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NHS England Data Sharing Remote Audit: University of Cambridge EPIC

This report records the key findings of a remote data sharing audit of the University of Cambridge (UoC) between 28 April and 2 May 2025.

Audit summary

Purpose

This report records the key findings of a remote data sharing audit of the University of Cambridge (UoC) between 28 April and 2 May 2025. It provides an evaluation of how UoC and its Processor conform to the requirements of:

  • the data sharing framework contract (DSFC) CON-321529-Q1B0S-v 2.02 
  • the data sharing agreement (DSA) DARS-NIC-321968-S4Q6L-v7.7
  • the organisation’s own policies, processes and procedures

This DSA covers the provision of the following datasets: 

Dataset Classification of data Dataset period

MRIS-Cause of Death Report

Identifiable, Sensitive

 

MRIS-Flagging Current Status Report

Identifiable, Sensitive

 

HES-ID to MPS-ID Admitted Patient Care

Identifiable, Non-sensitive

1997/98 – 2020/21

Mental Health Minimum Data Set (MHMDS)

Identifiable, Non-sensitive

2006/07 – 2013/14

Mental Health Services Data Set (MHSDS)

Identifiable, Sensitive

2016/17 – 2023/24

HES-ID to MPS-ID HES Outpatients

Anonymised, Non-sensitive

2016/17 – 2023/24

Civil Registrations of Death

Identifiable, Sensitive

Latest Available

Demographics

Identifiable, Sensitive

Latest Available

Mental Health and Learning Disabilities Data Set (MHLDDS)

Identifiable, Sensitive

2014/15 – 2015/16

Cancer Registration Data

Identifiable, Sensitive

Latest Available

Hospital Episode Statistics Outpatients (HES OP)

Identifiable, Non-sensitive

2003/04 – 2025/26

MRIS – Members and Postings Report

Identifiable, Sensitive

 

MRIS – Cohort Event Notification Report

Identifiable, Sensitive

 

HES Admitted Patient Care (HES APC)

Identifiable, Non-sensitive

2000/01 – 2025/26

National Diabetes Audit Identifiable, Sensitive 2003/04 – 2025/26

UoC is the Controller.

The European Prospective Investigation into Cancer (EPIC) Norfolk study is a long-standing research project that was established to examine the relationship between lifestyle (in particular, diet and physical activity), biological factors and health outcomes.

The study recruited men and women aged 49 – 79 years of age between 1993 and 1998 from 35 participating general practices in Norfolk.

The participants have continued to provide follow up data and attend additional health checks for over 30 years.

This is an exception report based on the criteria expressed in the Data Sharing Audit Guide version 4.0.


Audit type and scope

Audit type 

Focused

Scope areas 

Information Transfer 

Access Control 

Data Use and Benefits, including sub-licencing 

Risk Management 

Operational Management and Control 

Data Destruction 

Restrictions 

Access control - limited visibility of physical controls 

Overall risk statement

Based on evidence presented during the audit and the type of data being shared the following risk has been assigned from the options of Critical - High - Medium - Low.

Current risk statement: Low

This risk represents a deviation from the terms and conditions of the contractual documents, signed by both parties. In deriving this risk, the Audit Team takes into account compliance, duty of care, confidentiality and integrity, as appropriate.


Data recipient’s acceptance statement

The UoC has reviewed this report and confirmed that it is accurate.

Data recipient’s action plan

The UoC will establish a corrective action plan to address the finding shown in the table in section 2. The Audit Team will validate this plan and the resultant action will be followed up with UoC by the IG Risk and Assurance Team at NHS England, to confirm the finding has been satisfactorily addressed.

The Audit Team has identified 4 opportunities for improvement in section 3 which are provided for reference only and will not be followed up as part of any post audit review.


Findings

The following table identifies the 1 organisation nonconformity raised as part of the audit.

Ref Finding Link to area Clause Designation
  1.  

Security assessments have not been performed. Access Control System Management Policy, Section G

​​Organisation nonconformity​


Opportunities for improvement

The following table identifies 4 opportunities for improvement which could help an organisation improve its controls and processes.

Ref

Opportunities for improvement

Link to Area 

1

The UoC should consider specialist training for Information Asset Owners (IAO) and Information Asset Administrators (IAA). Operational Management​ 

2

The UoC should consider creating a Record of Processing Activities (ROPA) at the Medical School Level.

​​Operational Management​ 

3 The UoC should consider documenting the procedure for deleting sensitive (electronic) data. Data Destruction
4 The UoC should consider updating the publication template to reflect the source of the data supplied by NHS England in outputs produced. Use and Benefits

Use of data

The UoC confirmed that the datasets were only being processed and used for the purposes defined in the DSA and were not being linked with another dataset.  

Data location

UoC confirmed that processing and storage locations, including disaster recovery and backups, of the datasets were limited to the location shown in the following table.  These locations conform with the territory of use defined in section 2c of the DSA

Organisation Territory of Use

UoC

England and Wales

Backup retention

The duration for which data may be retained on backup media is:

Organisation Media type Period

UoC

Disk

30 days 


Disclaimer

The audit was based upon a sample of the data recipient’s activities, as observed by the Audit Team. The findings detailed in this audit report may not include all possible nonconformities which may exist. In addition, as the audit interviews were conducted through a video conference platform, certain controls that would normally be assessed whilst onsite could not be witnessed. 

NHS England has prepared this audit report for its own purposes. As a result, NHS England does not assume any liability to any person or organisation for any loss or damage suffered or costs incurred by it arising out of, or in connection with, this report, however such loss or damage is caused. NHS England does not assume liability for any loss occasioned to any person or organisation acting or refraining from acting as a result of any information contained in this report.

Last edited: 3 July 2025 3:31 pm