Mecc launch 18 05 12

Making Every Contact Count

Using Every Opportunity to Deliver Brief Advice

to Improve Health and Wellbeing

Implementation Guide and Toolkit

Launch Event

18th May 2012

Leicester Marriott Hotel

Welcome and Introductions

Professor David Walker

Director of Public Health, NHS Midlands and East

Executive Lead for Making Every Contact Count

Our Ambitions

Sir Neil McKay

Chief Executive, NHS Midlands and East

Why Make Every Contact Count?

Dr Rashmi Shukla

Regional Director of Public Health, West Midlands

Chair of MECC Steering Group

Case for MECC

• Growing evidence base

• Potential scale for impact

• NHS as an exemplar for health

Risk Factors 80% of heart disease, stroke, and type 2 diabetes cases and 33% of cancers could be prevented by eliminating tobacco and excessive alcohol, maintaining a healthy diet, physical activity

WHO declared these as the main shared risk factors in the development of Long Term Conditions (LTCs)

WHO. 2008. 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases

Global Economic Burden of NCDs:

Lost output 2011-2025

Healthy Lifestyle Profile

• Smoking: 19 to 22% of population smoke

• Alcohol: 14.6 to 17.9 % drinking at increasing risk with 4.0% to 6.1% drinking at high risk levels

• Physical activity: 61 % of men and 71% women do not meet recommended levels

• Obesity: men 22% to 26%, women 24% to 28%

• Healthy eating: 75% of men and 71% of women do not eat 5 pieces of fruit/veg a day

Life

years

gained

Age smoking stopped (yrs)

Life Years gained from stopping smoking

Alcohol Harm reduction

• Alcohol brief advice changes drinking behaviour of 1 in 8 people

• For a PCT of 310,000 cost = £48,000 to deliver IBA to 10,000 increasing risk drinkers

• 1,250 will change drinking behaviour

• Resulting in reduced, acute admissions and A&E attendances

• Estimated benefits to NHS = £126,000*

• ROI = £2.60 back for every £1 spent

* Based on DH ready reckoner v5.2

Health Benefits of Weight Loss

of 10kg in 100kg subject

Death: 20-25% decrease in premature mortality

Diabetes: 50% decrease in risk of Type 2 DM

30-50% decrease in blood glucose

Lipids: 10% decrease in total cholesterol

30% decrease in triglycerides

Blood 10mmHg decrease in systolic BP

pressure: 20mmHg decrease in diastolic BP

Survival in 20,244 healthy adults

aged 45-79 by health behaviours

Health Behaviours: • Non smoker • Alcohol <14 units/wk • Not inactive • Blood vitamin C >50 mol/l (5 servings fruit and vegetables daily)

Overall impact: 14 year difference in life expectancy Survival Function According to Number of Health Behaviours in Men and Women Aged 45–79 Years without Known

Cardiovascular Disease or Cancer, Adjusted for Age, Sex, Body Mass Index and Social Class, EPIC-Norfolk 1993–2006 Khaw et al. PLoS Med 2008 Jan 8: 5 (1): e12 (EPIC-Norfolk prospective study

4

3

2

1

0

Number of Healthy behaviours

-2 0 2 4 6 8 10 12

100

90

80

70

Year of study

% s

till

aliv

e

• Securing Good Health for the Whole Population 2004, Sir Derek Wanless • Fully engaged scenario

• High Quality Care for all: NHS Next Stage Review 2008, Lord Ara Darzi • Need to put prevention first

• Fair Society, Healthy Lives: Strategic Report of Health Inequalities in England 2010, Sir Michael Marmot

• Strengthen the role and impact of ill-health prevention

• NHS Future Forum Report

• NICE – Behaviour Change Guidance 2007

• NICE – Smoking Cessation Services Guidance

• SIPs (Institute of Psychiatry, Kings College, London) – alcohol brief advice

Further Supporting Publications

What do we mean by evidence based

practice?

“the conscientious, explicit and judicious

use of current best evidence in

making decisions about the care of

individual patients”

David Sackett et al…, BMJ 1996

Potential Scale of Impact across SHA Cluster

• Over 280,000 staff

• Millions of patient contacts a year in primary and

secondary care

• Very brief advice given 10 times a year by every

member of staff = 2.88 million opportunities to change

lifestyle behaviour

• Less than an hours time a year

for each member of NHS staff

• A healthier workforce

Who can Make Every Contact Count?

Ashok Soni

NHS Future Forum

What do Staff and Patients think about

Making Every Contact Count?

Dr Simon How

Project Manager for Making Every Contact Count

Insight was gathered from nine organisations

across the West Midlands, East Midlands and East of England

Gathering insight • Researchers spent a day in each of the nine organisations interviewing 49 staff and 54

patients.

• The interviews were carried out on site to provide context to the insight gathered and

maximise the numbers of the target audience

Methodology 1

• Cardiology

• Respiratory

• Gastroenterology

• Mental health

• General practice

• Stroke

• Community Practice

• Clinical assessment unit

Patient interviews:

• attitudes to healthy lifestyles advice

• which staff groups

• what would aid the conversation

Staff interviews:

• attitudes to delivering lifestyle advice

• situations and settings

• confidence levels

• influence of their own lifestyle

• what would help them in initiating and delivering brief advice

Role playing scenarios:

• This provided valuable insight into the factors that will play a role in delivering/receiving health lifestyle advice

Methodology 2

• Time

• Clinical vs. Non clinical

• Environment

• Effectiveness

• Staff behaviour

• Training

Key Themes

Time

The NHS should give advice if they have time – but

they’re too busy. (Patient)

Appointments take 10-15 minutes in which to diagnose, treat and refer. Offering health promotion advice on top of that takes time

away. (Staff ) It’s a good idea but how would it work? We don’t have much time with patients (staff)

• MECC is about delivering very brief lifestyle advice (30 seconds to 3 minutes) when appropriate

• MECC is not about giving advice upon every encounter with a patient/ colleague with an unhealthy lifestyle. It is about recognising when advice is appropriate and when it will be effective

• Prevention of illness will, in the long run, save the NHS time and money

• Brief advice does not always have to be delivered during clinical time.)

• Patients say that the relationship with a staff

member and the manner in which the advice is

delivered is equally as important as how

authoritative that staff members role is

perceived to be.

• Patients value the opinions of staff who had

been through a lifestyle change themselves.

This trumped whether they were clinical or not.

Clinical and non- clinical staff

If a porter gave me advice, I’d want a second opinion from the doctor

(patient)

I’d give advice if patients knew to expect it. They would need to know – otherwise some would say ‘what do you know? (staff)

It would be ok if he

was a bit jokey,

like ‘you should lay

off the fags mate

(patient)

Environment

It would need to be delivered one-to-one in a private area, not out in the open (patient)

Yes and we have a Gregg’s onsite which doesn't do much to support us in promoting healthy lifestyles (staff)

In the pharmacy, patients will discuss anything and have no objections – they

are open and welcoming of advice (patient)

• The training packages for MECC highlight the

importance of understanding and respecting a

patient/colleagues‟ feelings towards discussing

their lifestyle behaviours

• Staff feel that different health settings present

different challenges and opportunities

• MECC is about using opportunities as they

arise to help people make healthy lifestyle

changes, signposting or providing information

leaflets are seen as useful by patients

Effectiveness

If I was already thinking about doing or changing something, it might be a good final push. (patient)

Research shows that brief advice is effective, for example:

• 1 in 8 people respond to brief advice about alcohol intake

by reducing their drinking behaviour by one level e.g.

from increasing risk to lower risk

• 1 in 20 people go on to quit smoking following brief

advice

The communications campaign supporting MECC will

promote this fact to help both staff and patients understand

the impact MECC can have

Fine, give it to me. I won’t necessarily take it though (patient)

It could work, with the right people (staff)

Staff Behaviour

Overweight people understand –‘I’ve tried

this and that might work (patient)

Staff’s own lifestyles are key. Enthusiastic ex-

smokers have knowledge and passion (staff)

Patients have said to me, ‘well you’re not exactly

thin’. But when you’re in a healthcare setting it’s easier to raise (staff)

• Staff lifestyle and appearance are superseded by the development of a relationship between patient and staff member and their communication skills and interpersonal skills

• MECC is also about improving staff health and wellbeing

• Patients are receptive to staff who have made a lifestyle change themselves

and feel they are better equipped to provide advice on these issues

• Staff feel their lifestyle does not hinder their ability to give advice, however

patients do feel that staff appearance and lifestyle are important to patients‟

receptivity to advice

• MECC toolkit signposts to a range of training options from

e-learning modules to face to face training.

• Training will help staff members become more comfortable with giving alcohol and weight management advice

• Prompts (e.g. a card asking about lifestyle behaviours) may help staff members to begin a conversation

• Patients expect to be asked about their lifestyle behaviours

• Effective communications help create an environment where staff feel more comfortable giving advice

Training

We’d all need to have some formal

training around delivery (staff)

Manner and communications skills are crucial

(patient)

We know basic guidance but I’d be worried about saying the wrong

thing (staff)

MECC

SUMMARY

• MECC received positively by staff and patients

• Need to create an environment in which it is

OK to ask for and give lifestyle advice

• Staff are willing, but need training to build

confidence and capability

• Communication of consistent MECC message

is key

How to deliver Making Every Contact Count:

The Implementation Guide and Toolkit

Dr Lola Abudu

Public Health Consultant

NHS Midlands and East

Maureen Murfin

Public Health Workforce Development Manager

NHS Derbyshire County

Introducing the Implementation

Guide and Toolkit

Background to Implementation

Guide and Toolkit

Building Blocks for „wider‟ public health workforce development

• 2005 - Health Trainer Early Adopter

• 2006 - Hosting the Regional Health Trainer Hub

• 2007 - Introduction of Health Champions, volunteers trained in health improvement

• 2008 - Commissioned Report: Developing a Health Promoting Workforce

• 2009 - Workforce Transformation Project partnership with DCHS

• 2011 – Behaviour Change Guidance Development & Pilot testing

• 2012 – Implementation Guide and Toolkit

The Power of MECC

MECC is about encouraging people to

make healthier choices to achieve

positive long-term behaviour change for

better health and wellbeing among

patients / service users and staff

themselves

MECC involves:

Systematically promoting the benefits of

healthy living across the organisation

Asking an individual about their

lifestyle and if they want to make a

change

Responding appropriately to the

lifestyle issue/s once raised

Taking the appropriate action to either

give information, signpost or refer

service users to the support they need

• Much more than training staff

• Organisational development and

culture change

• Led by staff within the context of their

service and role

• A collective responsibility – staff and

organisation TOGETHER!

• Grown from the needs of the public and

what they need, want and expect

• A path to delivering system and scale

What does the Guidance Say?

A Closer Look at The Toolkit

Contents

• Foreword

• Introduction

• Section 1: What is MECC

• Section 2: An overview of the evidence and policy for MECC

• Section 3:How organisations can achieve systematic and

sustainable change through MECC

• Section 4: Who benefits from MECC?

• Section 5:The responsibilities of strategic and operational roles

within an organisation

• Section 6: What is the implementation process for MECC

• Section 7: What tools and resources are available?

• References and supporting documentation

The Implementation Process Not one size fits all but promotes key principles:

• Get Senior Managers on board and Champions in

place

• Assess the organisations current position as a health

promoting organisation (culture and structure)

• Take a systematic approach to service and workforce

development that supports and empowers service

users to improve their own health and wellbeing

• Take a team approach to implementation and training

• Have systems and processes to capture progress

• Support service users to engage with healthy lifestyle

messages

• Consider the role of staff health and wellbeing

• Implementation checklist

• Behaviour change pathway and competence mapping

• Example data capture forms

• Example CQUIN, NHS Midlands and East metrics

• Examples from practice

• Individual and team assessment tool

• Making the case presentation

• Links to policy drivers and initiatives

• Organisational assessment tool

• Prompt card and health benefit cards

• Orientation workshop slides

• Training options – MECC workshop slides and E learning

Tools and Resources

• Supported implementation

• TEST, LEARN & ADAPT the guidance and expand the

toolkit

• Contribute to evidence base.

What Next?

For further information contact:

Elaine.varley@derbyshirecountypct.nhs.uk 07881837059

maureen.murfin@derbyshirecountypct.nhs.uk

07785714543

http://nhs.lc/makingeverycontactcount

Questions?

Refreshment Break

Making Every Contact Count In Practice

Case Study Examples

Making Every Contact Count at

Cambridge University Hospital

NHS Foundation Trust

Barbara Brafman-Price, Smoking Cessation Clinical Lead Val Thomas, Public Health Consultant, NHS Cambridgeshire Mr John Latimer, Consultant and Lead Gynaecological Oncologist

Addenbrooke‟s

• Cambridgeshire has a relatively healthy population,

smoking prevalence around 20%

• How to increase Stop Smoking Services throughput ?

• High level of patient throughput in Addenbrookes and

The Rosie though its size and complexity presents many

challenges

• Commissioning an evidence based model

Background

• Substantial organisational change is required to create a culture and environment that is supportive of smoking messages.

• Opportunistic, Timing – Co-Creating Health – COPD – Partnership culture

• Behavioural change methodologies were increasingly visible

• Leadership - Identified a senior champion – Operations Director, key clinicians, Co-creating Health Co-ordinator

• Target one or a small number of areas

• Sustaining and developing - demands everyday determined, tenacious and committed leadership

• On going commissioner support

Making it happen: Early Critical Factors

Making it happen!

• Developing a workforce to deliver and support behavioural change

- Flexible, adaptable tailored training programme

- Network of “champions” created across the trust

• Developing the Infrastructure

- An easy to use electronic referral pathway

- Routine processes adapted

- On-site drop in clinic

• Creating a supportive environment

- Securing high level support and endorsement

- Lanyards

- Newsletters coverage

- Regular health promotion events

Training

• Flexible (delivered on the wards, mdt‟s, lunchtime

seminars, audit mornings)

• Adaptable (time negotiable to fit in to organizational

pressures)

• Tailored (What does it mean to each staff group? Why is

it important to their patients?)

What does it mean to be a Stop Smoking Champion?

• An easy to use electronic referral system (less than a

minute to place a referral)

• Assessment booklets adapted to prompt staff to make a

brief advice (changing the processes is vital)

• A drop in clinic for staff and patients

• Ongoing communication activities is paramount

• Champion network – extremely valuable

Developing the Infrastructure

Referral Process

Creating a supportive

environment

Corporate support is key Gareth Goodier and Pat Reid visit the team

Health Promotion events

What have we achieved?

• Start date January 2010 (dedicated project coordinator

June ‟10)

• 635 stop smoking referrals to date

• 1st year (2010) - 153

• 2nd year (2011) - 388

• 3r year (2012) - 94

• 300 staff trained in brief advice

• 50 Clinical champions

• Senior corporate support

• Staff and Patient stop smoking drop in clinic set up

• Competing priorities within the organisation

• Need for more robust data (Out of area patients)

• Resistance among staff

• Senior management turn around

• Staff turn around

• It is a very slow process, perseverance is vital!

Challenges

There is still work to be done

For further information contact:

Val Thomas, Public Health Consultant ( NHS

Cambridgeshire

Val.Thomas@cambridgeshire.nhs.uk

Barbara Brafman-Price, Smoking Cessation Clinical Lead

barbara.brafman-price@addenbrookes.nhs.uk

Derbyshire Community Health

Services NHS Trust (DCHS)

Linda Saxe

Workforce Health and Wellbeing Project Manager

Tracey Allen

Chief Executive

The Derbyshire Health Promoting Workforce Project

The Derbyshire Health Promoting Workforce Project

• Jointly funded collaboration with NHS Derbyshire County, Public

Health and DCHS

• Motivate, train and support all DCHS frontline staff to promote health and wellbeing

Over 5000 opportunities every day to do or say something that may help to improve someone's

health and wellbeing

Ultimately not only saving lives but adding

quality to those lives saved

How do we start to promote healthy lifestyle choices?

1. Getting staff to recognise those moments of engagement

2. Motivating and supporting them to do or say something

Project Development

• Steering Group

• Developed with staff and patient engagement

• Evaluated from the start with support from NHS

Derbyshire County, Public Health Research Team

• DCHS Board and senior management support

• Staff workshops

Information Gained from Workshops

• Lack of confidence, knowledge and training • Some services reported that they were promoting health and

wellbeing • Staff health and wellbeing • Time and job pressures • Right approach • Public Health / Health Promotion • Job descriptions /contracts • Change

• ‘Permission’

Patient Public Involvement

• Seamless approach

• Consistency

• Attitude and expectation

• Proactive approach and follow up

• Carers and families fully engaged

• Staff lead by example – examples from business

• Service users at the centre

• Viewed as active members of society

Training

• Unique approach

• Working with two services

• Meeting with managers & team Leader

• Meet with team

• Facilitated training session for staff

Key outcomes

• Increased confidence and motivation

• Part of staff role

• Interest and understanding of Public Health/Health Promotion

• Staff health and wellbeing

• Referrals to local specialist healthy lifestyle services

The Way Forward

• Organisational vision

• Embedded into values and culture

• Users perspective

• Ongoing evaluation

• DCHS Pathfinder Project

For further information contact:

Linda Saxe Workforce Health and Wellbeing Project Manager linda.saxe@dchs.nhs.uk 07771652957

Public Health at BCH: Making

every Contact Count

Sarah-Jane Marsh, Chief Executive

Context

•Three years ago our staff told us they wanted to do things differently

•They wanted to create the conditions where they could deliver real changes to the lives of the children and young people who rely on our services

•One of the areas they wanted to focus on was advocating for children and young people – a key part of which was to develop campaigns to support improvements in the lifestyles of our patients and their families

•Our Trust Board agreed to integrate this as one of just six key objectives going forwards

‘We will be an advocate for

children and young people’

What did we do to prepare to meet this objective?

Engaged a range of organisations

who had experience in

this area

Commissioned a MBA student to evaluate other

similar work and make

recommendations

Undertook a literature search

to identify a methodology we could adapt and

adopt

Appointed health

promotion facilitator

Developed good relationships

with the community/

local authority/SHA around health

promotion

We began to understand we’re in a unique position to create a virtuous circle

Children come into hospital with conditions ranging from a fever to a serious

heart condition

Lifestyle issues such as diet and exercise often have an

impact on children’s conditions and their ability

to recover

Parents are keen to understand more about

improving lifestyle issues at this point

Worked hard to make a broad range of staff our advocates for improving

lifestyle issues

Provide big opportunities to link lifestyle changes to

fundraising for the hospital – e.g. half-marathon, BRMB

Walkathon

So we started a journey…

Yesterday Today Tomorrow

•We consulted with over 1500 staff across the hospital, who wanted us to advocate on behalf of children and young people and wanted us to focus those efforts on lifestyle issues

•We recruited a Health Promotion Lead in 2009;

•We set about equipping staff with the knowledge and resources to offer public health advice on a range of issues

•We have a network of Health Promotion Champions

•We have well developed care pathways on smoking, asthma and sexual health

•We have increased referrals for child safety schemes and healthy start vitamins

•We have created ‘an offer’, not just for patients and their families, but also for staff: including onsite exercise classes twice a week, smoking cessation sessions and swimming clubs

•Still need to improve on the evaluation of our programmes (but UoB are getting involved)

•Staff from right across the hospital are equipped not just with key messages about public health, but with the resources and support to point patients and their families to the right support

•That staff aren’t just advocates for public health, but are given the opportunities and support to change their own lifestyles

•That we evaluate the impact to achieve sustainable funding

Integrating our work with MECC has created extra pull…

•We have used MECC for our staff training, preferring face to face over e-learning but using both where appropriate; •Training has been department based providing opportunity for department led actions to be discussed and developed; •Teams are now requesting the training having recognised the value and impact.

Training

Teams are now requesting the training having recognised the

value and impact.

Conclusion

•We’ve come an enormously long way in the three years we’ve been doing public health campaigns at BCH

•There’s a real drive for success at every level of the organisation

•MECC has helped take us further, and the training support has been great

•We know from the family feedback that we’re making a real impact on people’s lives at a time they’re most willing to embrace change

•But we need support in evaluation to help make the case for acute-based public health going forward

Piloting the MECC Toolkit within a Mental

Health Setting

Derbyshire Healthcare NHS Foundation Trust

Julieann Trembling

Staff Liaison Manager

Karen Wheeler

Physical Health and Wellbeing Lead for Mental Health

Why we Chose to become a Pilot Site

• The Mental Health Strategy “No Health without Mental

Health” (DoH, 2011), has a specific objective to improve

the physical health of people with mental health problems

and to reduce health inequalities

• The Boorman Report (2009) recognises the importance

of the healthy workforce. „It is essential that all NHS

Trusts put staff health and well-being at the heart of their

work‟

• People experiencing severe mental health problems

face a greater risk developing physical ill health

• 2 - 4 times greater risk of cardiovascular disease

• 2 - 4 times greater risk of respiratory disease

• 2 times greater risk of developing bowel cancer

• 5 times greater risk of diabetes

• A person with schizophrenia can expect to live for up

to 20 years less than someone without a mental

health problem

Killer Facts !

• Organisational readiness

(organisational assessment tool)

• Staff readiness

(workforce competence and resources)

• Enabling and empowering the public

(behaviour change pathway)

The Pilot - What we were asked to do

• The pilot ran from August -- December 2011

• Settings:

• Morton Ward (acute in patient ward, Hartington Unit,

Chesterfield)

• Audrey House (rehabilitation unit based in community,

Derby)

Delivering the Pilot

2 Step team approach:

• Orientation session

• Implementation session

How we delivered it

• Health Lifestyle behaviour change is a value based topic which cannot simply be taught through a training package

• Staff health is closely related and interlinked with how the health messages are portrayed to service users – our community is made up of our staff and service users, staff can be our service users and our service users can be our staff

• Whole team approach which is relevant to the setting and stage of recovery

• Flexible approach delivered in different ways

• Ensure pathways are developed and embedded into current practice

• Service User involvement in delivering this concept is important as peer advocacy is a powerful support

Lessons Learned

• Delivering the Concept

• Embedding the Concept

• Supporting the Embedding

Recommendations for taking MECC Forwards

Recognise the need to tailor the MECC message to address the needs of the team and consider the setting

• Introduce staff to concept of MECC at Trust Induction

• Coaching sessions with teams to consider and deliver the core MECC messages dependent on stage of skill required for care pathway, readiness to change of service users and adapt to settings

• Potential use of individual e learning in down time during mandatory training to reinforce message and individual responsibility

• Where possible introduce and link to existing quality initiatives such as part of “Productive teams work” (health & wellbeing module)

Delivering the Concept

Recognise that it is necessary to embed the principles within

current practices, using existing systems, so the philosophy runs

throughout the organisation.

Using frameworks such as:

• Core care standards, CPA Assessment forms ,Care planning

• Releasing time to care, essence of care benchmark tools

• Staff supervision - Re-enforcing the message

• Recognising the experts within settings – Identifying the

pathways

Embedding the Concept

Recognise that resources will be needed & shared in

delivering and embedding the philosophy

For example:

• Signposting information, Prompt cards

• Working with community partners

• Healthy Calendar

• Links to national campaigns e.g. BHF Heart City – Derby

• Recognising this isn‟t a stand-alone project needs to link

in with other appropriate projects including Public Health

Supporting the Embedding

• CQUIN L6b (From April 2012 - to develop an implementation plan for MECC)

• 4E committee addressing Health Equalities & Experience, Engagement & Enablement

• Multi-professional Philosophy promoting Health & Wellbeing

• Staff Health & Wellbeing group

• NHS Outcomes Framework

• East Midlands Health Trainer Services and Behaviour Change Hub

• NHS Future Forum

Supporting Drivers

• Service user empowerment - Peer advocacy

• Developing a co-ordinated & well communicated network for tackling health related issues

• Pursuing creative & innovative ideas

• Consider wider issues i.e. local economy sourcing local products

Longer Term Developments

For further information contact:

Karen.wheeler@derbyshcft.nhs.uk

Julieann.trembling@derbyshcft.nhs.uk

Moving Forward

Make Every Contact Count in your Organisation

Professor David Walker

Director of Public Health, NHS Midlands and East

Executive Lead for Making Every Contact Count

• Training and Guidance • Implementation support coordination centre -

• E- learning module – Every Contact Counts

• Cohort of train the trainers – 30 train the trainer sessions

• Workshops for;

• Implementation leads- using the guide and toolkit

• Education providers – embedding MECC

• GPs- MECC in primary care

• MECC Innovation fund • £5k grants to support innovative ways of capturing MECC activity and

feeding back to staff- call for proposals in June

• MECC on the web • E- version of Guide and Toolkit plus resources and case studies

http://nhs.lc/makingeverycontactcount

Questions?

MECC Guide and Toolkit Website:

http://nhs.lc/makingeverycontactcount

Contacts:

Simon How,

MECC Project Manager

simon.how@dh.gsi.gov.uk

Sara Dunling,

MECC Project Support

sara.dunling@eoe.nhs.uk