Knowledge Matters Volume 2 Issue 5

Kn o wl e d g e M an a g em e n t T e a m , S o ut h E a s t C o a s t S t r a t eg i c H e a l t h A ut h o r i t y k no wl e d g e. m a n a g e m e n t @ s ou t h e a s t c o as t . n h s . uk nw w. s e c . nh s . u k / k n o w l e d g e

INSIDE THIS ISSUE

FESTIVE

December 2008 Volume 2 Issue 5

Welcome to Knowledge Matters By Samantha Riley Welcome to a particularly fun filled festive edition of Knowledge Matters.

PROMs

The Danger of Averages

Psuedonymisation

Making links – UKCHIP

Health Informatics Career Framework

The WCC KM Library

Prescribing Dashboard

Stroke Metrics Dashboard

Unify 2

A : Ask an Analyst

Mental health update

Nursing metrics benchmarking

Page from the patch

SPOKE

Skills Builder - ROC curves

18 In the Post Bag 19 News and updates 20 Christmas Quiz

Fascinating Fact Last year on Christmas Day more people were admitted to South East Coast Trusts with a broken leg (22), than were born (18).

There are a few national developments that I would briefly like to draw your attention to. Firstly, you will be aware that the Informatics Review identified that the quality of data used to support policy, service planning, commissioning and performance management decisions is still often inadequate. As a result of this the Information Centre for Health and Social Care has established a national Data Quality Board which met this week for the second time. Terms of reference for the Board will be finalised in January and further details about the programme will be included in the February edition of Knowledge Matters. We will be running a South East Coast data quality event on 22nd January – contact me for further details or have a look at the website. Staying on the theme of quality, David Nicholson recently outlined the Department of Health’s vision for Measuring for Quality Improvement and the expectations of the NHS to support improvements in the quality of care experienced by patients. Each SHA will be developing a Quality Observatory which builds on existing analytical arrangements to support benchmarking, the development of metrics and quality measurement. I am currently working on the vision for our South East Coast Observatory and will update you on this next time. I would like to take this opportunity to thank the many contributors to this and previous editions of Knowledge Matters. If you would like to contribute next year please do get in touch! Thanks also to those of you who regularly make contact via the Knowledge Management inbox and website. We had a particularly unusual request which came into us recently (see page 18).

Knowledge Matters

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PROMS – What are they? By Martin Orton, Strategic Advisor, Information Centre for Health and Social Care Patient-Reported Outcome Measures (PROMs) are a means of collecting information on the clinical quality of care delivered to NHS patients as perceived by the patients themselves. The collection of these data will fill a gap in the set of information available on the care delivered to NHS-funded patients and will complement existing information.

Martin Orton

PROMs will be mandatory from April ’09, as specified in the Operating Framework (2008/9), for four surgical procedures for all NHS funded patients. The four surgical procedures are: • Hip replacements (approx. 56,000 per year); • Knee replacements (approx. 64,000 per year); • Varicose Veins (approx. 33,000 per year); • Groin Hernias (approx. 80,000 per year). The PROMs consist of a pre and post op questionnaire, each with 2 parts; a treatment specific section (e.g. Oxford hip & knee) and a generic quality of life measure (EQ5D), and have been trialled by the London School of Hygiene and Tropical Medicine. These PROMs will be completed by the patients independent of clinicians, providing a patient’s view of their care The pre-op questionnaires will be administered by the provider on day of admission or at pre-op assessment, and the post op forms will be sent to the patients by post, 3 months post-op for varicous veins and groin hernias, 6 months post-op for hip and knee replacements. The implementation and operation of PROMs will be centrally managed except for the pre-op questionnaire as described above. The management will be through contractors to the DH and The NHS Information Centre (The NHS IC). As shown in the diagram opposite, the Administration contractor will administer and collate the forms, convert them into electronic format and send them to The NHS IC. The NHS IC will link the PROMs records to the Hospital Episode Statistics (HES) data and where appropriate the National Joint Register (NJR) data. This adds demographics about the patient and details of the provider, treatment and the commissioners. A scoring algorithm is applied to calculate a measure of health gain, and once the patient identifiers have been pseudonimised or removed, the linked dataset will be made available on a monthly basis to the DH analysis contractors and other healthcare stakeholders subject to a set of terms and conditions.

Lot 1: “Administration”

N J

Pre-op

Lot 2: “Aggregation”

Information Centre: “Linkage” & “Repository”

S U

Develop adjustment

O t

IC identifiab le

Case-mix adjustme

Linked Pseud’se d

Post-op

Scoring, outcomes

Aggregation

Extract Service

Lot 3: “Analysis” Record level data

Academic stakeholders

Record level data

Aggregated data

Healthcare stakeholders

Aggregated data Record-level data

The regular analysis is expected to include a provider view, with a subset going to NHS Choices, and a commissioner view, allowing benchmarking and tracking of quality of care. Additional analysis will be able to look at topics such as differences between different treatments, different regions and for different groups of patients. With the process starting in April 2009, there should be sufficient volumes of completed pairs of PROMs questionnaires to start producing useful comparative data in early 2010. The Department of Health will shortly be publishing guidance for providers to alert them to their responsibilities in collecting PROMs data. In the meantime, if you have any queries, I’m more than happy for you to contact me martin.orton@ic.nhs.uk

Do you have something you would like to contribute to Knowledge Matters? Please contact us!

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The Danger of Averages…… By Kate Cheema, Specialist Information Analyst Why are averages so bad then? Well, they’re not exactly bad, they certainly have their uses but sometimes they are at best meaningless and at worst dangerous! Take Julius and Isabella below) as an example. They may be ‘average’ but it is very unlikely that they will actually have 2.5 children; however if they had three they would be ‘above average’, if they had two they would be ‘below average’. In the context of how many children you have it is unlikely that being average or not will really be relevant at a personal level. However, when it comes to something as emotive as school test results, house prices, waiting lists or even body weight we often have a tendency to judge ourselves, our houses, the local school or the local hospital on something that is simply a measure of central tendency and no more! A recent series of articles featured on the BBC website (http://news.bbc.co.uk/1/hi/magazine/7581120.stm) highlight examples that show just how abnormal the use of averages can make us look. For example, mean salary in 2006/07 was reported as £463 per week; the median, the middle value, was £377, £86 below the mean. In terms of frequency, the most common (mode) earnings are around the £260 mark, £203 below average. Why such a discrepancy? Well, as the mean is the sum of all the values (in this case, all the salaries earned) divided by the number of cases (in this case the number of earners), particularly high values (or especially low ones) can affect the figure significantly. If we had a group of ten people, nine of whom earned £400 per week and one of whom earned £450 per week, the average pay packet for the group would be £405 per week; nine would have below average earnings. Quick, set up a picket line, write to the Sun and e-mail your MP, 90% of us are below average! It is this same effect that means a Trust can meet its 18-week obligations whilst still having long waiters in a particular specialty; an average effectively strips all of the variability out of a dataset. The danger is in forgetting this and drawing conclusions (and writing policy) on the basis of a number that does not reflect the whole picture. The impact of outliers can be mitigated by using alternative measures of central tendency; why not try a median (the middle value) or a mode (the most frequent)? These measures are of course open to their own problems and still reduce rich and complex datasets to single numbers. Many readers of this newsletter will have at some point uttered the phrase “well it’s a bit more complicated than that” when asked to comment on the apparent ‘average decrease’ in performance or something similar. It is unlikely that the use of averages will ever be outlawed completely but in the meantime perhaps the perception of their apparently unshakeable authority as the descriptive number should be challenged more frequently. If you need any advice on the best measurement approach to take, please contact a member of the team – we would be more than happy to advise! Is there something that you wish you knew more about? To suggest future topics for knowledge matters contact the team

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Knowledge Matters

Pseudonymisation – What is it and what does it mean??? National policy on the secondary use of patient data requires that patient level records should be used in nonidentifiable form, except where there are valid and justifiable reasons for using identifiable data. The process of creating de-identified data is known as pseudonymisation. This is supported by providing additional derived data items instead of items that can be used to aid identification, such as age instead of date of birth and electoral ward instead of postcode. You may be wondering why this is relevant to you… Once introduced, pseudonymisation will have a significant impact on business functions for the NHS and will provide a particular challenge in the context of commissioning where increasingly the advice is that an increasing number of data sets need to be connected to enable effective World Class Commissioning……. NHS business operations, such as commissioning, use analysis of SUS CDS derived records to undertake a range of activities including assessing needs, managing demand, managing performance, research and reviewing service provision. Some of the analysis required operates at aggregate level and pseudonymisation should not have an impact. Some processes, however, rely on linking and examining records at individual patient level, for example in ensuring 18 week referral to treatment targets are met or performing analysis on readmissions. In these cases pseudonyms or spell identifiers will need to be used instead of NHS Numbers in analysis and for communication between organisations. In addition, pseudonymisation applies not only to SUS data but also to local warehouses, using the same algorithms that are used to generate the psuedonymised SUS data items will ensure that local and national datasets can still be linked together. NHS business processes will be reviewed through piloting to ensure that solutions are found to enable processes to be undertaken without using patient identifiers. Those NHS staff with legitimate reason to examine patient level information will be able to re-identify individual patients. This will be achieved by de-pseudonymising the pseudonym used for the NHS Number. Relevant NHS staff will only be able to do this through using suitable business functions in the Roles Based Access Control (RBAC) process to SUS; use of this facility will be logged and audited. This will enable those making primary use of SUS data to gain NHS Numbers from pseudonyms. NHS confidentiality policy requires that pseudonymisation is to be used in all NHS based secondary use data handling. This means that it applies to secondary uses made by commissioners, providers, SHAs and national bodies. So, when will this come into effect you may be asking? Initially, the plan was to implement pseudonymisation from 1st April 2009; however it has been agreed that implementation will now be delayed and timescales are under review.

Interested in this topic? Are you interested in understanding more about pseudonymisation? Are you aware of proposed changes to the Data Model or Dictionary? If so, you may be interested in attending our bi-monthly Data Flows and Standards group. Terms of reference, papers and dates of meetings are available on the Knowledge Management website or you can contact Samantha Riley to obtain further details (Samantha.riley@southeastcoast.nhs.uk)

SUS Release 4 Postponed The release of SUS scheduled for the 29th November 2008 has been postponed. This release will introduce a new set of reports to support the performance sharing of the 18 week target for referral to treatment across providers of NHS care. It also provides the capability for organisations to submit version 6.1 of the Commissioning Dataset Schema. The implementation of this release will mean that version 5 of the CDS schema is no longer supported.

Do you have something you would like to contribute to Knowledge Matters? Please contact us!

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Making Links – UKCHIP Jean Roberts, Director of ETD (Standards) Health Informatics staff function as the crucial support crew, the ‘pit team’ providing front-line clinical staff and managers with the information they need to make efficient decisions in support of individual care and epidemiological plans right through to activity profiles and financial analysis. Health information must be correct, timely, comprehensive and consistent to contribute to patient safety as well as adhering to data security standards. Many readers of Knowledge Matters will operate in the field of health informatics. You probably know where your own strengths are; the challenge is communicating those to both current managers and anyone you might face at interview. It may not be possible, in an appraisal meeting or a short interview for example, to describe all the responsibilities, accountabilities and good practices you take on. However, a registration under the UK Council for Health Informatics Professions (UKCHIP) can say in one short statement that you have been assessed as a professional by your peers, and work to clear open standards and governance. The Health Informatics Review is being followed by an Action Plan, expanding on the concept of professionalism. ‘UKCHIP membership’ will increasingly be appearing as a preferred element of person specifications for health informatics posts. As controlled sharing of data is extended - whether people, organisations or across sectors – it is imperative that all steps are taken to assure the public that you take your responsibilities seriously. So, what are the benefits of registration? As a UKCHIP registrant you will: • Demonstrate your commitment to keeping up to date in your field and acting responsibly and professionally; • Express your competence in a way that is recognized by the industry; • Be listed on an open register that can be referenced, proving you can ‘talk the talk’ and ‘walk the walk’; • Recognise the necessity of addressing patient and public safety concerns in the work that you do; • Gives you a potential ‘edge’ in jobs, re-gradings, internal staff reviews and personal career progression. For an employer, UKCHIP registration : • Provides another tool for recruitment and selection; • Can demonstrate, internally and to external performance monitors that your staff are fit to practice; • Helps staff to articulate their own developmental needs, providing direct input to departmental training needs analysis; • Can assist those who utilise external resources as UKCHIP registration indicates that contractors work to the same ‘gold standards’ that you expect of internal staff. Some have observed that 'all clinicians must register with a professional organisation before they can practice; why should health informaticians be any different?' This question will not be answered until professionalism becomes endemic. The UKCHIP strategic plan moves voluntary registration towards more formal certification, though not to mandatory requirements in the short term. Health informatics is fluid and expanding, as new technologies emerge, systems become more widely deployed and health informatics becomes more main stream. In response to this, UKCHIP has developed: • • • •

A full code of conduct, which stands comparison with those of more traditional professions; A registration protocol that is used by peer assessors to recognise an applicant; Continuing professional development criteria that facilitate registrants in demonstrating their 'fitness to practice'; Procedures for withdrawal of registration from those who do not continue to operate effectively, and appeal procedures against withdrawal or assessed level of registration.

Getting UKCHIP to this point has been done by members of the profession for the profession. We would strongly urge all those who are working in health informatics, particularly those in (and for) operational locations which impact directly on patient care, to consider registration with UKCHIP to demonstrate commitment to professionalism and respect for patient and public safety. Perhaps you feel your role is not in direct contact with patients, but that doesn’t mean that you can’t or won’t meet the required professional standards. You are an integral member of the ‘pit team’ – without operational equipment, robust solutions and efficient information support front-line services will be at risk. If you have not registered with UKCHIP yet, then go to www.ukchip.org and take steps towards being recognised as a professional! Annual fees are only £20 for a level 1 registration and £30 for levels 2 and 3. An ‘At a Glance’ poster answering UKCHIP frequently asked questions are available for the workplace; email admin@ukchip.net to request one (or more!). Is there something that you wish you knew more about? To suggest future topics for knowledge matters contact the team

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Knowledge Matters

Health Informatics Career Framework By Jackie Smith, Health Informatics Development Manager, NHS Connecting for Health A key element of the NHS Connecting for Health professional development programme is to develop knowledge and skills within the Health Informatics community; achieve professional status through standards, but also to focus on recruitment, career development and progression within this new and emerging field. The Health Informatics Career Framework (HICF) is a UK wide initiative. It is being led by Informing Healthcare, NHS Wales, with considerable input from NHS England through NHS Connecting for Health. Development of an HICF is also one of the key recommendations of the Informatics Review. Following consultation with stakeholders the initial version of the Health Informatics Career Framework (HICF) was launched in May 2008. The aim of the career framework is to: • Identify and open up career opportunities in Health Informatics; • Allow individuals to plan careers in Health Informatics; • Allow organisations to plan a more effective Health Informatics workforce. The HICF is currently populated with 50 generic jobs across Health Informatics (HI); each is described in the form of a specification covering: • Description of the roles and responsibilities involved; • An indication of related job titles; • Relevant National Occupational Standards and Knowledge and Skills Framework (KSF) links; • Relevant qualifications; • Relevant professional standards; • The HICF level. The HICF can help individuals by : • Illustrating career opportunities & examples of progression; • Aiding career planning by providing case studies; • Supporting progression across a range of different specialisms within Health Informatics; • Providing a skills escalation based on competencies; • Promoting the ‘bigger picture’ of Health Informatics. The HICF can help organisations with workforce planning; workforce modelling; succession planning and considering the workforce implications of service re-design We are currently working on the second phase of the project and both England and Wales have run a number of events which will contribute towards additional content for the HICF. In England three collaborative workshops were delivered around the country to develop and increase the job specifications. We are delighted with the output from these events and really appreciate the terrific efforts of HI colleagues who attended; we couldn’t do it without you! By the end of March 2009, we plan to increase the number of job roles on HICF from 50 to 100 job roles. We also ran a workshop in England for colleagues and organisations who were interested in assisting with the evaluation process. A number have agreed to help us but we’re still keen to hear from others who might also like to be involved. The results will be collated and developed into case studies to be shared on the HICF by April 2009. We have established an England HICF Steering Group made up of stakeholders, including, for example, Skills for Health, NHS Employers, Information Centre for Health and Social Services, as well as senior HI colleagues. The outcomes from the England Steering Group will be passed to the national Strategic Board which is due to meet in January 2009. NHS South East Coast has been promoting the framework to University undergraduates and have fed back that the framework has been extremely useful in encouraging informatics careers in the NHS. Please do take a more in-depth look at the career framework www.hicf.org.uk We’d love to have your input! Do you have something you would like to contribute to Knowledge Matters? Please contact us!

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- The Knowledge Management Library Angus Malcolm, Research Associate, Humana Europe Effective Knowledge Management (KM) is becoming increasingly recognised globally as a vital component in creating and running successful organisations. And this trend is just as true in healthcare. Knowledge Management has been incorporated as a fundamental component of World Class Commissioning (WCC), and this prompted NHS South East Coast, both at SHA and PCT level, to explore ways of maximizing the opportunities that KM offers to improve commissioning. But what is Knowledge Management? It emerged as a discipline in the mid 1990s, not least in response to the opportunities and challenges presented by the new technologies of the Information Age. These challenges included the plethora of raw data that it had become feasible to collect, with the accompanying opportunities of rapid processing that could turn those raw data into meaningful information. Essentially KM is a strategy, framework or system that enables organisations to create, capture, analyse, apply and reuse knowledge in order to achieve their goals. As Wittgenstein said, “Knowledge is the capacity for effective action,” and KM is the art/science of mobilising that capacity to deliver that effective action. In order to support WCC, Commissioners will need to base decisions on sound information and evidence. They will need access to a wide range of data, information and evidence which can be analysed, synthesised and used to undertake risk assessments, provide predictive analysis and enable modelling of health outcomes. The range of data and information which will be required to support this process will be drawn from a wide range of sources – Commissioners will need to have tools and techniques for gathering data and information from, both hard and soft sources, and to inform decision making. Managing and capturing a vast array of diverse sources will be key to success, and Knowledge Management will be key to enabling this process. And that is where our new exciting resource comes in. This has been produced by Humana Europe in partnership with NHS South East Coast PCTs and the SHA. It includes some general insight into the world of knowledge management and its applications across a variety of sectors and organisations. It also explores specifically how and where KM supports the achievement of the World Class Commissioning (WCC) Competencies. Specifically and most usefully, the resource offers a breakdown of how KM relates to each of the eleven WCC Competencies, with links to relevant articles and other helpful resources, all of which have been summarised and given a combined rating for relevance, accessibility and usefulness. You will find everything from practical guidance on HR aspects of implementing KM strategies, through to a philosophical discourse on the nature of knowledge- and let’s not forget a video on how KM stopped birds using Washington DC’s Jefferson Memorial as a public convenience! With more than 50 articles and as many links, this is a good starting point for anyone wanting to know what Knowledge Management is, and what it can do for them. Of course knowledge, like language, is not a static entity. It changes and evolves, sometimes quite rapidly, as we can see in the development of Knowledge Management itself. So we do not intend our Knowledge Management Library to be a static resource. We want it to expand, and that is where you come in! Humana and the S E Coast PCTs are already collaborating on adding some local case studies of KM-related best practice, and we want to add more! So whether you’ve spotted a great article, come across a useful site, or just seen an example of good practice you’d like to tell us about – please get in touch, because we want to hear all about it! Here’s the link! http://www.commissioning-circle.co.uk/knowledge_library/ Is there something that you wish you knew more about? To suggest future topics for knowledge matters contact the team

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Primary Care Prescribing Dashboard Rebecca Owen, Performance and Planning Analyst Rebecca Owen

Over the past few months we have been working with Wendy Smith and the pharmacists at Medway PCT to develop a Primary Care Prescribing Dashboard. This looks at ten key metrics around prescribing efficiency and good practice and is populated with monthly data from the ePACT system. Two views of the dashboard are available: the first view shows each metric by selected PCT. The second is a PCT view, showing each PCT by selected metric. On both views green or red rectangles are shown on the charts to indicate whether performance is going in the right direction – for some measures an increase is an indication of good performance, for others levels should be decreasing. A notes page is provided with explanations of each of the measures. The first chart looks at the overall cost per prescribing unit (PU). PUs are derived from practice lists. In general this would be expected to show an increase in line with national growth and fluctuations are seen overall as prices are adjusted by Department of Health.

PRIMARY CARE PRESCRIBING - EFFICIENCY AND GOOD PRACTICE MEASURES (refer to Notes sheet for definitions and explanations): South East Coast Total South East Coast Total

Cost per ASTRO PU

£3

84%

£140

82%

£120

80%

£100

78%

£80

76%

£60

74%

£40

72%

£20

70%

£0

% ACE II of Total ACE Prescribing

% Generic Simvastatin and Pravastation of Total Statins

Statins: Cost per 1000 STAR PU

Generic Rate

£3

35.0%

75%

30.0% 70%

£2

25.0%

65%

20.0%

£2 15.0% 60%

£1

Jul-08

Oct-08

Jan-09

Jul-07

Oct-07

Apr-08

Jan-08

Oct-06

% Oral Diclofenac of Total NSAID Items 50%

Jan-07

Jul-08

Oct-08

Jan-09

Apr-08

Jul-07

Oct-07

Jan-08

Apr-07

Oct-06

% High Risk Antibacterials of Total Antibiotic Items 25%

85%

Apr-07

0.0% Jan-07

Jul-08

Oct-08

Jan-09

Apr-08

Jul-07

Oct-07

Jan-08

Apr-07

Oct-06

Anti-bacterial Items per 1000 STAR PU

120

5.0%

50% Jan-07

Jul-08

Oct-08

Jan-09

Apr-08

Jul-07

Oct-07

Jan-08

Oct-06

% Generic Omeprazole/ Lansoprazole of total PPI ADQs 90%

Apr-07

Jul-08

Oct-08

Jan-09

Apr-08

Jul-07

Oct-07

Jan-08

Oct-06

Jan-07

Apr-07

£0

Jan-07

Four of the metrics relate to generic prescribing. GPs should be aiming to prescribe more cost effective generic varieties rather the expensive branded versions. A decrease is seen in the overall generic rate each year around October as the flu vaccine is a branded item.

10.0% 55%

£1

% Methotrexate 10mg of Total Oral Methotrexate 25%

45% 100 20%

80% 75%

40%

15%

70%

30%

65%

20%

35%

15%

25%

60%

10%

20%

10%

40 55%

15%

50%

10%

45%

5% 0%

Jul 08

Oct 08

Apr 08

Jan 09

Jul 07

Oct 07

Jan 08

Oct 06

Apr 07

Jan 07

Jan-09

Jul-08

Oct-08

Apr-08

Jul-07

Oct-07

Jan-08

Oct-06

Apr-07

0% Jan-07

Jan 09

Jul 08

Oct 08

Apr 08

Jul 07

Oct 07

Jan 08

Oct 06

Jan 07

Apr 07

Jan-09

Jul-08

Oct-08

Apr-08

Jul-07

Oct-07

Jan-08

Oct-06

Apr-07

Jan-09

Jul-08

Oct-08

Apr-08

Jul-07

Oct-07

Jan-08

Oct-06

Apr-07

Jan-07

40%

Two of the remaining metrics look at prescribing of anti-bacterial items, both total items and the anti-bacterial items that are associated with an increased risk of C-Difficile. Anti-bacterial prescribing is very seasonal and will increase over the winter months but we would be looking for use of antibiotics to decrease in general as they are used more appropriately. PRIMARY CARE PRESCRIBING - EFFICIENCY AND GOOD PRACTICE MEASURES (refer to Notes sheet for definitions and explanations) BRIGHTON & HOVE

% ACE II of Total ACE Items

EAST SUSSEX DOWNS & WEALD

0.4

0.3

The remaining 3 measures look at good practice in prescribing, where it has been recommended that certain drugs should not be routinely prescribed as other drugs are generally more appropriate, so it would be expected that prescribing levels would be low.

% ACE II of Total ACE Items

EASTERN & COASTAL KENT

HASTINGS & ROTHER

0.4

0.3

0.4

0.3

0.3 0.3

0.3 0.2

0.2 0.2

0.2 0.2 0.1

0.2 0.1

0.1

0.0

0.1 0.0 Jan-09

Oct-08

Jul-08

Apr-08

Jan-08

Oct-07

WEST KENT

Jul-07

Apr-07

Jan-07

Oct-06

Feb-09

Dec-08

Oct-08

Aug-08

Jun-08

Feb-08

Apr-08

Dec-07

Oct-07

SURREY

Aug-07

Jun-07

Feb-07

Dec-06

Oct-06

Apr-07

Feb-09

Dec-08

Oct-08

Aug-08

Jun-08

Feb-08

Dec-07

Apr-08

Oct-07

Aug-07

Jun-07

Feb-07

Dec-06

Oct-06

Apr-07

Jan-09

Oct-08

Jul-08

Apr-08

Jan-08

Oct-07

Jul-07

Jan-07

Oct-06

Apr-07

MEDWAY

0.1

WEST SUSSEX

0.4

0.3

0.4

0.3

0.2

0.1

0.0

0.3 0.3 0.2 0.2 0.1

Jan-09

Oct-08

Jul-08

Jan-08

Oct-07

Apr-08

Jul-07

Jan-07

Oct-06

Apr-07

Feb-09

Dec-08

Oct-08

Jun-08

Aug-08

Feb-08

Dec-07

Oct-07

Apr-08

Jun-07

Feb-07

Aug-07

Dec-06

Oct-06

Apr-07

Feb-09

Dec-08

Oct-08

Jun-08

Feb-08

Aug-08

Dec-07

Oct-07

Apr-08

Jun-07

Aug-07

Feb-07

Dec-06

Oct-06

Apr-07

Jan-09

Oct-08

Jul-08

Jan-08

Oct-07

Apr-08

Jul-07

Jan-07

Oct-06

Apr-07

This dashboard will be available on the Knowledge Management website from early January and we plan to update the data on a quarterly basis. We hope that the dashboard will evidence the current variation in primary care prescribing and support cross organisational learning to make prescribing more efficient.

Please contact me if you would like more information: rebecca.owen@southeastcoast.nhs.uk We are keen to receive your feedback to further develop and enhance analysis for this important area. Do you have something you would like to contribute to Knowledge Matters? Please contact us!

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Stroke Metrics Dashboard COMING SOON… Simon Berry, Specialist Information Analyst Over the past year, you will have read articles in Knowledge Matters about the work that has been undertaken in conjunction with interested parties from local Trusts, PCTs, Social Services and the Information Centre to develop key metrics for Stroke. The aim of the project is to provide a range of metrics that are relevant and meaningful to clinicians, practitioners both within primary and secondary care in dashboard form from current readily available and credible data sources. This draft dashboard is the first deliverable from that work and will be generally available in its finalised form in the next month. It brings together a series of metrics sourced from HES as well as additional Trust and performance information from the National Stroke Sentinel Audit. The dashboard allows a Trust or, where relevant, hospital site to be selected. For some measures it is possible to select either all patients or patients below the age of 75 years old. This distinction was felt to be relevant due to the differences in treatment options available for under 75s. The data extract driving the metrics selects emergency admissions patients with a primary diagnosis in the admission episode of I60-I64. A future development of the dashboard will be to allow the option of excluding the I60 diagnosis code (subarachnoid haemorrhage). The charts show the following – • Volume of activity (to provide context to Medway NHS Foundation Trust Stroke Dashboard <=75 Years Old other measures); • Hospital mortality rates after 7 days and 30 days; • Proportion of patients with a CT or MRI scan within 48 hours of admission or at any point in the episode; • Discharge destination split. This is grouped to show proportion of patients going to their usual place of residence, other hospital for rehab, care / nursing home, dying or going to other destinations; • Proportion of patients admitted from and discharged back to their usual place of residence giving a proxy as to the quality of life experienced by the patient post-stroke; • Length of stay for all patients and for those being discharged back to their usual place of residence only; • An SPC run chart of the 100 most recently discharged patients showing their individual lengths of stay in hospital and whether they were discharged alive or not. As well as showing the ranges of stays in hospital this can help identify long staying patients who may be delayed discharges; • The total value of activity and the average value per spell. ASU RSU CSU

Sentinel Overall 08 vs 06

Admissions

% Patients With CT Scan / MRI Scan

Mortality

35%

30%

25%

% Discharge Destination

Length of Stay (Days)

100%

90%

80%

70%

60%

50%

40%

30%

UPR

CH / NH

Other Hosp

Died

Other

20%

15%

10%

30 Day

Nat 06/07 7 D

Nat 06/07 30 D

CT Scan 01 Target

Total Value of Activity 000's

70%

10%

All LoS

04/05 04/05 04/05 04/05 05/06 05/06 05/06 05/06 06/07 06/07 06/07 06/07 07/08 07/08 07/08 07/08

Average Value per Spell

£4,000

£300

10%

20%

UPR LoS

% Stroke Patients Admitted from UPR & Discharged to UPR

04/05 Q1 04/05 Q2 04/05 Q3 04/05 Q4 05/06 Q1 05/06 Q2 05/06 Q3 05/06 Q4 06/07 Q1 06/07 Q2 06/07 Q3 06/07 Q4 07/08 Q1 07/08 Q2 07/08 Q3 07/08 Q4

7 Day

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

04/05 Q1 04/05 Q2 04/05 Q3 04/05 Q4 05/06 Q1 05/06 Q2 05/06 Q3 05/06 Q4 06/07 Q1 06/07 Q2 06/07 Q3 06/07 Q4 07/08 Q1 07/08 Q2 07/08 Q3 07/08 Q4

CT Scan

04/05 Q1 04/05 Q2 04/05 Q3 04/05 Q4 05/06 Q1 05/06 Q2 05/06 Q3 05/06 Q4 06/07 Q1 06/07 Q2 06/07 Q3 06/07 Q4 07/08 Q1 07/08 Q2 07/08 Q3 07/08 Q4

20%

Most Recent 100 Patients Run Chart

Alive

Died

Unknown

Mean 5.0

UCL 20.9

£3,900

60%

£250

£3,800

50%

£200

£3,700

Days

40%

£3,600

£150

25 20

30%

£3,500

£100

20%

£3,400

£50

10%

£3,300

01/02/08 06/02/08 08/02/08 18/02/08 26/02/08 28/02/08 04/03/08 13/03/08 19/03/08

07/12/07 10/12/07 15/12/07 27/12/07 29/12/07 07/01/08 21/01/08

24/11/07 01/12/07

18/10/07 19/10/07 23/10/07 02/11/07 05/11/07 08/11/07 15/11/07

12/10/07

11/09/07 25/09/07

30/07/07 31/07/07 03/08/07 12/08/07 03/09/07

15/06/07 17/06/07 29/06/07 04/07/07 17/07/07 20/07/07

28/05/07 30/05/07 12/06/07

04/05 Q1 04/05 Q2 04/05 Q3 04/05 Q4 05/06 Q1 05/06 Q2 05/06 Q3 05/06 Q4 06/07 Q1 06/07 Q2 06/07 Q3 06/07 Q4 07/08 Q1 07/08 Q2 07/08 Q3 07/08 Q4

£3,200

04/05 Q1 04/05 Q2 04/05 Q3 04/05 Q4 05/06 Q1 05/06 Q2 05/06 Q3 05/06 Q4 06/07 Q1 06/07 Q2 06/07 Q3 06/07 Q4 07/08 Q1 07/08 Q2 07/08 Q3 07/08 Q4

£0

At the top of the dashboard there is an indicator that shows the hospital’s overall performance on the 2008 Sentinel Audit compared to the 2006 Audit and tick boxes showing what kind of stroke units are present thereby providing some background as to what is seen on some of the charts. In addition to this dashboard, we have successfully worked with Worthing and Southlands Hospital to link Ambulance Trust and Trust data together. This has enabled us to look at the different timing points for stroke patients e.g. time from the time the ambulance being called to when the ambulance arrives and time of arrival to Hospital to time of scan. Over the coming months the plan is for this dashboard to be supplemented further by a Commissioner based dashboard. If you have any questions with regards to the dashboard, would like any further information/explanation or if you would like to get involved with the programme you can contact me at simon.berry@southeastcoast.nhs.uk Is there something that you wish you knew more about? To suggest future topics for knowledge matters contact the team

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Pag Page 10

Merry Christmas ……. Dianne Tew and the Unify 2 Team, Department of Health Hello all of you Unify 2 users! Merry Christmas from the Unify 2 team! We are of course conscious that over the past year, you may have occasionally been frustrated with Unify…… ……we have been trying our best to make the system as functional as possible and thought that this festive fun edition of Knowledge Matters provided an excellent opportunity to update you on progress that has been made over the past twelve months. In the next edition of Knowledge Matters we will tell you about a number of forthcoming developments…. Here are some of the key achievements over the past year………. Development of a Unify2 Logs database This has been an important step forward as it helps us to effectively manage the issues that you are logging, enables us to more quickly identify issues that are affecting a high number of users, log progress against each issue and prioritise tasks more effectively. We are developing a set of metrics using the data from the database – so in future you may see a Unify logs performance dashboard! Two New Unify2 Domains have been created This is a more recent development. Two new domains have been created within Unify which has allowed Programme Budgeting and Payment by Results collections to be managed via Unify. Discoverer Plus access provided to SHAs SHAs have been trained in the use of Discoverer Plus. This is a querying tool which enables data to be extracted from Unify 2 more flexibly. So if there are particular extracts that would be useful to PCTs and Trusts, we suggest that you make contact with your friendly SHA information teams.

Fun Facts ……. Did you know that ?? One billion records are now in Unify2 (despite the original Unify only having 16 million in twice the time). There are now 9000 active Unify2 users - making it the Department of Health’s largest system. Unify currently collects approximately 700 collections annually At any one time, between 24 and 35 are live. During 2008 approximately 440 logs were raised. 364 of these logs have been effectively resolved (leaving 76 for us to still sort out for you)

Unify2 Technical Support

Many thanks to the support team for all their efforts in 2008 to keep Unify2 afloat (and for never once shouting or screaming at users when they when they called for the 4th time in a day to ask for work to be completed urgently, immediately!) Last but not least the database administrator who worked out of office hours almost every week in 2008 to implement the fixes and enhancements We have also had a number of transient members of the development and support team in 2008, one of the most notable contributors being Steve Williams, who helped with the data flows whilst working on the Reference Cost project.

Support recently partly resolved the issue of Unify2 falling asleep during the night (it really is true). We have now put in an alarm than wakes it up at 6am. This has decreased the frequency of Unify2 nodding off (going down in NHS language) from 7-8 times a week to 2 or 3. We are still working on this issue. We will continue to work hard to resolve your queries as quickly as possible. To help us, please provide us with as much detail as possible regarding any technical issues that you may be struggling with. If we know exactly when the problem occurred, what exactly you were doing (in a technical sense of course!), what any error message said, we can resolve your issue more quickly. Please continue to log your queries with the Unify 2 Helpdesk unify2@dh.gsi.gov.uk Do you have something you would like to contribute to Knowledge Matters? Please contact us!

Knowledge Matters

Page 11

……. From Unify2 and the Team ! 18 weeks Referral-to-Treatment The RTT target is due to be delivered by the end of the year. Over the past year we have introduced 2 new RTT collections: • Adjusted 18 Weeks RTT collection; • Allows organisations to report data which has been adjusted to take into account legitimate pauses in RTT pathways; • 18 Weeks Performance Sharing collection; • Allows 18 Week breaches to be shared between provider organisations on multi-provider RTT pathways. This collection has involved IS developing "prov-prov" functionality within Unify2. The flow of data in Unify2 and especially the monthly RTT has improved considerably over the year. Some of the uploads taking up to 14 days to process at the end of 2007, the majority of these collections are currently processing in a couple of minutes.

Quality Data and Deadlines! Some of the new Unify2 functionality has helped us identify where there are problems (which had become an increasing concern) with organisations submitting returns on time and has supported the drive by the DH to publish data faster. Unify2 provides the ability to highlight which Trusts have supplied a late return. Where organisations are consistently missing deadlines, we will be following this up with SHAs – so watch out! Organisations are becoming more aware of our deadlines and, for some of the returns, response rates have improved, although we still have a long way to go. Latest analysis at the following link: http://nww.unify2.dh.nhs.uk/instantforumsetup/Forum10001900-1.aspx

Who’s who.........Sitting down left to right Brian Mullowoney (MMR, Diagnostics etc), Anil Jagtap (Discoverer expert), Stuart Hansom (Unify2 Admin), Dianne Tew (Unify2), Clive Seaman (Sitreps), Dave Wilson (MAR, QAR, GUMMAM) Back left to right Clare Jones (Vital Signs), Siobhan Oliver (DH Website), Christina Barfoot (Direct Access Audiology) Is there something that you wish you knew more about? To suggest future topics for knowledge matters contact the team

Knowledge Matters

Pag Page 12

A3: ASK AN ANALYST – If you have a question for the team please e-mail: Knowledge.management@southeastcoast.nhs.uk Q - I need to create a report using columns, where text flows down one column and then to the top of the next, as in a newspaper or magazine article. A – The good news is that they are easy to implement and you don’t even have to apply the column format to your entire document; you can columnise any text with just few simple clicks So… To create Newspaper columns: • Switch to print layout view. • Position the insert point in the location where the columns are to begin • Choose the Format, columns command • In the columns dialog box, which is subsequently displayed, set the desired number of columns. • Optionally, reset the column width and/or the column spacing • Optionally, select the line between options to display a vertical line between the columns. • Expand the apply to box and select this point forward • Click on the ok button • Type the column text NOTE! If you select a portion of text (as opposed to the whole document) then the column formatting will be automatically applied within a Word Section Break. 1. If working in Normal view the columns will NOT be displayed side-by-side, but rather as a single column, displayed on consecutive pages. 2. To see the columns layout side-by-side, view the columns in Print Layout view! 3. You can also apply a newspaper column definition after typing the text in this case, move the insertion point to the beginning of the first line to be affected, and then choose the Format, Columns command 4. Alternatively, you can apply a Newspaper column definition to and entire document (or an entire section) by positioning the insertion point anywhere in the document (or Section) by clicking on the Columns button on the standard toolbar, and by selection the desired number of columns on the grid that appears.

The Night Before Christmas (GEEK REMIX)

To change columns width using drag and drop techniques The easy way to do this is to display the columns in Print Layout View and with the Ruler displayed, simply drag the column header icons to the left or right.

To insert column breaks Normally (soft) column breaks will be applied automatically, so that the text with the section formatted as multi-column will flow within the section. If you wish to force a column break, then locate the insertion point at the location you wish the column break to appear. Then from the Insert drop down menu, select the Break command. The Break dialog box will be displayed. Select Column Break and then click on the OK button

‘Twas the night before Christmas, all over the place, Daily SITREP was signed off, none left to chase. CDS extracts were sent off to SUS, (Some in v6 - with a minimum of fuss!) With one week in hand to hit 18 weeks – Waiting lists were given a couple of tweaks. Spreadsheets were closed down for the season of Yule, And overworked databases given time to cool. The analysts took a few days to stop crunching numbers, To dream of new tech in their festive slumbers. CEO’s headed off on their Christmas vacations, Hoping Santa would bring performance to make them foundations. From the KM team at South East Coast, We’ll raise you a glass in a festive toast Wishing glad tidings and seasonal cheer Best wishes for Christmas and the coming New Year.

. Peter Nyaga

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Page 13

Mental Health MDS – first release of experimental statistics Jo Simpson, Senior Project Manager, Community and Mental Health, The IC The NHS Information Centre for Health and Social Care published The Mental Health Bulletin, which presents national findings for England, and an accompanying online database of trust level results on 29 October 2008. Health Services Journal welcomed this release as ‘the most comprehensive set of data ever collated on hospital and community mental health services’. The MHMDS contains record level data about NHS mental health services delivered to over a million people with severe and enduring mental health problems each year. This is the first time the NHS Information Centre has released statistics based on MHMDS data and the design of the analysis is new. This is one reason why these are released as experimental statistics. There are also some issues with data coverage and data quality. This initial set of tables provides details of patient numbers by age, gender and ethnicity. They also provide activity counts for inpatient and community services. The data show that: • From 1 April 2006 – 31 March 2007 over 1.1 million people 400,000 Age Under 16 were in contact with NHS specialist mental services – this Age 16-17 is a rate of access for the population of England of one 350,000 Age 18-35 300,000 person in fifty; Age 36-64 • About one in ten of these people (9.3%) spent time as an 250,000 Age 65+ inpatient in mental hospital and one in four inpatients 200,000 spent time compulsorily detained under the Mental 150,000 Health Act; • 106,600 people spent time in hospital in 2006-2007 – 100,000 about seven thousand less than in 2003-2004. Within the 50,000 same time period, figures suggest the number of NHS 0 beds available reduced by about 1,700; Admitted Only Non-admitted No Care • In 2006-2007 there were nearly 4,800 records with a Number of people using NHS mental health services in hospital stay exceeding a year – a fall from previous 2005-2006 by highest level of care*, by age in 2005-06 years; •• Although more men than women spent time as hospital inpatients, women outnumbered men as users of outpatient and community mental health services by more than 100,000. This was particularly noticeable in the over 65 age group; • In 2006-2007 over 80% of people in contact with services had a valid record of their ethnicity. 96% of people who were inpatients had a valid record of their ethnicity; • The figures seem to corroborate the findings of the National Mental Health Ethnicity Census (Count Me In) about the over-representation of some BME groups amongst detained patients. In this first publication only the data that are considered more reliable are used, the aim being to answer some basic questions about the use of specialist NHS mental health services, rather than to compare individual provider's performance. The online database is designed to enable provider Trusts to review their data and should be used for management or planning purposes with caution as there is some variation between Trusts in the quality and completeness the data. The release includes some basic analysis (patients numbers, rates of access) by PCT of GP practice and The NHS Information Centre welcomes suggestions on what other types of report would be useful in future releases. Further information: http://www.ic.nhs.uk/statistics-and-data-collections/mental-health/nhs-specialist-mental-healthservices/mental-health-bulletin or email: mhmds@ic.nhs.uk. Is there something that you wish you knew more about? To suggest future topics for knowledge matters contact the team

Knowledge Matters

Pag Page 14

Safer Smarter Nursing Metrics Benchmarking Adam Cook, Specialist Information Analyst You will recall, from previous editions of Knowledge Matters, the work being undertaken as part of the Safer Smarter Nursing Metrics Programme. For some time I have been working with Trusts to help them develop localised ward dashboards â&#x20AC;&#x201C; this work will continue over the coming year so if you are interested please contact me. For a number of indicators it measurements and definitions benchmarking in this we hope potential improvement and also

is not possible to compare performance between are used. However, for a number of indicators we hope to identify good practice that others can have an influence on measures that might be used by

organisations as very different comparisons are possible. By learn from, highlight areas for commissioners in the future.

Safer Smarter Nursing Metrics - Acute Trust Benchmarking

To enable the benchmarking to be undertaken, we requested some data from our Trusts. Most Trusts have now submitted data, which has enabled me to develop some early comparative benchmarking.

Dartford & Gravesham 40.0

300

Pressure Damage (per 10,000 Admissions)

250

250.0

MRSA (per 10,000 Admissions)

35.0

C-Diff (per 10,000 Admissions) 200.0

30.0 200 25.0

150.0

20.0

150

100.0

15.0 100 10.0

50.0 50 5.0

Drug Administration Errors (per 10,000 admissions)

Jan-08

Mar-08

Feb-08

Oct-07

Dec-07

Nov-07

Jul-07

Sep-07

Aug-07

Apr-07

Jun-07

May-07

Jan-08

800

300

0.0

Mar-08

Feb-08

Oct-07

Dec-07

Nov-07

Jul-07

Sep-07

Aug-07

Apr-07

Jun-07

Jan-08

Mar-08

Feb-08

Oct-07

Dec-07

Nov-07

Jul-07

Sep-07

Aug-07

Apr-07

Jun-07

350

May-07

0.0

0 May-07

There are four pages of data charts in this dashboard. The first shows a single Trust against all the metrics over time. This has the South East Coast total on it as a comparator.

Falls (per 10,000 admissions)

700

Complaints (per 10,000 occupied beddays)

80 70

600

250

60 500 200

50 400

Safer Smarter Nursing Metrics - Acute Trust Benchmarking

300

100 200

100

2007/08

2006/07

2004/05

Feb-08

Oct-07

Dec-07

Aug-07

Apr-07

Jun-07

Feb-08

Oct-07

Dec-07

Aug-07

Apr-07

2005/06

A similar web style latest position chart is also available

MRSA (per 10,000 admissions) SURREY

150

Jun-07

We have also produced a converse set of charts which shows all Trusts for one metric. Again this has the South East Coast rate on each chart as a benchmark position. SUSSEX

KENT

40 40

Frimley Park

Ashford & St. Peter's 35

Brighton & Sussex 35 University Hospitals

Dartford & Gravesham

East Sussex

East Kent Hospitals

Complementing this there is a web chart showing the latest position for each of the metrics.

Safer Smarter Nursing Metrics

C-Diff (per 1,000 admissions)

Queen Victoria

A M p r-0 a 7 Ju y-0 n 7 Ju -0 Au l-0 7 S g-07 e 7 O p-0 N ct-0 7 ov 7 D -0 e 7 Ja c-0 Fe n-0 7 M b -0 8 a r- 8 08 40

Royal Surrey County

Royal West Sussex

Surrey & Sussex

A M pra 0 Ju y-07 n 7 J -0 A ul- 07 u S eg -07 O p -07 N ct-07 o D v-07 ec 7 Ja -0 Fe n -07 M b-08 ar- 8 08

A M pr- 0 a Ju y-07 n 7 J -0 A u l-0 7 u Se g-07 O p-07 N ct- 07 o D v-07 ec 7 Ja -0 Fe n-07 M b -0 8 ar- 8 08

A p M r-0 a 7 Ju y-0 n 7 Ju -0 7 A u l-0 7 S g -0 ep 7 O -0 c 7 N t-0 ov 7 D -0 e 7 Ja c-0 7 Fe n-0 8 M b -0 a r- 8 08

Ashford & St. Peters

07 -0 7 -07 07 -07 -0 7 -07 -0 7 -07 -0 8 -0 8 0 8 p r- y n l- g p ct v c n b arA Ma Ju JuAu Se O No De Ja Fe M

15 35

Worthing & Southlands

07 0 7 -07 07 -07 -0 7 07 -0 7 -07 -0 8 -0 8 0 8 p r- y- n ul- g p ct- v c n b arA Ma Ju J Au Se O No De Ja Fe M 40

Maidstone & Tunbridge Wells

Medway 35

10 30

A M pr-0 a Ju y-07 n 7 J -0 A uul- 07 S g -07 e 7 O p -0 N ct-07 o D v-07 e Ja c-07 F n -07 e M b-08 ar- 8 08

0 20

A M p r-0 a Ju y-0 7 n 7 J -0 A uu l-0 7 S g -07 e 7 O p -0 N ct-0 7 o D v-0 7 ec 7 Ja -0 Fe n-0 7 M b -0 8 a r- 8 08

A M p r-0 a 7 Ju y-0 n 7 J -0 A u l-0 7 u S g -07 e 7 O p -0 N ct-0 7 o D v-0 7 e Ja c-0 7 Fe n-0 7 M b -0 8 a r- 8 08

A M p ra 0 Ju y-0 7 n 7 J -0 A uu l-0 7 S eg -07 O p -0 7 N ct-0 7 o D v-0 7 e Ja c-0 7 Fe n-0 7 M b -0 8 a r- 8 08

A M pr-0 a 7 Ju y-0 n 7 J -0 A uul- 07 S eg -07 7 O p -0 N ct-07 o D v-07 e 7 Ja c-0 F en -07 M b-08 ar- 8 08

A M pr-0 a Ju y-07 n 7 J -0 A uul- 07 S g -07 e 7 O p -0 N ct-07 o D v-07 ec 7 Ja -0 F n -07 e M b-08 ar- 8 08

A M pr-0 a Ju y-07 n 7 J -0 A uul-07 S g -07 e 7 O p -0 N ct-07 o D v-07 ec 7 Ja -0 Fen -07 M b-08 ar- 8 08

This is of course just a start. Looking at the initial data, we need to work with local organisations to make sure that the data makes sense, looks correct and that all information is to the agreed definitions and therefore comparable.

60 Worthing & Southlands

Brighton & Sussex University Hospitals

50 40 Surrey & Sussex

Dartford & Gravesham

30 20 10

Royal West Sussex

East Kent

Royal Surrey County

East Sussex

Queen Victoria

Maidstone & Tunbridge Wells

Frimley Park

Medway

We will maintain monitoring using this dashboard for the future, extracting the HCAI data from the HPA data capture system, and using a monthly spreadsheet from each Trust to upload the rest of the data. The majority of this data will come from clinical risk systems such as Datix and Safeguard â&#x20AC;&#x201C; this is a departure from the use of HES and SUS and since the data is collected and used locally we hope it will allow us to track trends effectively across South East Coast. The work described above is acute focused, however further work is going on at the moment to produce similar metrics for community services. This will provide us with the opportunity to widen the scope of the project from just nursing and will include many of the community clinical services such as community specialist nursing, podiatry, speech & language therapy, and others. Initially we will work to replicate the majority of the acute indicators for community based inpatient units, then wider community services will be looked at. If you would like more information or would like to get involved with this programme, please contact myself (adam.cook@southeastcoast.nhs.uk) or Pauline Smith (Pauline.smith@southeastcoast.nhs.uk) As ever, these tools are available to download from the Knowledge Management website!

Do you have something you would like to contribute to Knowledge Matters? Please contact us!

Knowledge Matters

Page 15

Page from the patch - Specialised Commissioning Group By Stephanie Newman, Director of Specialised Commissioning The South East Coast Specialised Commissioning Group (SECSCG) commissioning specialised services on behalf of the 8 PCTs in Kent, Surrey and Sussex covering a population of approximately 4.3 million. The aim of SECSCG is to ensure that high value, low volume services are commissioned and procured from providers that have the specialist people, equipment and skills to manage rare conditions, which are safe for patients and cost effective for PCTs. The strategic goal is to enable seamless services to complement activity purchased by PCTs in local service providers, allowing patients to receive the treatment they need in an appropriate setting or part of shared care arrangements. We currently commission services from a wide number of tertiary centres, either through tertiary contracts or consortia arrangements. The majority of the specialised services providers for SEC are in London and therefore, the SCG is mindful of access to these services. This is especially the case for the deprived communities or those with higher proportions of the elderly. We evaluate the potential for Specialised Commissioning Portfolio services that could be provided within SEC or Type Number of arrangements Value 2008-2009 where shared care arrangements could be Consortia & Supra Consortia 22 £85,494,000 2 £14,893,000 developed without compromising patient Mental Health SEC Ambulance Service 1 £124,410,000 clinical outcomes. Tertiary Contracts

£164,588,000

The Carter Report which was published in 2006, details the direction of travel for Specialised Commissioning Groups in England. The report states that commissioners should be able to demonstrate that optimum health benefit is achieved from the services commissioned for their population. The Report had 31 recommendations and we used these recommendations as the foundation for our strategic plan. The Carter Report recommended that Specialised Commissioning Groups should formally designate providers for specific specialised services. Designation will be based on a nationally agreed set of patient centred, clinical service, quality and financial criteria and be reassessed every five years. Designation will safeguard patient access to high quality, cost effective services and prevent unsafe/and or unplanned proliferation of services. Each SCG has agreed to take the lead on a couple of specialised services and to draw up a set of comprehensive national standards where they do not already exist. We will be leading on positron emission tomography (PET) and spinal cord injury services for adults & children. We have a work programme for the development of a number of specialised service strategies. These include: Burn Care Cardiac Services Cystic Fibrosis Hepatitis C Haemophilia Lysosomal Storage Disorders Neurology and Neurosurgery Newborn Screening Pulmonary Hypertension Radiotherapy Services Spinal Cord Injury Paediatric & Congenital Cardiac Services

Children’s services HIV/AIDS Mental Health Perinatal Services Rare Cancer Services

Cleft lip and palette IVIG (Therapeutic immunoglobin) Morbid Obesity Services PET/CT Scanning Renal Services

It is difficult to accurately predict future innovations in the area of specialised healthcare that will form part of the SECSCG portfolio in the long term. However, there is considerable amount of research that is currently being undertaken that would impact on the services commissioned by the SCG. The areas of research and innovation that have potential to significantly change clinical practice are: • Robotic surgery • Gene therapy • New novel molecules to treat different diseases • Identification of tumour markers to enable more individualised treatments • Development of diagnostic technologies to monitor response to treatment • Health proofing through screening services • Harnessing of technology to provide more cost effective services The SECSCG will continue to horizon scan so that PCTs in South East Coast are kept informed of potential innovations, which will have an impact on activity, expenditure and patient outcomes. If you would like further information on the work we undertaken, have a look at our website www.secscg.nhs.uk or alternatively contact Jackie Chamberlain on 01903 708453, email: jackie.chamberlain@secscg.nhs.uk.

Is there something that you wish you knew more about? To suggest future topics for knowledge matters contact the team

Knowledge Matters

Pag Page 16

Risk Prediction in Sussex with Colin Styles, Information Architect, Sussex HIS An emerging technology is using Data Mining tools to find patterns in data, and use this to predict future activity. One common health application is to use Data Mining to predict risk of patient admission in the coming year, based on historical events. Although there are off-the-shelf tools to achieve these, these can be costly and they are not tailored to nuances of the local Sussex dataset, nor to answering specific local questions. Over the past year, we have also developed an in-house data mining model. It was initially planned simply to use this to benchmark the predictive power of off-the-shelf tools. However, a statistical analysis by East Sussex Public Health department revealed our in-house tool to be as good as, if not better than, third party tools at predicting admissions in East Sussex!! (For the statistically minded our model has a PPV score of 34.1% for top 1% of population and an ROC curve area value of 81.5%). Called SPOKE (Sussex Predictor of Key Events), our model uses the Correlation of predicted vs actual admissions: SQL server analysis services Data Mining algorithm. It predicts risk of unplanned chronic admission for each person in Sussex, based on Actual % of Patients Admitted their demographics, acute hospital (3 years I/P plus one year O/P Predicted % of Patients Admitted and A&E) and community activity history.

100

The model has a number of potential uses, for example:

•

• •

to help identify specific high-risk patients in a GP practice, eg as the basis of a Community Matron caseload; to understand the ‘variables’ that increase risk of admission – eg smoking status, previous admission history; to understand the Sussex population and overall level of risk, and to model how this will vary as the population structure changes in the future.

The model is based on the ‘Neural Network’ Data Mining algorithm, and the University of Brighton have agreed to work with us to review our model with a view on commenting on how this can be further improved.

Using SPOKE to identify key influencing factors:

One feature of the model is that it is relational and therefore allows us to feed in additional events as they become available to us, thus improving the model’s predictive power further. For example, subject to Information Governance arrangements it is also planned to incorporate Mental Health and Primary Care activity, to further improve the model’s accuracy. We hope that by using SPOKE, PCTs within Sussex will be able to provide targeted care to prevent patients at risk of readmission from needing to be admitted. I would be really interested to hear from others undertaking this type of modeling work to see what we can learn from each other. If you would like to know more about SPOKE, please do get in touch with me (colin.styles@sussexhis.nhs.uk) We are more than happy to share our approach and learning with others! Do you have something you would like to contribute to Knowledge Matters? Please contact us!

Knowledge Matters

Page 17

What is a ROC curve?? Graham Evans - Head of Public Health Intelligence NHS East Sussex Downs and Weald NHS Hastings and Rother Working on a project to assess the accuracy of using a predictive model to identify risk patients was my first experience of ROC curves.

high

So what is an ROC curve I hear you whisper? Well it’s not an illustration of the rise and fall of the popularity of Guns ‘n Roses, although they are making a come back at the moment. Now you’d think that ROC would stand for some fancy Greek sounding statistical term, but it stands for the disappointingly named Receiver Operating Characteristic. Welcome to the jungle of statistical tests, where if you have a little patience, I’ll briefly run through the sweet child o’ mine that is the area under the ROC curve. The predictive model that we were asked to look at was one that allocated a risk of an unplanned admission for a chronic disease event in the following year to each individual registered with a practice. I won’t run through the ins and outs of predictive modeling here, I’ll leave that to my Michelle or Mr Brownstone (I’m running out of song references now!). We took the risk scores allocated to each individual patient and looked to see if they were actually admitted the following year. We looked at those identified in the top 1% of the population in terms of highest risk to see what proportion were actually admitted. This is called the Positive Predictive Value (PPV) and is useful in testing the accuracy of a model at predicting patients with the highest risk of admission. However as the predictive model allocates a risk score to each individual patient, its important to look at the whole distribution of risk scores i.e. those identified as low or medium risk to test the accuracy of the model across the whole population. To do this, we can use the area under the ROC curve. To create an ROC curve you plot sensitivity (the true positive rate) against 1 – specificity (the false positive rate) at lots of cut-offs across your population. If your model is useless at predicting an admission then the area under the curve will equal 0.5 (the straight line in the figure shown). Essentially you are looking for a curve when you plot the points, so the bigger the bulge the better. An area of 0.7 is a reasonable result, 0.8 very good and 0.9 superb. The example in the figure showed an area of 0.81. We used SPSS to draw the ROC curve and calculate the area under the curve. You can compare the area under the ROC curve if you want to compare models. So that was my very quick tour round the Paradise City that is the ROC curve and I’ll leave you with the scary thought that the classic album Appetite for Destruction by Guns ‘n Roses is now 21 years old!

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Pag Page 18

In the Post Bag

Dear Mr O’Tority

Sleepy Time

Year

We have also applied SPC to the present delivery errors which have resulted in Delivery to “Off List” recipients (Graph 3). We have been able to attribute Breaches of the UCL and some near misses to when Mr Blitzen was acting as navigator, you may consider a change from the traditional “instinctive” navigation system to more modern equipment.

Blitzen

Delivery Errors (deliveries to “Bad”)

Time Taken for Delivery

% of Children with average yearly behaviour of “Good”

We have had a look at the data you have supplied and have a few suggestions on some areas you may want to look at. We have analysed your procedure document and understand Graph 1, Seasonal Goodness trends that you make a list and check it twice. Your current production Forecast Based on current methodology forecasts are created at the beginning of the year and are then not 100% checked against actual requirements until the delivery date. We have analysed the data you provided us have noticed that there is a 50% seasonal trend that would affect your forecast requirements (graph Actual 1). We would recommend that you initiate a process of monthly updates using an “annualisation” method to adjust your forecast 0% requirements so that you can adjust your production capacity JFMAMJJASOND accordingly. Dancer We have also applied Statistical Process Control (SPC) to Graph 2, yearly delivery time analysis your delivery times over the last 12 years (graph 2) and have noticed that there appears to be a concerning number of breaches of the upper control limit when Mr Wakey Time Upper Control Dancer is in charge. This area warrants further investigation and techniques such as cusum could be applied. Graph 3, Delivery Errors

Upper Control Lower Control

Time Taken for Delivery

Graph 4, Adverse events

Year

Rudolf

Adverse Events (Spotted/stuck in chimney)

Our final area of analysis was the adverse events monitoring. We have noticed that whilst on the whole the likelihood of an adverse event is proportional to the time taken for delivery, there is an outlier in the deliveries involving Mr Rudolf. We suspect that this may be attributable to Mr Rudolf’s unconventional hi-visibility attire rather than his delivery abilities. We hope this helps!

Knowledge Management Team

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News New Operating Framework and Vital Signs Guidance The Operating Framework for 2009-10 has now been published and is available on the Department of Health website. The refresh planning guidance package, which includes the technical guidance and spreadsheet version of the templates has now been loaded onto Unify. There is a link to this from the Unify front page which is located in the Unify2 forum, in the Resources section of Vital Signs 2009-11. If you have any queries on Vital Signs, there is a forum on the Knowledge Management website. It is likely that other people will have the same queries Christmas Timetables The Christmas Timetables for 18 Weeks PTL, Audiology PTL, Daily Sitreps, Weekly Sitreps and GP Extended Hours have now been published on Unify2. For both the 18 weeks and Audiology PTLs, returns covering data for week ending 21st Dec will need to be submitted by providers by close of play on 2nd Jan and signed off by commissioners by close of play the following Monday (5th Jan). No PTL is required for week ending 28th December. The weekly sitreps for 15th -21st December and 22nd – 28th December should both be submitted by close of play on 31st December, although the return for week ending 21st can be submitted earlier. Daily sitreps covering the period from 8am 22nd December to 8am 29th December should be submitted in one return on the 29th. There will be no sitrep on New Year’s Day – information for that day will be covered in the 2nd Jan sitrep. Sitreps should be submitted as normal on 30th and 31st December. The census date for the GP Extended Hours return has now been reset to 22nd December; however PCTs can enter data prior to that if they are confident the numbers will not change before the 22nd. Data Timeliness Since June 2008, the Department of Health have been monitoring timeliness of a number of data returns on Unify2. Reports have been published on the Unify website, with organisations being given 1 point for a late submission and 2 points where returns were more than 3 days late. This could also become part of the Annual Health Check in the future. The timetable for returns can be found in the forum on Unify2. World Class Commissioning Data Pack The NHS Institute, working in partnership with NHS South East Coast and CHKS, have developed an online tool to interrogate indicators for World Class Commissioning and the Next Steps Review pathway. The system is now live and can be accessed at www.institute.nhs.uk/wccdatapack . Delegates for the Turning Data into Information for Improvement programme should already have been provided log-ins; use the e-mail address on the front page of the website to request a log-in if you don’t already have one. Another informative IM&T publication Our attention was recently drawn to another highly informative newsletter that has been published on a bi-monthly basis for some years. The ‘Go Between’ is edited by the Head of IM&T at South West London and St George’s Mental Health Trust in London. Current and back issues are available to download from the ASSIST website http://www.bcs.org/server.php?show=ConWebDoc.13667

Page 19 18 Weeks It is likely that Audiology data will be published in January, so organisations need to ensure that they resolve any issues with their data completeness in line with the letter sent out recently. The 18 weeks HCC indicator is still to be finalised but it is likely that Trusts will need to meet their data completeness measure in order to achieve 18 weeks – so even if an organisation has good 18 weeks performance they could fail this indicator by having poor data completeness. Please let us know if you think your data completeness methodology needs to be adjusted. SUS release 4 has been delayed – a new date for this should be set in January. Organisations still need to ensure, however, that they migrate to CDS 6 which will enable SUS to be used to its full capability in 18 weeks reporting. Patient Experience Tool Updated The Department of Health has recently developed a 'Patient Experience First Steps Diagnostic Tool' to aid understanding of data from the national patient survey programme. The overall aim of the tool is to help organisations make sense of the large volume of patient experience data available, and be able to easily identify areas where they can improve the experience of their patients. The tool can be used in a variety of ways to meet performance and improvement requirements. For example, NHS trusts and PCTs can track their own performance over time, benchmark their results against similar organisations, inform local improvement activities (including Local Delivery Plans) and monitor the impact of these activities on patient experience. The tool can be downloaded from the Department of Health's website. Commissioning wiki launched A commissioning wiki (supported by the National Library for Health) is being developed by information professionals, pooling knowledge of resources and sharing good practice so that knowledge and library service professionals can better support NHS staff involved in commissioning health services. There is no need to log in to the wiki - simply browse through the list of chapter headings on the contents page, or read the Introduction. From both of these pages, you will be able to access the rest of the handbook http://commissioning.pbwiki.com/ Data Completeness In response to a number of queries, the DH have decided to share the calculations behind the September ready reckoners and data completeness indicators. These can be downloaded from the new RTT publication website: http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics /Performancedataandstatistics/18WeeksReferraltoTreatments tatistics/index.htm Healthcare Commission Update The deadline for requests for review of the 0708 AHC has now passed. Final decisions on these will be made by mid March. The scoring system for the 0809 AHC is being finalised and will be made available via the Healthcare Commission website once it has been signed off.

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Pag Page 20 New Team Member Hi everyone! My name is Aleksandra. I took up the role if workforce information support analyst at the end of November. I recently graduated from Royal Holloway where I studied Environmental Sciences. During my course I developed many useful skills in this in the analysis and interpretation of complex datasets. While looking for opportunities to make a good use of my skills, quite unexpectedly, I found the NHS to be one of the places where people with numerical or analytical skills are in demand. Now, I am here and I wonder how I have managed to work with Excel for years and SURVIVE all this time without a… …LOOKUP function?!

STOP PRESS……. National Library for Health Specialist Library launched

Commissioning

The Commissioning Specialist Library (CSL) was recently launched. The CSL is free, and aims to be a one-stop shop providing timely and efficient access to high quality information resources for all those involved in commissioning for health and wellbeing. It endeavours to include the best available evidence, examples of good practice, policy and data to support world class commissioning. Learn more in the next edition of Knowledge Matters or visit the following site. http://www.networks.nhs.uk/news.php?nid=2461

Knowledge matters is the newsletter of NHS South East Coast’s Knowledge Management Team, to discuss any items raised in this publication, for further information or to be added to our distribution list, please contact: Knowledge Matters C/O Knowledge Management Team NHS South East Coast York House 18-20 Massetts Road Horley,Surrey, RH6 7DE Phone: 01293 778899 E-mail: Knowledge.management@southeastcoast.nhs.uk To contact a team member: firstname.surname@southeastcoast.nhs.uk

Christmas Quiz Following the Success of last year we have decided to once again put together a Christmas quiz! The quiz will test your knowledge of the KM Team, see how much you have remembered from previous issues and challenge your 1 googling skills. th

The Quiz will be available from Friday the 19 of December Follow the link below to access it ! http://www.surveymonkey.com/s.aspx?sm=kXef98OSH1lkAp RR8kndVQ_3d_3d As always there will be a fabulous prize for the winner! 1: Other search engines are available

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