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The Universal Free school meal Programme applied. Free, but what will it really cost?

I have children who are entitled, come September, to the universal free school meal programme. Department of Education advice came out last week. See here >>universal infant free school meals.

I wonder whether this will bring back a national treasure to benefit those who need it most, or is it just a Pandora’s box of problems?

The new system, raises two concerns for me, over which I now have little control or choice.

Firstly, on nutritional decision making. I fundamentally disagree with the low fat milk approach. I hope it reflects the plan only in milk, and not across all the food groups.

Whilst I fully understand the popular and State drive for cutting down obesity levels, cutting out fat across all the food groups may not be the key to national health. This ‘low-fat is good’ approach is controversial, and low fat in particular in dessert, replaced with artificial sweeteners is a false choice. I believe that the paleo approach to food, back to basics, is a better choice. Throw out artificial things, and eat almost everything that is natural, in moderation. Not all fats are the same. Children who are growing, need the kind of fat that is in milk. It’s not the same as chips.

The whole programme of child health in school is based on sweeping generalisations in my view.  We’re told an awful lot of twaddle of how our kids should eat and exercise by state-sent leaflets in book bags. Add to that, the fact that the BMI comparison is flawed, and its communications to parents method is fundamentally flawed. (Letters saying your perfectly healthy, well proportioned child is obese, or underweight, partly due to its tool as an average cross group measure, in the National Child Measurement Programme (NCMP) anyway. But that’s another, longer story.) It’s no wonder parents are confused, not knowing the best thing to do on these school meals or not.

“On 17 June 2014 the department announced a new set of simplified standards. The new standards are designed to make it easier for school cooks to create imaginative, flexible and nutritious menus. They will be mandatory for all maintained schools, academies that opened prior to 2010 and academies and free schools entering into a funding agreement from June 2014, and will come into force from January 2015.
One significant change in the new standards is that lower fat milk or lactose reduced milk must, from January 2015 be available for drinking at least once a day during school hours. The milk must be offered free of charge to pupils entitled to free school meals, and to all pupils where it forms part of the free school lunch to infants.”

On the drinks policy, my child would much rather drink water than milk with a meal. I hope both will be on offer. If not, I’ll support the school with jugs and help out to darn well offer it myself.

And secondly, on cost.

Currently, my children every week, eat both hot lunches and packed lunches from home. I pay the school’s private provider, for regular, hot lunches three days a week, and I provide packed lunch on two.

From September, I will no longer be able to choose to book and pay for those meals myself. And I will no longer be able to choose for some days and not others. It’s all or nothing.

The local provider will also no longer permit parents of year R-2 children to book meals and pay for them, so even if I am fortunate enough and wanted to, I can’t opt out of the state system and pay for only those meals my children will actually eat.

The result is, if I want to continue the mix of hot and packed lunch choice I make for them, based on our family life, schedule and the nutritional content of what I want them to eat, I am required to sign them up for all five days, and either they get the imposed routine and eat more hot dinners – or carry on with our current set-up and two days a week the hot lunches will go to waste.

However having spoken to my local school meal service today, they confirmed that after 4 weeks they plan to have a review of waste, and cut back on food provided.

The net result, the local private provider will receive more money from the State, for my children’s hot lunches, than I pay myself now. And likely as not, there will be food wasted as well, because the providers will need to allow that some children may take it up all days.

I understand that to administer detailed choices would be costly. From September, schools will need to administer instead of me, how many children are taking up the meals, and any changes in numbers week on week.

However, it need not increase the admin cost to schools or state, if I could continue to book for my children, as I do now, selecting their days and meals in advance, there would be a more cost effective use of our State money, without any change in administration. It would be up to the provider to bill as used, not blanket. Surely in these days of electronic charging, not hard, and could be made without manual intervention by the state, except for regular audits, which will need to happen anyway in any well governed accounting system.

It feels as though the Government simply doesn’t trust us to feed our children properly. I think I do a fairly good job. But I’m not sure I trust the state imposed food standards to do a good job if the funding should be reduced in future, quality will fall again, back to the bad old pre-Jamie days. I’d like to have kept universal child benefit for all instead. Those entitled to free school meals, were then and would still be now. I welcome anything that will help families feed their children well. The work by the Trussel Trust and others, shows what desperate measures are needed to help children who need it most.

But why impose it via this method on all without rigorous planing and evaluation? My school certainly doesn’t feel it has happened, and has had a ‘a couple of emails’, it’s a bit of an unknown.  Instead, I now have to decide, to keep my kids in hot dinners, take them out, or keep our preferred mix and feel wasteful.

Where do you draw the line between support  and interference in our family life?

You could say don’t look a gift horse in the mouth, but it’s what is going into my children’s mouths that matters most. Jamie Oliver did his darnedest to educate and bring in change, showing school meals needed improvement in quality across the board. What has happened to those quality improvements he championed? Abandoned in free school & political dogma. Where is the analysis for true quality change, rather than change for a point of policy? Is our children’s health a political football, which is being given as a concession in this Parliament, now rushed through to get checked-off, without being properly checked out first?

It seems there were pilots and trials but we haven’t heard much about them. There is plenty of history, but where is current discussion? I agree with David Laws, on the closure of school kitchens, but this mother believes current infrastructure and education should be fundamental to this programme, not coming in later as a secondary support measure. I wouldn’t normally choose to link to the Mail, but no other broadsheet seems to have covered it since the Department for Education guidance was issued last week.

Mr. Laws said,

“It is going to be one of the landmark social achievements of this coalition government – good for attainment, good for health, great for British food, and good for hard working families.

Ignore the critics who want to snipe from the sidelines.”

I don’t want to be a critic from the sidelines, I’d like to be an informed citizen and a parent with choice. This is a consumer choice and health issue, having an effect on a practical aspect of my parenthood. It’s not a tenet of education substance. Like this person, I want to ask and understand. How will it affect the majority? Will this have a positive effect on the nutrition children get, which may be inadequate today? What guarantees are there that adequate food safety and quality issues are properly and independently governed? Will it be overall less costly and beneficial to children and parents? Will it reduce stigma? Will it increase hot dinners consumed and reduce packed lunch intake? (So much less healthy, we are told.) Is the cost worth the benefit for a minority or even for the many? Will it benefit our children’s health?

Free, but what will it really cost?

Honestly, I don’t know. But that’s my main concern. It’s being done in such a rush, I don’t think anyone knows.

Data-cropped-FF

Flagship care.data – [3] Commercial use in Practice

I looked in two previous posts at the background theory [1] to commercial uses of our data, then, the background to my concerns of commercial use with data intermediaries. [2] This is now part three,  my glimpse into commercial use in real-world practice. It’s become rather a saga.

Here’s the short version: “In general commercial uses of data, I am increasingly learning that if you don’t pay for the product, you are the product. We need to shout a bit louder, that we are not a product for sale. It’s not only that there is an increased risk in a move of our health records from binder to byte and broadening access to them. We take issue with the change of approved purposes from care, to commercial use.”

At the Health Select Committee on July 1st, [3] I believe  Sir Manning misses the key issue the public has with care.data and health record sharing, when he gave a response to Q562 to David Tredinnick MP:

‘We made big mistakes over the last 10 years’

“I am saddened by some of the comments that have been made this afternoon about the lack of trust and also by the impugning of our motivation. [...]

We made big mistakes over the last 10 years, and we have a once-in-a-generation chance to get it right. I am absolutely clear that we have to engage the public in an open debate about the balance of risks and benefits. There will always be risks with data. There were risks with the Lloyd George envelope; notes were lost, they flew and went all over the place. There will always be risks, but those risks and the benefits are both enhanced by the technology.”

Whilst I applaud Sir Manning’s apology, and his call for open debate, I think he misses here the fundamental point of disagreement the public has with the HSCIC current practice. Selling our health data.

It’s not only that there is an increased risk in a move from binder to byte and broadening their access. We take issue with the change of approved purposes from care, to commercial use.

And these commercial (ab)uses in current form must stop if we are to trust the governance system in future.

Health Records for Commercial sale

HSCIC currently sells our health records for commercial purposes, to intermediaries with commercial re-use licenses, and had no consent nor our permission for this in the past, it continues to do so in the present and appears to have no concern or intention to stop doing so, for the future.

Mr. Kelsey added at the HS Committee,

“We have a very big job to do, and I hope that you will hold us to account in delivering it.”

To which I can only reply, it is you who say it. But who is accountable?  The Open Debate which Sir Manning calls for has not been taken up by NHS England. We are told this is a programme of national importance, one which Mr. Kelsey has repeatedly said, including to the Health Select Committee previously, on which the entire future of the NHS depends. Why then, no national discussion, no news since the pause and a focus on updated communications of the current plan.  The current plan with flaws in consent collection, scope determination, confusion of purposes.

There are so many ways this could be improved and gotten right, but not by November and without public debate.

How can you insist a programme so vital for the entire future of the NHS yet encourage no public discussion?   This seems to be a theme in NHS England recent programmes. [4] The decision to outsource the GP support services was taken in private sessions, not available to the public like the rest of the Board Meetings [5]. Other programmes, pilot and actual plans for implementation go on without public discussion.

There’s been no apology for the data sharing policy developed since 2010 which has encouraged commercial trading and enabled this erosion of security, confidentiality and trust in the data management system of our nation’s health records. No one at the Department of Health has said, we got this policy wrong. No one at NHS England, the same people if under a different label. Poor Sir Manning at the Information Centre who carried out their policy, has been left to say there were ‘big mistakes’ made. But not by him since July 2013.

Trust and care.data off course

That our trust now lies in tatters, is not the fault of the Health Select Committee member to whom Sir Manning says,  he is saddened and disappointed. It’s not Joe Public’s fault who had no idea this was going on, until six months ago.  Where did these policies and plans since 2010 come from? Where did the use of our data go so astray and why is flagship care.data now so terribly off course? Mr. Cameron outlined it in 2011. What happened in the three years?

Health records for sale

As I wrote in a previous post,

“Some of that data goes back into our health market as business intelligence, both for NHS and private use, for benchmarking, comparisons and making commercial decisions. In our commissioning based marketplace, this re-use of data is now becoming normalised.”

But should it be normal that our medical records are for sale?

When celebrity Michael Schumacher’s notes are for sale, [6] being offered concretely to the media, we all see that is wrong. Just imagine 70 million copies of Schumi’s record, each with our own name on it, being offered to anyone outside of those who need it for our care. Offered to these commercial  for-profit data intermediaries. It’s not a theory – this is what is happening to our records, today. Don’t accept the ‘anonymised’ statements, they’re simply not true. Identifiable data and pseudonymous data has been sold. The register confirms it, and that was only a 10% sample.

“To earn the public’s trust in future, we must be able to show that our controls are meticulous, fool-proof and solid as a rock.”

said Sir Nick Partridge in his summary review.[7]

I think banning data sharing for commercial use and re-use would be a good start.

What is it to be used for and why?

When we think of our health records being used by others,  we need to separate the uses of the data, in order to understand different ways it is used, who uses it and why. Data once it is processed becomes knowledge which is used as Business Intelligence. It is common in discussion to conflate use in care with care.data. It’s even in the name. But the uses of care.data are secondary. Not to be used by clinicians caring for us, not replacing hospital notes to give to consultants when we are referred for a hospital stay. Not providing discharge papers. It’s only approved for commissioning and sketchily [imo] approved for risk stratification.  [ref p.5 ] [8]

care.data extracted from GP surgeries, is not even approved for research purposes, but to read all the recent debates you’d think research depended on it. Research using GP extracted patient data, is not an approved use of care [dot] data. Research using GP extracted patient data is not an approved use of care [dot] data. Repeat, ad nauseaum.

What is already being done, and what is used legitimately i research such as public health (albeit without our past knowledge or consent), is with our hospital data, HES, SUS, Mental Health data, usually with CAG review, and through 251 approval sometimes through DAAG review at HSCIC – it is available and is on sale to all sorts of other non-care providers. And that is planned to continue.

The records extracted so far, when not used for research appear in recent years increasingly used for comparison, the concept of ‘ranking and spanking’ professionals and providers of healthcare.  They are also used in commissioning, payment validation and understanding costs and spending. But beyond that, there are all sorts of others who still come under the umbrella of ‘health purposes’ but don’t directly benefit the NHS or individual patients. What is their demand and what are they being supplied?

In the newly created NHS marketplace, customers at individual level are patients, or at a market level they could be any part of the healthcare buying structure, a GP practice, a Clinical Commissioning Group, a Hospital Trust.

The challenge of any demand and supply chain process, is that you need a market willing to pay at the price you are prepared to sell. And you need to offer what they want to buy. For that, the buyers must see a value in the data they want to obtain. Where is the value for these areas of use: Generic NHS Business Intelligence, Generic Commercial Intelligence and Pharmaceutical intelligence?

Health records as Business Intelligence

Some companies take data and process it before selling it to NHS and other health providers in England. This provides a third party service and skill set which the HSCIC nor the NHS Trust for example, has themselves, such as IMS Health.

So business intelligence used for the benefit of the NHS, makes sense and is necessary to a greater or lesser degree depending on your attitudes to comparison websites, green/red flagging professionals and commissioning. Benchmarking was provided by Tribal until that part of their business was bought out by Capita.

These companies’ experience and market is healthcare. The kind of knowledge they can give to the NHS is highlighted in their case studies.

So for clinical care, and for commissioning at individual organisations, these tools are clearly useful and use individual patient level data. [9]

Al sorts of other places and individuals perform these services. They include a wide range of commercial organisations, small and large.

Health records as Commercial Marketing Intelligence

Commercial buyers however, can include wanting data for identity verification, fraud prevention and background checks. Services such as Experian offer. These may be what the loose definition in the Care Act would say are now banned, but are they? What is to say that a company which offers the use of private health services, healthy eating or pharmaceutical marketing is not providing information to others, for the promotion of health?

“Experian employs more than 12,500 people in 34 countries worldwide, supporting clients in more than 60 countries. Annual sales are $3.1 billion (£1.7bn/ v2.5bn).”

Identity verification can be done, matching data across a biographic footprint, ” in databases, established for 45 million UK citizens and hold in excess of 1 billion records.”

“Experian public sector currently works with 380 plus local authorities, 52 police and investigatory bodies, as well as central government agencies including DVLA, HMRC, DWP and the Cabinet Office.” [10]

There is clearly a lot of data sharing in the public sector, about which we may understand very little. But mostly the buyers of data want to sell something. Companies buy lists of people to use in marketing campaigns, who might be interested in what they’re selling — and companies also want to learn more about their current customers.

This is where I find the level of detail and what is done with our data, more than a little freaky.

Every UK consumer is classified into one of 22 types, aggregated into six groups. The 22 types are linked to six decision-making styles, providing insight into consumers’ motivations when using different media and the processes they go through in deciding about products and services.

“TrueTouch is built using over 700 individual data variables. These are chosen for their ability to illustrate an individual’s range of behaviours in relation to media consumption, including use of different channels, responsiveness and exposure to media. These are distilled into two core data sources: Quantitative data Experian’s UK Consumer Dynamics database compiles information on all UK individuals, their demographics and lifestyles, attitudes and responsiveness to media. It includes known data on demographics and lifestyles from publicly reported sources such as the ‘edited’ electoral roll, company directors, shareholders and council tax, as well as Experian’s proprietary lifestyle information taken from its programme of consumer survey.” [11]

I don’t know what segment I am in.  But I know that I will have data stored in many of those different data sources they mention. So do they actually know more about my habits and inclination, that I have self-awareness? If their tool has over 850 million input sources which they process, it’s more than likely. 34 million email addresses, 20 million mobile phone numbers, 49.7m names and addresses.

Experian may well have much of this data from the electoral roll (unless like me, you opted out of these uses) but in the HSCIC  January-April 2014 register of releases [7] data was given to Experian for use in Mosaic. (see July – 132kb right of page)

“Mosaic is Experian’s powerful cross-channel consumer classification designed to help you understand the demographics, lifestyles, preferences and behaviours of the UK adult population in extraordinary detail.” [12]

That they understand and track my behaviours probably better than I do, and at such detailed level, I find surprising and invasive. In fact, I find it threatening in a similar vein to the visceral reaction that the Facebook experiment generated this week online.

As SF Gate reported,

“Using unsuspecting members as human guinea pigs is repugnant. And when the biggest social network on the planet does it, can its leaders be trusted with their own technology?”

This idea that just because one can and the technology permits it, does not mean that one should. It just feels wrong to find out others  may manipulate our thinking and behaviours in such a targeted way. Just as Experian does with consumer data:

Within rural areas we are able to pick out the individual households that are likely to be commuting to towns and cities nearby…”[12]

Individual households? Understanding my behaviours, gives them information which they use to nudge or influence my decision making. Understanding our behaviour ‘in extraordinary detail’ helps companies market and sell more to customers.

There are other re-uses even for health purposes, which seem less transparent and more about us as general consumers, rather than for our health. For example, the use of HES data is in social marketing targeting:

“In this way, companies who process data such as Beacon Dodsworth received data in the last year and offered it for commercial exploitation by others “HES data may be used by pharmaceutical companies “to improve [their] social marketing / media awareness campaigns”. Others included  OmegaSolver and Harvey Walsh.”

These companies have re-use licenses for data. what that means is better explained here by medconfidential. [14]

How will HSCIC know how data will be used after release and how will it be audited and how often? When it comes to human tissue, the HTA only audits tissue banks in the UK once every three years. That’s a long time in between audits if something has gone horribly wrong in best practice.

Health records as Commercial Pharmaceutical Intelligence

To global pharma it is again not the data itself which is of value, but in the knowledge it reveals. The pharma business intelligence. It can show at an individual level what is being prescribed or show  any gaps it reveals, which will allow pharma, to address ‘unmet clinical need.’  The data already compares hospital prescribing and reports make recommendations used by NICE on what drugs to use and recommend. My concern is that to treat the worried well who have cash to spend, will deflect attention from the needs of the sick and poor and that even if only at postcode level, we will be targeted for pharmaceutical marketing.

“The parties will initially look at how anonymised, integrated health data can be used to identify unmet clinical need in patients with diabetes. In the UK, diabetes affects approximately 2.9 million adults overall, with more than 90% of these patients having type 2 diabetes. This makes diabetes one of the most common chronic medical conditions and represents a significant strain on U.K. health services.”

(HSCIC Astra Zeneca MOU December 2012) [15]

Astra has another Memorandum with IMS Health. So we, whose data it is, have zero transparency and can request no accountability for the use of our data once it has left the HSCIC.

And it matters because when there are data breaches in these companies, we should know whether our data has been involved.

In January 2012  AstraZeneca signed a three year partnership with IMS MOU [16] and stated it builds on AstraZeneca’s existing ‘real-world’ data and research partnership with HealthCore in the US, the health outcomes research subsidiary of WellPoint.  Wellpoint which had a massive breach a year ago, July 2013. So how do we know where our data was stored, and if it were involved or not? Here is what pharma use data for, to analyse “unmet clinical need.”

“The partnership with IMS Health will give AstraZeneca access to pre-existing anonymised electronic health records, which include clinical outcome, economic and treatment pattern data. In addition, the companies will jointly develop a customised research and data analysis platform. The information will provide a deeper insight into how medicines that are already on the market are working in real-world settings across Europe, painting a picture of unmet needs …”

We can look at this more than one way. Some feel strongly commercial use should exclude Big Pharma. On the one hand, the State and Government does not own manufacturing of drugs nor medical products. Though we used to do both.  Recently, that we did own, has been increasingly sold to commercial buyers or venture capitalists.

The State and pharma work together, often through University research, to create future health solutions, drugs and the drive towards personalised medicine and diagnostic tests. When companies which own our data are sold and bought internationally what happens to our data they own? Boots Alliance bought data from HSCIC, and they are about to be bought by US Walgreens. So many questions.

Those more informed than me will know all about the challenges of pharmaceutical companies, the patent cliff, mergers and diversification. IP, diagnostic tests and generics in the market. Big Pharma and the State are working together in much research to find solutions and discoveries to current and future medical issues.
How far does cooperation stretch and when does it become inappropriate? Is commercial interest supportive of State practice or driving decision making policy? Should commercial companies fund any costs at our NGOs? And do those which buy the most data, get a bigger slice of the influence of what conclusions reports using the data, reach? Whilst there is a public move to #Alltrials I believe we should demand #Allreports in the public interest as well. I would like to have transparency at HSCIC how their reports are funded,  when working with partners which are frequently commercial pharma partnerships.

Mr. Hunt recently defended to the Health Select Committee the reasons why a commercially supported pharma lobbying group was used to advise on the NHS Commissioning plan – the Specialised Healthcare Alliance. Supported by 14 pharma companies, these corporate members are contributing £12,000 each towards the costs of the Alliance for 2014.

Are we really seeing transparency on who is driving change in our health service?

The Richness of our records open for Exploitation

The value of Big Data is only extracted by exploiting its richness. And these days, with mobile phones, social media and shopping habits tracked by the minute, the average citizen like me, it seems can’t easily avoid being part of it, whether we want to be or not.

But if we don’t even have the right to control and own our data and we can’t control the knowledge generated from it, how can we control who knows what about us and what they use it for? If we’re unaware of its existence, how can we understand its impact on our life to make free and uninfluenced choices in what we buy, for example? Or understand how we may be segmented and discriminated against. And this is aside from the assumption that the data held is accurate and that as a result, no mistaken judgements are being made about us.

As for our health data, how can we control its use by these massive data managers if we don’t even know who they are at the end of a chain of re-use licenses?

Put Business Intell, Commercial Intell and Pharma together

The vast amounts of data already held and analysed to the nth degree by these data intermediaries, means that making even more data available to them is going to increase the segmentation and risk of identification. They already have data on individuals and is it not enough that they make analysis at household level as shown by Mosaic? Individual health level data seems that they could put a final piece in the puzzle and know exactly who in which house had which ailments, their lifestyle risk factors could be refined and these data brokers would be able to look inside our very bodies.

One which fits data together, we do know from the HSCIC data release register, and press reports in March, is Harvey Walsh. The company tracks individuals pathway data, over time and the website now says:

“Harvey Walsh use non-sensitive and non-identifiable HES data for patient pathway mapping that is used by the healthcare industry with the NHS to improve the quality of healthcare management and service delivery by better understanding how patient cohorts move around the healthcare system.”
[Harvey Walsh's system] “AXON holds non identifiable and non-sensitive HES (Hospital Episode Statistics) data and other sources of data including GP Practice Prescribing, QOF, Demographic and NHS personnel data sets.”

Data snapshots combine to give a Picture over a Lifetime

So now, not only can these companies understand us in infinite detail, but can do so over our lifetime. We are tracked over time and anaylsed not as a snapshot, but as a living album of snaps, moving across time. They know what we do commercially, in our lifestyle and how it interacts with our health and what may affect our consumer habits and help nudge our decision making. Put them together, and it starts to feel like I’m on The Truman Show.

I’d like to know though, once the data is processed, what happens to the new combined knowledge set, it creates? The original raw data as extracted may not be given to others, but is it the same product and protected, if it now shows up as a small piece, in a bigger jigsaw?

Omega Solver took their product offline this year, after privacy campaigners identified the risk of identifying individuals.
Acxiom as a world data leader example, is a company which provides consumer data and analytics for marketing campaigns and fraud detection. Its databases contain information about 700 million consumers worldwide.

“For more than 40 years, Acxiom has been a leader in harnessing the powerful potential of data.”

It seems others share my concerns, as this article on how data brokers use of our data is creepy, from Julia Angwen showed up in my alert feed this week, and another in ProPublica from last September. As she says,

“Commercial data has become a honeypot that government likes to dip its hand into.”

You can see more on this, in her interview with PBS News:

Our lifetime data is attractive to commercial marketing and all sorts of organisations who wish to understand us and sell to us. The one purpose, possibly the least trusted I have not really touched on. Hospital records have been shared with insurers and used for refining policy. Records have been sold to re-insurers, even since January 2014. And these insurers mine and use data much more deeply than we want to imagine. In fact, as I finish this I see the FT front page tomorrow carries a current story how insurers trawl our Big Data.

FT Insurers trawl Big Data
FT Insurers trawl Big Data

 

 

 

 

 

 

HSCIC Data Sharing Agreements will prevent Data Merger?

IMS Health UK & Ireland’s general manager, Michael Sanvoisin shows that exploiting the different data sets ‘out there’ in Big Data, is kind of the whole point. [17]

“The smartest use of data will be the effective combination of all the various sources of open data and patient information services available in the marketplace, augmented by companies’ own internal information and data from other reliable and reputable sources.”

IMS Health is working in partnership with the MHRA – and in particular the clinical practice research datalink (CPRD) – to help the UK increase its capabilities to build cohorts of patients for clinical trials. This has led to the linkage of IMS Health’s Hospital Treatment Insights (HTI), the aggregation of HES and prescribing data, to the CPRD. This powerful linked dataset enables the identification of specific patient cohorts and allows companies to monitor patient flow between primary and secondary care.

IMS Ardentia’s Costed Care Pathways (CCP) sequences clinical events together with detailed financial information to give a longitudinal view of a particular patient care pathway.” [17]

When these global companies have in addition, bought data from HSCIC, where is the transparency for patients to know what internal practice at these private companies prevents all data becoming one Big Data set,  in identifiable or pseudonymous formats, and sold or shared onwards with others?

The Recent register states explicitly, that IMS will not do this, that the data will not be sold onwardly, but how about the knowledge they create from it?

IMS Health works in partnership with pharma for example:

“ANDromeda is an engagement tool enabling greater market access with a tailored need across all functions within pharmaceutical companies.

And in the UK,  are involved in work shaping our health market: “that may involve looking at how primary care organisations operate or focusing even closer on area-level commissioning, such as GP consortiums.”

Where is our Data being Used?

“The effective combination of IMS Health’s proprietary data assets, in addition to the vast swathes of open data being made available, can help inform key strategic decisions for both the NHS and pharma. Moreover, it can drive an increase in joint working towards shared benefits and therefore transform healthcare services in the UK and beyond.”

“in the UK and beyond.” So I ask myself, which countries outside the UK have received our medical records? Remembering that non-US citizens have no privacy rights in the US, if it landed there, we can say good bye to ever getting control of that knowledge back again.

Indeed HES extracts have been given to places in the US, specifically the University of California, the FOI request I got back confirmed. The Partridge Report contained two examples of data which has gone to Kyoto University. Yes, Japan. And remember, if the data is completely aggregated and anonymised it’s not included in these registers, because it is open, green data. So what exactly went to California, Japan and who knows where else. No one knows 100%. The Report only sample tested 10% of all releases.

IMS received 251 access (which is required for confidential data without consent) for identifiable data extracted from hospital pharmacy systems, sent to HSCIC and linked with HES (hospital records). The main customer for these products will be the pharmaceutical industry. (Lines 101-2).

IMS Health is massive, as is the global health data they hold.
On the IMS One intelligent cloud, the company connects more than 10 petabytes of complex healthcare data on diseases, treatments, costs and outcomes to enable our clients to run their operations more efficiently.

Drawing on information from 100,000 suppliers, and on insights from more than 45+ billion healthcare transactions processed annually, IMS Health’s 9,500+ professionals drive results for over 5,000 healthcare clients globally. Customers include pharmaceutical, medical device and consumer health manufacturers and distributors, providers, payers, government agencies, policymakers, researchers and the financial community.

Another user of our data is Optum UK (formerly United Health Group, and if that sounds familiar it was Simon Stevens [18] last employer). I wonder for example, does that mean it is also used by Optum Insight in the US? This presentation by Christopher M. Blanchette,  shows different data providers of ‘RWE’ real-world evidence and where their data is sourced.

If international companies have NHS England patient data and re-use licence, is it likely in to have been exported around the world or how can we know in which locations it is used? I want to know how often data is given directly to International companies? How often is data given to companies in the UK, who have foreign centres outside the UK, which would routinely share that data with their central systems and therefore export it? It is a basic right of data management to require fair processing for identifiable data, to know who has it for what purpose.

How do we protect consumers’ concerns?

And as US Commissioner Julie Brill’s report shows, in the States there are concerns how this data is used and they are acting on it. Are we doing the same here?

Dr.Neil Bhatia in Hampshire, a GP who founded the non-commercial website care-data.info, asked HSCIC in an FOI request for the data *about him* which was released to these type of intermediaries. He was told, the data controller, the Health and Information Centre, does not know. And he can’t ask for what data is held in pseudonymous format – even though the data is pseudonymous with a key to make it linkable with new identifiable data coming in, so to me, that makes little sense. It is by its nature, re-identifiable.

But if HSCIC won’t release it in a Subject Access Request (SAR), we can then only surmise, whether our individual data was contained in bulk data transfers. So from the released data register, we should look at what types of companies are using pseudonymous (so called ‘amber’ data), and assume our own data was indeed included.

Overseas Data Distribution and Protection

care.data, it was said at the Health Select Committee meeting by Mr.Kelsey in March, was only for use in the UK but the HES/SUS data application form includes a field for use overseas. So, does that mean policy for export has changed for all data, or should they have spoken more precisely meaning only that “GP data extracted in care.data” was only to be used in the UK?

Because IMS, again, already has access to primary data from CPRD and secondary care data according to line 10 from HES. And whilst, it states “[Note added 28/3: The data are onwardly released only in aggregate form] I am curious – where does ‘onward’ mean? There is no Ltd. on the company name, no territory or geography indicated in the register. So if data is released to an American firm, should we assume it sits on US servers and is accessed directly by their US staff? Does onward only restrict them from giving the raw, identifiable data they received, to others outside IMS? Is it availble in non-aggregate form inside the whole of the IMS system? I, in the general public, can’t tell from the register and IMS is hardly going to tell me. We should be able to find out. I’ve found it a challenge, and my FOI request to HSCIC [14] to find out what data may have been given to US or Asian organisations, was tougher than my entire lifetime of dental appointments combined.  It shouldn’t be difficult. Patients should be able to easily ask, to whom did you give my health data and where, for what?

Do we know enough about the plans to use and commercially re-use our data for commercial ‘health purposes’ as being broadly defined in the Care Act? If not, patients should be asking. GPs don’t have time.

Why does it matter? Because legal jurisdiction of data is still (perhaps outdatedly) physically geographic at least in aspects with which I am familiar. When working on global implementations of confidential employment data, we had to gain legal advice from each territory submitting data, on how we should legally properly manage data from over 50 countries in the world and its access by regional and global teams in the US, Europe or Asia.  And on simple terms, we should always handle, process and use data in a way the individual expects and feels common-sensed appropriate to the purpose for which it was submitted. British citizens are not protected by US privacy laws because they apply only to US citizens.

“Existing laws do not sufficiently address data brokers’ handling of sensitive data in marketing or risk mitigation contexts,”

says Julie Brill’s statement. Well they don’t protect us Brits, at all, so I want to know if it’s being used abroad.

Few in England, will expect their data to have been made as freely available at identifiable individual pathway level, as it appears to have been in recent years. Do I at least have the chance to protect my children’s future data privacy, if not my own now?

Surely we can trust Data Protection Laws?

Because of the legal status of data which is deemed “de-identified” or “anonymized”, it is claimed they don’t violate our rights to health information privacy – Data Protection law accords us only the right to fair processing, not to prevent its processing, due to the the Health and Social Care Act 2012 which requires its extraction — but if it’s possible to re-identify longitudinal data sets – and if the whole point of getting these data sets together is to combine them, surely common sense would say, it may be legal, but that doesn’t make it right. There are other DPA expectations which HSCIC also fails to meet. The Minimum data required, for example. Deletion. Accuracy. I am guessing that every single one of the eight Principles have been broken by our data extracted before the HSC Act 2012. Yet, everyone seems to be ignoring this.

When it comes to Data Protection, identifiable data is treated differently from anonymous data. Amber individual level ‘pseudonymous’ data, is not the same as aggregated anonymous statistics and the care.data privacy impact assessment [19] confirms the risk of re-identification, yet the data is being treated as if it is anonymous. I can’t believe people working in the field believe themselves these data groups should be looked on as being equal. In my opinion, it’s not so much a case of wearing rose-tinted spectacles, it’s more like a blindfold on the wise monkeys; hear no evil, see no evil. [20]

I can quite clearly state on behalf of many, we feel that our rights to privacy have been and continue to be violated, no matter what the letter of the law says.

Whilst HSCIC may see only its own data sharing practices in a silo, that’s not how the impact of its sharing works in real life. It’s a join the dots between different data sets from different sources.

Can Good Governance Give us Confidence?

We are told that data-sharing agreements make it illegal for the data to be combined with other data held by the recipient, to make it identifying. But if the Data Controller doesn’t know what data the company already has, and doesn’t even keep track of what data has been given to them already, it must be impossible for individuals within these massive corporations to know the impact of adding their piece of the jigsaw puzzle. Over time, they will not track either, what from their company has already gone into creating the Big Data picture.

We could only rely on release controls and good governance, but for the past ten years reported in HSJ and the Partridge Review, it appears some datasets have been inappropriately shared without audit, which would have spotted the mistake.  Governance is simply inadequate. In my opinion, not with malicious intent. Rather, simply, the data sharing strategy has been too fast for its own good practices to keep up. Now, it has to catch up fast.

As awareness increases, so too is the push back on the privacy grab. How do we feel about losing our individual rights, the removal of confidentiality and consent, the right to freedom from cold-calling, and to know who has our data for what reasons. And do we feel the same if we lose those rights in the name of commercial or public interests?

The British public is pushing back on banking failures and resents increasingly to see the minority of individuals benefiting commercially at the expense of the many. We resent the paternal state definition of the ‘Public Good’. 

Private vs Public Good?

Business benefit vs the wider public good is in some ways an intangible and unquantifiable, but a debate which needs revisited on an ongoing basis says Dr. Mark Tayor when it comes to health records’ data privacy. [21]

The public interest considered by CAG in reviews of data release applications, must consider protecting both the public interest in research access to confidential patient data and the public interest in a confidential health service. Add to that the public interest of providing a national health service, and its safe to say ‘the public interest’ will be hard to satisfy for all of the people, all of the time and will be subjective.

“that the purpose for which the data will be used should be in the public interest and for the provision of health and care services; [and] that any approved processing must respect and promote the privacy of patients and care service users… ” (Hansard, 10 March 2014, Col.137)

Perhaps even more subjective, is the atmosphere of public interest and how interested the public is, in how how level decisions affect us on the ground. Certainly, Snowden and other data sharing revelations have coloured the muddy backdrop of how our data is gathered and used by others, and increased calls for transparency.

The Department of Health will be furious with the Home Office I expect this weekend, as they triggered a massive outcry over the perceived lack of transparency and scrutiny afforded to MPs and civil society over the Data Retention and Investigatory Powers Bill.  Even Radio 2 gave it 20 minutes coverage.  [22] (From 01:36.40) This kind of governmental out-of-touchness with the public and the perceived desire to hide something in the rush to the new legislation, is what undermines trust in all areas of the public-state relationship.

It implies a paternal notion, of “we know best, so just trust us little children.” Well, that ain’t gonna fly.  Seahaven is not “the way the world should be.”

Patient empowerment to own our Health Records

This flawed process, within and beyond NHS data sharing, has also created a sense of loss and disempowerment. Whilst presentations are all about ‘patient centred’ care, and ‘personalised medicine’ sounds so about the individual patient, it seems safe to say patients have been left out of the digital decision making and sharing how those decisions will affect the public on the ground. This for care.data, should have been central to plans to ensure support and success. There are still unfilled positions supposed to be filled by patient organisations or patients on the tech board.

It seems endemic to new programmes too. Or have patient organisations been widely involved in the genomic plans for the nation and not told us? Unlikely.

The talk thus far, does not match the walk. Knowledgable patient involvement is as desired by some of those leading parts of NHS patient engagement, as a chocolate teapot is useful. One is documented having said on another programme, “this was not a suitable point for patient involvement.”  Either you want patients involved or not. Involved means from the beginning. Not as the decoration at the end, a way to tick the engagement box.

The notional idea of patient empowerment in this programme is tokenism, if the most basic principle of care, the only thing I can control in my consultation – my patient confidentiality – is treated with such little respect.

Is the public good really defined and does it outweigh the private good and our long established rights of consent and confidentiality? Does it vary depending on circumstance and if so, who decides?
It certainly doesn’t seem to be us, the patients in healthcare. Nor as citizens in any other field of our personal data.

If you don’t pay for the product, you are the product

In general commercial uses of data, I am increasingly learning that if you don’t pay for the product, you are the product. Maybe we need to shout a bit louder, that we are not a product. We do not all want the knowledge of our health & lifestyle to be for sale.

We’ve got used to these third party uses through the recent media revelations and the acceptance that current Government seems to be prepared to sell anything the State has in its possession. I wonder how representative that is of what the people would choose to do?

So at the risk of repetition, let’s not forget the basics:

1. Our health records are for sale without our consent.
2. These companies are some who have bought data in the last year.
3. At these prices.

The list of past customers in the Partridge Review of those who received data before April 2013 shows the extent of what was hidden from us for twenty years.

Should we be asking, what may be hidden still?

By stretching the scope of the potential discussion around the ‘industrialisaton’ and use of our health records for secondary purposes, we must not normalise the basics which we at first, found so surprising. We need to get them fixed first. Then, only then, will patients be willing to look at broader future scope. If I can’t trust you to manage my hospital record when I broke an ankle, why would I want to trust you with my genomes in future? It reveals a complete disconnect at NHS England level with the public in care.data thinking.

Come back to reality and listen to patients’ real concerns. We don’t want our data given to third parties, these data brokers and intermediaries or to continue re-use licenses. Even if it’s for ‘the promotion of health’ the purposes in the Care Bill.

And honestly? NHS England and the Department of Health  shouldn’t want that acceptable in policy either, because they need to know who has our data, to govern it to make sure it is acceptable. As Sir Nick says in his report, the future data governance must be:

“meticulous, fool-proof and solid as a rock”

One more big mistake in who received our data in the future, and all cards will be off the table.  For this to work, you need to properly manage it. And all this at the time where NHS England has now decided to outsource population wide databases, through the Steria outsourcing. Ha. Get that outsourcing security wrong, and for all your future programmes, as Truman would say, “Good morning, and in case I don’t see ya: Good afternoon, good evening, and good night!”

In the words of more Americans for whom I have a respect & love of their self-determined own words,  Simon and Garfunkel, ‘Slow down, you move too fast.’

Julie Brill’s Statement made a recommendation in the US:

“A second accountability measure that Congress should consider is to require data brokers to take reasonable steps to ensure that their original sources of information obtained appropriate consent from consumers.”

We should feel that we consent to this mining of our health, wealth and lifestyles and know what is done with that knowledge. I feel disempowered because in finding out how my health data is used, I’ve discovered a brave new world of how my personal data is used. By commercial business. By Government.  By suits and wonks as may be nicknamed.  I am not equipped or informed enough to understand it all, but I’m doing my best to find out.

We need to trust in the people who manage these systems, who drive the policy and who advise the two, to work together and make technology work well for the rest of us. It should work well with privacy and security, and functionally.

Patients must speak up and Ask Questions

Patients must start asking more questions about these commercial uses and re-use licenses, because whilst the commercial intermediaries may access data for the purposes permitted in the Care Act, we are not a partner in patient engagement. Our data is being mined in the name of NHS improvement. Our samples being gathered in the name of science.

We are the product for sale. Our name, and everything else about us.

*****

image source: Time cover 2011

[1] Previous posts: Commercial uses of care.data and

[2] care.data use with intermediaries  

[3] Health Select Committee July 1st, 2014: http://data.parliament.uk/writtenevidence/committeeevidence.svc/evidencedocument/health-committee/handling-of-nhs-patient-data/oral/11192.html

[4] NHS England Board meetings - to outsource support

[5] Decision to outsource Primary Care support services

[6] Schumacher’s health records stolen  http://www.mirror.co.uk/news/world-news/michael-schumachers-medical-files-probe-3823793

[7] The Partridge Review Summary

[8] Risk Stratification guidance issued to CCGs

[9] IMS Health Ardentia http://www.imshealth.com/deployedfiles/imshealth/Global/Content/Technology/Technology%20Platforms/Ardentia/Ardentia_Royal_Free_PLICS.pdf

[10] Experian Public Sector http://www.experian.co.uk/assets/identity-and-fraud/authenticate-for-public-sector.pdf

[11] Experian’s Truetouch http://www.experian.co.uk/business-strategies/truetouch.html

[12] Experian -MOSAIC http://www.experian.co.uk/marketing-services/knowledge/case-studies/mosaic-case-studies.html

[13] HSCIC Data Register of Releases

[14] Medconfidential on commercial re-use licenses and Omega Solver https://medconfidential.org/2014/commercial-re-use-licences-for-hes-disappearing-webpages/

[15] Astrazeneca MOU with HSCIC – http://www.astrazeneca.com/Research/news/Article/121204-astrazeneca-to-collaborate-with-the-hscic

[16] Astrazeneca MOU with IMS http://www.astrazeneca.com/Media/Press-releases/Article/20120111–astrazeneca-and-ims-health

[17] IMS Health using NHS patient data  http://www.imshealth.com/deployedfiles/ims/Global/Content/Solutions/Healthcare%20Analytics%20and%20Services/Healthcare%20Outcomes/IMS_HTI.pdf

[18] HSCIC FOI Request on data sharing with the US & Asia

[19] The Eight Data Protection Principles  via ICO

[20] care.data privacy impact assessment http://www.england.nhs.uk/wp-content/uploads/2014/01/pia-care-data.pdf

[21] Previous post: The Partridge Review

[22] Public vs Private Good – “Information Governance as a Force for Good? Lessons to be Learnt from Care.data”, (2014) 11:1 SCRIPTed 1 http://script-ed.org/?p=1377

[23] Data Retention and Investigatory Powers Bill.  Radio 2.

****

See Wired: for an overview of care.data in general http://www.wired.co.uk/news/archive/2014-02/07/a-simple-guide-to-care-data and what good things should be taken from it when flagship care.data goes down http://www.wired.co.uk/news/archive/2014-03/06/care-data

images

That’s the power of artists’ privacy.

“That’s the power of artists’ privacy. It preserves the melodies otherwise drowned out by words, stories, information.”

Joshua Rothman – in The New Yorker

This article in The New Yorker on July 9th 2014, is a keeper. So I just had to keep a post linked here for posterity. He begins:

“These days, when we use the word “privacy,” it usually has a political meaning. We’re concerned with other people and how they might affect us. We think about how they could use information about us for their own ends, or interfere with decisions that are rightfully ours. We’re mindful of the lines that divide public life from private life. We have what you might call a citizen’s sense of privacy.

That’s an important way to think about privacy, obviously. But there are other ways. ”  Read on here >> just, perfect.

Virginia Woolf, 25th January 1882 – 28th March 1941

“To be silent; to be alone. All the being and the doing, expansive, glittering, vocal, evaporated; and one shrunk, with a sense of solemnity, to being oneself…”

 

room_own_woolf_small

When it comes to working in Tech: Are some Women more Equal than others?

“Anon, who wrote so many poems without signing them, was often a woman.”

Virginia Woolf, A Room of One’s Own

I watched two unequal sides play the beautiful game in the 2014 World Cup in Brazil semi-final. The host nation was crushed in a 7-1 defeat. Germany simply outclassed them and once they had the first goal pressed their advantage to drive home another quickly, after which the Brasilian side didn’t have a hope. As a team, they fell apart.

Inequality in what should have been a good match, resulted in tears.

There was a  lot worse than tears in this story of inequality last week, when the team at the heart of tech dating agent Tinder fell apart. “When news broke that a former vice president of partner-matching Tinder filed a sexual harassment suit against the mobile dating app company, the most salacious parts of the complaint quickly spread around the Internet, reported Chloe Angyal.”  See the rest of the story via Reuters. Or the Techcrunch version.

It appears the issues are more about the personal rather than professional relationship gone wrong, but in any event the male-female public exploitation in the media, the story of power and punishment is damaging personally and professionally. Frankly, I’m not that interested in the nasty side of the story. But does it harm the appearance of women working in start-ups and tech?

Are women perceived as equals in tech? Do we perceive ourselves as equal or are we our own worst enemies in how we manage and speak of other women, in leadership roles?

To become leaders, we must first start at entry level. I wonder in part if the langauge we use in tech has put women off entering the world of ‘the geek.’ The recent workforce numbers released by Google and surrounding other tech firms in silicon valley show women are unequally represented. I wonder if the imbalance is a result of concrete skill sets – the numbers of girls studying maths, physics, engineering appear ever dwindling -, fitting into the corporate environment – the unusual set up of game style office for example – or nature of work. And how much is down to expectations. “Nice girls don’t play games, they do something sensible.” In fact, in my experience tech is a nice place to be. Geeks are more accepting based on value-add to the team goal in a flat team structure, than I’ve found working in white-collar management for example, where in-house politics starts to play a role. However, some women find that the working environment in either, can’t meet their needs for the other part of their life, parenthood.

Whilst more women in the UK are working than ever, it’s not always in the jobs or employment type which are equally well paid or sought after. Cashiers, waitressing, care roles. Women are over represented in jobs that offer flexibility and there is great gender inequality in pay.

In the UK, in a broader field,  the HSJ looked specifically yesterday, at employment in the Health Service and just published its findings. There are more female leaders running NHS organisations than there were last year. And they held awards for women last night.

But it was Alistair McLellan’s comment I found more fascinating on the types of criticism female leadership receive, than the stats they found.  Again, like the Tinder slanging match, treatment which women both meet out and receive, may be different from that of their male counterparts.

“It is the nature rather than the level of criticism that is different for female leaders, and it tends to be more pernicious and undermining of a leader’s resilience.”

I do wonder if we women are guilty as charged, of being more critical of fellow leading women than men. Or is it that we find bold and assertive women somehow more threatening, as more out of the ordinary, than the same behaviours in male managers? Am I guilty of thinking that ever myself? Do we criticise women in terms of emotion and men according to performance? Are an angry man and an angry woman on the front bench seen as equals? Would both be told to ‘calm down dear’? Does the politics of white-collar management deter women from leadership?

“Time and again it is suggested to HSJ that a female leader is struggling because she is neurotic, devious, scatter-brained and/or self-centred; or that her troubles have arisen because she is a flirt or a sycophant and has been overpromoted as a result.”

“And before female readers get too angry at their male colleagues, the critics are just as likely to be women – or indeed, those who would normally consider themselves strong supporters of equality.”

I’ve been in the receiving position. My female manager suggested I was overpaid and overpromoted. I had been offered another role  in another company. I stuck to my guns and received the salary rise I hoped for. I was twenty-two.  I went on to various jobs, salary increases and promotions in the same company. And I’ve always worked daft hours, given my all for the team and made sure the company always had their money’s worth. You can look to women leaders and say, it can be done.  There are good role models to show it is possible.

(Though some role models, leave something to be desired such as Sheryl Sandberg, chief operating officer of Facebook’s response in their transparency approach  and ‘apology’ after recent research revelations.)

But if there are fewer women in tech, it is for reasons I may not understand. It is an area where in my own experience, everyone who works together on a project and sees knowledge and result as a common goal, are pretty uncaring from whom a solution comes. Appreciation and team accolades were fairly distributed in my own experience.

I don’t think it is peculiar to tech to have too few women represented, although it could be fair to say the environment has its own quirks. (Just visit Google’s London office for example.) It’s challenging but a fun place to be in the tech workplace. It’s often project based, demanding a quick learning curve, with weird and wonderful hours supporting parts of the world you’ve never heard of. You need to be prepared to do a lot for each other, often at short notice, pulling out all the stops for a last minute fix and testing. It demands a lot of flexibility, energy, problem solving, teamwork and humour.

Whilst similar human qualities are also necessities as a parent,  the flexibility aspect can be something which managing the other role of parent, can absorb entirely. The cost of childcare is prohibitive for many going back into anything other than a similar type of demanding role and environment with its according payscale which they left, if mothers want anything left to take home after costs.  But for me personally the question then becomes, do I want a lifestyle in which I would see my children neither for breakfast nor read them a bedtime story? Or do I work in a non-tech job and  give up on the past?

So perhaps it’s a question of why women have to leave the workplace in general rather than tech. Perhaps we simply can’t go back into that environment with the flexibilty we need in the other part of our life, as a parent?

Why this matters to tech, and the implications for society are here. Women in tech, like women in politics are necessary to offer balance of opinion, experience and expectations. Just as importantly I believe it should reflect all the different parts of society in ethnicity, able and disabled, religion and other areas. I’ve gained all sorts of valuable experiences working in the voluntary sector, as a mother and having free time for other learning since having children. But it is mainly my professional experience that is still examined in applications.

Whilst past experience in tech is of great value now, to go back and  functionally design the system I once worked with, I would need a tech refresher. But that would be easy. What is much harder, is the expectation of my partner that for our children, I would be the one expected to take time off for sickness, unless I had a full time carer for them. And even if we were to split time off 50/50 we’d find it hard. Business travel is not compatible with home & family. So that kind of role I once had, is impossible. So the choice now to have a high-level tech job and put my children second, if sick or for six weeks of the summer holidays, is not a choice I feel fair to make, which would put my wants first and my children’s needs second. And that’s the reality of my choice. It is perhaps a luxury to have any choice at all.

In effect, in motherhood, we might call for employment equality. We may be entitled to it. But we may not always be able to really choose it in reality. In Japan, this is a real problem on a number of levels. What’s the solution?

In Alistair McClellan’s words,

“The answer to these double standards is simple: we must all be alive to criticism that is skewed by prejudice, however subtle, and hold ourselves and others to account to combat it.”

NHS England has an opportunity to do that in patient  involvement organisation / positions on the tech board right now.

ciarand
patient org places on Informatics Board

I do hope that some informed tech and non-tech women are considered.

The Japanese women, might have hit the nail on the head when it comes to most people’s beliefs about motherhood and working in leadership positions.

“I think only a small number of women can pursue leadership positions,” she said.

“I think in our society you have to choose whether you want to have a career or be a mother; you can’t do both.”

If you were an employer with two women of similar skill sets and experience, one with young and one without or with older children, would you see her role as a mother as a negative effect on the likelihood of employing her? I believe so.

Not because of the fact she had children, but because of the potential secondary demand on her time. As a ‘working’ mother, a woman always has a second job.

For female employees in tech, I believe that counts against us. I believe I will only be able to go back to full time tech work as an older woman, once my children are out of school. That will bring challenges of its own. So whilst we may seek equality, and we told we are all equal, I do wonder when it comes to the paid, working life:

Are some women more equal than others?

****

FUN FACT: see The last photograph of Virginia Woolf http://www.telegraph.co.uk/culture/art/art-features/10914210/The-last-photograph-of-Virginia-Woolf.html

****

The Tinder romance gone horribly wrong: http://www.slate.com/blogs/moneybox/2014/07/01/tinder_sexual_harassment_suit_former_executive_claims_she_was_called_a_whore.html?wpisrc=burger_bar

Google employment figures: http://www.motherjones.com/media/2014/05/google-diversity-labor-gender-race-gap-workers-silicon-valley

HSJ: NHS Workforce findings http://www.hsj.co.uk/news/workforce/slow-progress-appointing-women-leaders-in-the-nhs-research-finds/5072756.article#.U72ckahHyqY

HSJ: Progress on Equality is no reason to stop Challenging Prejudice http://www.hsj.co.uk/5072777.article?contentid=MAST#.U72RJahHyqY

Japan: http://www.abc.net.au/news/2014-05-29/japan-child-care-crisis-threatens-workplace-diversity/5487556

 

kafka

Happy [belated] Birthday Kafka

Yesterday, July 3rd, was Kafka’s birthday. I started to write about him, and fell asleep with a book in my hand, waking in Kafkaesque style this morning not knowing where I was or why. But thank goodness, I did not wake up as a beetle. [1]

The overly used descriptor Kafkaesque has more recently come to take  on a generic meaning, and his name  associated with a dark view of the state and surveillance. [2]  I wonder what he would have made of it?

The surveillance state is more contemporary than ever in mainstream thought, since Snowden, a year ago. We can look at The Trial, in which the protagonist is accused of an unknown crime, under assumed guilt and secrecy surrounding the process and reflect on the latest moves towards a secret court in the UK. In ‘The Great Wall of China‘ Kafka considered both points of the debate how to protect the People from outsiders, the Barbarians. As we see security at airports tightened today against an invisible threat, its central theme as valid today as in the 1920s, exploring the authority’s exploitation of fear and uncertainty over what constitutes a nation and what should be defended. In Das Schloss ‘the Castle‘ the authorities are drowning in documents, but cannot find the one which is relevant to the accused. Kafka questions the purpose of massive data gathering when the authorities appear not use the documents they collect. Both the latter stories mentioned in Alan Greenblatt’s article, on the Surveillance Society. [3]

His work is perhaps more relevant than ever.

As a Germanist, his work featured strongly in my studies, but I appreciate it more now, and am currently working on a project which is based in the time of his life (1883 -1924) and into the second world war.

It was both a fascinating and demanding time and place to live.

He was a German speaker living in what is now, the Czech Republic. The issues of identity and belonging are everyday ones for the residents like him, in a country whose borders were fluid and changing. Whose government switched the state language between Czech and German, and issued new passports in his lifetime, more than once, and in state institutions in which it was dictated how many employees should be of which – Czech or German – ethic origin. It is little spoken of today, but the fifty years before WWII set the stage for the struggle of ethnicity and its horrific consequence for millions of ordinary citizens in post war Czechoslovakia and its neighbours. The resulting forced migrations [4] of 3 million ethnic Germans from the Sudetenland alone, and the deaths of a disputed number in the region of half a million, and up to two million more who disappeared, is a little talked of consequence of the war and its preceding years.

He died before this, in 1924. His best known works are those in which the State, power, identity and emotional struggles are entwined in dark and often unexpected situations.

His work is ever popular, and his many themes, quotes and associated artwork are widely used. His concepts contemporary.

He was reportedly an avid reader, and advocated reading books which challenge:

“I think we ought to read only the kind of books that wound and stab us. If the book we are reading doesn’t wake us up with a blow on the head, what are we reading it for?”  

– from a letter to Oskar Pollak (January 27, 1904)

He inspires me to keep writing mine.

 

******

Artwork from the Schocken/Pantheon Kafka library, cover designer Peter Mendelsund

[1] Metamorphasis: http://www.sparknotes.com/lit/metamorph/ – one of Kafka’s best known works

[2] Salon’s view of the NSA’s Internet surveillance program and how it uses Section 702 of the FISA Amendments Act.

[3] Alan Greenblatt article, Our Surveillance Society – What Orwell and Kafka might say -  June 2013 http://www.npr.org/2013/06/08/189792140/our-surveillance-society-what-orwell-and-kafka-might-say

[4] Forced migrations of ethnic Germans in post WWII http://en.wikipedia.org/wiki/Flight_and_expulsion_of_Germans_%281944%E2%80%9350%29

1984 author edits

care.data communications and core concepts [Part one]

“My concerns about care.data are heightened, not allayed by the NHS England apparently relentless roll-out and focus on communications. Whilst they say it will take as long as it needs, there is doublespeak talk of Oct-Nov. pilots. It is still all about finding the right communications, not fixing flaws in core concepts.”

Today at the Health Select Committee Mr. Tim Kelsey, on behalf of NHS England, said that care.data pilots will be in October/ November and in the meantime they are listening to the “constructive challenge to NHS England how to build trust in the [care.data] programme.”

Here’s my real experience of that listening, why it may not help and what still needs done. (And in under 4 months if in time to be of any use for the pathfinder pilots, which are only of use to the whole if done properly. )

[Part one]  care.data communications and core concepts – Ten takeaways from the Open House event.

The NHS England led Open House Day [1] on June 17th was a listening opportunity according to the draft agenda for:

“patients and the public to influence the work of NHS England at national and regional level.”

Within the other programmes of Patient Online and Patient Participation, care.data was a one hour session. It included the blue plasticine people short animation, a speech by Mr.Kelsey, a 15 minute table discussion on one pre-given theme from a range of four, reading aloud the summary of that discussion from each table within the room, one question per venue raised outside the room to the panel via video link in London, and their answers. Our discussion topics were brief, controlled and relatively superficial. It could have been a productive day’s workshop on only that.

The Open House  took place simultaneously in four venues across England, Basingstoke, Leicester, York and London, connected through a live videolink at a number of points throughout the day. The recording in part, can be viewed here.

I attended the Basingstoke event, particularly keen to learn about national programmes such as care.data and hear about any updated plans for its rollout, to learn about patient online, and to meet the NHS England team in the South as well as other interested people like me. I hoped for some real public discussion and to hear others get their questions aired, shared and on the table for resolution.

I met one other ‘only’ patient and whilst I was kindly told by a further active PPG organiser, that I should never refer to myself as ‘only’ a patient, but you know what I mean. I’ve applied as a lay rep on our local CCG for an opening next year, until then, I’m learning as much as I can from others. Other attendees I met were those already more closely involved with NHS England in some way already. As NHS England staff, facilitators, representatives from Clinical Commissioning Groups, Patient Leaders and PPG leaders.

Here are some of the things I learned:

1. Public Awareness

Mr.Kelsey asked the room (he was in London, other locations took part by live link) how many have:

a) heard of care (dot) data and

b) how many think they understand what it is is?

We couldn’t see his room, but he said ‘about half’ understood it. Our room’s show of hands was similar.

My reaction: One would expect everyone attending to have heard of it, the event after all was billed as in part about care.data. The level of understanding should be higher than the average in the public, since many (in Basingstoke at least) were NHS England or more involved than the average citizen.

Feedback overall was consistent with the latest MORI Ipsos poll [2] commissioned by the Joseph Rowntree Reform Trust in which the minority know it well and over 50% say they have never heard of it. That’ s a long way to go to reach people, inform them adequately to meet legal Data Protection minimums and let them enact their patient choice.

ipsosmori_q4know

2. Communications Message

A consistent, frequent communications message is that ” there are FAQs and materials, we have the answers, we just need to communicate them better.”

My response: communication is failing because the core scope of what care.data is, is fluid. Without something concrete and limited, it cannot be explained neatly. As one NHS England communications member of staff said to me this week, ‘we haven’t got an elevator pitch.’  So it’s not about the materials or the methods, it’s the substance that is flawed. When you’re talking about extracting, storing, sharing and selling some of our most intimate information, a vague notion of pooled experience is not good enough to trust. People want to know exactly what information, is being shared for what purpose, with whom, where. And how long will they keep it for?  NHS England simply do not have the answers to that, so, that elevator pitch? It’s never going to get off the ground in a meaningful way. And anything less than the answers to those questions, doesn’t meet the Fair Processing requirement of Data Protection Law.

Today at the Health Select Committee Mr.Kelsey was asked, will patients be able to trace in future where their data went? There was a rare and stunning silence. And after a benefits statement, there was still no answer given to the question. [update: Hansard now available, Q525/526]

3. Timing

Mr. Kelsey said, on rollout timing that NHS England would take it  ‘as slowly as we need to.’

My response: This reiterates the ‘no artificial deadlines’ but appears to be doublethink in contrast with the statement confirming  ‘autumn 2014′ extraction for Pathfinder (pilot) 100-500 practices. How will the pathfinder (pilot) locations be ready to test a communications process which as yet does not exist? How will it pilot a consent process for young people, the vulnerable, those with complex health system needs, the at risk, those outside ‘the system’ with GP records? A process which by its nature must be applied to any opt in or opt out choice, if others make a decision on their behalf yet from the meetings’ discussion, whose informed consent appears not even begun to be considered?  Or how will solutions to past Data protection Law failings be found from thin air, when data has been breached in the past, continues to be shared in the present and there is no solution to resolving those failings for the future?

4. Language simplification

There is a tendency to oversimplify the language of the Care Act, into ‘care.data will not be used for any purpose other than ‘health benefit’ – whereas benefit is not mentioned in the wording:

Care Act 2014My response: Is to question why this is? Does benefit sound better than promotion perhaps? Again, words should be used accurately.

5. Users simplification

NHS England are similarly very keen to point out explicitly that care.data  cannot possibly be used for insurance or marketing purposes, such as junk mail.

My response:  Yet again, the wording of the Care Act does not state this explicitly. In fact, it leaves pharmaceutical marketing for example, quite open, ‘for the promotion of health’. And there is no legal barrier in the Care Act per se, for firms which receive data for one purpose, such as BUPA the hospital provider in London, using it for another, such as BUPA as refining premiums. BUPA Health Dialog received individual level patient data in the past. How do those patients know what it was then used for or shared with? Perhaps Data Sharing Agreements can specify this, but the Care Act, does not.

6. Use by Data Intermediaries to continue

care.data will continue to be on offer to third party Data Intermediaries it was confirmed in the panel Q&A.

My response: some third party intermediaries in part perform outsourced data services for the NHS. But do they also use the data within their own business to inform their business intelligence markets? They sell knowledge gleaned from raw data onwards,  or have commercial re-use licenses for raw data over which we in the public have no visibility or transparency.  We cannot see within these businesses how they build their own ‘Chinese walls’, self-imposed restrictions to ensure security between different parts of the same umbrella organisation. Allowing third parties to re-sell data means control over its use, owners and management is lost forever. Not secure, transparent or trustworthy. I explore their uses with commercial brokers more here in a previous post. [3] Considering I was told that my personal confidential data will not be shared with third parties, in a letter signed by the Secretary of State for Health, I am most unhappy about this. I will find it hard to trust new statements of best intent, without legislation to govern them.

7. Data Lab – restricting user access

Mr. Kelsey indicated that going forward the default access to our health data will be on the premises of HSCIC, the so called “Fume cupboard” or “Data Lab.” However he noted, this would not be for all, but be the ‘default’.

”The default will be access it on the premises of the IC. That won’t be universal for all organisations….”

My questions: Whilst a big improvement from giving away chunks of raw data via CD or to remote users, these processes need documented and publicly communicated for us to trust they will work. How will we know who all the end users are if the same rules do not apply to all? How will those exceptions be granted? Documented? Audited? Will raw data extraction still be permitted? It’s the exceptions which cause issues and in future, the processes and how they are seen to be governed must be whiter than white. For those with direct access, users of the HDIS or HES, will a transparent list of users be published? At least for now, they do not show up on extraction audits so the public cannot see what those users access or why. So, a good step, but can’t stand alone.

8. Governance

We were informed, an Independent Information Governance Oversight Panel (IIGOP), chaired by Dame Fiona Caldicott, has agreed to advise the care.data Programme Board to evaluate the first phase pathfinder (pilot) stage.

My feedback: I find this interesting not least because the Information Governance Review [4] under her direction in March 2013 decided that commissioning purposes were insufficient reason to extract identifiable data. Personal confidential data should only be disclosed with consent or under statute and “while the public interest can also provide a legal basis for disclosure it should not be relied upon for routine data flows. [footnote, p.63]“

What value is Independent Governance if it has no legislative teeth and can only advise? At the Health Select Committee today, he said she would be able to offer a view, and a number of parties will be able to express views & be ‘in agreement’. But I wonder who owns the ultimate final go/ no-go decision whether the pilot should progress to full roll-out?

9. Anonymous Sounds Safer

Feedback on the handout: The care.data notes need not only to be accurate but transparently truthful.

In my opinion, words are again misused words to indicate that data is anonymous. 1706204_datauses Whilst the intention of the merged CES output (GP records combined with HES files) may be that some users will see only pseudonymous data, the extracted and stored data is identifiable unless opted out. Name is held in the Personal Demographics Service. [5] This is one of the key communications messages I have taken up with HSCIC, NHS England, raised to the DH through my MP. To reassure the public by saying name is not stored, is deliberately deceptive unless it states simultaneously that it may already be held in the PDS and/or linked on demand.[6]

1706datauses

The Partridge Review [7] has dispensed with the notion that data is anonymous once and for all. Now it must be managed accordingly as identifiable data within Data Protection law and communications must stop misusing the anonymous concept to reassure the public.

“It’s a beautiful thing, the destruction of words.”                                 ( George Orwell, 1984)

10. My own experience of engagement

The most interesting part of the day for me personally however, were the discussions which were unstructured and when we were free to talk amongst ourselves. Unfortunately, that was very little. The structure (at least in Basingstoke and appeared similar on screens elsewhere) was based around tables of about 10 which included at least two NHS England staff at each.

At the end of the morning session, before lunch, as the other participants had left the table, a Communications person and I got into conversation on the differences between care.data, the Summary care Record (SCR) and where Patient Online was to fit in our understanding of which data was used for which purpose.

We discussed that since care.data is only monthly retrospective extracts, not for real-time record access, it would not be a suitable basis for Patient Online access – care.data is for secondary uses. So, we moved onto the challenges of SCR access at local level and how it will be possible to offer everyone Patient online when so many have opted out of the Summary Care Record. We began to talk stats of SCR availability and actual use in hospitals.[8]

Sadly, the table facilitator appeared to decide at that point, that our discussion needed guidance and rushed to fetch a senior member of staff from Strategic systems. And rather than engaging me in what had been a very positive, pleasant two-way conversation, with the Comms person asking me questions and our exchange of views, the Strategic Head took over the conversation with her NHSE team member, effectively restricting further discussion, even with her body positioning and language. Being informed is OK, as long as its the ‘right’ information?

I don’t think that’s what patient engagement is about. The subject needs real, hard discussion, not just managed exchange using pre-designed template cards of topics that we are told we ‘should’ discuss. Perhaps ignorance is strength, but in my opinion, keeping Communications staff informed only ‘on message’ and not of the wider facts and concerns is shortsighted and does them, and patients, a disservice, but then again:

“If you want to keep a secret, you must also hide it from yourself.” (George Orwell, 1984)

For [Part two] care.data communications and core concepts – Questions, Communications and Actions : link here >>

*****

[1] The NHS England Open House recording June 17th http://www.nhsengland-openhouse.public-i.tv/core/portal/NHSopenhouse

[2] IPSOS Mori poll conducted for the Joseph Rowntree Foundation: http://www.ipsos-mori.com/Assets/Docs/Polls/jrrt-privacy-topline-nhs-2014.pdf

[3] My post on uses of our records with commercial Data Brokers – http://jenpersson.com/flagship-care-data-2-commercial-practice/

[4] The Information Governance Review ‘Caldicott 2‘ https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/192572/2900774_InfoGovernance_accv2.pdf

[5] The Personal demographics Service at HSCIC (including name) http://systems.hscic.gov.uk/demographics/pds/contents

[6] The Data Linkage Service at HSCIC http://www.hscic.gov.uk/dles

[7] The Partridge review: http://www.hscic.gov.uk/datareview

[8] Summary Care Record use statistics https://www.whatdotheyknow.com/request/scr_care_settings_with_viewing_c#incoming-446569

***

Fun fact: George Orwell’s Nineteen Eighty-Four is currently number 5 in the UK Classics Fiction Amazon ranking. And 86th in fiction overall. Sales up over 5,000% in the US since the Snowden revelations, a year ago.

 

care.data communications and core concepts [Part two]

“My concerns about care.data are heightened, not allayed by the NHS England apparently relentless roll-out and focus on communications. Whilst they say it will take as long as it needs, there is talk of Oct-Nov. pilots. It is still all about finding the right communications, not fixing flaws in core concepts.”

For part one of this post see here >>care.data communications and core concepts [Part one]

1984Other sessions on the 17th Open House included:

Patient participation in general practice: exploring how can you be involved in the changes in general practice, including the introduction of the Friends and Family Test and changes to the GP contract in relation to Patient Participation Groups.

Patients Online: This session was to enable attendees to find out more about work to increase the number of patients who can access their health records online, book GP appointments online and order repeat prescriptions. The accompanying film was described by a fellow table guest as, ‘awful. Too long, dull and dry.’  It felt that there was a lot of weight given to this part of the day and that the uses of data during the event were all mixed into one pot. care.data will not be the source for patient online access, yet we came away thinking of the data as one source to enable that purpose. Poor communication or clever marketing, will depend on your point of view.

The big picture however, of how our health records will be used and bring benefit is in my opinion, being manipulated and purposes conflated to make one thing seemingly lead to another, which are in fact unrelated.

care.data is for secondary purposes, not direct care use by physicians for example. We are told this sharing of data is a requirement for other things as well. Firstly for patient safety and quality. And for integration between services.

Integration

Mr.Kelsey said at the Open House day, (around 36:00 minutes in, if you listen yourself) “we’ve all heard this word integration, I’m not terribly sure what it means, but I think what it means is that local people have a proper say in the way that health services are designed. So to give you voice, to give the local community voice, care.data is really important….”

I should hope that Mr.Kelsey has a jolly good understanding of integration and knows exactly that it is the merging of health and social care under the motto ‘transformation’. Social care under ADASS and health care are under all sorts of pressures to integrate, budgets are being pooled, shared and ring-fenced in various discussions, including my local county Health & Adult Social Care Select Committee:

“…Director Adults’ Services, told the (Chichester) Committee [9] in November 2013: The Care Bill would mean a radical whole system change involving the biggest ever transformational change for Adults’ Services The Council was building the foundations for further significant change.”
Perhaps on the day, he meant something else.

Mr. Kelsey did, in his speech note however, that the programme should be respecting the fact it is *their* data, *not* the NHSs. (This is in contrast to his previous position in which patients should not be given an opt out choice – Prospect Magazine, 2009 when his stance was “no one who uses a public service should be allowed to opt out of sharing their records. Nor can people rely on their record being anonymised”).

It’s an argument oft repeated that we should *own* our data, but somewhat meaningless if it took a campaign and public outcry to require an opt out mechanism, and put the programme on hold. I feel the language is being manipulated to create the impression we don’t already own or have rights to our health data. The opposite is true.  And many know that, just see the killer question below from Leicester. As long as records are held only at GP level, we will have much greater control and visibility of their use, than if shared centrally.

Many I have spoken with ask why it is not possible to leave data at local GP level for only clinical care, and extract nothing identifiable from hospitals without consent?

Other People’s Questions

In that vein, I summarise what 4 other people asked Mr. Kelsey and his panel in London about care.data on the day, and what I felt was missing from the answers to give balanced communications. The locations of about 80-100 people at each, were each allowed to put forward one question to the panel via web link, the question selected from all those discussed at the tables, by an organiser at the site. They covered Benefits / Data Uses / Confidentiality / Communications.

View them for yourself here, from 01:13.06 in the NHS Open House video:

Question selected to be asked from Basingstoke: “If people opt out of giving data will then the results not then be inaccurate?”

The larger volume of data, the better quality the data will be, the greater the benefits will be. Choosing not to opt out. That will, depending on the volume of that, affect data quality to a degree we won’t know that. Over time, once people’s concerns have been addressed, we hope that quality will improve.

Missing from the answer: [10] HES data is cleaned, SUS data is not, and both are known to have significant quality issues on validity and accuracy. The data has been extracted and stored for twenty plus years. Higher volume of data does not equate with a higher quality of data. You don’t make a better quality haystack, just by adding more hay. The volume of data is less important than it be representative of all parts of the population, but there is a risk that those opting out tend to be, as one GP has told me, ‘the white middle class and educated leaving others overly represented’. Only having more data is not a solution for quality.

*****

Question from Leicester: “Are we saying there will be only clinical use of the data – no marketing, no insurance, no profit making? This is our data.”

Panel: New legislation was brought in which made it very clear, data could only be released for the benefit for health and care, and it cannot be released solely for commercial purposes – yes, data can go to a private sector organisation, yes commercial companies, but only where they are working for the benefit of health and care, for example, Dr.Foster Intelligence, or other data information intermediaries who do a lot of work with data and who do a lot of work with the NHS to help inform decisions. Data will still be available to commercial companies. The other point, there is going to be independent scrutiny, which will be formalised within the law, to have independent scrutiny by the Confidentiality Advisory Group, which already exists which can independently scrutinise the releases.

Missing from the answer: care.data is not for clinical care. This indeed is our data and belongs to patients not NHS England, and should be respected as the NHS Constitution requires. Data continues to be released, and will continue to be so even under the Care Act legislation, to third parties in financial transactions. No recipient organisation by function (such as insurance) is excluded per se, rather recipients are judged based on their intended use of the data. The precise terms are open under the Act :

Care Act 2014****

Question from London: “How do you propose to reset expectations and perceptions, with any future communications, and  given that the way the first round was handled, provoked apparently such strong public resistance and suspicion about the NHS England motives?”

Panel spokesperson: We didn’t get it right the first time round, partly because we approached that at the National level. There was a leaflet that went out nationally. We will work with the 100-500 GP practices, and work co-produce materials in those areas and work with what is already there locally, GP practices, LMCs, PPGS, Healthwatch, using local knowledge, and patients so we can make sure everyone can understand, we understand how we can communicate this, what the concerns are, so we can get the message across, so everyone can understand what the choice is and what this is about.

Mr.Kelsey added: …[...]This isn’t about us and you, this is about us collectively. How do we ask patients and citizens for permission to use their personal information…we need to get that conversation right.”

Communications materials

Draft FAQs and information sheets to use in those conversations were on the table for participants information and to take away. The Data Uses page wording is interesting but poorly phrased, as it misled a couple on my table to think the ‘extraction’ was not identifiable. (see point 9 above). And the Benefits case study header is “How might it reduce variations in cancer treatment & care” but concludes that actually the Cancer Registry already does this, and they instead mean something similar would be useful for diabetes. This misuse of benefits makes me think, they’re finding it jolly difficult to find real ones. But if we all at these public meetings, believe the presented stories with the positive spin as fact, then fact they will become.

“And if all others accepted the lie which the Party imposed—if all records told the same tale—then the lie passed into history and became truth.” (George Orwell, 1984)

What next?

It is vital in my mind that care.data communications match reality of what needs done technically and in procedures, to drive expectations of what care.data will deliver and when. Why does an easy read brochure make no mention whatever of who data may be sold to? There is no mention of what organisations continue to receive HES and wider data. Instead it talks about data being shared to ‘know the health needs of everyone’ yet the very people who are outside the system are the ones whose needs we don’t know today – there is a huge amount  known from the rest of the existing patients’ needs from QOF and other GP data extractions, even that used in CPRD for research – purposes for which GP records under care.data are not approved.

The current doublespeak between the comms message and the reality are so far apart, between the technical possibility of what can be done well now, and what needs done to achieve the hoped for benefits, that the current message is setting up the project for failure and benefits will not be realised any time soon. It’s not ready to roll out through ‘improved communications’.

To be fair, the smaller workshop I attended on the 27th, flagged ‘still need to consider how best to engage here’ with many population groups. But it appears to me the Communications teams are effectively doing their best to package something which is not ready to be wrapped. To dot the i on the report, when the chapters aren’t in place yet.

“They were engaged in producing something called an Interim Report, but what it was that they were reporting on he had never definitely found out. It was something to do with the question of whether commas should be placed inside brackets, or outside..” [1984, George Orwell]

I’ve worked on both technical and change management/ communications teams [in another industry]. Project teams’ close working and each having an understanding of the other is vital. But the team members I have met so far, appear to work in silos, without enough linkage to know the functional gaps between them, in technical system, procedures and the link to change & comms. There is no way in my lay opinion, that a pilot of these half-formed knowns will be ready for autumn. For the NHS England leadership to continue to plug that it is, with messages of emotional manipulation of why more data is needed, will condemn care.data to Room 101.  A tortuous drawn out reformation of an existing concept. When really it needs planned afresh from the ground up to get the needs of the people it should serve designed into its consent, collection and communications processes – not added on as the ribbon at the end.

I was more optimistic about the benefits in the past, as long as the procedures around consent, governance and security were addressed. Having spoken with and listened to the needs and concerns of various charity representatives this week, at another smaller event, I am much less so.  Their complex needs, people who go in and out of different parts of the health and social care system at different times in their lives, with real concerns around confidentiality and risks have not begun to be addressed. Real issues for all of disclosure to GPs to ensure care may affect us all. But for many of their clients, they have needs which often carry huge trust and security issues which could put not only their medical care, but their faith in the charities and people working with them, in jeopardy.

I may be in a minority, but I’d rather have my factual understanding and ask hard questions than hear only a tailored communications message, if we are to get this right for our public good.
“Being in a minority, even in a minority of one, did not make you mad. There was truth and there was untruth, and if you clung to the truth even against the whole world, you were not mad.” (George Orwell, 1984)

I therefore asked the group at the end of the morning workshop, as Mr.Kelsey had done at the Open House event, how many of the attendees were really comfortable and confident that they knew what care.data was so that they could be a go-to point for questions, or even advocate for the programme as NHS England hoped.

Did they understand what data would be extracted, why and used by whom. About 1/6 raised  a hand. That’s *after* the event at the end of the morning spent discussing what issues exist for hard-to-reach, or as one attendee said ‘easy-to-ignore’ groups, and how communications channels will reach them.

One said he did not need to know all the facts to help be a comms channel. Another said he wouldn’t advocate for something he himself did not believe in. It was the first time we started to get genuine cross-group discussion, when in the meeting the table model had been employed again, but for those groups, disabilities, challenges, societal issues are not in silos.  Real debate, of hard issues is needed, and yes it’s awkward and might not be able to be ‘managed’ in the same way, but it’s real.

Our group identified a similar basic concept need across their client interests – a rolling consent model which allows opt in and out to change over time. Consent not only for what parts of planned uses the data would be used, but should also consider what parts of the record they are happy to share. Military, youth offenders, teens, the at-risk nature of these groups may mean they wish sections of their history to be restricted if not used for clinical care. And they may wish to share data when under the care of a GP but restrict it again, when under a military one. Or teens may be happy to permit data sharing at another time in their lives, but not permit access to their whole history. The DH Youth Offender expert raised the prickly issue of teen confidentiality and how will consent be gathered when parents may not tell them about the scheme at all, thinking there is ‘nothing to know’. We explained the concept of Gillick to the comms staff and that it’s not about an age of consent in the normal legal sense. What happens if a teen finds out their data has been extracted and wants it removed as teen or adult? We asked about name stored in the Personal Demographics Service and asked why data could not be deleted if clinician and patient both agreed a mistake had simply been made.

These complex and simple core questions need asked to get the whole thing built on a sound and trusted foundation. And they need to be in place for a pilot to make it worth having at all.

If the needs, concerns and understanding of the reps in the room can’t be addressed in a dedicated workshop, how will a remote campaign achieve it for the population at large?

Some at our table asked why the system needs  more data when you haven’t managed or used much of what we had in the past? I would also ask what progress is to be expected on unresolved quality and procedural issues with the current systems and data? Simply adding more hay to make a bigger haystack, does not make it easier to find a needle.

No wonder we can ask if it is really not just about commercial uses which comms don’t want to talk about, wonder why you never mention the data linkage service using PDS data [5] held and have concerns of overzealous surveillance by Big Brother.

There are risks becoming so heavily reliant on centralised data. Recently, patients have been wrongly deleted from GP lists, leaving them without a doctor through the cleaning firm’s administrative or process error.

Some are concerned that patients lose trust in their GP and withhold information. Others about this honey-pot of data for the individual citizen’s security. Professionals have voiced concern for GPs and consultants if factual misrepresentation  by statistics used for ‘ranking and spanking’ will adversely impact their decision making and make them more risk averse. In a negative way. Or with respect to waiting times and treatment, the heavy use of data in measurement creates a risk that it is misrepresenting the facts through lack of context or even, as in several high profile press cases recently, that such pressure is felt, that records are falsified.[12]

“And when memory failed and written records were falsified—when that happened, the claim of the Party to have improved the conditions of human life had got to be accepted, because there did not exist, and never again could exist, any standard against which it could be tested.”                                 (1984, George Orwell)

I’m concerned about all of the above. Perhaps holding care.data in room 101 until it is a manageable and explainable concept, backed up with technically and procedurally sound processes, would be the best place for it, for some time to come. Results and expectations create failure if they cannot marry up in reality.  This isn’t about communications. If you don’t really know what you’re communicating and can’t get it understood easily, then it’s back to the drawing board.

My concerns about care.data are heightened, not allayed by the NHS England apparent relentless rollout and focus on communications. Whilst they say in doublespeak it will take as long as it needs, there is talk of a Oct-Nov pilot launch. A pilot must test the finished model at small scale, not a less-than-half-ready one. Whilst the public push is all about finding the right communications, what is needed is fixing flaws in core concepts.

Doing without it, and waiting, would be better than doing it wrong.

*****

For part one of this post see here with ten learnings from event feedback >>care.data communications and core concepts [Part one]

UPDATE: 3rd July 2014 – If you want to give your views on proposals to introduce tighter controls and safeguards on the use of personal health and care data do so by 8th August to Room 2N12. https://www.gov.uk/government/consultations/protecting-personal-health-and-care-data

Or respond online here> http://consultations.dh.gov.uk/data-sharing/protecting-health-and-care-information

[links 1-8 reference Part One]

[1] The NHS England Open House recording June 17th http://www.nhsengland-openhouse.public-i.tv/core/portal/NHSopenhouse

[2] IPSOS Mori poll conducted for the Joseph Rowntree Foundation: http://www.ipsos-mori.com/Assets/Docs/Polls/jrrt-privacy-topline-nhs-2014.pdf

[3] My post on uses of our records with commercial Data Brokers – http://jenpersson.com/flagship-care-data-2-commercial-practice/

[4] The Information Governance Review ‘Caldicott 2‘ https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/192572/2900774_InfoGovernance_accv2.pdf

[5] The Personal demographics Service at HSCIC (including name) http://systems.hscic.gov.uk/demographics/pds/contents

[6] The Data Linkage Service at HSCIC http://www.hscic.gov.uk/dles

[7] The Partridge review: http://www.hscic.gov.uk/datareview

[8] Summary Care Record use statistics https://www.whatdotheyknow.com/request/scr_care_settings_with_viewing_c#incoming-446569

[9] Minutes of the November Health & Adult Social Care Select Committee in Chichester http://www2.westsussex.gov.uk/ds/cttee/hasc/hasc141113ucmins.pdf

[10] The Quality of Nationally Submitted Health and Social Care Data, England – 2013, Second annual report, Experimental statistics – http://www.hscic.gov.uk/catalogue/PUB11530

[11] My post on commercial use of data with brokers

[12] Falsified hospital waiting times: The Telegraph http://www.telegraph.co.uk/health/healthnews/10590713/One-in-four-hospitals-records-false-waiting-times.html

***

Sales of 1984 have rocketed since the Snowden story broke in 2013: http://www.latimes.com/books/jacketcopy/la-et-jc-nsa-surveillance-puts-george-orwells-1984-on-bestseller-lists-20130611-story.html

1127206-md

If at first you don’t succeed – try, try again. But think about changes first.

On June 24th 2014, it is the 700th anniversary of the Battle of Bannockburn, at which the Scots defeated the English, and their ruling King, Edward the second.

The legend of Robert the Bruce ahead of the battle, hiding out in a cave on the run after six defeats,  is renowned the world over. The Scot saw a spider building a web. Time and time again the spider would fall and then climb slowly back up to try again. After many attempts, the spider managed to begin to weave a web on the cave wall and achieved its aim. Robert the Bruce, so the story goes,  was inspired by the spider not to give up and went on to defeat the English at Bannockburn. The motto of the story is usually:

“If at first you don’t succeed – try, try again.”

Whilst perseverance is an admirable trait, stubborness may not be. Trying the exact same thing which failed previously, in precisely the same way, may be said to be either determined or foolish. Trying again, but incorporating learnings from the past failure with flexibility to incorporate learning-by-doing, seems an altogether smarter choice.  Modifications for improvement and changes in action and their execution based on lessons learned have a higher chance of success*.

“Bannockburn is arguably the most famous battle to be fought and won by the Scots in Scotland, but it is widely acknowledged to be more than that— it continues to conjure up ideas of freedom, independence, patriotism, heroism, perseverance, and triumph against overwhelming odds.” [Bannockburn Heritage Centre]

In projects, overwhelming odds against achieving success can be built-in from the beginning, through lack of foresight to plan how to measure it. If you don’t know how you will measure success, it is hard to know when it has been achieved and at what cost. To measure success, you first need to know tightly what are your defined project scope and purposes. This helps set the goals of what you want to achieve technically, its  human understanding and crucially, expectations of how and when success will be measured.

Steve Jobs is sometimes quoted:

“You can’t just ask customers what they want and then try to give that to them. By the time you get it built, they’ll want something new.”

Trying again isn’t always about trying the same model, rolling out the original communications plan louder, or slower, or just again, but about embracing changes and adding in flexibility for future change.  Change is not a single event, but a process, and any attempted project launch needs to be prepared to learn from the past but also to plan for the future, as that process occurs. The scope of the project however, must stay tightly controlled, or risks losing control of budget and achieving the project aims.

By being visionary about what will be needed in future and aiming to be ahead of the design specifications there is room left for learning-by-doing in the ‘how’ you want to achieve the project, but it can’t allow deviance to become an entirely different ‘what’ of project scope.

To try and meet a future goal, basing it only on present specifications and expectations, means it will be outdated and fail when you reach the future implementation date. By launch date, the design and functionality are already outdated and not fit for purpose.

To compensate for that, measurable bite-sized chunks of projects, can be a way of frequent checking in to see if you are still on track with the overall aims of what you want to achieve, whilst retaining the flexibility to adapt to the human aspects of progress, and how you will achieve it.

Measures of success therefore need to be taken frequently to stay on track, ensuring alignment with your defined project scope and purposes. ‘Checking in’ to see if you are still on the correct course. This helps set the goals of what you want to achieve technically, in human terms and on a timeline, which crucially sets expectations of how and when success will be seen to have been achieved.

Some of the success at Bannockburn was recorded at the time in poetry. More recently, the themes have been preserved in music.

If the Flower Of Scotland tribute to Robert the Bruce, the Scots’ ‘almost National Anthem’ at least in terms of sporting events, is not your thing, you might prefer Aaliyah’s rendition of the theme, Try Again. Though her wardrobe choices are slightly more surprising than the Corries.

The theme is the same. To think again, before trying again, is wise.

“Those days are past now
And in the past they must remain
But we can still rise now
And be the nation again
That stood against him
Proud Edward’s Army
And sent him homeward,
Tae think again.”

Flower of Scotland, the Corries, 1967

*****

For more recent celebrations see: http://www.visitscotland.com/

Photo credit: Dilip Barman via photo.net ‘ thistle near Bonar Bridge north of Inverness, Scotland.

*My lessons learned from experience of change management in  global projects rolling out SAP, 2001-2006.

3wisemonkeys

Hear no evil, see no evil, speak no evil – the impact of the Partridge Review on care.data

3wisemonkeysThe Partridge Review came out on Tuesday 17th and everyone should read it. But not just the summary. Both the full version and [1] summary are here.

So what is positive about these massive revelations? At long last it appears that the hands have come off the ears and the real issues are being listened to.

My summary: “NHS England cannot now put a hand over its eyes & hope care.data issues are only about communications.”

I feel somewhat relieved that the issues I have been concerned about for the last ten months, have now been officially recognised. Amongst them,  it has confirmed the utter lack of clear, publicly transparent and some quite basic, governance procedures.

It’s no surprise then, that our medical records, on at least two occasions in this sample 10% review of the releases, have gone to undocumented destinations. (Let’s ignore the fact of the other 90%!? of which we have no visibility yet).

At least eight insurers or re-insurers were in this 10% sample, so how many times did such companies get it, in the other 90% which has not been reviewed and we haven’t heard about? And how will ‘promotion of health’ purposes exclude them in future? In my opinion, it won’t. Why would an insurance company be excluded if it requests data in order to provide health care coverage? This is the wording of the Act, not ‘for the benefits of the NHS’ or any other more ‘friendly’ patient facing framing.

Care Act 2014At the NHS Open Day on Tuesday, the same day as the release, I believe [the video link was good but patchy and it was a passing reference] a panel spokesperson stated that commercial information intermediaries [2]  will continue to be approved recipients. Gah – why this is such a bad idea, I wrote about here. [3]

The Partridge review said there had been no complaints.  [4] MedConfidential pointed out an example of those of which they know. Kingsley Manning told the Health Select Committee [5] on 8th April, there had been seventeen opt outs of Hospital Episode Statistics, ever.  Fourteen in 2013 and three prior to 2013.

“Q377Chair: There is not an opt-out rate for care.data yet, presumably.

Kingsley Manning: No, not on that, but in terms of the number of people who have acted to opt out, it is 3 opt-outs up until April 2013 and a further 14 opt outs since 1 April 2013.”

Would I be wrong to suspect each was accompanied by a  complaint? You don’t usually opt out of something you are happy with.

The reason for these low numbers of both complaints and opt out in the wider public? WE DID NOT KNOW. The public didn’t know we had anything to be unhappy about. Many still do not.

As soon as I fully understood the commercial selling of my family’s patient records, this below is the query for advice / complaint I made in January to ICO, before the launch was postponed. I wanted some guidance from an outside body, because I was being told the law permitted this extraction, so what good would a further complaint to HSCIC do? I had already written to my MP and had a response from the Secretary of State / Department of Health (which told me patient identifiable data was not shared with third parties), as well as feedback to my concerns raised by email with HSCIC, all of which only tried to reassure me. I had no one to otherwise raise concerns with. The ICO advisor I spoke to told me at that time, that they had had many similar complaints.

I’ll be blunt and say now, especially since the Open Day [more on that later, especially on the content of care.data FAQs we received], I think it’s fair to say I am far better informed about care.data than most in the public. I’m not trying to be immodest, but when Mr. Kelsey asked for a show of hands, how many had heard of care.data, all put their hands up. Bearing in mind the rooms were full of highly involved people, NHS England staff, CCG and PPG leaders, and few ‘ordinary patients’ like me, and the agenda contained a section on care.data, it’s unsurprising we had heard of it. When Mr.Kelsey asked, “how many of you understand what it is?” the response was around 50%. I’d dispute also, that all of those 50% truly do.

Some of the comms material we were given is factually incorrect, for example, around research. Currently, GP held data planned for care.data extraction and its merger with HES, into Care Episode Statistics (CES), is approved for commissioning purposes but not for research by the GPES group. It’s not approved for research purposes, so its no good telling us how good it is to have it for the benefit of research. What has already been released for research, and continues to be so, is what was already extracted in the past, with or without consent, and informing patients.

I have spoken with several NHSE Communications people who genuinely asked me, or left me asking the question for them in my own mind, “If I don’t understand it, then how is the public expected to?”

The concerns I had now almost five months ago, seem vindicated by the report. The actions taken since, the loose wording of the Care Act 2014, and little evidence of intention to make any change which is binding i.e. the opt out is only granted at the whim of the Secretary of State, it’s not statutory and that there is no independent governance to be put in place , have done nothing to bolster my confidence these gaps have been filled. I paste below, the text I submitted as a complaint/request for guidance, not only to show I made one, for the record, but so as to lay out in simple terms, what I would still like to see addressed in a robust way or is missing entirely.

Simon Denegri, Chair of INVOLVE – the UK’s national advisory group on public involvement – and NIHR National Director for Public Participation and Engagement in Research, wrote a response on his blog [6]. I agree with the spirit of his post, and positivity, [he also writes excellent haiku] but where I disagree I outline below. There is room for positive hope for care.data, but first, let’s properly address the past.

“I am sure that many better informed people than I will pore over the detail. Others will use it to strengthen their case that we should put a stop to any manner of data sharing.”

Perhaps most key, I disagree with his fears the report could be used by ‘others.’ I don’t know anyone who wants to see a stop to ‘any manner’ of data sharing, including me. It’s the *how* and *why*  and *with whom*  that still needs work. Some of us may not want it without active consent, but that is part of the how, not if.  It’s not *any* manner that I object to, it’s *this* manner specifically.

I have read the Review in detail and whilst there is much positive in attitude in the Review, the reality of what difference this will make with any real bite, is hard to find.

For example, “The HSCIC will plan a new ‘data laboratory’ service which will protect the public’s information by allowing access to it in a safe environment with HSCIC managed networks and facilities.”  But this is with caveats, as it’s the “default,” Tim Kelsey said on Tuesday to the NHSE Open House. It does not mean *all* and if global third party intermediaries and business intelligence companies are still to receive data, then I can’t imagine the  global likes of IMS Health, or Experian, or Harvey Walsh will send someone along to Leeds every time they want to extract data. Who will  be given special permissions and how will they be decided and recorded, how will it be documented what data they access, if they get a free pass?

Unknown others have direct access to the HES system now through HDIS. Public Health should rightly use our health data, but a  transparent list of all approved organisations here too, would be a positive step.

Simon’s post continues,

“As you would expect from a previous Chair of INVOLVE, Nick Partridge, has secured fundamental changes in the governance of HSCIC and data releases going forward.  These include patients and the public sitting on the main committees reviewing data releases, open publication of data releases and a programme of ‘active communication’ with the public”.

Patients and public on the DAAG committee. If they are informed about data governance law and good practices, yes, if it’s just ‘representative’, not so useful. But DAAG is HSCIC staffed, and HSCIC has a legal and policy remit from the Department of Health and in its roadmap to distribute data, and will create ‘a vibrant market of data intermediaries’, as it would be wrong to exclude private companies simply on ideological grounds.  So the concept of ‘independent’ is flawed. Where are the teeth needed to reject an application, if it’s in the interest of the reviewing body, to accept it?

“It’s my view that the Partridge review, its recommendations, and the swift response from the Health and Social Care Information Centre (HSCIC), offers us the opportunity of a fresh start with the public on this issue.” [S.D.]

This could be used as an opportunity to brush the past aside and say time for a fresh start, but it can only be so if there is confidence of change. NHS England cannot now put a hand over its eyes and hope the issues go away or that it’s only about communications. The past needs fisking, issue by issue, to avoid they happen again. And the real risks need addressed, not glossed over. Why? Because let’s assume the public all thinks it’s fine, and none of us opt out. Then through these still flawed process holes, a huge data leak. The public loses trust all over again, and the opportunity for the care.data benefits is lost forever. Get it right now, and you build a trustworthy and seaworthy future, for the future public good.

There are other more detailed questions I would raise, [I previously worked in functional database design amongst other things] and I will believe these recommendations will have an effect, if and when I see the words become actions. The Review by PwC and Sir Nick Partridge is a positive listening and speaking exercise, but the plans must become reality with actions, some under legislation, in my view.

And perhaps the simplest, unspoken point seems to being deliberately ignored as if just not seen, unmentioned, except by data protection gurus [7]. There is legal obligation to provide information to citizens before their data is released, in a transparent way, to whom and for what purpose. What happened to Fair Processing? [8] Past and present?

Sir Kingsley Manning, Chair of HSCIC, asked in the Guardian on 22nd January [9] that we have ‘intelligent, grown up debate’ about data sharing. Well my hand is certainly off my mouth. I wrote a feature in my local paper and I’m still speaking to anyone I can to promote fact-based informed decision making.  But wider Public Debate is still sorely lacking [BBC Question Time anyone?] Through it, I’d like to encourage wider knowledge of the why, who and what of secondary purposes of data sharing and to ensure we can get it done transparently and safely.

Why?

To ensure we, as patients, continue to trust telling our GPs and hospital consultants all the information that we need to, and have no fear it will be held against us by an insurer or others. We need to trust we will not be penalised whether through disclosure, by stigma and exclusion from policy or care; or whether by opting out, we could be penalised for not participating and not get ‘advantages’ offered to others, just like store loyalty cards. We may think the insurance debate is irrelevant, if like me, we are not ‘self-payers’ or don’t use a private insurer. With a £30bn gap in planned budget and needed spend over the next five years, someone is still going to be paying for our healthcare. If it’s not the State, then who? The risk more of us will pay for our own care in future is real. If not for us, for our kids, and their privacy will be a whole different ball game if genomics gets involved.

Meanwhile, we are told for care.data identifiable personal data is crucial for patient safety tracking. In my opinion, patient safety will be harmed if confidence in confidentiality fails. The relationship between clinician and patient will be harmed. And no number of Dr. Foster Intelligence reports by tracking quality or safety, will be able to fix those failures which it has helped create.

Perhaps most tellingly, NHS England is still to make a statement on the Review. There is no news yet here.

It still seems to me the NHS England leadership and its data sharing policy carried out through IC past and present, wants to continue without grown up debate under the PR motto ‘it’s all going jolly well’, and to act with the attitude of a teenager, who with a shrug of the shoulders will tell you:

‘It’s easier to ask for forgiveness than permission.’

***********

January 25th, 2014 – my ICO complaint / guidance request

{abbreviated only to show  issues I feel still need addressed}

Dear ICO
I would like to ask for your urgent advice.

I am a mother of X children under 12. [...] Our confidential patient data is being extracted via care.data to the HSCIC. Until my recent research to understand what this was all about, I did not know that HSCIC stored all our patient confidential health data from all sorts of health providers: Hospitals, Mental Health, National Child Measurement Programme, [10] Immunisations and Health visitors.

I have not knowingly given my permission for our data to be stored or transmitted to or from HSCIC in any format in the past. If by signing a consent form for treatment I also signed consent for sharing with this central body, it was without my knowledge and therefore without informed consent.

I have significant concerns over its use, now that I understand how widely our patient data may be used and now even shared abroad. [11] [...]

There is no public information on :

1. How long our data will be stored for  – data retention and data deletion and cross border governance
2. There is no opportunity for health record deletion of anything which was simply a mistake i.e.: recorded on the wrong record, or a misinformed opinion on lifestyle entered by the GP, not fact
3. How will future governance be assured that it will not be slackened to allow less strict pseudonymisation, and identifiable releases; for example to US firms who establish themselves in the NHS England healthcare market?

I do not believe that the legal rights created through the Health and Social Care Act are sufficient justification to overrule the Common Law of Confidentiality, and the Data Protection Act 1998. [And the data shared before 2012 was not covered by the Act which did not exist and was not retrospective.] Even if the dissent codes are applied, patient data has been or will be extracted to the HSCIC (without my permission) and it will contain identifiable items such as clinician name, practice and CCG locations, and referral dates which may be used as identifiers to connect with HES data stored at HSCIC – since HSCIC also holds data in the Personal Demographics Service [PDS], [12] I believe they may also link the data [13] then to my personal demographic identifiers. Just an undefined or internal  governance procedure to suggest that they would not, when it is technically possible, is not sufficient oversight. [...]

I do not consent for the use of our [hospital HES or other] data in health research – because it has not been explained to me, what that term means and the implications of this assumed consent.

I cannot know what the other future uses will be for our health information stored today. I do not feel that I can apply any fair processing to their health records due to the lack of publicly available information and scope of the full uses of their data today and in future. [...]

Sincerely,
Jen Persson
XXXXXXX

———————————

[1] The Partridge Review Summary and Full report http://www.hscic.gov.uk/datareview

[2] On selling data to Intermediaries and the governance which permits it  https://medconfidential.org/category/press-releases/

[3] Commercial users of NHS patient data - third party use – my blog http://jenpersson.com/flagship-care-data-2-commercial-practice/

[4] Complaints and why confidence needs restored https://medconfidential.org/2014/press-release-partridge-review-patients-need-proof-to-restore-confidence/

[5] Health Select Committee 8th April 2014 http://data.parliament.uk/writtenevidence/committeeevidence.svc/evidencedocument/health-committee/handling-of-nhs-patient-data/oral/8416.html

[6] Simon Denegri’s blog response to the Partridge Review http://simondenegri.com/2014/06/17/partridge-reviews-elegant-demolition-of-past-practice-on-personal-data-offers-opportunity-for-fresh-start-with-the-public/

[7] Information Rights and Wrongs - Jon Baines’ blog http://informationrightsandwrongs.com/2014/06/18/the-partridge-review-reveals-apparently-huge-data-protection-breaches/

[8] ICO Processing Data Fairly and Lawfully http://ico.org.uk/for_organisations/data_protection/the_guide/principle_1

[9] The Guardian, January 22nd 2014 ‘Lack of Debate on the Sale of Patient Information‘ http://www.theguardian.com/society/2014/jan/22/debate-sale-patient-information?CMP=twt_gu

[10] National Child Measurement Programme data managed by HSCIC http://www.hscic.gov.uk/ncmp

[11] Data use in the USA Memorandum between DH, HSCIC and the US  Dept of Health and Human Services to include exploring secondary stores http://www.healthit.gov/sites/default/files/hhsnhs_mou_final_jan_21.pdf

[12] Personal Demographics Service http://systems.hscic.gov.uk/demographics/pds/contents data already stored at HSCIC

[13] Data Linkage Service at HSCIC to manage the requests for data which is stored in different silos and brought together on request http://www.hscic.gov.uk/dles

Image courtesy of an interesting post on the history of the featured monkeys: http://frontiersofzoology.blogspot.co.uk/2013/04/why-are-three-wise-monkeys-usually-apes.html

Suarez, Sweets and Foreign customs

When England play Uruguay this week,they might be hoping the Southern American team’s secret weapon may have been taken away.

Not one of the world’s best players whom we know from playing at Liverpool, Suarez, but the team supply of dulche de leche, as the BBC reported:

Brazilian officials say they confiscated 39kg (86lb) of caramel spread from Uruguay’s football team as it arrived in Brazil for the World Cup.”dulce de tres leche - 3 milk dessert

I first discovered dulche de leche when a friend in South America brought me back two jars. She was a very good friend.

It’s a caramelized milk product, made by mixing milk with sugar, baking powder and vanilla extract. has the consistency of a thick sticky nutella and is found in many desserts and pastries from the region.

At the time, I ran a cupcake company and so the Dulche de Leche based, Salted Caramel cupcake was born.

But nothing has ever tasted as good as the Torta de Tres Leches I had in Santiago in 2013. So good, it was worthy of the photo above. Mind blowingly sweet, but with a saltiness and lighter-than candy floss sponge, it is a blend of taste and consistency I’ve never had before or since. I can recommend making your own.

I doubt the footballers have time for cake though, so I do wonder what they used it for? Breakfast spread? I should think their diet regimes are planned to the nth degree based on nutritional values.

Answers on a postcard please…

*******

Ten recipes using the South American speciality.

Mum on Fire – my blog