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NHS England Data Sharing Remote Audit: University of Oxford

This report records the key findings of a remote data sharing audit of University of Oxford (UoO) between 16 and 29 May 2024. 

Audit summary

Purpose

This report records the key findings of a remote data sharing audit of University of Oxford (UoO) between 16 and 29 May 2024.  It provides an evaluation of how the UoO and its Processors conform to the requirements of:

  • the data sharing framework contract (DSFC) CON-319043-Y2R5H-v2.03
  • the data sharing agreement (DSA) DARS-402963-P0Y5D-v1.8
  • the organisations’ own policies, processes and procedures

 This DSA covers the provision of the following datasets:

Dataset Classification of data  Dataset period 
Emergency Care Data Set (ECDS) Anonymised/Pseudonymised 2019 – 2023  Month 7 
COVID-19 Vaccination Adverse Reactions Anonymised/Pseudonymised Latest available 
COVID-19 Hospitalisation in England Surveillance System Anonymised/Pseudonymised Latest available 
COVID-19 SGSS First Positives (Second Generation Surveillance System) Anonymised/Pseudonymised Latest available 
COVID-19 Vaccination Status Anonymised/Pseudonymised     Latest available
COVID-19 General Practice Extraction Service (GPES) Data for Pandemic Planning and Research (GDPPR) Anonymised/Pseudonymised     Latest available
Covid -19 UK Non-hospital Antigen Testing Results (pillar 2) Anonymised/Pseudonymised     Latest available 
HES-ID to MPS-ID HES Accident and Emergency Anonymised/Pseudonymised     2016 -2019 
Hospital Episode Statistics (HES) Admitted Patient Care Anonymised/Pseudonymised     2018 - 2023 Month 7 
HES Accident and Emergency Anonymised/Pseudonymised     2016 - 2020 Month 12 
Secondary Uses Service Payment by Results Episodes Anonymised/Pseudonymised     2017 – 2021
Secondary Uses Service Payment By Results Spells Anonymised/Pseudonymised     2017 -2021
Secondary Uses Service Payment By Results Outpatients Anonymised/Pseudonymised     2017 - 2022
Mental Health Services Data Set (MHSDS) Anonymised/Pseudonymised     2016 -2019 
Improving Access to Psychological Therapies (IAPT) v1.5 Anonymised/Pseudonymised     2018 - 2021
Civil Registrations of Death Anonymised/Pseudonymised     Latest available 
National Diabetes Audit Anonymised/Pseudonymised     2016 -2019 

The Controller is the UoO and the Processors are Public Health Scotland (PHS), the University of Edinburgh (UoE) and the University of Liverpool.

The Coronavirus Clinical Information Network (CO-CIN) has collected data for the International Severe Acute Respiratory Infection Consortium (ISARIC) Coronavirus Clinical Characterisation Consortium through a commission from the Chief Medical Officer. ISARIC conduct Urgent Public Health Research to provide evidence that informs public health policy in response to the COVID-19 emergency. ISARIC is a global federation of clinical research networks, providing a proficient, coordinated and agile research response to outbreak-prone infectious diseases.

The ISARIC Coronavirus Clinical Characterisation Consortium is a UK-wide consortium of leading experts in outbreak medicine with a proficient, coordinated, and agile research response to COVID-19. Their purpose is to prevent illness and deaths from infectious disease outbreaks. 

PHS provides research services to ISARIC through their Electronic Data Research and Innovation Service (eDRIS) and the National Safe Haven (NSH) which is a secure environment where project data is uploaded, stored and accessed. The NSH is hosted by the Edinburgh Parallel Computing Centre (EPCC) based at the UoE.

The interviews during the audit were conducted through video conferencing.

This is an exception report based on the criteria expressed in the Data Sharing Remote Audit Guide version 4.


Audit type and scope

Audit type Routine
Scope areas

Information Transfer
Access Control
Data Use and Benefits
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 UoO, PHS and UoE have reviewed this report and confirmed that it is accurate.

Data recipient’s action plan

The UoO will establish a corrective action plan to address each finding shown in the findings tables in section 2. The Audit Team will validate this plan and the resultant actions at a post audit review with the UoO to confirm the findings have been satisfactorily addressed.

The Audit Team has identified 1 opportunity for improvement in section 3 which is provided for reference only and will not be followed up as part of any post audit review.


Findings

The following tables identify the 1 agreement nonconformity, 1 organisation nonconformity, 3 observations, and 3 points for follow-up raised as part of the audit.


UoO

Ref Finding Link to area Clause Designation
1 The DSA limits access to substantive employees employed by the UoE as stated in the DSA. The Audit Team found 2 of the users accessing the data were not substantive employees of UoE. There was no formal process to allow researchers who were substantive employees of other organisations through an honorary contract with UoO to access data. Operational Management DSA, Section 5b

Agreement nonconformity

2 UoO did not provide annual data protection training to researchers. There were no checks in place to ensure that researchers from external organisations attended annual data protection training with their employing organisation. During the audit UoO contacted the researcher employing organisations and confirmed they had attended annual data protection training in the last 12 months. Operational Management DSFC, Part 2, Schedule 2, Section A, Clause 1.2 Observation
3 The data processing agreement in place between the UoO and PHS did not reference the current DSA and DSFC to ensure the Processor acknowledges compliance with these documents. Operational Management DSFC, Part 2, Clause 4.1 Observation

PHS

Ref Finding Link to area Clause Designation
4 The retention period for the study data was not recorded in the Information Asset Register (IAR). Operational Management PHS Records Management, Document Storage and Retention Policy, Section 5 Organisation nonconformity
5 The NSH user agreement form did not reflect the territory of use as defined in the DSA, therefore requires updating. Access Control DSA, Section 2c Observation

UoE

Ref Finding Link to area Clause Designation
6 At the post audit review, the Audit Team will review the status of the NSH infrastructure migration and decommission of the hardware including the disks which held NHS England data. Data Destruction  

Follow-up

7 At the post audit review, the Audit Team will examine some technical requirements of the DSFC which were not available at the time of the audit. Access Control  

Follow-up

8 At the post audit review, the Audit Team will review the status of database software updates. Access Control  

Follow-up


Opportunities for Improvement

UoE

The following table identifies 1 opportunity for improvement which could help an organisation improve its controls and processes.

Ref Opportunity for Improvement Link to Area
1 The UoE should consider implementing email alerts for high priority issues to notify relevant technical staff and the service desk. Access Control

 


Use of data

The UoO 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

The UoO 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
UoE UK

Backup retention

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

Organisation Media type Period
UoE Media (e.g tape) 14 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: 10 September 2024 4:12 pm