NELA+ stands for National Emergency Laparotomy Audit. NELA+ is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit Programme on behalf of NHS England and the Welsh Government. A clinical audit like NELA+ is undertaken by an independent body to assess the quality of care in hospitals by looking at how it treats its patients and the outcomes of those patients. NELA+ is a national clinical audit, so that means it is being carried out in over 180 hospitals in England, Wales, and Northern Ireland. NELA+ will look at the quality of care received by patients undergoing, or considered for, emergency laparotomy.

An emergency laparotomy is a major operation where the surgeon has to cut open the abdomen (stomach area). It is called "emergency" because it must be done very soon or even immediately and cannot wait until a later date. It might be carried out for several reasons including internal bleeding, perforation (burst), obstruction (a blockage) or infection. In many cases it might be the only option available in order for the patient to get better.

NoLap is the term used when a decision is made not to perform emergency abdominal surgery.

It applies to patients who come into hospital very unwell with a serious problem in their abdomen (tummy). In many of these situations, clinicians would usually consider an emergency operation (called an emergency laparotomy).

However, after careful assessment and discussion, the team may decide that surgery is not the best option. This might be due to the person’s individual wishes. It could also be because the health conditions they have make the operation too risky, or because the underlying problem is too severe. In this situation the decision not to operate is called a NoLap decision.

A NoLap decision does not mean that care stops. Instead, the focus shifts to providing the most appropriate treatment and support for the individual, which may include medical treatment, symptom relief, and care focused on patient’s wishes.

All hospitals in England, Wales, and Northern Ireland that carry out emergency laparotomy are expected to participate in this audit. We want to improve the care that patients undergoing emergency surgery receive. To do this, we will collect important information on how well your hospital is providing care to you. We will then give hospitals all the valuable information we have obtained. This will highlight areas of their service where they are doing well, and areas in which they can improve. It will also allow hospitals to compare themselves with others all around the country.

We collect information about the care patients receive whilst in hospital. This includes information about the investigations and treatments received, how long it took for different parts of treatment to be given, and whether a patient went to a critical care bed. In England and Wales, the personal information we collect is name, date of birth, NHS number, postcode and sex. This information is not provided by hospitals in Northern Ireland.
NELA+ patient data is submitted directly to NELA+ by clinical teams treating the patient or from the hospital records.

NELA+ will not publish information that can enable individual patients to be identified.

By collecting and sharing this information, we are able to highlight areas where hospitals are doing well, and areas in which they can improve the quality of care for patients so that they can put plans in place to achieve this. It will also allow hospitals to compare themselves with others in England, Wales, and Northern Ireland and in doing so improve the quality of care by sharing examples of good practice.

You can find further information about the information we collect and how we use it in our privacy notice.

The patient information received and managed by the NELA+ team is treated as confidential. The information is only available to the NELA+ team in a pseudonymised format, which means that individual patients can only be identified by a computer-generated sequence of numbers. This data will be retained for the duration of the audit and 5 years after it is completed.

We maintain the confidentiality and security of patient information in the following ways:
• All reports are produced at an aggregate level (national, regional, hospital).
• In each audit publication, the statistical information is reviewed to ensure the risk of identification is minimised, and where necessary, small numbers are suppressed. This assessment follows guidelines issued by the Office for National Statistics.

The NELA+ team are based at the Royal College of Anaesthetists (RCoA) and the Royal College of Surgeons of England (RCS). Both the RCoA and RCS conform to the General Data Protection Regulation (GDPR) and other legislation that relates to the collection and use of patient data, and have strict security measures in place to safeguard patient information. NELA+ stores the pseudonymised patient data on a secure computer to which only authorised audit team members have access. The IT system has various levels of security built into it, including:

• ID password security: the data is stored on a password protected system, which prevents unauthorised users gaining access.
• The stored data files are encrypted.

NELA+ only shares patient-level data following a strict governance procedure to ensure compliance with the General Data Protection Regulation (GDPR).

• NELA+ has permission to link patient-level data with other national databases on a case-by-case basis. NELA+ holds a current Data Sharing Agreement with:

  • NHS England for English hospital data (Hospital Episode Statistics

  • Office for National Statistics (ONS) for information on deaths

  • National Wales Informatics Service (NWIS) for the Welsh hospital data (Patient Episode Database for Wales - PEDW)

  • Intensive Care National Audit & Research Centre (ICNARC) for critical care data

  • National Bowel Cancer Audit (NBOCA) to share data on those patients in NELA+ who also have a bowel cancer diagnosis

Linkage with HES and PEDW data enables NELA to compare the number of records submitted to NELA+ with the number recorded retrospectively in HES/PEDW to ensure high data quality. This linkage also enables analyses on things like longer-term outcomes like hospital readmissions, and examination of patient comorbidities. Linking with ONS data allows NELA+ to report mortality rates in the first 30 days after patients are admitted to hospital.

Researchers may apply to NELA+'s Data Controller - the Healthcare Quality Improvement Partnership (HQIP) - for access to NELA+ data. These requests undergo a stringent approvals process as outlined here.

For more information on data sharing for uses outside of the NELA+ programme, please see here.

As funders and commissioners of NELA+, NHS England, Digital Health and Care Wales, and HQIP are the joint data controllers for the patient data submitted to the audit i.e. they are the organisations in control of processing the data.

Under UK GDPR the following legal bases apply: processing is necessary for the performance of a task carried out in the public interest or in the exercise of official authority vested in the controller (Article 6 (1) (e) and Article 9 (2)(i) processing is necessary for reasons of public interest in the area of public health, such as protecting against serious cross-border threats to health or ensuring high standards of quality and safety of health care and of medicinal products or medical devices, on the basis of Union or Member State law which provides for suitable and specific measures to safeguard the rights and freedoms of the data subject, in particular professional secrecy. The lawful basis according to the Data Protection Act Schedule 1 is Condition 3 (public health).

Under the Common Law Duty of Confidentiality (CLDC), NELA uses Section 251 as its legal basis to meet the CLDC.

NELA+ currently has approval under Section 251 to collect patient level data (reference number: CAG 5-07(d)/2013) for all emergency laparotomy patients admitted to hospital as well as for patients indicated for emergency laparotomy but who do not undergo the procedure.

Click here for more information on Section 251.

The rationale for this is that as many of these patients are extremely unwell before and after they have had an emergency laparotomy or are considered for an emergency laparotomy, it would not be feasible to ask all patients for their consent.

 In Northern Ireland, Section 251 does not apply hence why data is pseudonymised and matched locally.

The RCoA takes the security of your data seriously. In order to prevent unauthorised access or disclosure, we have put in place suitable physical, electronic and managerial procedures to safeguard and secure the information we collect online.

Local clinical teams enter patient data into a secure web-based tool provided by Crown Informatics. Only the hospitals participating via the doctors, nurses and clinical audit staff and the NELA+ project team will have access to the web-based tool. Security and confidentiality is maintained through the use of passwords and a person-specific registration process.

Occasionally, the NELA+ is asked to support medical research to improve surgical care. Researchers make these requests directly to HQIP who will then contact NELA+ after the application has been reviewed to ensure it is in the public interest. More information on this process can be found at the:

HQIP Website

In supporting medical research, we take care to ensure there are appropriate safeguards in place to protect patient confidentiality and ensure the data are used securely.

Because some patients are very sick before and after they have had an emergency laparotomy, it would be very hard to ask all patients for their consent. It is important that we get information from all patients, not just those that are well enough to give consent. That's how we can provide an accurate overview of quality. It can be a distressing time for patients and their families, and asking them about this project at this time would not be their most important priority.

In 2018, the NHS decided that people should have the right to 'opt out' of having their data included in such audits. However, the National Emergency Laparotomy Audit is exempt from this - losing even a small number of cases could provide the wrong picture about a hospital's performance. The national data opt-out is broad legislation that allows you to remove consent from having your data used for a variety of planning and research purposes. You can find out more here: https://digital.nhs.uk/services/national-data-opt-out

NELA+ have created a leaflet to further explain the national data opt-out.

 Please note that this does not apply to service users in Northern Ireland.

If you have a specific objection to having your data included in NELA+, you can still withdraw your information from NELA+. Send an email to NELA@rcoa.ac.uk and put 'patient request to opt-out' in the subject line or call the NELA team at 0207 092 1580. We will then contact your hospital to request that they do not enter your details into the audit. If your data has already been collected, we may be able to delete it if it has not already been used for audit analyses.