Data have been widely hailed as ‘the raw material of the 21st century’
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and ‘better use of data’ is a central feature of the NHS Long Term Plan.
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Yet, data alone does not produce insights. To capitalise on opportunities to improve
health and care, we need the data and outstanding data analysis. However, policymakers
and academia have almost exclusively focused on pure academic research around the
aetiology of disease; the field of practical coalface analytics has been largely neglected.
By practical coalface analytics we mean: variation in care analyses that identify
opportunities to improve quality, safety and cost-effectiveness of care; modelling
around waiting lists, or optimum locations for new services; evaluations of whether
new interventions or reorganisations have achieved their clinical or logistic objectives;
monitoring volume of activity and cost to ensure value from clinical contracts and
more. These kinds of analyses are essential to ensuring data can be used to deliver
improvements in patient care, earlier identification of problems and efficiency gains.
They require similar skills, methods and tools to traditional epidemiology research.
However, the practical analytics workforce is given little formal training and has
been largely sidelined. Analyses are typically done behind closed doors, which blocks
error-checking and reuse; clinicians and commissioners often lack the skills and support
needed to ask good questions of data. Consequently, current use of data analysis to
support decision making in the NHS is variable, and often poor.
To address these concerns we set out to: (i) identify the technical, cultural and
regulatory barriers to the better use of analysis; (ii) identify potential solutions
to these barriers; (iii) frame these barriers and solutions as action statements in
a standard format (‘specific person/organisation should do this specific thing so
that this specific outcome can be achieved.’); (iv) outline what successful change
would look like in the format of ‘we'll know we’ve won when’ statements.
This paper reports the themes and solutions arising from our discussions. Specifically,
we set out the need for: a 21st-century NHS analyst workforce supported by clear career
trajectories and training opportunities; a culture of ‘build it once and share it
to everyone’ built around modern, open analytic methods; capacity building for non-analyst
staff to participate in conversations about data; and frameworks to ensure good value
from externally commissioned analytics. We conclude by outlining the actions that
NHS governing bodies can take to start making positive progress in these areas.
A 21st-century NHS analyst workforce
The NHS currently has approximately 10,000 NHS data analysts.
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Most of these individuals are in very junior roles focused on data management which
are advertised as ‘admin/clerical’ rather than ‘scientific/clinical’ and remunerated
according to ‘Agenda for Change’ pay bands,
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which are constrained by requirements developed for nursing staff. Analysts are given
little to no guidance on the skills that they need in order to progress, without strategic
thought about providing inspiring leaders to look up to. This is compounded by the
fact that, despite being highly technical and closely mirroring epidemiological research,
operational research has evolved over time largely through informal sharing of methods
among practitioners, rather than a formal literature or ‘commons of knowledge’. Combined,
these issues pose a problem for career development and staff retention.
For the NHS, and its patients, to benefit from high-quality practical operational
analytics, we need a 21st-century NHS analyst workforce, with a range of skills and
skill levels, delivering innovative and efficient data analysis on questions relevant
to clinicians, commissioners, patients and policymakers.
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To create this, NHS analysts need clear career trajectories and effective development
and training opportunities.
Clear career trajectories
To start, we need to recognise that if great analysts are to be retained in the NHS,
they need to be inspired and to see opportunities for progression. Crucially, these
opportunities should recognise and appropriately reward analyst's technical skills,
which can have a high market value outside of medicine, whereas current NHS job descriptions
require them to become generalist managers in order to rise in seniority. In our view,
the NHS would do well to learn from other Government Analyst professions, for example:
the Government Economic Service, Government Statistical Service, Government Operation
Research Service and Government Social Research Service. These professions each have
a head of profession, clear career paths and progression opportunities supported by
genuine continuing professional development. They hold their staff to high standards
by setting out clear best practice guidance, offering analysts accreditation and requiring
analysts to adhere to a clear code of conduct.
To replicate this type of professional model, the NHS must start by formally reclassifying
analyst roles under the NHS Agenda for Change categories as ‘scientific/clinical’,
not ‘administrative/clerical’. This reclassification will require the creation of
a new national competency framework and accompanying payscale that set out the job
descriptions and skills required from junior analyst grades all the way up to a new
head of profession role. This will make it clear to analysts what they need to do
in order to progress, and help non-technical senior managers identify, appoint and
train appropriately skilled data analysts. Looking further into the future, it is
possible that a Royal College of Analysts (or equivalent) will be required. Such an
institution can, if appropriate, look to develop methods of accreditation and licensing
to re-assert professional identities and legitimise allocating resources for training.
In the United States, for example, the American Medical Informatics Association has
developed accreditation and certification standards for clinical informatics.
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Training
Providing a clear progression pathway will only result in positive change if analysts
are provided with the training they need to meet the skill requirements of higher
grades. Training needs to be offered at different levels so that anyone who wishes
to gain or improve their analytical skills can do so. For example: school leavers
would benefit from the creation of an NHS Data Analyst and Data Scientist apprenticeship
scheme; undergraduates and postgraduates would benefit from the creation of degrees
in applied analytics for health and social care; and working professionals would benefit
from accredited certificate programmes offering specialist skills training. Furthermore,
those in the wider NHS workforce should be able to access training through massive
open online courses in applied practical health analytics, so that all staff who wish
to develop new and better analytic skills can do so. More data-literate managers will
ask better questions of their analysts and be able to differentiate between good-quality
and poor-quality work.
Clearly, the creation of these opportunities will not be ‘free’ either in terms of
funding or staff time. For this reason, there will need to be a coordinated effort
from national Arms-Length Bodies, local NHS organisations, national funders, the NHS
Leadership Academy, Health Education England, academic organisations and others to
provide leadership and funding. To justify this investment, those who benefit from
NHS training schemes and from learning-on-the-job with NHS data must be expected to
pay-it-forward and openly share their learnings. To facilitate this, those who are
currently in senior management or analytical roles should be given time for capacity
building; a platform to share from; and mentees.
A culture of ‘build it once, share it to everyone’
Public trust in the use of NHS data relies heavily on transparency and accountability.
Yet, it is currently difficult to hold people to account for poor quality analysis
or for duplicative or wasteful analytic work. Complex analytic work in the NHS is
commonly done in siloes, behind closed doors by national, local and regional NHS organisations,
as well as private sector organisations. This means the results of the analyses are
withheld from outsiders; critically, it also means that the methods used to process
and analyse data are not shared. As a consequence of these closed working methods,
people outside the direct analytic team are blocked from critically reviewing the
methods to spot errors and fix them; nobody can learn from the work or replicate it;
and nobody can reuse it on their local data. Furthermore the system is deprived of
a commons of knowledge that would help train new and inspire staff, and provide the
formal and informal structures needed to support collaborative improvement of analytic
methods: it is notable that while most medical and paramedical specialties can fill
several library shelves with textbooks, this is not the case for operational research
in the NHS. In our view, adoption of modern, open analytic methods could rapidly build
the collaborative culture that would support rapid innovation and capacity building.
Use modern, open tools and approaches
As a starting point, the NHS needs to foster a culture that relies less on ‘manual
labour in Excel’ and embraces the benefits of modern, open analytic methods such as
re-usable scripts and open source tools including Python, R and Jupyter notebooks.
This would benefit the existing analytic workforce and attract more highly trained
data scientists, who are used to working this way, to work for the NHS. To begin,
senior leaders should make it clear that these are acceptable methods for use within
the NHS by: promoting, supporting and rewarding the use of open script-based tools;
more actively supporting the use of platforms like Github and Stack Exchange; ensuring
their staff have the time needed to share; providing best practice guidance on how
to share appropriately; insisting that all shared analytical code is supported by
‘good enough’ documentation to enable reuse.
This will require a collective and modestly resourced effort to create a public library
of tagged, edited and curated workbooks and ‘how-to guides’, with the patient data
stripped out, that can be readily reused. Data controllers, regulators and policymakers
can support this by making it mandatory (with exceptions) for NHS analysts to share
code in this manner when the code has been developed with public resources. Furthermore,
existing professional bodies, such as the Association of Professional Healthcare Analysts
(AphA), should be supported to promote conversation and community around these shared
resources by bringing the analyst community together twice a year for a conference
(held on a weekday during work time and centrally funded) during which analysts can
share insights, present work and build informal networks. Examples of great work showcased
during these conferences should be written up in technical detail and added to the
public library so that it can be celebrated and used to inspire others. Examples of
where this is already happening are provided in Box 1. To minimise duplication, when
analysts start a new project they should be expected to begin by identifying and evaluating
existing solutions. To make shared scripts more widely reusable, central NHS organisations
should aim to develop agreed standards for data schema wherever this is practical
and desirable.
Recognise the power of pooling technical skills and domain knowledge
Good data analysis is contextual. It is not just about knowing how to ask and answer
a question using data, but knowing what the important questions to answer are and
why, and how to interpret the answer in the context. Furthermore, what is best practice
for data science in other fields might not be relevant or appropriate in the clinical
domain depending on the specific features of medical data.
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Contextually specific analysis can only be delivered by teams that understand: where
the data come from, its strengths and weaknesses; the right technical analytic approaches;
how to communicate the outputs and how the outputs will be used to inform practical
decisions in a system. As such, NHS analysts should not be isolated in analyst-only
teams but embedded within mixed teams made up of analysts, clinicians, managers, researchers,
software engineers and outstanding communicators. This will ensure user needs are
better met and technical analysts are able to better understand the domain in which
they are analysing data.
Help staff become better customers and users of data
Managers and clinicians commonly feel out of their depth when commissioning or evaluating
analytic insights provided to them. Conversely, analysts can feel frustrated by senior
leaders asking unrealistic questions, or wanting to view numeric outputs as concrete
‘indicators’ rather than practical ‘measures’ to initiate a discussion. In addition,
there is often no clear pathway or connection between data-driven research and real-world
implementation. This leads to a disconnect between the user need and the analysis
delivered. It is, however, possible to avoid this outcome.
As a starting point, NHS organisations should build an expectation that non-analyst
staff will have sufficient data literacy to conduct informed conversations about data.
To ensure this is not an unrealistic expectation, basic training in data analysis
for clinicians and managers should be mandatory in training, and accessible (with
adequate modest funds) later in career. National NHS bodies should hold local NHS
bodies accountable for providing this training and enforcing staff attendance by commissioning
a national, independently developed, ‘Analytical Capability Index’ to track whether
an organisation has room to improve, and signal to leadership where gaps lie in their
organisation, how they compare to peers, and who they can learn from.
More thoughtful use of outsourcing
At present, analytic work is commonly outsourced, or commissioned from one NHS organisation
by another (such as Commissioning Support Units). This may be driven by a lack of
in-house capability for the reasons given above; it can also arise when NHS managers
lack trust in their own analysts, or lack the technical capability to evaluate analysis
conducted in-house. This skills shortfall at the commissioning level can result in
weak product from the outsourced contractor, or a mismatch between aspiration and
delivery. By giving managers the skills they need to better manage their own analysts,
they will be capable of identifying when there is a genuine need to commission specialist
input from health economists, epidemiologists or statisticians (for example), and
when there is not. Furthermore, they will be better equipped to evaluate the outputs
of commissioned analysis and to ensure that public money is well spent.
To further support this reduction in the reliance on more efficient and judicious
use of specialist outsourced analysis, centralised support from a national advanced
analytics advisory service should be provided. This support should include: standardised
outsourcing contracts for analytics with clauses that all data and code are shared
with the contracting NHS body; training and guidance on how to effectively commission
– and then evaluate – external analytics; and appropriate procurement frameworks.
Such a service could help govern the quality of outsourced analytics by requiring
managers to get approval from it first before commissioning external analytics in
the same way that the Cabinet Office governs government digital and technology spend.
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This can ensure that outsourced analytics adds value and that the process of outsourcing
generates intelligence on specific skills gaps in the NHS. Lastly, local and national
organisations should give careful consideration to the product expected from outsourced
analytics: at present, a commissioning organisation will typically receive summary
results without the full methodology used. This blocks critical evaluation and verification,
but it also perpetuates the outdated closed approach critiqued above, at a time when
we should be moving towards collaborative development of a commons of knowledge, as
seen in all other areas of medicine and data science.
Next steps
Delivering on the outlined suggested improvements will require collaboration across
NHS organisations and the Government, as well as professional bodies, and detailed
thought. However, we believe that the changes described are realistic and achievable,
in part because many have previously been delivered in other sectors and countries.
To enable delivery, we identified the following key domains where targeted action
from specific NHS governing bodies could make a significant difference: promotion;
training and professional development; knowledge sharing and skills exchange; community
building; governance and standardisation; development of best practice. Collectively,
for each of these domains, we developed targeted and practical ‘action statements’
in the format of: ‘this specific person/organisation should do this specific thing
so that this specific outcome can be achieved’; the full list of ‘action statements’
informing the development of this paper is shared in the Supplementary Material. To
maintain focus on tangible outcomes, we also broke down the overarching aim of ‘bringing
NHS data analysis into the 21st century’ into tangible goals so that progress can
be tracked. These are listed in Box 2 and take the format of ‘we'll know we’ve won
when this specific outcome has been achieved’.
Conclusion
There are huge opportunities for using data science to improve the quality, safety
and efficiency of care. These opportunities are being needlessly neglected through
a lack of clear career paths, and a historic failure to harness existing best practice
into a commons of knowledge. But there is a vast skilled workforce that could, through
use of open methods and structured support from the NHS, rapidly deliver an explosion
in high-quality, verifiable, shared analytics. We hope this paper will stimulate further
discussion between policymakers, analysts, the clinical workforce, data controllers
and all members of the NHS and wider community, so that we can collaboratively achieve
this goal.
Box 1.
Examples of good practice.
NHS-R community R is a powerful, free open source data science and statistics environment,
used in industry, academia and major corporations (e.g. Microsoft, Google, Facebook)
but its use in the NHS is almost non-existent. The NHS-R community, led by Professor
Mohammed A Mohammed at the University of Bradford, aims to support the learning, application
and exploitation of R in the NHS through workshops, video tutorials and providing
a platform for discussion and sharing of developing best practice solutions to NHS
problems. Find out more here: https://nhsrcommunity.com/
Association of professional healthcare analysts (AphA) AphA is a membership organisation
which aims to raise the profile of healthcare analysts and provide a professional
support network. It provides its members with a framework of professional standards
that, along with standardised training and development opportunities, will ultimately
lead to analysts becoming professionally registered. It also hosts an annual conference
to foster community growth and knowledge sharing. Find out more here: https://www.aphanalysts.org/
Box 2.
Short-, medium- and long-term goals written by workshop attendees in the format of
‘we'll know we've won when’ this specific outcome has been achieved.
‘We'll know we've won when’: • There are staff at board-level in managerial/strategic
roles who once did an ‘inner join in Structured Query Language’, just as we have clinical
leaders who once treated thousands of patients. • Problems are solved once by one
Clinical Commissioning Group or Trust, who share their workbook to others. • Industry
researchers and NHS analysts are able to learn from a rich competitive and collaborative
ecosystem of analysts producing shared workbooks on a single library. • Github has
more than 20 NHS analytics repositories with more than 100 contributors. • NHS analytic
resources are deployed more on new interesting questions that can improve quality
and safety of care, and less on financial monitoring. • Datasets and analytic approaches
become more standardised because of collaborative, shared, transparent approaches.
• Clinicians and managers know where to go to get answers, how to ask good questions
and get good answers that meet their needs. • A manager who wants to learn how to
be a better customer for data insights knows what to read and what course to go on.
• An analyst who wants to help the NHS with their skills can find a course, and things
to read, that help them develop their skills. • Your average sixth former will have
heard of health analytics as a career option and where to learn more about it. • The
NHS stops charging itself for exchanging raw data and only pays for value-added analytical
activities. • There is a clear career pathway for analysts, including a specialist
role that rewards and develops technical capability without recourse to becoming a
manager. • Evidence-based decision making, backed by high-quality data analysis, is
seen as business as usual across the NHS. • NHS analysts are seen as essential members
of the workforce and are appropriately treated and rewarded. • There is a clear quality
assurance process for data analysis conducted for the NHS by its own staff or by external
consultants. • No claims such as ‘X Trust can save X millions by taking X action’
are made without the underlying methodology being made clear.
Supplemental Material
sj-pdf-1-jrs-10.1177_0141076820930666 - Supplemental material for Bringing NHS data
analysis into the 21st century
Click here for additional data file.
Supplemental material, sj-pdf-1-jrs-10.1177_0141076820930666 for Bringing NHS data
analysis into the 21st century by Ben Goldacre, Martin Bardsley, Tim Benson, Kate
Cheema, Roger Chinn, Ellen Coughlan, Sarah Dougan, Marc Farr, Loraine Hawkins, Adrian
Jonas, Andy Kinnear, Morag Mcinnes, Mohammed Amin Mohammed, Caroline Morton, Rahul
Pasumarthy, Neil Pettinger, Ben Rowland, Neil Sebire, Paul Stroner, Jeni Tennison,
Samantha Warnakula, Oliver Watson, Emma Wright, Hamish Young and Jessica Morley in
Journal of the Royal Society of Medicine