Knowledge Matters Volume 8 Issue 1

Volume 8 Issue 1 April 2014 Welcome to Knowledge Matters I hope that you all had a jolly lovely Easter holidays. I was going to tie into the whole Easter and re-birth theme, but of course that was all last year—we are now one year on from the big changes that the Health and Social Care Act wrought upon us. Now is a good time to reflect upon that year.

Many new organisations were created, and had to adapt to the changes in the NHS environment. Many rose to the challenge and have made great successes out of their lot, but there were some high profile failures too, proving that this was never going to be an easy ride. There are plenty of people and organisations out there still who stuck their heads in the sand and carried on with business as usual. This may work well on the shop floor, as it were, where clinicians meet patients, but behind the scenes in the worlds of commissioning, innovation, service redesign and the myriad other back-room functions change is constant and adaptation to that change is the only way to survive.

This year we need to consolidate and exploit what went well, and learn from our own (and others’) mistakes, so that we can all carry on to a bright and prosperous future, which if we’re lucky may even include shiny new offices.

This edition of Knowledge Matters contains articles on where you can find cancer data, online learning, and the launch of the new Safety Thermometer webtool. Samantha shares her insights on the Staff Friends and Family tool and the Inpatient Survey. Plus all the regular features.

If you’ve got something to share and would like to have a page in a future edition of Knowledge Matters then let us know. We’re always looking for new voices and fresh ideas.

Inside This Issue : Online Learning

2

Accessing Cancer Data and Information

6

News

12

Safety Thermometer Webtool

3

Update from The World of Insight

8

QO @ The Expo

13

Skills Builder

4

Ask An Analyst—Highlighting bar charts

10

The Easter Crossword

14

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Learning online

By Kate Cheema, Specialist Analyst There’s so much out there to learn, and with more and more universities making their course material available free through the phenomenon of the MOOC (massively open online course), you can cover subjects as diverse as the fundamentals of public speaking to the diversity of exoplanets. But where can you get free, online courses relevant to health data and information?

Whilst there are some excellent pieces about data handling and analysis in general (check out Johns Hopkins offerings on everything from getting and cleaning data to advanced analysis in R) there is very little, if anything, available specifically applicable to healthcare in the UK. Even less available are e-learning tools that can be used to help the non-analyst utilise and interpret data effectively.

Sensing a need here at QO Towers we are in the process of developing a suite of e-learning modules to help non-analytical folk get to grips with the key bits of data that they may need to understand, in order to get the best out of the pile of information that is available to them. We already have a couple available which support the NHS Safety Thermometer. These focus on the key analyses used with this data set (run charts, funnel plots and pareto charts) and steps the user through the main characteristics of each type of analysis and how to use it for improvement. Check it out at http://www.seqo.nhs.uk/ elearning/NHSST_Analytics/story.html You may think that this kind of thing could be delivered through a quick powerpoint presentation but what makes a good e-learning module different is the addition of interactive elements and a variety of media. We try to add lots of ways for the learner to explore the topic in their own time and at their own pace. Occasionally you might hear the dulcet tones of one of the QO team explaining things in more depth, but this is a long way from simply being an on-line presentation. Learners are asked quiz questions to check their knowledge and encouraged to explore pictures and videos to help develop their own understanding.

Finally we have to acknowledge that not everyone wants to sit in front of their computer (especially if they've been sitting in front of one all day) and that the train or bus ride home can often be the most convenient time to do a spot of learning. So we have ensured that our e-learning modules can be made available offline on phones and tablet devices.

As we develop our e-learning portfolio we’d be interested to hear from you what you might like to see made available as an e-learning opportunity. Perhaps you’d like an accessible tutorial on interpreting mortality statistics, or a primer on the difference between length of stay and bed days?

Drop us a line at info@qualityobservatory.nhs.uk to find out more.

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3

Safety Thermometer Webtool

By Kate Cheema, Kiran Cheema and Neil Wilkinson It’s been a labour of love and occasional frustration but through hard work and a dedicated delivery team the NHS Safety Thermometer ‘Classic’ webtool has finally been launched. Many of you will be familiar with the site as we already publish some of the public analysis through it and it’s been the home of the Medication Safety Thermometer data collection throughout the testing phase.

But now you can use the site as an alternative data collection mechanism of the ‘Classic’ tool.

You can use the webtool to collect your data over a broadband, wifi or 3G connection and then export it, load it into your local FrontLine Safety Thermometer and submit it to the HSCIC in the usual way. The data input form is the same as the classic Excel based tool so you won’t need to learn any new data entry methods.

Full details and step by step training can be found on the site. To get your organisation set up and ready to go, please send a request to info.safetythermometer@nhs.net Following some useful feedback from trusts, we’ve also added some ward level analytics which include all the usual plots but for individual wards and teams within the context of their organisation.

Alongside this, as mentioned on page 4, we’ve added some e-learning to help you make the most of the analysis available on the website; check out the ‘classic’ analysis menu for more.

We really value your feedback and ideas. We’ve got a list of future developments but we want this webtool to be as much yours as ours so please get in touch via the forums to tell us your views and what would be useful for you. If you don’t tell us what you want, we can’t develop it!

Equally, as with any newborn there will be teething problems (and sleepless nights!) so please alert us to any bugs you find in the system.

As with any delivery it takes a team of people to make it go smoothly and it’s been a real team effort with colleagues from the Quality Observatory, Haelo, the HSCIC and our tester organisations. So thanks for the hard work of all concerned and apologies for all the birthing puns! (Just wait for the launch of the Maternity ST webtool).

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Using Statistical Process Control for rare events Statistical process control; how it warms our hearts to think of such a simple approach to understanding our variation and how to respond to it. But not all our data works well with typical SPC approaches and we can run the risk of reaching incorrect conclusions, especially when: • • •

More than 25% of our data points are at zero We have a very low incidence of an event We have a very small sample size Look at this chart as an example; 72% of the data points are at zero which indicates that (in this case) it can be many months between an event happening. This means that it is very hard to detect a statistically valid change. An example might be MRSA counts, where some trusts only record 2 or 3 infections per year. Never events is also an example of where, if you monitored monthly you would end up with a very spikey looking chart! This isn’t quite the same as having very low incidence rate of an event; an event may happen on a fairly regular basis but as a proportion relative to the possible volume of events be very small. A good example of this is medication error; errors may occur fairly regularly on any given ward or unit, but against a backdrop of thousands of doses being given out correctly, the relative proportion of errors is very small. This makes

change hard to detect.

Small sample sizes can often be a problem too, particularly if you are looking at a relatively small group of patients. For example, if you were looking at improving the patient experience of people with lysosomal storage disorders (which has an incidence rate of between 1 in 5,000 and 1 in 10,000) you would be surveying a very small number of patients on a monthly or even quarterly basis. The smaller the sample size, the harder it is to detect statistically significant change. Another example might be detecting the proportion of patients with a pressure ulcer in a small nursing home.

It might be tempting to think that you could just aggregate the data and plot that instead, taking a year’s worth of MRSA data and plotting the results on an annual basis. But this would limit your ability to detect any change in year. An alternative approach would be to use a rare event SPC chart.

There are two options, and which one you choose depends on what data you have available to you: •

Opportunities between events (using a g-chart) •

Time between events (using a t-chart)

Conceptually, the t-chart is probably easier to understand and is often the easier data set to gather. Rather than plotting the proportion, count or average (whatever your measure might be) on a timescale, you plot the time between each event occurring. For example, you could

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5 plot the number of days between an MRSA infection occurring. Then, rather than a spiky looking chart you get something much easier to interpret against the control limits.

The opportunities between chart can be more difficult to grasp, but essentially instead of counting the time between each event you are counting the number of opportunities there were for the event to happen between each occurrence. Think about wrong side surgery; every time surgery is carried out on a kidney, hip, arm, leg, eye etc. there is an opportunity for the surgeon to do it on the wrong side. There may be 1,000 surgeries carried out before a wrong side surgery occurs and then 1,500 before the next.

Thus we have had 1,500 opportunities between the two wrong side surgeries.

Medication error is another excellent candidate for examining opportunities between.

The charts themselves are structured in a similar way to any other SPC chart, with a centre line and upper and lower control limits, and interpreted accordingly. These are calculated using quite complex formula (see below for your edification) but most SPC software can apply this without having to worry about the detail. You can see an excellent example from the ‘Health Care Data Guide’ here which shows the number of doses dispensed between adverse drug events.

Initially there is between 2,000 and 6,000 doses between each event, but the chart clearly shows this increase to upward of 12,000 and indicates special cause suggesting that there has been an improvement in adverse drug events.

Rare event handling using SPC can be a little complicated but very useful. It is worth noting that some commentators have argued against the need for the use of rare event approaches. A paper by Donald Wheeler is referenced below which expands some of the arguments.

If you’d like to learn a bit more about rare event approaches in improvement check out the e-learning module at http://www.seqo.nhs.uk/elearning/Rare_event/ story.html or get in touch with us at the usual address. We offer SPC training and can cover rare event methods too!

References: Provost L and Murray, S. (2011), The Health Care Data Guide: Learning from Data for Improvement, Jossey-Bass, San Francisco Wheeler, D (2011), Working with rare events: what happens when the average count gets very small?, Quality Digest Daily.

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Accessing Cancer Data and Information

By Rebecca Matthews, Analyst At first glance, cancer data can be tricky to find and access. A lot of it is held by the various cancer registries, data is split between primary and secondary care, hospital cancer data is often in its own separate information system and it’s highly sensitive data, so if you find the data you want there’s no guarantee you’ll be given access to it.

However there’s a lot of data out there, and even a lot of data that is publically available. The sections below should provide a brief overview of what there is.

The cancer landscape When starting any analysis around cancer, the first question you may need to answer is what’s the current landscape like? What’s the prevalence and incidence of cancer in a particular area? The NCIN (National Cancer Intelligence Network) has provided some useful overviews for this and their Cancer e-Atlas www.ncin.org.uk/ cancer_information_tools/eatlas/ default.aspx has a snapshot of the latest incidence data by tumour type compared to the national average. Note this is currently only shown at PCT level, but will be available at CCG and SCN levels once data becomes available. Cancer Research UK also publishes data on incidence and risk factors: http://www.cancerresearchuk.org/cancer-info/cancerstats/ The Office of National Statistics (ONS) publish registrations data for the whole of England www.ons.gov.uk/ ons/rel/vsob1/cancer-statistics-registrations--england--series-mb1- /index.html and if you need to look at cancer prevalence down to CCG or even practice level, then the annual QOF data, published by the HSCIC, includes this information: http://www.hscic.gov.uk/catalogue/PUB12262 The QOF prevalence data can also be accessed via the Cancer Commissioning Toolkit https:// www.cancertoolkit.co.uk/. The CCT is a repository for a wide range of cancer statistics and information including General Practice profiles which compare a practice to their CCG and England across a huge range of indicators covering demographics, screening, waiting times, presentations and diagnostics. The CCT also contains more in depth analysis for provider data and particular service areas. Much of the data in the CCT is publically available, but NHS users can apply for a user account to access the full range of available data within the toolkit.

You could also look at information which might indicate a higher risk of cancer in a particular area e.g. lifestyle indicators (smoking, obesity), age of resident population and deprivation. A lot of this will also be included in the CCT and can also be found on the ONS website, in the Public Health Outcomes Framework on the HSCIC website and in numerous other places.

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7 Diagnosis – how and when When looking at how and when patients have received their cancer diagnosis, you can look at the CCT again which will have data around the number of patients diagnosed via emergency or managed presentations. The NCIN have also published an updated Routes to Diagnosis workbook which looks at the proportion of diagnoses through different routes. Four tumour groups within this (breast, colorectal, lung and prostate) have also been provided down to CCG level – the latest data currently available is 2006-2010: http://www.ncin.org.uk/publications/routes_to_diagnosis The CCT also publish, as part of the service profiles, some data around the stage of cancer at diagnosis – currently only available for lung cancer and at provider level. Staging data is also included in the new Cancer Outcomes and Services Dataset, but this has only just started being collected so no data is available from this yet. More information can be found on the NCIN website: http://www.ncin.org.uk/ collecting_and_using_data/data_collection/cosd If you want more information from the national cancer screening programmes (breast, cervical and bowel) then annual data for breast and cervical is published by the HSCIC. There is less data easily available for bowel screening, but some data is included in the practice profiles in the Cancer Commissioning Toolkit.

Treatment Waiting times for cancer treatment has been a performance target for several years, so there is a lot of information around this. Data is published quarterly by NHS England http:// www.england.nhs.uk/statistics/statistical-work-areas/ cancer-waiting-times/ and monthly performance reports are available if you have a log-in to the national Cancer Waiting Times database.

As cancer treatment generally involves a hospital stay or an outpatient appointment at least, information on these will be available via SUS or HES in the same way as any other hospital activity. You’ll need to identify the relevant diagnosis codes/speciality codes and then can use these to look at treatment for patients with cancer (admissions, length of stay and any other measures that may be of interest).

Outcomes Unfortunately the main outcomes measures with cancer patients are mortality and survival. Information on these is also available in the CCT practice profiles, with more detailed analysis of ONS data being provided in the indicator portal section of the HSCIC website: https://indicators.ic.nhs.uk/webview/. Data at local authority and county level can also be found in the Public Health Outcomes Framework. The NCIN e-Atlas and Cancer Research UK website (mentioned above) also include mortality data.

This is just an overview of the most easily accessible information around cancer, and there will be other information available.

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Update from the world of Insight

By Samantha Riley, Director of Insight, NHS England

Hello again Knowledge Matters readers! As ever lots has happened since the last edition was published. Firstly, NHS England published the national guidance for the Friends and Family Test for staff.

From 1st April 2014, all NHS trusts providing acute, community, ambulance and mental health services in England are required to implement the FFT for staff. The first set of results for staff FFT need to be reported to NHS England in July 2014 and will be published in August 2014.

We received quite a number of very helpful responses as a result of sharing draft guidance with the service before Christmas and carefully reviewed and considered all of the comments prior to publishing the final guidance. For the first year, we decided to take a flexible approach to how trusts implement staff FFT because we want it to be an improvement tool that works locally. We will be reviewing staff FFT after the first year of implementation to understand which approaches have worked most effectively in terms of giving staff a voice and driving improvements for both staff and patients. Key points to note in terms of requirements for staff FFT are as follows: Staff FFT data is to be collected and reported quarterly for Q1, Q2 and Q4 after the end of each quarter. For Q3 (when the staff survey is undertaken) there is no requirement to undertake staff FFT, although trusts may wish to do so; A sample of staff should have the opportunity to respond to FFT in each of the three quarters, and all staff should be included once per year, as a minimum requirement. Trusts may decide to provide all staff with the opportunity to respond each quarter if they so wish; Staff have the opportunity to respond to two questions with a free text comment provided after each question: One about the care provided by the organisation A second about the organisation as a place to work Organisations may choose to implement their Staff FFT confidentially or anonymously, but they are required to inform staff how their data will be used and honour any statements they make. When carrying out staff FFT, trusts will need to ensure that they comply with the Data Protection Act 1998, and the NHS Code of Practice on Confidentiality (2003); Recommendation that organisations collect equality and diversity data. This data is for local use and not reported nationally; Local organisations have flexibility in which additional information they collect to categorise responses e.g. staff grouping or site. This data is for local use and not reported nationally; Response options mirror that of the patient FFT (“extremely likely” to “extremely unlikely” with a “don’t know” option); Ability for provider organisations to choose the method of collecting the data (as per patient FFT); A lot of feedback has been received on how results should be published. We feel that we need to undertake further work to understand the best format for publishing staff FFT data and will provide details on this prior to the first publication.

Here’s the link to the guidance http://www.england.nhs.uk/wp-content/uploads/2014/02/staff-fft-guide.pdf If you have any queries please email england.staff.friendsandfamilytest@nhs.net

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On 8th April, the 2013 Inpatient Survey results were published.

This publication marked the eleventh survey of adult inpatient services in England in the National Patient Survey Programme.

Similar surveys were carried out in 2002 and from 2004 to 2012. Over 62,000 patients from 156 acute and specialist trusts took part in the survey, a response rate of 49%.

So, what do the results tell us? Well, the general trend has been a positive improvement in the national results for individual questions, however in several areas there has been no significant change from 2012. In some cases, while there have been improvements in the most positive responses, this represents a shift from good or average responses to very good, rather than moves away from the poorest response categories. For example, the proportion of respondents feeling that they ‘always’ got enough emotional support from hospital staff has increased, due to a reduction in the proportion of patients reporting ‘sometimes’ as opposed to ‘no’.

Key aspects of experience that have shown improvement from 2012 to 2013 are information provision, communication and cleanliness. Key areas where the survey results indicate opportunities for further improvement are around discharge and medication:

While 54% of patients reported ‘definitely’ feeling involved in decisions about discharge, a large proportion of patients (46%) did not feel this way (response options “yes, to some extent”, “no”); 42% of patients who felt that they needed an explanation about medication side effects were not given one

The results also indicate a small increase in the proportion of patients sharing a sleeping area with those of the opposite sex when first admitted to a ward. Additional CQC analysis shows that there has been a significant increase in elective patients reporting this way, but not those admitted as an emergency.

The single question showing the greatest improvement relates to whether patients were asked to give their views on the quality of care during their stay, with an increase of 7 percentage points from 2012 to 2013 (up from 14% to 21%). However, this result indicates that almost 8 out of 10 (79%) patients’ views were not sought.

As always, it is of course important to look at the detailed data from the survey. I would encourage you to go and have a look at the CQC website which contains a wealth of reports and information http://www.cqc.org.uk/public/reports-surveysand-reviews/surveys/inpatient-survey-2013 This is of course the first year that we have had the Friends and Family Test operating alongside the Inpatient Survey – I would be interested to hear from any trusts who have undertaken analysis to look at the relationship between the two. I would love to hear from you! samanthariley@nhs.net

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Highlight Specific Areas in Bar Charts Application: Excel 120%

I’ve made a chart showing all England provider data from lowest to highest. However it is difficult to distinguish those organisations that are relevant to my area?

How could I do this?

100%

80%

Score

60%

Lower Quintile Upper Quintile 40%

Alex—Surrey & Sussex Area Team 20%

0%

Solution: Complexity 2/5 — Highlighting Data on Bar Charts You’ve already sorted the data and added in upper and lower quintiles, which is great as that’s already a good basis to give you some extra contextual detail. As it stands your chart does tell us something, but you’re right, if you want to look at the providers in your region it’s not that easy to pick them out.

The obvious solution to this is to label the x-axis. You may have already tried this and found out that, with this many organisations, were we to add labelling then that would actually clutter up the chart and make it unreadable. The best thing to do in this situation is to highlight those organisations that you’re interested in.

This is actually a very simple process. Fig.1 is a sample of the current data that makes up the chart. What we have to do now is to create another couple of extra data items to plot. These will be one for the label and one for the number.

In this case we have 3-digit provider codes so in the Trust field (column B) I’ve put a short locally meaningful name for the providers Fig.1 we are interested in, then in the Local field (column D) we need to replicate the original value. (See Fig.2) Fig.2 You can of course just copy it over, however I prefer to use a formula, which means that I can use this spreadsheet as a template for future iterations where the providers that we are interested in are not in the same place.

All I’ve done is used something that says if there is no name then don’t put in anything, but if there is then copy the data, in this case in cell D2: =IF(B2="","",C2), I’ve then copied this down to the bottom of the column.

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11 You then plot the two new data elements on the chart, by right-clicking on the current chart and choosing Source Data, (Fig. 3). Use Trust (column B) as the x-axis labels, and the Local provider information (column D) as an additional set of data.

Of course when you plot this you may well find that you’ll end up with a version of your chart with extra columns and blank spaces in it, making it more difficult to read than it was in the first place (Fig.4). If this is the case then you will need to format the columns to overlap. Select your new data in the chart and right-click your mouse, Fig.3 dependant upon your version of excel, the option Format Data Series, will either be the first or last option on the dialog box – choose this. If you’re using Excel 2003 then you need the last tab in the box (labelled Options), if you’re using a later version of Excel then it’s the first highlighted selection, “Series Options” (Fig.5) Fig. 4

In both of these you need to increase the Overlap option to 100 – once this is done then close the dialog box and, voila, you should have something that now shows your chosen organisations in relation to all the other providers in the country (Fig.6).

Further modifications could be added for extra functionality, for example you could add the data series values to show the score for your highlighted trusts—of course if you do that you’ll need to remember to use a custom number format that hides all the zeros.

Alternatively you could connect your new column of data to a dropdown selection box then you could actively select a single provider, or even groups of peer organisations.

Fig.5

Fig.6

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NEWS The Environmental and Health Atlas for England and Wales The atlas provides interactive maps of geographical variations for a range of health conditions and environmental agents at a neighbourhood (small-area) scale in England and Wales. The maps have been developed as a resource for those working in public health and public health policy and for the general public to better understand the geographic distribution of environmental factors and disease.

Access the atlas at: www.envhealthatlas.co.uk/homepage/ gotoatlas.html

http://

‘Harm Free’ Care Update The new monthly update on Harm Free Care is now published via www.harmfreecare.org. It contains the happy news that the online data collection and analysis tool has officially been launched. See page 5 for more details.

QO to QOnquer Confed Come and see us at this year’s NHS Confederation 2014 Annual Conference at the ACC Liverpool on the 4th-6th June. We’ll be showcasing just a few examples of what we can offer to all NHS organisations. Come and say hello at stand H37.

HSCIC Statistics Products Survey

Dementia Prevalence Calculator The Dementia Prevalence Calculator (DPC) (version 3) launched this month is being hailed as a major step forward in providing locally relevant information about dementia care and facilitating the local planning of services specifically around the diagnosis of people with dementia. The dementia prevalence calculator is accessible to registered users of the NHS England Primary Care toolkit which includes GP practice staff, Clinical Commissioning Groups, Area and Regional Teams and other approved stakeholder organisations through the following link www.primarycare.nhs.uk.

The latest version of the calculator has been designed with the same look, feel and functionality of the other Primary Care modules, to facilitate ease of use and navigation. From within the DPC module, users can access online help, help menus and supporting documentation in the resources section.

QO Birthdays There have been a couple of QO birthdays since the last issue.

Suzanne celebrated hers earlier in April, and successfully managed to avoid being photographed for this issue.

Rebecca, on the other hand, has just celebrated her birthday, and is seen here with a traditional QO gift.

The HSCIC publishes around 200 official statistics publications every year and are seeking views to help them set strategy for future publications.

The survey is open between Monday 14th April - Sunday 8th June 2014. Anyone may take part in this survey, but HSCIC are particularly keen to hear from regular users of statistical publications.

Access the survey at http://www.hscic.gov.uk/ article/4699/Statistics-Products-Survey

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QO AT THE INNOVATION EXPO In March this year the QO joined up with Central Southern CSU, to man a stand at the Innovation Expo in Manchester.

NHS Innovation Expo was set up by NHS England to provide an opportunity to meet and greet Commissioning Care Groups, Commissioning Support Units and other entities which support providing care for the patient. It was nice to see new and innovative methods used to promote all aspects of health care.

A nice way to promote ideas was to set up “Camp Expo” which allowed staff to share their experiences. These were members of staff on the frontline, sharing the good and bad stories of the work they do. This was a good place for networking as inevitably someone somewhere in the NHS has been through the same problem and instead of reinventing the wheel it gave an opportunity to build relationships and share good working practice.

The Dementia Café was a fantastic place to promote the great work done by individuals in aiding and supporting dementia suffers. This in turn allowed individuals to interact and engage in an informal manner.

As innovation is in the title of this Expo it would be silly not to mention how technology has and will continue to play an integral role in the care we provide to our patients. Ideas such as video calling patients for GPs, providing efficiencies by electronic prescriptions and all round improvement in the patient’s journey through their care.

Lastly, an exceptional concept was to have an Entrepreneur zone which allowed the entrepreneurs amongst us to shine and promote the ideas they have to improve patient care and, importantly, to improve the patients’ experiences.

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EASTER CROSSWORD

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Welcome Matt!

Hi I’m Matt, the latest new recruit to the Quality Observatory team! My new role will be to help out on the web development side of the team, beginning with the new Quality Observatory website, so keep an eye out for that in the next few weeks.

I have previously been working as an analyst in East Sussex and have worked in the NHS for nearly 12 years, including working closely with the Quality Observatory in the past, which technically still makes Amit the new boy!

Bank Holiday At A&E

Fascinating Facts

Have fun during the holidays, But be careful what you do, Or you could end up in A&E

Go and see a movie,

Waiting in a queue.

A film with that Brad Pitt, Starting choking on your popcorn,

You could go and grab a ball,

Can make you have a fit.

Take it to the park, Then you slip and sprain your wrist,

Have a little something

That would be a lark!

At your favourite inn,

Not sure that would last long at QO Towers!

You slip, you trip, Take a trip to the zoo,

The tallest chocolate Easter egg ever was made in Italy in 2011.

At 10.39 metres in height and 7,200 kg in weight, it was taller than a giraffe and heavier than an elephant!

and lacerate your skin.

See the bears and apes, Fall in an enclosure,

Go and watch the footie,

get in lots of scrapes.

The oppositions fans are drunk, A fist or knife,

Maybe have a round of golf,

Will get you in a funk.

But listen out for "Fores!"

With a golf ball in the head,

Have fun during the holidays,

You'll have been in the wars.

But be careful what you do, Or you could end up in A&E

An afternoon in the garden,

Waiting in a queue.

Planting up the veg, When the spade goes thru' your wellie, It really has an edge.

Knowledge matters is the newsletter of NHS South East Coast’s Quality Observatory, to discuss any items raised in this publication, for further information or to be added to our distribution list, please contact us.

Hosted by: Central Southern Commissioning Support Unit

E-mail: info@qualityobservatory.nhs.uk

To contact a team member: firstname.surname@qualityobservatory.nhs.uk