aims to explore the benefits and disadvantages of telephone triage in general practice. Telephone triage is an innovative approach used in general practice to manage patients' requests to see a doctor. Patients who ask for a face-to face appointment are asked to speak to a doctor on the phone first. The doctor then decides whether and when the patient needs to be seen in surgery, or whether the issue can be dealt with by phone. Management support for this innovation is being offered by two commercial organisations and reported gains include: - the ability to deal with two thirds of requests by telephone; - to greatly reduced waiting times for appointments; - improved continuity of care; - improved patient experience and reduced A&E attendance and emergency admissions. This study fulfils a need for independent research to better understand its impact on staff and patients and to evaluate whether it is feasible and cost effective. In this study, researchers at RAND Europe and the University of Cambridge, (with funding from the National Institute of Health Research) will work together to evaluate the impact of the approach scheme. The study began in September 2014 and will run for two and a half years, ending in February 2017. It involves the use of quantitative and qualitative methods and cost-consequences analysis to address the following research questions: 1. How does a GP telephone triage approach affect patient experience and use of primary and secondary care services? 2. What is the impact of GP telephone triage on the nature of consultations for patients and staff, and how appropriate is this approach for hard-to-reach groups? 3. What are the cost consequences of a telephone triage approach in general practice? Study methods include primary data collection using surveys of: - patients regarding their experience of the service; - practice managers on telephone triage use/costs; - qualitative interviews with GPs, practice staff and patients; - quantitative analysis of secondary data including data from the English GP Patient Survey, data on the proportion of patients who leave a practice without changing address and data on hospital utilisation. The HES data are needed to understand the impact of the telephone triage approach on hospital utilisation (e.g. A&E attendance, outpatient referrals, elective admissions and emergency admissions). The analysis of healthcare utilisation data will be based on a before-and-after difference-in-differences analysis comparing practices involved in the study with other practices in England. The analyses will allow for baseline and pre-intervention trends and controlling for practice size, rurality, deprivation, and population age/sex/ethnicity.
SLIC: This study has been commissioned by the King's Health Partners in order to determine the effectiveness of their Southwark and Lambeth Integrated Care Programme, focusing on the older people programme. RAND Europe therefore want to be able to use the data to measure changes in admission of older people to A&E and a number of other outcomes in order to be able to meet the needs to the SLIC team. King's Health Partners commissioned the evaluation as it considers it is of fundamental importance that it robustly tests its impact on the quality and value of the health and social care system. The evaluation will serve the following purposes: - to provide assurance for local people, participating organisations and sponsors on the extent of impact and that this assessment of impact is independent and robust; - to inform local decisions on the spread and application of integrated care; - to highlight areas of success and areas for learning and improvement locally to share learning with the health and social care system nationally. The evaluation has both direct benefits for the King's Health Partners, as well as the potential for wider learning as this is one of the first major scheme of its kind 'integrating care' in the UK. The use of HES data will help RAND in fulfilling its mission which is to improve health and health care systems, by providing policymakers with objective, empirically based research to inform their decision making. RAND Europe are contracted to submit annual reports with a final report due in summer 2017. Following the first annual report being submitted for review by the SLIC Evaluation Steering Group and by the King's Health Partners, it has been identified that the level of activity was lower than anticipated during the first two years of SLIC. Future analysis based on more recent data is needed for to be able to understand whether efforts to increase the uptake of the intervention have had a measurable impact. TELE-FIRST: RAND Europe would also present findings at national and international conferences, including the annual NHS Confederation conference and the HSRN conference. The findings will enable providers and policy makers to assess if such an approach should be advocated in their locality and whether it would be appropriate for all types of patient. The study focuses on evaluating the telephone triage approach in a group of practices willing to adopt use of a telephone triage system. If the findings support the use of the new approach, the work will show how the approach could be rolled out to a wider group of GP practices, what the potential barriers would be, and how these barriers might be overcome. There are major potential benefits of the new approach to consultations in terms of improved access to GPs, reduced waiting times, improved continuity of care, and reduced workload for GP practices. RAND Europe are contracted to submit a final report in spring 2017.
Only aggregate analysis with small numbers suppressed, in line with HES analysis guide, will be made available to any third party. SLIC: The confirmed output is an annual written report produced for the SLIC Evaluation Steering Group. These will be made publically available through the SLIC, RAND and the University of Cambridge's respective websites. Additionally RAND Europe will produce articles for publication in academic journals and present at conference (poster or oral presentations). The first annual report has been produced and is currently under review by the SLIC Evaluation Steering Group and by the King's Health Partners. Analysis will be conducted annually up until June 2017. The findings and detailed methodology will be made publically available through RAND Europe, the University of Cambridge and SLIC websites. The interim analysis will inform the SLIC older people's programme as it progresses and it is intend that the final analysis will form the basis of reviewed academic publications. TELEFIRST: The outputs from the research will have three principle audiences: policy makers; NHS managers in primary care; and academic audiences. RAND Europe will publish findings in academic peer-reviewed journals and present findings at academic conferences. RAND Europe will seek to actively engage policy makers at local and national level, along with local service managers, NHS providers, researchers, patient groups and other stakeholder groups that the applicant believes would be the beneficiaries of the proposed research. Written outputs would include articles in peer reviewed journals as well as a final report as outlined by the NIHR Health Services and Research Development programme (due March 2017). A summary of the findings of the research and recommendations will be provided in a four page briefing document. This summary will be targeted to policy makers and practitioners. Patient and public involvement (PPI) members will be asked to assist in the production of a short summary for a nontechnical audience. RAND Europe would also present findings at national and international conferences, including the annual NHS Confederation conference and the HSRN conference. The outputs for both studies are to be made available to all relevant stakeholder and this is likely to include the British Medical Association and the Royal College of General Practitioners. The chair of the NHS Primary Care Workforce Commission Professor Roland (PI of the project) has strong links to the policy community and will ensure that the research is shared with the relevant audiences.
Raw data received by RAND Europe will be stored and managed by the Information Controller for RAND Europe. All individuals will access to the data are substantive employees of RAND Europe or the University of Cambridge. The data will only be accessed by these staff on a need to know basis and for the purpose of the two studies detailed in this agreement. Pre-processing will include the following: linking episodes to create a dataset delineated by admissions; for each practice the data will then be aggregated into 5 year age groups separately for each gender. Aggregated data will then be analysed RAND Europe and the University of Cambridge team. Data aggregated and anonymised by practice, age and gender will then be linked at practice level to other datasets held by the University of Cambridge and used in statistical analyses. The other datasets (none at patient level) are: - GP Patient Survey data obtained from the Department for Health and NHS England; - Practice level Deprivation Scores obtained from the Association of Public Health Observatories (Now Public Health England) - GP Census data obtained from HSCIC - Quality Outcomes Framework data obtained from the HSCIC website - Other freely available practice level indicators obtained from the NHS Digital Indicator Portal No data linkage to record level data will occur for either the SLIC or Tele-First studies. SLIC: RAND Europe will model the level of demand for services recorded in the HES data, aggregated at practice level. Some condition and cause specific outcomes (e.g. falls) will also be included in later analyses. A comparison will be made between practices involved in the SLIC intervention against a selection of matched practices from around the country. The model will include data before the intervention, including random effects so that the underlying admission rate in each practice is accounted for and that this rate can change year on year. An interaction term between years (following intervention) and intervention group allows for the assessment of the effect of the intervention. The annual analysis will follow the same format as that used in the practice based analysis of the national integrated care pilots [Roland M et al. Case management for at-risk elderly patients in the English integrated care pilots: observational study of staff and patient experience and secondary care utilisation. international Journal of Integrated Care 2012; 12] Outcomes are used to assess changes in hospital utilisation following implementation of the Older People's Programme. Changes in hospital utilisation will be assessed using changes in emergency admissions, elective admissions, bed days, A&E attendance and outpatient attendance. In order to place these changes in context, changes in hospital utilisation within Southwark and Lambeth will be compared to similar populations in South London and the rest of England. TELE-FIRST: RAND Europe and University of Cambridge will conduct analyses to compare A&E attendance, outpatients attendance and emergency admissions between study practices and control practices in England. The analysis will be based on a before-and-after difference-in-differences analysis allowing for baseline and pre-intervention trends and controlling for practice size, rurality, deprivation, and population age/sex/ethnicity. It is anticipated that data covering a period of up to three years prior to and up to two years post introduction of the triage system will be sufficient to support the analyses. In these models practice level random effects with an unstructured covariance matrix will be included for each year so that the underlying outcome level (and associated clustering/over dispersion) in each practice is incorporated and may change each year. An interaction term between year (following intervention) and intervention group allows us to assess the effect of the introduction of the triage system in each of the two years following intervention. Where possible, a second set of models will model intervention effects with monthly data. These models will be similar but further include a spline approach that models both sudden and gradual changes using interactions between the intervention group and (1) a post intervention indicator and (2) a linear year variable that begins at the intervention, respectively). When analysing secondary care usage a mixed effects Poisson regression will be used to model the count of admissions. For each practice data will be aggregated into 5-year age by gender groups and the rate of admissions will be modelled using freely available data on the age and gender profiles of the practice population. In doing so the applicant will be able to adjust for patient level age and gender and will further adjust for the same practice level variables as listed above.