NHS Digital Data Release Register - reformatted

Care Quality Commission (CQC)

Opt outs honoured: N

Basis: Care Quality Commission's statutory powers - 2012 amendment to Section 64 of the Health and Social Care Act 2008

Format: Identifiable Sensitive

How often: Ongoing

When: unknown — 11/2016

HSCIC Id: DARS-NIC-359603-D2Q6M-v0.0

Data: Hospital Episode Statistics Accident and Emergency

Data: Hospital Episode Statistics Admitted Patient Care

Data: Hospital Episode Statistics Critical Care

Data: Hospital Episode Statistics Outpatients

Data: Office for National Statistics Mortality Data (linkable to HES)

Project info

Output: The on-going outputs produced are:
Intelligent Monitoring: outputs are published on the internet as indicators and overall provider ranking. This is aggregate information with small numbers suppressed.
Data packs: used by the inspections teams and shared with providers. This is aggregate information with small numbers suppressed.
Outliers Programme: analysis of certain metrics derived from these data are shared with trusts who have hit a statistical threshold that is regarded as being of concern. A trust receives analysis only of patients admitted at that trust with a comparison to overall national rates.
National Reporting: used to support the creation and population of national reports providing a qualitative review of health and care supported by aggregated information. The nature of these reports varies year on year depending on CQC's topics of interest. This is aggregate information with small numbers suppressed.
Thematic reviews: used internally to inform CQC's regulatory activities. They provide an in depth review of selected areas of care, for example dementia care. This is aggregate information with small numbers suppressed. They are shared publicly.
In the monitoring of organisations for ongoing compliance against essential quality and safety standards, CQC uses screening techniques in its Intelligent Monitoring tools, which analyse a wide variety of data sources to highlight possible outlying concerns that trigger actions where concerns are raised. Such screening methods are aided by a more local approach to information gathering and analysis, which is being developed in consultation with appropriate stakeholders. These techniques, currently along with national surveys of patients, help to create a more holistic understanding in informing its work with ongoing compliance, investigations, and thematic reviews.
In addition, the data will also be used in the CQC’s remit to investigate serious concerns about the quality of public services. These data will be a vital pillar in both a national system of monitoring registered organisations, and the development and publication of reliable performance indicators.

Activities: The identifiable data are loaded into a separate database which is analysed by a small team (currently 5); this is the only team that can access the identifiable data. They analyse the data and provide cuts - anonymised at both record and provider level - for statistical packages for use in the Intelligence Directorate only by identified staff. These staff request the bespoke breakdowns from the analytical team.
Regarding the use of the data, HES, HES-ONS, HES- MHLDDS (using the MHLDDS Bridging file) and MHLDDS data are loaded into statistical packages and their outputs are used for the population of Intelligent Monitoring, individual data packs, outlier analysis, thematic reviews, and national reporting products to support the objectives above. The outputs have small numbers suppressed in line with the HES analysis guide.
Regarding the use of the data, HES, HES-ONS, HES-MHLDDS (using the MHLDDS Bridging file) and MHLDDS data are loaded into statistical packages and their outputs are used for the population of Intelligent Monitoring, individual data packs, outlier analysis, thematic reviews, and national reporting products to support the objectives above. The outputs have small numbers suppressed in line with the HES analysis guide.
CQC presently identify the sources of data and the calculation methodologies for each of the products. In order to publicise more clearly to the public how CQC uses identifiable data, the CQC Board has approved our Information Governance strategy that requires CQC to conduct a review of the information it collects and uses directly/ indirectly from the public and how this, in turn, is communicated more widely. This review will build on current moves (for example, review of published leaflets) to be more transparent about how such information features in our regulatory programme.

Objective: Renewal of NIC-292297-K3G0K

The Care Quality Commission (CQC) is a Non-Departmental Public Body and was established under the Health and Social Care Act 2008. It took on the functions of the Healthcare Commission, the Commission for Social Care Inspection, and the Mental Health Act Commission.
CQC has the function of regulating health and adult social care services in England (provided by the NHS, local authorities, private companies or voluntary organisations), and protecting the rights of people detained under the Mental Health Act.
CQC ensures that health and social care services provide people with safe, effective, compassionate, high-quality care and encourages them to improve.
CQC use these data to populate indicators within their Intelligent Monitoring Tool. This tool helps CQC focus inspections of providers by deciding when, where and what to inspect. These data are also used to construct data packs which bring together information and analysis for each provider and are used for inspection planning. These data are also used within the applicants Outliers programme to identify when key metrics relating to mortality rates and maternity outcomes reach a level that may warrant further investigation.
In addition, CQC use the information in thematic reviews and national reporting; for example the Annual State of Care report.
It is occasionally necessary to identify to a trust examples of their own patients whose care appears problematical. A single field - local patient identifier - is used as the HESID is not known to the trust. With this exception, no record level data is released to third parties.
CQC uses identifiable in relation to its code of practice as per the below –
Under the 2008 Act (amended 2012), CQC is responsible for the regulation of:
treatment, care and support provided by hospitals, GPs dentists, ambulances and mental health services.
treatment, care and support services for adults in care homes and in people’s own homes (both personal and nursing care).
services for people whose rights are restricted under the Mental Health Act.
CQC monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and it publishes what it finds, including performance ratings to help people choose care.
For reference to CQC's rationale for requiring access to identifiable fields, please refer to Tom Ward's letter of 06 November 2014 ref: "Review of CQC requirement for HES and MHMDS sensitive fields"
CQC’s use of identifiable data is subject to our statutory Code of Practice on Confidential Personal Information (the code). The purpose of the code is to provide transparency on our use of information for data subjects and other stakeholders and as a guide for staff on the practices we will follow.
The code is a requirement of the Health & Social Care Act 2008 which itself creates safeguards on our use of information in addition to the requirements of the Data Protection Act 1998 and compliance with other relevant legislation and common law duties (as detailed in the code appendix)
Of particular relevance to this application is our first ‘principle’ governing our use of information. “We will only obtain confidential personal information where it is necessary to do so for the purpose of exercising our functions”. We are satisfied the substance of this application and letter of 06 November 2014 meet this requirement.
All use of confidential personal information by CQC is in accordance with the ‘necessity test’ which informs our decision on obtaining, using or disclosing. This test is the foundation for the code and is designed to ensure the minimum processing is performed.
Of relevance to this application, we ensure that access to the requested identifiable data is limited to the small team of whom it is necessary to process these data to produce non-identifiable outputs for internal CQC use. This is in accordance with our fourth principle, that ‘We will use only the minimum necessary confidential personal information. We will use anonymised information wherever possible…”
It is also our policy is to extend the application of the Code to information relating to the deceased, providing further safeguards to the use of identifying data (Principle 7).

Benefits: In the applicant’s monitoring they prioritise the care and welfare of patients. People who use services should experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights.
CQC uses these data to help determine five core questions about services:
Are they safe
Are they effective
Are they caring
Are they well-led?
Are they responsive to people’s needs?
HES, HES-MHLDDS (using the MHLDDS Bridging file) and MHLDDS data are used to determine key performance indicators in the Intelligent Monitoring product. Each indicator is categorised in one of the core domains that, in total, provide a view for both the public and clinicians on the quality of the provision of care.
The pre-inspection data packs help the planning and review stages of an inspection that seeks to highlight areas of poor care requiring improvement while also seeking to promote good practice.
HES and HES-ONS data are used in the outliers programme. Outlier events, such as high mortality or readmission rates may be identified either by CQC's own analyses or by those of Dr Foster. For both, CQC gathers all available information - including HES analyses, where appropriate, and advice from experts - and presents this to an internal review panel. This panel decides whether to not CQC investigate. When CQC decide to proceed, the data is shared information with the trust for them to review and comment upon. One of the review actions a trust may carry out is a case note review. On rare occasions the trust is unable to reconcile HES counts with their local systems. In those cases CQC may share a small number of values for the local patient identifier (lopatid) with the trust so they can identify patient notes to review.
HES, HES-ONS, HES-MHLDDS (using the MHLDDS Bridging file) and MHLDDS are used in analyses for thematic reviews and in the development of new Intelligent Monitoring indicators; for example, in reviewing quality of access to care across different ethnicities.
Thematic reviews provide in-depth analyses of chosen topics to inform CQC staff, clinicians and the public about that service/ area of care while also highlighting areas for improvement/ best practice; working with inspector colleagues, themed inspections allow CQC to develop recommendations for making improvements in the delivery of care. These recommendations are then incorporated into future inspections to encourage continual improvement.
Intelligent monitoring is updated at least once a quarter. Outlier analyses are undertaken on a monthly or bi-monthly basis. Data packs are created on an on-going basis for impending inspections. National reporting is a combination of predominantly annual reports as well as topic-specific reports released on a one off basis.

Source: NHS Digital.