National Clinical Improvement Programme (NCIP) requirements specification

NHS Digital have received a mandatory request to establish and operate a system for the collection, analysis, linkage and dissemination of theatre data information through the NHS Improvement’s Mandatory Request - National Clinical Improvement Programme (NCIP) Theatre data set discovery project. 

This document provides the requirements specification for the data collection to support phase 1 (discovery) of a national theatre data set which is required to support the National Clinical Improvement Programme (NCIP) digital product. It should be read alongside the NCIP Theatre data set project data set technical specification. 

This new collection will enable clinicians and health care professionals – surgeons, in the first instance – to view their personal outcome data in the context of local and national benchmarks. This information will support quality improvement activities, with the aim of delivering improved patient care.

Under the mandatory request, The NCIP Theatre Data Set Discovery Project will involve collecting patient level theatre data held in local theatre systems¹ from five to seven NCIP selected Discovery sites that have agreed to participate. The mandatory request is limited to the duration of the discovery collection phase October 2019 to March 2021.

The data will be securely collected by NHS Digital from each provider participating within the discovery using existing NHS Digital services, namely Secure Electronic File Transfer (SEFT) or Messaging Exchange for Social Care and Health (MESH).² Data will be landed and processed within the NHS Digital Data Management Environment (DME).

Each provider will provide a single submission (or multiple submissions to account for separate systems or data quality corrections) containing data extracted from theatre systems for all theatre activity which occurred within any of the following periods:

For the purpose of the discovery project the data collection will include all patient activity records contained with theatre systems including: 

• • theatre Session Details 
  • patient details (to support data linkage) 
  • risk factors 
  • operation details 
  • clinician/anaesthetist details (to support attribution of activity) 
  • perioperative pathway (i.e. key operation timings such as incision time, closure time). 

Each submission should contain theatre data for the current year to date plus the four previous full financial years as specified below: 

• • 1April 2020 - current
  • 1 April 2019 – 31 March 2020 
  • 1 April 2018 – 31 March 2019 
  • 1 April 2017 – 31 March 2018 
  • 1 April 2016 – 31 March 2017 

Legal restrictions must be applied to the processing of the NCIP Theatres dataset including the Exclusion of patient information relating to In vitro fertilisation (IVF) and gender recognition where this information can identify the data subject:

• NHS Digital MUST NOT collect personal information about legally restricted terms relating to In Vitro Fertilisation (IVF) or Gender Recognition in line with the restrictions imposed by the Human Fertilisation and Embryology Act 1990 as amended by the Human Fertilisation and Embryology Act 2008 or the Gender Recognition Act 2004.
• in order to comply with the above Acts, any theatre data set records containing procedure codes relating to IVF or Gender reassignment MUST be anonymised at source, with all patient identifiers removed, prior to submission to NHS Digital as part of the discovery project. Where it is not possible to anonymise records, records should be fully removed prior to submission to NHS Digital.
• to align with Secondary Uses Service (SUS) submission rules the latest anonymous and legally restricted codes should be applied (or their equivalent where local procedure codes or SNOMED-CT codes are used)
• NHS Digital will anonymise on receipt any records containing procedure codes relating to IVF or gender realignment which it inadvertently receives

NHS Digital are requested to undertake data linkage of the Theatre Data Set discovery data to Hospital Episode Statistics (HES) Admitted Patient Care (APC) data to specific procedure level. The exact algorithm to be agreed between NHS Improvement and NHS Digital.

Theatre data collected during the discovery project will be de-identified, with a common pseudonymisation key applied, and disseminated to NHS Improvement in a form which enables further data linkage to the Hospital Episode Statistics (HES) Admitted Patient Care data which NHS Improvement already receive from NHS Digital. This will enable data to be analysed and assessed to see whether it meets the discovery objectives such as accurate attribution of activity to the individual clinician.  

NHS Digital may undertake analysis of the Theatre Data Set discovery data for data quality and validation purposes and to inform the development of a National Theatre Data Set.

Analysis and assessment of the feasibility of theatre data set discovery data to support accurate consultant attribution will be undertaken by NHS Improvement NCIP team.

NHS Improvement will be responsible for publication of any data in line with their publication policy.

NHS Digital will not publish the data collected under this mandatory request as the information collected falls within section 260(2) of the Health and Social care Act.

NHS Digital will disseminate theatre data collected during the discovery phase in pseudonymised form to NHS Improvement, with associated bridging files for linkage to Hospital Episode Statistics (HES) Admitted Patient Care data, to support an assessment of suitability for the purposes of consultant attribution and theatre productivity.  An identical data dissemination will be made to the National Clinical Improvement Programme.

The pseudonymised theatre data will be disseminated to NHS Improvement via the Data Access Request Service (DARS) under a data sharing agreement and will not include confidential patient information.

NHS Digital is requested not to disseminate theatre data collected during the discovery phase to any other party except with express permission of NHS Improvement. Where such permission is provided, theatre data may be disseminated via DARS under a data sharing agreement and will not include confidential patient information.

In line with the National Data Opt-Out operational policy guidance national data opt-outs will NOT apply to the proposed dissemination of pseudonymised personal data to NCIP. Any future dissemination of the information will be assessed to determine whether national data opt-outs should be applied.

This requirements specification will be subject to formal change control.

Any changes to this specification will need to be formally agreed by NHS Digital and NHS Improvement following consultation in line with s258(1) Health Social Care Act 2012.

For further information about this specification please email [email protected].