Volume 8 Issue 5 December 2014 Welcome to Knowledge Matters Welcome to this very festive edition of Knowledge Matters. I’m always struck this time of year just how fast time flies by, swiftly followed by a slight panic that other than getting older, I've failed to actually achieve anything in the preceding year. But just the shortest pause for reflection convinces me that this is not the case and here at QO towers we are incredibly proud of what we have achieved in 2014. We have continued to build on our successes as a team that is passionate about the role high quality analytics plays in the delivery of world class healthcare. I’m particularly proud of how the team, in a constantly changing and challenging context, have absolutely maintained our line of sight to the patient and the true meaning of the NHS. In a world of profit margins and overheads it is easy to get distracted, but just looking at the articles in this edition shows the QO’s commitment to the core ethos at the heart of the NHS. Trishna’s articles and updates on the continuing roll out of the Friends and Family Test programme (pages 4-6) shows how the feedback of patients (and staff) is making a real difference to care. Amit’s review of MyNHS (page 12-13) illustrates the commitment of this vast public service to transparency and co-design, and news from the patient safety collaborative (page 10-11) once again underlines the commitment of the QO to the measurement and improvement of patient safety. Indeed, these three articles perfectly illustrate the three pillars of quality care: efficacy, experience and safety. We’re really pleased to have a guest article from a police colleague (page 2), demonstrating our common challenges (and great graphics!). I am delighted and proud to have been part of the QO’s growth in 2014 and look forward to working with you all throughout a happy and healthy 2015!
Inside This Issue : Top of the Table
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Festive fun crossword
8
News
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Friends and Family Test: GP roll out
4
Measurement in the KSS patient safety collaborative
10
Team updates
17
Staff FFT update
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MyNHS
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Back page frolics (read Adam’s carol, it’s a work of genius!)
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Christmas Appeal
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Ask an Analyst: Timey Wimey
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Top of the Table Inspector Simon Guilfoyle We’ve met lots of fascinating new people throughout 2014 and one of the things that has struck us is that many of the issues we are presented with in healthcare measurement are also problems in other places. Who knew?? So we’re really pleased to have an article from Inspector Simon Guilfoyle who, along with the ever eloquent Stick Child, explores the application of systems thinking to policing….. When the Chair of the House of Commons Education Committee asked Michael Gove (Secretary of State of Education at the time) about comparative performance measurement between schools, this happened: Chair: If “good” requires pupil performance to exceed the national average, and if all schools must be good, how is this mathematically possible?
Michael Gove: By getting better all the time. Now, sniggers to one side, there’s a few important points here. The first is that I don’t disagree with striving to get better all the time; neither do I think performance shouldn’t be measured. I also believe it can be useful to understand apparent differences in comparative peer performance.
So, what’s the problem? Well, it’s the way it’s so often done – league tables. Here’s an example using police forces, although you could replace them with schools, hospitals or other institutions, if you like. League tables are over-simplified, misleading, fundamentally illegitimate, charlatans of the performance world; they purport to convey information about comparative peer performance, when in fact they are little more than mirages. They lie to you. They tell you stuff that isn’t there. They set you off on thought processes and assumptions that are utterly unwarranted. (A bit like slightly more elaborate binary comparisons. Ugh!) But the most dangerous thing about them is that they appear so plausible.
A notable problem with league tables is that they are routinely methodologically unsound and notoriously unstable. (This is particularly true of league tables constructed from complex public sector data). Due to statistical considerations I won’t inflict on you here, it is often mathematically impossible to neatly rank institutions in the tidy fashion we are so used to (i.e. one at the top, one at the bottom, and the remainder nicely stacked in between, from best to worst). You see, in league table world, about half of those ranked end up as ‘below average’, and someone is always bottom. So not everyone can be above the national average! Why not? Because it’s an average.
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3 What we should be doing is trying to establish if there are significant differences between peers, and this can be done very simply in a couple of ways, as demonstrated by Stick Child…
In this first example, the six police forces we saw earlier are assessed against each other, taking into account confidence intervals in the data. (Don’t worry if you’re unfamiliar with the term, just trust me that it’s important). As you can see, this tells us that two forces are performing significantly differently to the other four (i.e. there are no overlaps between the two groups). We can’t, however, neatly rank them from ‘best’ to ‘worst’, because we can’t separate the ‘top’ two from each other, and we can’t separate the other four from each other. Here’s another way of understanding comparative peer performance in a more contextualised manner: This time we can observe that the six police forces are all within the boundaries of ‘normality’ (by applying Statistical Process Control methodology). If any of them were outside of the dashed lines we might be concerned that particular force was significantly different from its peers; however, in this case, all six forces are clustered around the mean average (solid horizontal line) and within the range of anticipated performance for the group. Therefore, there is absolutely no way the forces should be placed in ranked order – they are likely to move positions each time a snapshot is taken because of normal variation, but as long as they stay within the lines (and ideally, improve as a group), it is wrong to judge performance based on apparent position. You see, when this happens, we encounter the other big problem associated with the league table mindset – concern about someone’s position in a league table leads to unfair assumptions about performance, unnecessary ‘remedial’ activity to address the perceived deficiencies, pressure from management, sanctions, and so on. And all based on something that essentially isn’t there. Cue gaming and dysfunctional behaviour! Like clockwork.
And a final thought – if league tables are constructed using crime data, are we even measuring the right thing? Read more from Simon at www.http://inspguilfoyle.wordpress.com/ and follow him on Twitter @SimonJGuilfoyle
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GPs roll out Friends and Family Test By Trishna Julha, Programme Support Analyst, Quality Observatory GP practices are now implementing the Friends and Family Test, your opportunity to influence the future quality of health care. GP practices are thus set to provide monthly feedback on the care offered to their patients to NHS England. The bedding-in period for the implementation of Friends and Family Test (FFT) by GP practices started a few weeks earlier, on the 1st December 2014. The month of December allows them to iron out any FFT implementation details – set up their systems, start collecting feedback and work out any issues. (In short, to find the answers to the basic information gathering questions of the Five Ws and One H: Who, What, When, Where, Why and How?) GPs are asking their patients at least two questions. The first FFT question, as per the guidance of NHS England, asks if patients would recommend the practice to their friends and family. GPs are allowed flexibility on how to make FFT available to their patients, that is, how to collect the responses – handwritten, online, telephone call, etc. As from January 2015, this collected data will be submitted monthly through the CQRS, as per the submission guidelines, published recently. (http://www.england.nhs.uk/wp-content/ uploads/2014/11/fft-gp-data-sub.pdf)
GPs should also ask a second question (more is definitely allowed!) - a free text question defined by the practice to gain further insight into the patient’s care experience. This feedback is not to be reported to NHS England but GPs may choose to share comments locally if patients give their consent. The flexibility around the free text question may make it sound less important. However, it provides the starting point for improvement, enabling GPs to look at individual issues which can be addressed quickly, as well as identify feedback themes over time. It helps to meet the fundamental principle behind the FFT programme of improving services for patients.
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5 The monthly submitted data will be published on NHS England’s website and NHS Choices. Publication is currently expected to start after the first three months’ data has been submitted. NHS England will be publishing the total percentage of extremely likely plus likely responses. According to the GP practices FFT guidance (http://www.england.nhs.uk/wp-content/ uploads/2014/07/fft-gp-imp-guid-14.pdf), FFT does not provide results that can be used to directly compare practices because the flexibilities in collection methodologies and variation in population in different areas mean that we not comparing like with like. But FFT can help mark progress over time, as has been the case for ten GP practices in North Durham, which became the early adopters of FFT. They collected more than one thousand responses and actions were taken as a direct result of FFT comments. The latest FFT Update Newsletter distributed electronically by the national FFT Communication team showcased some of the actions: FFT Feedback - “We would like prescriptions to be quicker”. Wessex GP Practice response: “We have restructured the staff duties to allocate more dedicated time to managing the large number of repeat prescriptions. We understand it is important that you have your medication on time and we hope this will help to improve the service to you. Please remember to order in goodtime for us to process the request, as all prescriptions need to have a GP review and signature prior to being collected or being sent to the pharmacy.” FFT Feedback - “We don’t want to queue for a long time at reception.” Wessex GP Practice response: “We have restructured the staff duties and now have a second person available to help when there is a queue. Please remember you can book appointments on line and also check in for your booked appointment at the check in screen near the door.” In January 2015, NHS funded community and mental health services’ providers should also have implemented the FFT. The first submission of data for these organisations, including early implementers, will take place in February 2015, relating to feedback received in the month of January. (http://www.england.nhs.uk/wp-content/uploads/2014/11/fft-guid-subs-mh.pdf) The Friends and Family Test continues its crusade to bring the improvements you want in the healthcare you receive…
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Staff Friends and Family Test – Quarter 2 published By Trishna Julha, Programme Support Analyst, Quality Observatory Staff experience is said to be the best predictor of patient experience (Point of Care Foundation, 2014). Results of the Staff Friends and Family Test for Quarter 2 reveal that 77% of staff would recommend their organisation to friends and family in need of care or treatment. 242 NHS service providers submitted their responses to the second quarterly survey which allows staff to give feedback on NHS services based on recent experience.
Introduced in April 2014 in all NHS Trusts providing acute, community, ambulance and mental health services in England, the survey is expected to bring a cultural shift in the NHS, where staff has further opportunity to speak up and have their views heard and acted upon. The latest data also reveals that nationally, the percentage of staff who would recommend their organisation to friends and family as a place to work is 61%.
The Staff Friends and Family Test is not a requirement in Quarter 3 when an existing NHS staff survey takes place. Staff FFT is not designed to replicate the annual NHS staff survey; rather to complement it and provide a more up-to-date picture of staff experience in a bid to inform decision making. If you would like to know more about the Staff FFT Quarter 2 results, they are available at: http:// www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-testdata/
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Friends and Family Test: Analysis Site Christmas Appeal Here at QO Towers we look after a lot of websites; as the delivery method of choice for all self respecting dashboards these days it crucial we keep on top of updating them. As with any product though we need to make sure they’re still useful and relevant to the folk that use them. The Friends and Family Test Analysis Site is one where we worry about its welfare; after all, a website isn’t just for a major policy launch, its for life! As a reminder, the FFT Analysis site was launched in April 2013 to provide various analyses of the national FFT data published for inpatients and A&E services, followed by Maternity FFT data the following September. The site boasts the ability to compare with peers, regional and national benchmarks at the trust and ward level for all the various collections alongside time series plots, correlations of results with response methods and the ability to see wards and organisations in an overall national distribution. The site kept up with the reporting changes too, moving from the score to show proportion of positive and proportion of negative responses. As the Friends and Family Test expands to include GPs, community services as well as outpatients and daycases, the FFT analysis site has the potential to grow significantly. But before we can do that, it would be fantastic to hear from you whether the site provides the analyses you need, what you would like to see on it and whether you would want to see more of the collections coming on stream included on it. We won’t even ask you to give £2 a month (much better causes for that!) but do feel free to e-mail us at info@qualityobservatory.nhs.uk with your views on the site and its future. Check out the site (N3 only) at:
nww.fft.england.nhs.uk
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FESTIVE CROSSWORD Take a break from building those skills, with a fiendish festive crossword from our resident puzzlemaster, Aleks!
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Drop us a line at info@qualityobservatory.nhs.uk if you’re clever enough to work out the solution; you might even get a mention in the next edition of Knowledge Matters!
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Measuring Safety: measurement in the Patient Safety Collaboratives By Kate Cheema, Measurement Lead, KSS PSC The Kent Surrey Sussex (KSS) Patient Safety Collaborative is one of 15 new patient safety collaboratives established across England in October 2014, putting patients, carers and clinical staff at the heart of patient safety improvements. Hosted and supported by KSS AHSN, the KSS Patient Safety Collaborative is part of the largest and most comprehensive safety programme of its kind in the world. Over the coming years the Patient Safety Collaborative will work with its members to empower patients and staff to develop a patient safety culture which supports everybody challenge poor practice and to implement improvements in patient care. The Patient Safety Collaborative has been talking to its members, patient groups and partners in social care, industry, education and research since January 2014 to find out what their safety priorities are, and to establish the clinical areas that the collaborative should focus on. Following a public consultation with more than 300 groups and individuals in October and November 2014, the following workstreams have been established as priorities for Kent, Surrey and Sussex:
Pressure damage Sepsis Safe discharge and transfer Medication errors Acute Kidney Injury Two cross-cutting issues will form the foundation of all patient safety work:
Measurements of patient safety Leadership, culture and capability
I am delighted to be involved with the measurement element of the Patient Safety Collaborative and am greatly looking forward to working across all the workstreams to make the most of the data we have available. Measurement helps us prove we have made a difference, and identify where change or intervention is needed. Without it, we run the risk
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11 of good work being lost under the burden of poor evidence. The Kent, Surrey & Sussex Patient Safety Collaborative offers a unique opportunity to support local organisations in measuring and evidencing their improvement work in high priority areas. The Patient Safety Collaborative will also look towards the development of measurement approaches that look beyond the measurement of retrospective harm, with a view to anticipating and preventing harm. In the Kent, Surrey & Sussex Patient Safety Collaborative we have a number of key principles the provide the foundation for measurement throughout the collaborative:
Measurement will be undertaken with a true ‘measurement for improvement’ ethos and not used for judgement or punitive purposes
Measurement will be undertaken to support learning and spread of best practice through sharing and publication
We must ensure that any measurement approach clearly harnesses the power of our existing data sets as well as opening up possibilities for the development of new collections
We will gather just as much data as is required to identify change and ensure that any additional data collection burden is kept to a minimum
One of the key elements of our approach to measurement across Kent, Surrey & Sussex Patient Safety Collaborative is to share data and encourage Collaborative members to utilise the wealth of existing data sets already available. Using simple visualisations such as those shown here, we can use our data to help answer two key questions: 1.
Have we made an improvement?
2.
What is the variation across Kent, Surrey & Sussex? We’re keen not to reinvent any proverbial wheels when measuring key outcomes and processes in each of the workstreams. We want, wherever possible, to adhere to our key ‘measurement principles’ and utilise the expertise across the region in using exiting measures and data sources. In order to help us do this, we will establish a measurement reference group. If you feel you have some expertise to offer to this reference group, please do get in touch: kate.cheema@qualityobservatory.nhs.uk
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My NHS By Amit Chavda My NHS is a tool developed by NHS England to provide transparency on range of outcomes from a local to a national level. The aim of the tool is to drive improvements by providing a snapshot of the published data which would not normally be accessible to general public. Health Secretary Jeremy Hunt said:
“Transparency is about patient outcomes, not process targets.” What is My NHS and what does it do? Is this something that will actually provide some sort benefit to all? My NHS is a tool which has been developed to provide information to patients and the public about the care they receive from Consultants and the NHS trusts they visit for their treatment(s). My NHS allows patients and the public to analyse which consultants are positive outliers and those which are OK and can analyse the same for at NHS trust level. Patients and the general public using this tool to look for NHS trusts will find something that looks like this:
And if looking for consultants will find something like this:
Not all consultants, under each of the specialities, have the same format as the above but are similar. It shows the number of cases undertaken, in-hospital mortality rate and so forth. My NHS also allows patients and the general public to have access to data on: Social Care – data on how local authorities are performing on adult social services Public Health Services – data on services delivered within hospitals and general practices Public Health outcomes – Outcome data per local authority. Data on Mortality rate, excess weight, smoking prevalence, physically active adults, alcohol admission, children healthy and ready for school and injuries due to falls in people aged 65 and over. Mental Health Hospitals – provides a quality indicator for mental health hospitals provided by NHS trusts. General Practice Data – Coming soon! info@quailtyobservatory.nhs.uk
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13 So lots of data to have a look at but, back to our initial question, is it useful? Whilst it is fantastic that all this data is being made available there are a couple of issues. The first problem, which can be foreseen, is that it has the potential to make assessment of healthcare services even more complicated and confusing for patients. As with everything in life one would like to have the best, especially when it comes to healthcare; we all expect and want the best care in the cleanest hospital with the best nurses and the best consultants performing the surgery or providing our treatment. As most patients would like to be seen by a consultants that is a positive outlier not just an ‘OK’ one, there is potential for confusion, overwhelmed consultants and NHS trusts with waiting time issues and an effect on skill sets. After all, we’d all want to be treated in an establishment which has a green Care Quality Commission inspection rating, who’s A&E performance, mortality rate, recommended by staff, infection control, number of patients waiting more than 52 weeks and the Friends and Family test: Inpatient are all green. The danger is that, presented with a lack of context and guidance, users will see anything other than ‘green’ as ‘bad’. The second issue is that it is possible that information been omitted in the data that has been used in MyNHS. But what could this be? Our main problem with what has been presented, particularly at a consultant level is the acknowledgment that most NHS trusts have a multitude of training programmes one of which involves registrars (doctors that will eventually be a Consultant). During the last couple of years of their training programme registrars have developed enough of a knowledge base to take on a list, clinics and treatment autonomously with oversight from a consultant. A question to be asked is whether this data is included in the published data and if it is what does this do to the data? Does it make a positive outlier consultant okay? In the end what it does do is it skews the data and therefore not an accurate reflection of the individual consultant, but rather their whole team. It isn’t clear whether the user of MyNHS would be made aware of this. There is also a lack of important contextual information presented. For example, we are unable to extract the length of stay from the data published and therefore don’t know how long a patient stays post-surgery or treatment. How many elective or day case procedures are undertaken by the consultants and those consultants who have an ‘OK’ rating, do they only undertake the more complicated procedures and the more complex patients for example the frail patients? All of this is important contextual information that could have a significant impact on the results, particularly at the consultant level. So, whilst we encourage and applaud the wider publication of healthcare data, we would urge caution in its use and the reductive ‘good’ or ‘bad’ summarisation of key statistics. www.QualityObservatory.nhs.uk
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WIBBLY WOBBLY TIMEY WIMEY Application: Microsoft Excel 2010 Hi I have inherited a spreadsheet from a colleague and I am having problems with one of the charts. I’m trying to add an axis to the Graph but I just can’t seem to find the controls to add the axis (I’m more used to using excel 2003) and every now and again the value for team 7 (28:30) seems to change its label to 4:30 . Can you advise ? What’s going on? Vincent O'Mahoney Project Officer First Community Health & Care
Solution: Complexity 2/5 — Changing axis and dealing with Time! Hi Vince thanks for writing in with your issue. There are two separate issues that you seem to be having: sorting the chart axis and dealing with time. Lets first look at sorting out the axis. Adding an Axis: The chart controls in excel 2007 + are a little different than in excel 2003. First You will need to select your chart : click anywhere on the chart and the chart tools tabs should appear in the top toolbar. Select Layout : and the layout options should become visible.
Select Axis -> Primary Vertical Axis From the Drop down options select “Show default Axis”
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15 This should work and an y axis should be added to your chart ! At first glance everything looks great ! However lets take a closer look at our axis … Now our data set contains a time of 28 hours and 30 mins. We have added it to a cell as “28:30”
However when we plot our chart the axis resets to 00:00 every 24hrs! Excel is trying to be helpful and automatically changes the cell formats to a hh:mm Time format. What we would recommend is to convert your time string into a decimal value. The easiest way to do this is to simply change the cell formats to “general” this will convert all the Time stamps to decimal “day” values, 12:00 becomes 0.5 days 24:00 becomes 1 day etc. you can * 24 to get “hours” as shown in the table example below.
2 Decimal “DAY” Value 1 Original value unchanged
Cell D4 Formula = “=C4”
Excel auto formated
Cell Format = general
3 Decimal “Hour” value Cell E4 formula= “=D4 * 24” Format = “general” Use this Value to plot your chart axis will now read right !
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NEWS Skills development survey Skills for Care and the Health and Social Care Information Centre (HSCIC) have been commissioned by the Department of Health to explore the size, scale and professional development needs of the informatics workforce in adult social care. The term ‘informatics’ relates to staff whose role is concerned with the collection and analysis of social care data, and/or the sharing of social care data and information and/or the use and development of technologies that can facilitate this.
The Informed modules are located on the eLearning for Healthcare website: http://www.e-lfh.org.uk/programmes/healthinformatics Caption Competition What could Charlene be thinking? Send us your very wittiest answers to be in with a chance of winning a highly coveted prize!
They plan to produce a national profile of the social care informatics workforce in March 2015. If this is relevant to you or your team find out more at: http://www.skillsforcare.org.uk/NMDS-SCintelligence-research-and-innovation/ Informatics/Workforce-survey--social-careinformatics.aspx Informed: an online introduction to the use of informatics in healthcare Informed is a free e-learning course that explains how informatics supports the delivery of health and social care. It is aimed primarily at people who have recently joined the NHS in an informatics role. At present, it is only available to those with an NHS e-mail account. The course is made up of five modules:
Introduction to health informatics
Introduction to healthcare
Primary and secondary uses of data in health and care
Improving the quality and safety of care through health informatics
Organisation and structure of health and care service
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To enter, simply send you name and postal address (in case of prize winning!) along with your entry to: info@qualityobservatory.nhs.uk Good luck!
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FESTIVE FUN AT THE QO In time honoured tradition, the QO team sallied forth into the throbbing metropolis that is Horley for a spot of Christmas cheer and a celebration of the successes of the year past. The town’s charity shops had been scoured for suitable gifts and here are a selection of the spoils:
Congratulations! Congratulations to Kate Cheema and Amit Chavda who have both successfully completed (and passed!) the Mary Seacole Leadership Programme. They’ve both survived a year of assignments and study to come out with new knowledge on healthcare leadership and were delighted to note the focus given to measurement and evidence throughout the course. Well done chaps!
The Mary Seacole Programme is aimed at people who are in or are thinking about their first formal leadership or team management position from either a clinical or non-clinical background. The next programme starts in April 2015 and more details can be found at: http:// www.leadershipacademy.nhs.uk/programmes/ mary-seacole-programme/
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O, Little Town of Horley
O little town of Horley Just off the M Two Three You've been the home for many a year Of the Quality Observatory And from thy spreadsheets shineth The data bright and clear The hopes and fears of the NHS Charted year-on-year For data flows out of trust And gathered in the centre While mortals sleep, the analysts keep The numbers being entered. Then the dashboard is updated Proclaiming outcomes good and worse And praises sing to improvement made And to poor performance, a curse How expertly, how expertly The wondrous data has flown! Analysts impart to managers hearts The wisdom that is shown. Confidence limits are showing The range the activity is in, Where medians and top quartiles, Help benchmarking begin. O Q.O. of Horley Give to us, this day Some Websites, maps and charts and tell us what they say We hear the merry analysts The insights that they tell O share with us, foretell with us Statistics in Excel
Festive fact Alcohol consumption increases by 40% in Britain in December. This might account for the fact that New Years Day sees the highest number of emergency admissions for less than 24 hours to hospital for acute intoxication.
Fascinating Facts Many people can’t stand Brussels sprouts because of a gene variant that affects how they perceive bitterness.
Simon says……. Although now mostly vegetarian, in Victorian times, mince pies were made with beef and spices. Mmmmm, beef.
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: Hosted by: Central Southern Commissioning Support Unit E-mail: info@qualityobservatory.nhs.uk To contact a team member: firstname.surname@qualityobservatory.nhs.uk