Volume 3 Issue 6 February 2010 Welcome to Knowledge Matters Hello everyone and Happy Chinese New Year! We’ve got a great range of articles for you this issue from the National Audit Office, NHS Information Centre, Department of Health and of course the Quality Observatory! Since the last issue, the Innovation and Improvement Taskforce have awarded funding to six bidders—we have made great progress over the past month or so in the specification of metrics to demonstrate progress made for each bid and for some bids, the provision of analysis to demonstrate a baseline. An update on the regional innovation fund appears on page 14 and in future issues of Knowledge Matters we will be covering in detail each of the bids describing their aims, agreed measures and progress. The Department of Health have made a series of short films demonstrating excellent clinical practice which has improved quality and at the same time provided a more efficient service. I am pleased to announce that one of these films focuses on the excellent short stay hip replacement programme led by Mr Hugh Apthorp (one of our successful bidders). If you would like to learn more about Mr Apthorp’s practice, the film can be viewed (and downloaded) from the Department of Health website. Here’s the link http://www.dh.gov.uk/en/News/Media/DH_112226 Since the last issue, I have set up a blog. I intend to update my blog every two weeks and update my followers on our progress and our short term plans. So, if you can’t wait for Knowledge Matters, follow my blog! I currently have 4 followers (myself, my Dad, Kate and Adam), but hopefully after this edition of Knowledge Matters I will have lots more!! :-) Here’s the link to my blog http://samrileysqualityobservatory.blogspot.com/ We have also established a Twitter account to notify our followers of new products and updated products—so follow our Twitter account (secshaQO) if you want to keep up to date with the many new products developed by the Quality Observatory!
Inside This Issue : The Tackling Demand Together Toolkit
2
Stroke dashboard updated
5
Skills Builder—Turning cross tabs into lists
10
A quantum leap in mental health data
3
Improving dementia services -an interim report
6
Better Care, Better Value
12
A Busman's Holiday……...
4
3
- Indicators update
A : Ask an Analyst
8
Best Practice Tariffs - an Introduction
Quality Account Indicators
9
Regional Innovation Fund update 14
http://nww.sec.nhs.uk/QualiityObservatory
13
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What can the new ‘Tackling Demand Together’ Toolkit do for you? By Clare Sandling, Section Head, Ambulance Policy Did you know that ambulance services across England are experiencing a huge 6.5% year on year increase in demand, which costs around £60m extra annually? Providers, commissioners and analysts have put their heads together with the Department of Health to produce an exciting new toolkit that helps explain why ambulance trusts are seeing such a massive increase in demand year on year, and what that tells us about wider urgent and emergency services. The holy grail for the NHS in the coming years is to make efficiencies whilst at the same time improving quality. This toolkit shows how the urgent and emergency care sector is an area where this is a realistic possibility. The toolkit is packed with concrete analysis on the factors influencing ambulance demand, including seasonal factors, social attitudes, deprivation and demographic change, and how some of these can be addressed through provision of alternative high quality, accessible urgent care services. The tookit includes 3 new tools which PCTs and trusts can use to plug in local data, to calculate cost savings of changing the balance of their service provision, to benchmark between PCTs, and to calculate the impact of demographic changes in their local population. The toolkit is interactive and includes question sheets and ‘action grids’ for providers and commissioners to work through in relation to the different factors. The toolkit shows that 75% of the rise in ambulance demand is attributable to just 4 conditions – falls, breathing problems, unconsciousness/passing out, and chest pain (London data). These could be linked to common areas such as long term conditions, alcohol misuse and older peoples services, showing that a focus on providing better prevention and management of those areas could potentially reduce the number of ambulance calls. The toolkit also showed that 43% of patients taken to A&E by ambulance were discharged without being admitted, and 2/3 of those did not require follow up (HES data). Although we have to be careful not to judge that all of those patients did not need to attend A&E, it seems likely that many could have been treated closer to home. As a commissioner or provider in the NHS I hop that you will find that working through the toolkit helps your organisation to:
• • •
understand and analyse the rising demand for ambulance services in your area by looking at these different factors improve your provider/commissioner working relationships through addressing shared problems together better understand how commissioning integrated urgent and emergency care services can reduce 999 demand and create efficiencies.
The toolkit “Tackling demand together: A toolkit for improving urgent and emergency care pathways by understanding increases in 999 demand”, was launched by David Nicholson, Chief Executive of the NHS, at the Ambulance Service Network’s ‘Emergency and Urgent Care: Today and Tomorrow’ event on 13 October 2009. Commissioners and providers across the country are already making use of the toolkit, and the Emergency Care Intensive Support Team (ECIST) has been encouraging local trusts to use it on their visits, and it complements the materials produced as part of the Emergency Services Review in summer 2009. This is not a Department of Health document – this is a toolkit was developed by a team of providers and commissioners, people with first hand knowledge about transforming services locally. I hope you will find this toolkit is of real, concrete use to you in the challenge of making urgent and emergency care services more efficient and more suited to local needs. The Tackling Demand Together toolkit, which is an interactive PDF tool, can be found at: www.dh.gov.uk/en/Healthcare/Emergencycare/Modernisingemergencycare/DH_4063824
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A quantum leap forward in mental health data By Jo Simpson, Senior Project Manager, Mental Health & Community Care Team The NHS Information Centre’s latest release of annual statistics from MHMDS annual returns in November 2009 was received with enthusiasm. Dr Veena S Raleigh of The Kings Fund commented ‘The MHMDS is a quantum step forward in terms of mental health data….’ and a recent report from CQC on monitoring ethnicity amongst mental health inpatients highlights that ‘The Information Centre’s recent report on access to community and inpatient services by various demographic characteristics, including ethnicity, illustrates the wealth of information that is available to providers and commissioners of services.’ The NHS Information Centre is now providing information from the MHMDS in a variety of formats and covering an increasing range of topics. The annual release now consists of: • Mental Health Bulletin: Third Report from MHMDS annual returns, 2004-2009 available from http://www.ic.nhs.uk/ pubs/mhbmhmds0809. This bulletin includes national statistics about working age and older adults accessing NHS secondary mental health services, including inpatient, outpatient and community services. • MHMDS Online – http://www.mhmdsonline.ic.nhs.uk This web site presents most of the same analyses broken down by provider / commissioner trust and with some SHA / peer group comparisons using a graphical interface • MHMDS Data Tables -http://www.ic.nhs.uk/pubs/mhbmhmds/dd Trust and SHA level results to download as Excel spreadsheets. The November publication included five years information (up to March 2009) about the number of people in contact with NHS secondary mental health services and the number who are detained in hospital or on CPA, as well as volumetrics about inpatient, outpatient and community service activity. It also introduced some new analyses for 2008/09 covering: • Rates of access to mental health services by different combinations of characteristics (age, gender, ethnic group) and different geographies – SHA, PCT, plus PCT peer group comparisons. • Experimental statistics about Supervised Community Treatments • Information about people on CPA aged 18-69 – the denominator group for National Indicators 149 and 150 covering accommodation and employment (see chart below). Now that a regular flow of MHMDS has been established the NHS IC is also publishing routine quarterly MHMDS reports, which include data quality reports and the provisional Service Performance Indicators, that are being developed as part of the DH’s Performance Framework for mental health trusts. These can be downloaded here: http:// www.ic.nhs.uk/services/mhmds/ quarterly . The NHS IC has been working with provider trusts to make it easier for them to interrogate their MHMDS submissions earlier in the data flow. The IC is also supplying PCTs with record level MHMDs data on request. This is making much more timely information available to the service. Used together with the Adult Psychiatric Morbidity in England, 2007 survey (http://www.ic.nhs.uk/pubs/ psychiatricmorbidity07 ), which was published last year, the MHMDS is the key source of information for defining the characteristics of people who use specialist mental health services and understanding local needs. MHMDS will also be the data source for currencies for payment by results for mental health and the Advance Notification for these changes was published at the end of last year (http://www.connectingforhealth.nhs.uk/dscn/dscn2009/advance/an0609.pdf ). Information from MHMDS will also be published on Neighbourhood Statistics for the first time in March 2010. For further information please contact enquiries@ic.nhs.uk.
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A Busmans holiday……. By Katherine Cheema, Specialist Information Analyst
In early December 2009 I went on holiday. I went on holiday with my boss, perhaps not the most usual approach to leisure time, but as she was paying, who was I to argue! Samantha and I indulged in a working holiday, in Orlando USA, to experience the Institute of Healthcare Improvement’s National Forum. And what an experience it was! It’s a mammoth event, with over 5,000 delegates, 78 workshops and four keynote speakers, so you can imagine how overwhelming it was to step through the doors into such a throng. But every session was more engrossing and inspiring than the next, with keynote sessions that took the whole room on an intellectual, and occasionally, emotional journey. I attended four workshops in total. One was particularly interesting, detailing the methods employed by one small healthcare provider to dramatically decrease their mortality due to severe sepsis and septic shock. One of the most compelling aspects of this particular presentation for me was the simplicity with which the project utilised their information to tell a story, that not only convinced a room full of conference delegates that something needed to be done, but also a hospital of clinicians. There was no standardised mortality ratio, no confidence intervals or even any benchmarking; just a simple tale of what the problem was, plotted over time to see how the interventions they implemented affected their key outcome (mortality). You can see how straightforward it was (although obviously, we’d advocate removal of the grey background!). This really underlined for me, not just how important good information is to any improvement project, but how crucial it is that this is accessible to every person who has a stake in the improvement, including the patient. . I know that I am an analyst whose primary interest is data (some might call me a bit geeky….), but I must say that over the past year or so, the importance of story telling has had a significant impact on me. If we start with a story which we can back up with high quality, well presented analysis and tools which are meaningful to front-line staff, this has much more impact and utility for our audience. In term this should of course have a positive impact of the quality of care delivered to patients. If any further proof of this were needed, the enormous exhibition hall provided it in abundance with examples of work undertaken across the USA and internationally (including a few NHS examples) to improve the care of patients. The good, the bad and the downright ugly in terms of appearance of information were on display, but the most powerful examples of improvement projects were always accompanied by excellent standards of presentation of relevant data. It struck me that measurement is much more embedded in health systems within the USA intending to make changes and improvements within and across organisations than the NHS—this is an something which the Quality Observatory has been trying to encourage over the past few years, however I do feel that we still have a long way to go! I was struck at every turn how enthused everyone was; although, being English, I declined from joining in the occasional cheers from the floor. Still, it was inspiring to find so many people unashamedly passionate about making healthcare better for their patients, and for the nation as a whole. Obviously the healthcare reform that the USA government is currently considering gave the majority of delegates particular food for thought and perhaps one of the most powerful messages I was able to take away was that whilst our healthcare system is by no means perfect, we have a moral, not just a legislative, obligation to ensure that it is equitable and of the highest quality for each and every individual. We were reminded that healthcare itself has no intrinsic value; that good health, happiness and wellbeing is what matters and that “the best health care is the least health care that we need”.
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A Busmans holiday……. Samantha’s reflections…. I’ve been lucky enough to a couple of IHI forums previously and have found them really inspirational. 2009 wasn’t a great year for me, so I decided that something inspirational was in order! Orlando (and Mickey Mouse) beckoned! The conference was truly inspiring and I think gave myself and Kate lots of ideas about how we could more usefully support the NHS audience in South East Coast with informative and useful analysis to support improvement. I very much agree with Kate’s reflections that measurement appeared to be much more embedded in the US health systems that we witnessed and the importance and power of story telling. The session that had the most impact on me recounted the experience of a hospital who had for some years received awards for the quality and safety of care provided to patients, but over a relatively short period of time experienced a significant decline. In terms of the indicators that they reviewed on a regular basis to monitor this, they were not very different to those monitored by the Quality Observatory on our Quality Dashboard (updated quarterly). The key learning for the hospital in question was that the leading indicators for review prior to quality indicators demonstrating a decline were workforce indicators (sickness absence and turnover). We are now reviewing our monitoring to ensure that it covers the key indicators which mark a decline in service provision quality. It was a great trip to Orlando. In addition to learning lots, both myself and Kate were able to add to our shoe collections…!
Stroke dashboard update By Simon Berry, Specialist Information Analyst The stroke provider dashboard has now been updated to the end of Q2 2009/10. A problem had been found with previous versions of this analysis which is associated with a national HES data cleaning rule that meant that for certain hospitals significant numbers of patients were excluded, this issue only appeared when patients had in excess of 1 consultant episode in their hospital spell. The Information Centre have acknowledged this issue and are keen to resolve it, however this is likely to take sometime. In the meantime, I have managed to create a work-around for this and I am confident that the analysis now includes >99% of stroke admissions. Ashford & St Peters Hospital Trust Stroke Dashboard - All Patients - ICD10 I61, I63 & I64 ASU RSU CSU
T Phase 1 Sentinel 08 vs 06 Phase 2 Sentinel 08 vs 06
M
Mortality
% Patients With CT Scan / MRI Scan
35%
160 30%
25% 120 100
20%
80
15%
Length of Stay (Days)
% Discharge Destination
100%
100%
90%
90%
80%
80%
70%
70%
60%
60%
50%
50%
40%
40%
30%
30%
30 UPR
CH / NH
Other Hosp
Died
All LoS UPR LoS Nat All LoS
Other
25
140
Nat All LoS UPR
20
15
60
10
20% 5%
20
10% 0%
Total Value of Activity 000's £800 £700
7 Day
30 Day
Nat 06/07 7 D
Nat 06/07 30 D
CT Scan 01 Target
0%
Average Value per Spell £6,000
60%
£5,000
50%
£4,000
40%
£3,000
30%
£2,000
20%
£1,000
10%
£0
0%
20%
5
10% 0%
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 08/09 Q1 08/09 Q2 08/09 Q3 08/09 Q4 09/10 Q1 09/10 Q2
0
CT Scan
0
% 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 08/09 Q1 08/09 Q2 08/09 Q3 08/09 Q4 09/10 Q1 09/10 Q2
40
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 08/09 Q1 08/09 Q2 08/09 Q3 08/09 Q4 09/10 Q1 09/10 Q2
10%
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 08/09 Q1 08/09 Q2 08/09 Q3 08/09 Q4 09/10 Q1 09/10 Q2
Previously it was possible to exclude the diagnosis code I60 – Subarachnoid Haemorrhage from the analysis using a check box at the top of the page, this has been expanded to mirror Vital Signs and now selecting the check box also excludes I62 Other Nontraum atic Intracranial Haemorrhage.
Exclude ICD 10 Codes I60 & I62
Admissions 180
•
B
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 08/09 Q1 08/09 Q2 08/09 Q3 08/09 Q4 09/10 Q1 09/10 Q2
In response to feedback from the patch I have also made the following changes to the dashboard –
Most Recent 100 Patients Run Chart 250 Alive
Died
Unknown
Mean 18.9
UCL 79.8
200
£600 £500 Days
150
£400
100
£300 £200 £100
50 Site National
31/10/09
28/10/09
21/10/09 26/10/09
06/10/09 14/10/09 15/10/09 16/10/09
01/10/09
23/09/09 24/09/09 25/09/09 28/09/09 29/09/09
19/09/09
15/09/09
05/09/09 07/09/09 09/09/09 11/09/09
03/09/09
28/08/09
19/08/09 21/08/09 24/08/09
13/08/09
09/08/09
0 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 08/09 Q1 08/09 Q2 08/09 Q3 08/09 Q4 09/10 Q1 09/10 Q2
£0
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 08/09 Q1 08/09 Q2 08/09 Q3 08/09 Q4 09/10 Q1 09/10 Q2
The drop down box for selecting All Patients / Patients <= 75 years of age has been modified to All Patients / Patients <=80 years of age
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 08/09 Q1 08/09 Q2 08/09 Q3 08/09 Q4 09/10 Q1 09/10 Q2
•
Data for Royal West Sussex and Worthing & Southlands has now been merged under West Sussex Hospitals Trust, the individual sites are still selectable to see differences site to site. The dashboard is available for download from the Quality Observatory website, feel free to contact me with any questions or suggestions you may have for future development of this dashboard. I would love to hear from you! Simon.berry@southeastcoast.nhs.uk
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Improving Dementia Services in England — an Interim Report By Karen Taylor, Director of Health Value for Money Audit & Shamail Ahmed, Audit Principal, Health Value for Money Audit The National Audit Office’s 2010 report into dementia care found that the Department of Health has developed an ambitious and comprehensive strategy for dementia, but there has not yet been a robust approach to implementation and there is a strong risk that value for money for dementia care will remain poor. In our first report on this subject, in July 2007, we reported that dementia services in England were not providing value for money to taxpayers. This report was the subject of a Committee of Public Accounts (PAC) hearing in 2007 and the Committee’s subsequent January 2008 report concluded that the Department had not given dementia the same priority as cancer and coronary heart disease and it had not therefore seen similar improvements. The Department told the Committee that dementia would now “have its place in the sun” and that it was now a national priority and, in particular, that it would develop a National Strategy. Following publication of the National Dementia Strategy Living Well with Dementia, in February 2009, the PAC asked us to report back to them by the end of the year on the extent to which the Strategy addressed their concerns. In January 2010, we published an interim report on progress in improving dementia services, which assessed the Department’s response to the Committee’s recommendations and the robustness of its strategy and implementation plan. It also evaluated the machinery in place to implement the strategy, including whether the right mechanisms are in place to deliver the improvements needed. The strategy, which was developed following extensive consultation, sets out a vision in which people with dementia and their carers are enabled to live as well as possible. It focuses on outcomes: public and professionals’ awareness of dementia; earlier specialist diagnosis and intervention through Memory Services; and higher quality health and social care for people with dementia. The Department estimated that implementation of the strategy would cost an additional £1.9 billion over ten years. However, not all of the objectives were costed; for example, seven of the objectives are being piloted and cost estimates for these objectives will not be finalised until 2011. There was also no estimate of the cost of training NHS and social care staff. Moreover, the 2009 National Framework for Continuing Care and recent legal judgements are likely to mean that more people with dementia will be eligible for NHS-funded care. Implementation costs are therefore likely to exceed the estimated £1.9 billion over ten years. Furthermore PCTs did not have baseline information on extent of demand or costs of services and would not have this information until mid 2010. We consider that the Department’s intention on funding the strategy largely through efficiency savings will be difficult to achieve. The aim of achieving savings through reducing the amount of time that people with dementia spend in hospital, when they no longer have a medical need to be there and reducing premature entry to care homes through providing better support in the community, will require investment in services and support in the community which will take time and be challenging to realise. Through our fieldwork we identified annual efficiency savings of £284 million a year that could be made now. This is, however, dependent on widespread adoption of good practice and PCTs willingness and ability to move funding from the acute sector to other health and social care settings, which has historically been difficult to achieve. In a time of financial constraint this is likely to be even more problematic and the NHS and social care systems face a huge challenge in identifying and releasing the efficiency savings required to implement the strategy. The lack of joined up health and social care planning that we identified will also hamper the release of efficiency savings. We found little progress since 2007 in improving dementia training for health and social care professionals. Almost every healthcare worker will come into contact with people with dementia, but there is no required dementia training for generalist healthcare professionals. Dementia is not included in the core requirements for nursing degrees and there is still no accreditation scheme for dementia training. We found no improvement in GP knowledge and awareness of dementia over the past five years and little progress has been made in bringing together the independent medical schools, universities, training and education bodies to improve dementia training. Most people with dementia will receive care at some point from social care staff such as domiciliary carers or care home staff but often these staff will have received no training in caring for people with dementia, and many will have
Page 7 no qualifications at all. The process of registration of social care staff by the General Social Care Council has been suspended, meaning the quality of care and even the safety of some of society’s most vulnerable adults is being put at risk. The Department has commissioned Skills for Care and Skills for Health to map the training needs of the workforce and the training currently available across. The mapping exercise is expected to conclude in March 2010 and make recommendations to inform the Department’s workforce action plan. Departmental leadership during the strategy’s development was judged as excellent by most stakeholders. By January 2009 the Department had appointed nine Deputy Regional Directors of Social Care with strong health/social care backgrounds. Whilst they have a personal key performance indicator related to implementation of the Strategy, they have no direct performance management role and are expected to achieve change through influence. The PAC recommended in 2007 that the Department should appoint a National Clinical Director to lead on the Strategy and drive its implementation but this was not implemented until January 2010 when two separate National Clinical Directors were appointed for dementia and older people. Empowered local leadership is essential to delivering the transformational change envisaged in the strategy. However, we found that leadership and ownership for improving dementia in local NHS and social care delivery organisations was not yet in place in most places. Few frontline staff could identify leaders who were championing dementia, and few could give examples where the profile and priority of dementia at local level had increased. Our forum and surveys showed that senior clinicians were not yet taking the lead in improving dementia care in their general hospital, and frontline nurses had received no information or leadership about the strategy. Local leadership and buy-in at the frontline will need to be urgently improved if the strategy is to be delivered. Only a third of GPs and one fifth of Consultant Old Age Psychiatrists who are familiar with the strategy believe that it will be successfully implemented within five years. Importantly, in order to drive change, effective mechanisms and levers need to be in place. The main levers for the devolved NHS are described in the NHS Operating Framework. This includes performance management of national priorities (Vital Sign indicators), commissioning for quality, the GP incentive scheme (the Quality and Outcomes Framework), performance metrics for use in benchmarking and regulation. However, improving dementia services has not been given national priority status in successive Operating Frameworks and is not, therefore, actively performance managed. The other levers, meanwhile, are not yet in place or are immature as regards dementia. Overall we conclude that improving services and support for people with dementia lacks the urgency and priority that the Committee of Public Accounts was led to expect and that there is a strong risk that value for money will not be improved within the strategy’s five year implementation plan. Our full report can be accessed on our website www.nao.org.uk alongside a number of additional outputs:
• • • •
an analysis of the Enriched Opportunities Programme; Results of the Old Age Psychiatrists Survey; Results of GP survey; and IpsosMORI report on the results of our online discussion forum
Knowledge Matters available on Knowledge Matters is now published at http://issuu.com/secqo
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Formula auditing in Excel Application: Microsoft Excel 2003 Q- I have just taken over someone else’s spreadsheet and it contains lots of formulae. Is there anything in Excel which can help me break down the formula and show me which cells are linked to it? A- Yes there are a number of tools in Excel which can help you. Formula Auditing can visually help you identify which cells are used in the formula or you can use the Evaluate Formula option which will show a break down of a nested formula for you. We’ll begin with Formula Auditing.
Solution: Complexity 2/5 — Uses Built in Formula Auditing Functions 1. Click on View > Toolbars and ensure that Formula Auditing is ticked. You should be able to see the Formula Auditing toolbar. 2. Trace precedents This option allows you to visually identify the Cells that are being used in the formula of the cell that you have selected. Click on the cell that contains the formula, and then click on the Trace Precedents Icon from the Formula Auditing toolbar. Excel will trace the cell's precedents by drawing a blue arrow from the precedent cell to active cell. In this example cells B6 and B7 are linked to cell B4 and cells D6 and D7 are linked to cell D4. You can trace more than one cell at a time. To remove the arrows simply click on 3. Trace dependants This option allows you to Identify dependent cells. Dependent cells are the cells that use the values of other cells in their calculations. Select a Cell that is being used in a formula, and then click the Trace Dependents Icon on the Formula Auditing toolbar. Excel will draw a Blue Arrow from the Active Cell to the Dependent Cell as shown in the figure below. To remove the trace dependants arrows simply click on
If you are auditing more than one cell and would like to get rid of all the arrows then click on
More information on formula auditing can be found in the excel reference guides section of http://nww.sec.nhs.uk/knowledge
Need help? Something not working right? Why not ask an analyst! E-mail: Quality.Observatory@southeastcoast.nhs.uk
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Quality Account Indicators By Samantha Riley, Head of the Quality Observatory One of the requirements set out in High Quality Care for All, was for NHS Trusts to publish annual quality accounts starting from 2010. Quality accounts will report on the quality of services provided covering the three domains of quality: -
• • •
Safety; Effectiveness; Patient Experience.
The SHA has proposed a collection of indicators under each of these headings for acute Trusts (which have been discussed at the SHA Medical Directors and Directors of Nursing forums) which Trusts may wish to chose to include in their Quality Accounts. By agreeing a common set of metrics with very clearly defined definitions, it will be possible for the Quality Observatory to provide regular comparative analysis to NHS organisations within Kent, Surrey and Sussex. By identifying the variation between different organisations and feeding back regular analysis, we hope to see an improvement against the agreed indicators and a reduction in variation. The measures on offer are: Safety measures • Hospital falls per 1,000 inpatient admissions; • Results of hand hygiene audits; • Rate of complications of medical and surgical care per 10,000 episodes; • Rate of drugs, medicaments and biological substances causing adverse events in therapeutic use per 10,000 episodes; • Incidence of catheter associated UTIs per 10,000 bed days; • Hospital acquired DVT per 1,000 admissions; • Wound infection rates for joint replacement and pelvic surgery; How clean were the toilets and bathrooms you used in the hospital?- national distributions
Trust value
England mean
England UQ
100%
95%
QVH
90%
FPH
85% RWSx
% score 2008
Clinical outcome measures • Emergency readmissions within 28 days; • Risk adjusted mortality (CHKS methodology); • Post MI mortality; • Post stroke mortality; • Unplanned returns to theatre (within spell); • Hip fracture repairs within 48 hours ; • Pressure damage (definition as per Safer, Smarter Nursing Metrics);
D&G
BSUH SASH
80% WASH ESHT RSCH MTW
EKHT MED
75% ASPH
70%
65%
60% 1
3
5
7
9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77 79 81 83 85 87 89 91 93 95 97 99 101103105107109111113115117119121123125127129131133135137139141143145147149151153155157159161163165
Trust number
Patient experience measures • % patients that would recommend the hospital to a relative/friend; • Inpatient survey score - How clean were the toilets and bathrooms used in the hospital; • Inpatient survey score - Did you have confidence and trust in the doctors treating you; • Inpatient survey score - Did you have confidence and trust in the nurses treating you; • Inpatient survey score - Were you given enough privacy when being examined or treated; • Inpatient survey score - Were you involved as much as you wanted to be in decisions about your care and treatment; Comparative analysis is already available for a considerable number of the above indicators, for others it is necessary to undertake further detailed work to agree clearly defined definitions to ensure that indicators are comparable and we will be undertaking this work over the coming months. For at least one indicator, we also need to consider data collection mechanisms as we do not have access to regular data. For each of the above indicators we are intending to provide quarterly comparative analysis (except of course for the inpatient survey indicators which is annual). Work undertaken to date will be uploaded to the Quality Observatory website within the next week or so. We are keen to look at the potential to offer the same service for mental health, community services and primary care and would be keen to hear about which indicators would be useful to include for these services. If you have ideas—please do get in touch samantha.riley@southeastcoast.nhs.uk
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Turning cross tabs into lists This Little Macro transforms a data table that is layed out in Cross Tab layout like : Month1 Month2 Month3 Month4 month5 Data Item1
1
2
3
4
5
Gets transformed into a flat file layout like: Data Item Month1 1 Data Item month2 1 Data Item Month3 1 Month4 Data Item 1 Data Item Month5 1
1
This can be very useful for data collections where the info and column labels change or if you want to process/query or store the data in a database
2 3
To use this Macro Simply select the Top left cell in the table (Data Item 1) and Run!
4
5
Here is the Code: Sub Unpivot() 'Specify the starting point startrow = ActiveCell.Row startcolumn = ActiveCell.Column 'create a variable we can change in the loop leaving the original ref of the startcell unchanged startrowloop = startrow 'input box to specify column offset i.e. no of columns between the left column and the data (in the example offset =0) columnoffset = InputBox("Column Offset?") 'Find the last column in the table assumes that the table has no blank cells Range(Cells(startrow, startcolumn), Cells(startrow, 256)).Select Selection.Find("").Activate endcol = ActiveCell.Column 'Find the last row in the table assumes that the table has no blank cells Range(Cells(startrow, startcolumn), Cells(64000, startcolumn)).Select Selection.Find("").Activate endrow = ActiveCell.Row 'calculates the number of iterations required a = endrow - startrow 'calculates the number of rows to insert
Page 11
b = endcol - startcolumn - columnoffset - 2 'Select the top left area of the table to process Cells(startrowloop, startcolumn).Activate 'loop for each row in original table For J = 1 To a 'Loop to insert New rows and copies table values For i = 1 To b 'inserts new row ActiveCell.Offset(1, 0).Select Selection.EntireRow.Insert 'Adds data to the columns that do not require transposing Range(Cells(startrowloop, startcolumn), Cells(startrowloop, startcolumn + columnoffset)).Select Selection.Copy Cells(startrowloop + i, startcolumn).Select ActiveCell.PasteSpecial Next i 'copies values to be transposed Range(Cells(startrowloop, startcolumn + columnoffset + 2), Cells(startrowloop, startcolumn + columnoffset + b + 1)).Select Selection.Copy
'pastes and transposes Table Values Cells(startrowloop + 1, startcolumn + columnoffset + 1).Select Selection.PasteSpecial Paste:=xlPasteAll, Operation:=xlNone, SkipBlanks:= _ False, Transpose:=True
'Copy Column Headers Range(Cells(startrow - 1, startcolumn + columnoffset + 1), Cells(startrow - 1, startcolumn + columnoffset + b + 1)).Select Selection.Copy
'paste and transpose column Headers Cells(startrowloop, startcolumn + columnoffset + 2).Select Selection.PasteSpecial Paste:=xlPasteAll, Operation:=xlNone, SkipBlanks:= _ False, Transpose:=True
'set rowref's for next row to unpivot startrowloop = startrowloop + b + 1 'selects next row for unpivot Cells(startrowloop, startcolumn).Activate Next J
End Sub
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Better Care, Better Value Indicators Update By Simon Berry, Specialist Information Analyst The quarter 2 data for the Better Care, Better Value indicators has recently been published and the Quality Observatory Dashboard has been updated accordingly. In addition, data for Epsom and St Helier Hospitals NHS Trust has been added to the dashboard. When looking at all of the indicators, the estimated savings for the whole of South East Coast is £198.8 million. Below you can see a breakdown of savings for Commissioners and Providers PCT Measures Surgical Thresholds Emergency Admissions 1st Outpatient Appointments Low cost prescribing - lipid modification Low cost prescribing - proton pump inhibitor Low cost prescribing - renin-angiotensin system Total
7%
14.5%
6%
14%
5%
Below nat. average
Did Not Attend Rates
First to Follow Up ratio
Day Case Rate
12%
90%
3%
2.5
0.12%
2.5%
2
70%
13.5%
4%
13%
3%
12.5%
2%
Non Elective Pre-Operative Bed Days
Elective Pre-Operative Bed Days
0.14%
80% 10%
0.1% 8%
60%
2% 1.5
0.08%
50% 6%
1.5% 40%
0.06% 1
4%
30%
1% 0.04%
20% 0.5%
0.02%
10%
£1,000
£1,000
£1,000
£0
£0
£0
£0
£0
£0
£0
2009 -Q2
2009 -Q1
2008 -Q4
2008 -Q3
2008 -Q2
Non Elective PreOperative Bed Days
£7,000
2009 -Q2
2009 -Q2
2009 -Q1
2008 -Q4
2008 -Q3
2008 -Q2
2008 -Q1
£6,000
2007 -Q4
2009 -Q2
£1,000
2009 -Q1
£1,000
2008 -Q4
£1,000
2008 -Q3
£2,000
£1,000
2008 -Q2
£2,000
2008 -Q1
£2,000
2007 -Q4
£2,000
2009 -Q2
£2,000
2009 -Q1
£2,000
2008 -Q4
£3,000
£2,000
2008 -Q3
£3,000
2008 -Q2
£3,000
2008 -Q1
£3,000
2007 -Q4
£3,000
2009 -Q2
£3,000
2009 -Q1
£4,000
£3,000
2008 -Q4
£4,000
2008 -Q3
£4,000
£8,000
2008 -Q1
2009 -Q2
2007 -Q4
2009 -Q1
2008 -Q4
2008 -Q3
2008 -Q2
2008 -Q1
2007 -Q4
2009 -Q2
2009 -Q1
2008 -Q4
2008 -Q3
2008 -Q2
2008 -Q1
2009 -Q2
2007 -Q4
2009 -Q1
2008 -Q4
2008 -Q3
2008 -Q2
2008 -Q1
2007 -Q4
2009 -Q2
2009 -Q1
2008 -Q4
2008 -Q3
2008 -Q2
2008 -Q1
£4,000
2008 -Q2
£4,000
2008 -Q1
£4,000
2007 -Q4
£5,000
£4,000
2009 -Q2
£5,000
2009 -Q1
£6,000
£5,000
2008 -Q4
£6,000
£5,000
2008 -Q3
£6,000
£5,000
2008 -Q2
£6,000
£5,000
2008 -Q1
£6,000
2007 -Q4
£7,000
2009 -Q2
£7,000
2009 -Q1
£7,000
2008 -Q4
£7,000
2008 -Q3
£8,000
2008 -Q2
£8,000
2009 -Q1
£5,000
£8,000
2008 -Q4
£6,000
Elective Pre-Operative Bed Days
First to Follow Up ratio
Day Case Rate
£8,000
2008 -Q3
£7,000
Did Not Attend Rates
0
2008 -Q2
£7,000
0%
0%
2008 -Q1
£8,000 Admission at 14 Days
2007 -Q4
2009 -Q2
2009 -Q1
2008 -Q4
2008 -Q3
Emergency Re-
£8,000
0%
2007 -Q4
Reducing Length of Stay
2008 -Q2
0% 2008 -Q1
2009 -Q2
0.5
2%
2007 -Q4
2009 -Q1
2008 -Q4
2008 -Q3
0% 2008 -Q2
11.5% 2008 -Q1
1%
2007 -Q4
12%
2008 -Q1
Here’s a reminder of what the dashboard looks like. The top graphs show performance over time, the colour indicates whether performance is better than national top quartile (green), between national average and top quartile (yellow) and worst than national average (red).
Betw een nat. average & top quartile
Emergency ReAdmission at 14 Days
Reducing Length of Stay 15%
81.2 7.5 1.1 10.6 53.9 2.0 156.3
Better than nat. top quartile
Better Care Better Value Indicators Medway NHS Foundation Trust
2007 -Q4
There is still significant variation in performance between organisations and this is where the dashboard can really help as it shows how Trusts and PCTs are performing currently, whether they are improving against each indicator and how they are performing compared to other organisations within South East Coast and against national benchmarks.
Acute Trust Measures Reducing LoS Outpatient DNAs Increasing Daycase Rate Reducing 1st to Follow Ups Non-Elective Pre-op Bed days Elective Pre-op Bed Days Total
9.1 11.9 7.9 7.4 1.6 4.6 42.5
The dashboard can be downloaded from the Quality Observatory website. Here’s the link http://nww.sec.nhs.uk/knowledge/index.php?option=com_docman&task=cat_view&gid=220&Itemid=75 We are currently reviewing the design of the dashboard and would welcome feedback from users to ensure that we provide a product which meets the needs of our customers. Please do contact me with any suggestions! Simon.berry@southeastcoast.nhs.uk
Winner of Christmas Quiz We are pleased to announce the winner of the 2009 Christmas Quiz. Congratulations to Daniel Seymour from West Kent PCT. Your prize will be in the post to you next week. The team very much liked Kevin Tansley’s tie-breaker (Kevin was the winner of the 2007 quiz). Better luck next year Kevin! The Quality Observatory provide good value because.... It’s free at the point of delivery
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An introduction to Best Practice Tariffs By Chris Young, PbR Tariff Development Manager The NHS is currently facing a period of uncertainty with an increasingly tight financial situation and a different economic outlook. Although the Government has promised NHS frontline spending will rise in line with inflation in 2011/12 and 2012/13, the scale of the productivity challenge (£15-20bn efficiency savings during the period from 2011-14) is unprecedented in recent times. Success will require bold and thoughtful leadership; re-thinking how the NHS works; challenging current practice and thinking outside of organisational and professional interests. The Department of Health’s new “best practice” tariffs have a central role supporting these productivity improvements, whilst ensuring that we place quality at the heart of, and make it the organising principle of the NHS (High Quality Care for All). In the recent Payment by Results 2010/11 package, the Department of Health (DH) launched details of the first set of mandatory best practice tariffs for two elective and two non-elective areas of service: cataracts; cholecystectomy (gall bladder removal); fragility hip fracture and acute stroke care. Each service area is characterised by significant unexplained variation in practice, a compelling evidence base and a clear consensus of what clinical best practice constitutes. They are designed in accordance with issues affecting quality and value, and are structured and priced to be patient-centred, both incentivising and adequately reimburse for the costs of high quality care. Table 1: Benefits of the new best practice tariffs Service Area
Benefits of best practice tariff
Cataracts
A patient-centred and efficient pathway
Cholecystectomy (gall bladder removal) Acute Stroke
More efficient service Better experience for patients Reduced mortality Increased number of independent and non-institutionalised individuals
Fragility Hip Fracture
Reduced mortality Increased number of independent individuals Prevention of further falls and fractures More efficient service
Development of the broad principles of best practice tariffs have been overseen by established DH governance groups which include clinical, provider and commissioner perspectives, and service specific tariff detail with clinical experts, including the National Clinical Directors for Stroke care and Trauma care. Best practice tariffs are a bold move away from setting mandatory tariff prices just at the national average, instead aiming to better-reflect the costs of delivering best practice with a mix of incentives for both provider and commissioner to challenge the status-quo. Figure 1: Features of the new best practice tariffs Best practice tariffs offer new opportunities for discussions around quality, giving more control to commissioners and more incentives to providers. With average growth of around 5.5 per cent in Primary Care Trust (PCT) allocations expected in 2010/11, this represents a real opportunity to discuss and put into effect the changes that will deliver the most benefits to patients in the future, such as driving the implementation of the standards identified in the new best practice tariffs. Not all best practice tariffs are necessarily a cheaper option than the tariff based on average costs. Nor will they be as simple to apply as ordinary tariffs, they have all been designed however to ensure that funding, over time, is aligned with patients benefiting from the best quality care, delivered at the right time and in the right place. Full details of best practice tariffs are found in the 2010/11 PbR Guidance, available at the Department’s (PbR) website (www.dh.gov.uk/pbr). Any comments should be directed to the following e-mail address PbRComms@dh.gsi.gov.uk
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Regional Innovation Fund Update By Peter Houghton, Director of Innovation In April 2009, Strategic Health Authorities were given a legal duty to promote innovation. This duty came with funds which will be allocated over the next 5 years. For 2009/2010, South East Coast SHA received £1.94 million. The first round of the South East Coast Regional Innovation Fund (RIF) bidding process was launched on 16th September and closed on 31st October 2009. Applications were encouraged (and received) from all sectors of the NHS with the following high level assessment criteria being provided to potential bidders : -
•
the innovation will improve the quality of service delivered;
•
is at least cost neutral (and ideally delivers increased efficiency and cash releasing savings);
• is aligned to the Healthier People, Excellent Care (HPEC) vision. For the first round of bidding, it was made explicit that applications which intended to evaluate and/or spread existing innovative practice more widely across teams and organisations were encouraged and would be prioritised for approval. This approach was consistent with both the view of Jim Easton, national Director for Improvement and Efficiency, that ‘the short-term challenge is spreading the examples of fantastic individual services we can already point to yet haven’t been widely adopted’ and the ‘Establishing the Evidence’ project led jointly by Jim Easton and Professor Sir Bruce Keogh. The call for bids to the regional innovation fund stimulated a significant amount of interest from across South East Coast. Over 200 proposals were received from a wide range of organisations and individuals, focussed on a variety of clinical areas. I would like to thank all of those people who sent us bids for funding. We were surprised by the number and range of bids, and very encouraged at both the extent of innovation and improvement happening across South East Coast and the enthusiasm and creativity of staff across all specialties and professions. The Innovation and Improvement Taskforce (which I jointly chair with John Wilderspin) met on 5th January 2010 and agreed funding for six bids, all of which will support the transformation of the clinical pathways in Healthier people, excellent care and help us improve quality and reduce costs. However, there were a number of bids, which we were unable to fund this year, which have potential, if developed further, to deliver benefits and we are keen to follow these up in the months ahead. Successful bids were as follows. In future editions of Knowledge Matters we intend to cover each of the bids in more detail and update you on progress!
• • • • • •
Spread of the innovative short stay hip replacement work undertaken across South East Coast (Mr Hugh Apthorp); Normalising birth and reducing Caesarean Section rates across South East Coast (Mr Tony Kelly) Developing a Local Enhanced Service for Long Term Conditions (Dr Gregg Rogers) Re-designing community mental health teams in Sussex - Better by Design (Dr Richard Ford) Enhancing telemedicine and access to acute care at Queen Victoria Hospital NHS Foundation Trust (Bill Kilvington) Improving End of Life Care in Surrey (Sarah Wardle)
Congratulations to you all!
Quality Observatory catalogue in development The Quality Observatory is currently finalising a catalogue of all of their products, tools and dashboards. The catalogue will categorise products in a range of ways, including by clinical pathway. This should make it much easier for users to identify existing tools available which will be of interest to them. In addition, there will be a searchable indicator library. The catalogue will be available by the end of March and will be posted on the Quality Observatory website. The searchable library will go live with the launch of our new website in April.
Page 15
NEWS Spend and outcome tool and fact sheets launched (SPOT) The Department of Health has commissioned the Association of Public Health Observatories (APHO) to develop a tool which helps commissioners to link health outcomes and expenditure. The development of this tool and a Spend and Outcome Fact sheet for every PCT in England has been led by Yorkshire and Humber Public Health Observatory. The ability to link spend and outcome is explicit in two of the World Class Commissioning competencies; '6 prioritise investment' and '11 make sound financial investments'. The tool and fact sheets can be viewed by clicking on the link below
New reports from the IC The link below points to some new quarterly publication reports that SUS Data Quality and Operation Support, NHS Information Centre, are publishing. Every month one of three reports will be published: NHS Number validation, invalid Commissioner Codes and invalid Site Code of Treatment within SUS. Subsequent reports will start to build a time series to measure how the percentage of valid records is changing over time, by Provider, SHA and at a National level. Each report has an associated word document which gives a high level summary of the results. The publication schedule is shown within the same table and the next report, NHS number, is due 23/02/2010.
New Regional Health Profiles
The purpose is to give guidance with the quality of these fields, they are not used for measuring or scoring an Organisation in any way. I hope this is something that you and your teams will find beneficial and I will welcome any comments or improvements you feel would be beneficial for your analysis.
To augment the existing Local Authority Health Profiles, APHO have published ten Regional Health Profiles which can be accessed at: http://www.apho.org.uk/default.aspx? QN=HP_REGIONS_2009
http://www.connectingforhealth.nhs.uk/ systemsandservices/sus/delivery/dataquality/quality/ kpireports
Health Inequalities Indicator
Daily SitRep Changes
We would like to bring to your attention the latest update on the World Class Commissioning Assurance Framework – Health Inequalities Indicator.
Following the collection on 1st March 2010, providers will no longer be required to submit the sections of the Daily SitReps relating to winter pressures (sections 3 and 4). Sections 1 and 2, which relate to swine flu patients, will still need to be submitted on both 2nd and 3rd March. There will then be a change to weekly reporting on hospitalisations and deaths relating to swine flu. The first collection of this data will be on Wednesday 10th March and the revised form will be available shortly on Unify2. The PCT swine flu return, H1N1, will continue as at present. Swine flu reporting will be reviewed in April and March but it is expected that this will continue into the summer. More details are available on the Unify2 website.
http://www.yhpho.org.uk/resource/view.aspx?RID=49488
The Association of Public Health Observatories (APHO) recommended a measure of health inequalities for inclusion in the 2009 World Class Commissioning Assurance Framework. The recommended indicator is the slope index of inequalities in life expectancy. Data have been published for 2001-05, 2002-06, 2003-07 and data for 2004-08 have just been made available in the WCC data packs on the APHO website. Graphs have also been produced for each PCT for the last two periods listed only. The data are available at http://www.apho.org.uk/resource/ view.aspx?RID=75050 In addition, a guidance document to assist PCTs with the interpretation of the slope index and setting trajectories can also be found at the link above. This includes questions and answers and technical information on the data sources and calculation methods used.
Training and development sessions:
Vital Signs Update
Dates for the next 3 months are:
Thanks to all organisations for sending in their initial plans in January. The second and final cut of this year’s Vital Signs is due to be sent to be submitted by 17th March with SHA sign-off on 26th March. Any queries on this should be directed to planning@southeastcoast.nhs.uk.
25th March 13th April 19th May To book your session contact:
The QO have released the following days for bookable “clinic” sessions. These sessions can be used for individual 1-2-1’s or for Group training. You can utilise the team for 1 hr or for the whole day !
Quality.Observatory@southeastcoast.nhs.uk
Page 16
Owners of Quality Observatory mugs ……. Professor Sir Bruce Keogh and the Secretary of State for Health, Andy Burnham, MP are now proud owners of Quality Observatory mugs. As you can see, both were delighted with their mugs and have fed back that using the mugs appears to have improved both the quality of drinks contained therein and the experience of drinking that afternoon cuppa!
Welcome to Faz Welcome to Faz Dar who joined the Quality Observatory in January as Statistical Advisor, Urgent and Emergency Care. Faz will be spending 12 months with the Quality Observatory. The Department of Health are funding Faz’s post—the aim of which is develop a suite of whole system metrics for urgent and emergency care. Faz will also be undertaking work to assess the impact of the ‘Tackling Demand Together’ toolkit described on page 2.
Free training opportunities 8 places are available on a one day technical writing course. The course helps people improve the effectiveness of written communication For anybody who writes training, technical or Business information in the form of User Manuals, reference guides training Handbooks and technical guidance documentation. The course is planned for 6 & 7 April and will take place at York house, Horley. Places are only open to NHS employees within South East Coast region.
Fit to Eat Pancake Day!! Hip,hip hooray, Eggs, flour, sugar and lemon That's the way to put weight on! Let's make just the two One for me and one for you Then run back and forth with the pancake pan To get the weight off, as quick as we can!
An introduction to control charts... NHS South East Coast Quality Observatory have been working with the NHS Institute for Innovation and Improvement to produce ‘An introduction to the use of control charts’, a guide designed to show how useful control chart methodologies are in a wide range of healthcare improvement projects and help demystify some of the technicalities. The guide is packed with practical examples of how control charts have been applied in a variety of situations and simple illustrations showing how you can do the same. The guide is available to download from the Institute’s website from the following link : http://www.institute.nhs.uk/index.php? option=com_joomcart&Itemid=194&main_page=document_pr oduct_info&cPath=76&products_id=642 Alternatively you can request a hard copy from the Quality Observatory who have approximately 70 copies available: quality.observatory@southeastcoast.nhs.uk
Interested? Have a look at the course outline: http://www.plainwords.co.uk/co_technical_documents.html e-mail us by the by 15th March at: quality.observatory@southeastcoast.nhs.uk In the event of high demand for spaces, names will be drawn at random and notified by 19th March.
Fascinating Fact There was a 300% increase in Emergency admission for Depressive episodes from Valentines day 2008 to 2009.
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: NHS South East Coast York House 18-20 Massetts Road Horley,Surrey, RH6 7DE Phone:
01293 778899
E-mail: Quality.Observatory@southeastcoast.nhs.uk To contact a team member: firstname.surname@southeastcoast.nhs.uk