NHS Digital Data Sharing Remote Audit: NHS Dorset Clinical Commissioning Group

Purpose

This report records the key findings of a remote data sharing audit of NHS Dorset Clinical Commissioning Group (CCG) between 10 and 14 January 2022.  It provides an evaluation of how the CCG conforms to the requirements of both:

• the data sharing framework contract CON-338307-D8Z0G
• the data sharing agreement (DSA) DARS-NIC-54727-S3Y1T-v4.3

This DSA covers the provision of the following datasets, though not all are supplied to the CCG: 

The Controller is the CCG, and the Processors are the Dorset Healthcare University NHS Foundation Trust (DHC) and Microsoft Limited. Microsoft Limited supplies cloud storage services, via the Microsoft Azure platform, and don’t process the data. 

The Dorset Intelligence & Insight Service (DiiS) reporting solution is hosted on Azure and managed by DHC. The DHC and Dorset County Hospital NHS Foundation Trust are both Joint Controllers for DiiS. The above datasets are supplied directly to the DiiS platform by NHS Digital. 

The CCG was working in the spirt of an Integrated Care System (ICS) in advance of the changes when the CCG will be absorbed into an ICS. The ICS is expected to take on the commissioning responsibility that currently sits with the CCG. It will also be responsible for broader aims such as strategic planning for the area. The DiiS is expected to be part of the ICS and help support its responsibilities across Dorset.

The pseudonymised data supplied by NHS Digital, along with health data from other providers, is used to provide intelligence across the Dorset ICS (“Our Dorset”) and its constituent Primary Care Networks to support population health management. The DiiS reporting solution brings together data from multiple organisations across Dorset to support the needs of the population within the CCG area.

Towards the end of 2021, NHS Digital identified specific concerns with respect to the ‘Our Dorset’ Power BI dashboards published by the CCG on the internet. NHS Digital was of the view that these dashboards were displaying pseudonymised patient data without small number suppression, without adequate Role-Based Access Controls (RBAC) and with a risk of re-identification. 

As part of the planned development and phased roll out of the solution, RBAC had been implemented and small number suppression was implemented for aggregated presentations prior to the audit. Thereby the audit being carried out was undertaken on the latest version of the solution.

Based on these concerns, this audit was restricted to the dashboards published by DiiS and therefore excluded other Processors named in the DSA that provide support to the wider commissioning services. 

This report also considers whether the CCG and relevant Processors conforms to their own policies, processes and procedures. 

The interviews during the audit were conducted through video conferencing. 

This is an exception report based on the criteria expressed in the NHS Digital Data Sharing Remote Audit Guide version 1.

Audit type and scope

Data recipient’s acceptance statement

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

Data recipient’s action plan

The CCG and DHC will establish a corrective action plan to address each finding shown in the findings tables below. NHS Digital will validate this plan and the resultant actions at a post audit review with the CCG to confirm the findings have been satisfactorily addressed. The post audit review will also consider the outstanding evidence at which point the Audit Team may raise further findings.

The following tables identifies the 6 agreement nonconformities, 1 organisation nonconformity, 7 opportunities for improvement and 3 points for follow-up raised as part of the audit. 

Use of data

The datasets were not being processed or used for the purposes defined in the DSA, see findings 1 and 2. The datasets were only being linked with those datasets explicitly allowed in the DSA.

Data location

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

Backup retention

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

Good Practice

During the audit, the Audit Team noted the following area of good practice:

• the DiiS team and dashboard end user (Dorset General Practitioner) were able to clearly demonstrate the value the data supplied under this DSA has had with proactively benefiting health and social care within Dorset area.

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 Digital has prepared this audit report for its own purposes. As a result, NHS Digital 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 Digital 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.