CVD: Primary Care Intelligence Packs NHS South Gloucestershire CCG
June 2017 Version 1 Contents
1. Introduction 3
2. CVD prevention • The narrative 11 • The data 13 3. Hypertension • The narrative 16 • The data 17 4. Stroke • The narrative 27 • The data 28 5. Diabetes • The narrative 42 • The data 43 6. Kidney • The narrative 53 • The data 54 7. Heart • The narrative 65 • The data 66 8. Outcomes 82
9. Appendix 88 This document is valid only when viewed via the internet. If it is printed into hard copy or saved to another location, you must first check that the version number on your copy matches that of the one online. Printed copies are uncontrolled copies.
2 CVD: Primary Care Intelligence Packs Introduction
3 CVD: Primary Care Intelligence Packs This intelligence pack has been compiled by GPs and nurses and pharmacists in the Primary Care CVD Leadership Forum in collaboration with the National Cardiovascular Intelligence Network
Matt Kearney Sarit Ghosh Kathryn Griffith George Kassianos Jo Whitmore Matthew Fay Chris Harris Jan Procter-King Yassir Javaid Ivan Benett Ruth Chambers Ahmet Fuat Mike Kirby Peter Green Kamlesh Khunti Helen Williams Quincy Chuhka Sheila McCorkindale Nigel Rowell Ali Morgan Stephen Kirk Sally Christie Clare Hawley Paul Wright Bruce Taylor Mike Knapton John Robson Richard Mendelsohn Chris Arden David Fitzmaurice
4 CVD: Primary Care Intelligence Packs Local intelligence as a tool for clinicians and commissioners to improve outcomes for our patients Why should we use this CVD Intelligence Pack The high risk conditions for cardiovascular disease (CVD) - such as hypertension, atrial fibrillation, high cholesterol, diabetes, non-diabetic hyperglycaemia and chronic kidney disease - are the low hanging fruit for prevention in the NHS because in each case late diagnosis and suboptimal treatment is common and there is substantial variation. High quality primary care is central to improving outcomes in CVD because primary care is where much prevention and most diagnosis and treatment is delivered. This cardiovascular intelligence pack is a powerful resource for stimulating local conversations about quality improvement in primary care. Across a number of vascular conditions, looking at prevention, diagnosis, care and outcomes, the data allows comparison between clinical commissioning groups (CCGs) and between practices. This is not about performance management because we know that variation can have more than one interpretation. But patients have a right to expect that we will ask challenging questions about how the best practices are achieving the best, what average or below average performers could do differently, and how they could be supported to perform as well as the best.
How to use the CVD intelligence pack The intelligence pack has several sections – CVD prevention, hypertension, stroke and atrial fibrillation (AF), diabetes, kidney disease, heart disease and heart failure. Each section has one slide of narrative that makes the case and asks some questions. This is followed by data for a number of indicators, each with benchmarked comparison between CCGs and between practices. Use the pack to identify where there is variation that needs exploring and to start asking challenging questions about where and how quality could be improved. We suggest you then develop a local action plan for quality improvement – this might include establishing communities of practice to build clinical leadership, systematic local audit to get a better understanding of the gaps in care and outcomes, and developing new models of care that mobilise the wider primary care team to reduce burden on general practice.
5 CVD: Primary Care Intelligence Packs Data and methods
This slide pack compares the clinical commissioning group (CCG) with CCGs in its strategic transformation plan (STP) and England. Where a CCG is in more than one STP, it has been allocated to the STP with the greatest geographical or population coverage. The slide pack also compares the CCG to its 10 most similar CCGs in terms of demography, ethnicity and deprivation. For information on the methodology used to calculate the 10 most similar CCGs please go to: http://www.england.nhs.uk/resources/resources-for-ccgs/comm-for-value/
The 10 most similar CCGs to NHS South Gloucestershire CCG are: NHS South East Staffordshire and Seisdon Peninsula CCG NHS Basildon and Brentwood CCG NHS Swindon CCG NHS Fareham and Gosport CCG NHS Horsham and Mid Sussex CCG NHS Surrey Downs CCG NHS Bracknell and Ascot CCG NHS North West Surrey CCG NHS North Hampshire CCG NHS East Surrey CCG
The majority of data used in the packs is taken from the 2015/16 Quality and Outcomes Framework (QOF). Where this is not the case, this is indicated in the slide. All GP practices that were included in the 2015/16 QOF are included. Full source data are shown in the appendix.
For the majority of indicators, the additional number of people that would be treated if all practices were to achieve as well as the average of the top achieving practices is calculated. This is calculated by taking an average of the intervention rates (ie the denominator includes exceptions) for the best 50% of practices in the CCG and applying this rate to all practices in the CCG. Note, this number is not intended to be proof of a realisable improvement; rather it gives an indication of the magnitude of available opportunity.
6 CVD: Primary Care Intelligence Packs Why does variation matter?
A key observation about benchmarking data is The variation that exists between that it does not tell us why there is variation. Some of the demographically similar CCGs and variation may be explained by population or case mix and some may be unwarranted. We will not know unless we between practices illustrates the local investigate. potential to improve care and outcomes for our patients Benchmarking may not be conclusive. Its strength lies not in the answers it provides but in the questions it generates for CCGs and practices. Benchmarking is helpful because it highlights variation. For example: 1. How much variation is there in detection, management, Of course it has long been acknowledged that some exception reporting and outcomes? variation is inevitable in the healthcare and outcomes 2. How many people would benefit if average performers experienced by patients. improved to the level of the best performers? But John Wennberg, who has championed research 3. How many people would benefit if the lowest performers into clinical variation over four decades and who matched the achievement of the average? founded the pioneering Dartmouth Atlas of Health 4. What are better performers doing differently in the way Care, concluded that much variation is unwarranted – they provide services in order to achieve better outcomes? ie it cannot be explained on the basis of illness, 5. How can the CCG support low and average performers to medical evidence, or patient preference, but is help them match the achievement of the best? accounted for by the willingness and ability of doctors 6. How can we build clinical leadership to drive quality to offer treatment. improvement?
There are legitimate reasons for exception reporting. But ……. Excepting patients from indicators puts them at risk of not receiving optimal care and of having worse outcomes. It is also likely to increase health inequalities. The substantial variation seen in exception reporting for some indicators suggests that some practices are more effective than others at reaching their whole population. Benchmarking exception reporting 7 allows us to identify the practices that need support to implement the strategies adopted by low excepting practices. Cluster methodology: your most similar practices
Each practice has been grouped on the basis of demographic data into 15 national clusters. These demographic factors cover: • deprivation (practice level) • age profile (% < 5, % < 18, % 15-24, % 65+, % 75+, % 85+) • ethnicity (% population of white ethnicity) • practice population side
These demographic factors closely align with those used to calculate the “Similar 10 CCGs”. These demographic factors have been used to compare practices with similar populations to account for potential factors which may drive variation. Some local interpretation will need to be applied to the data contained within the packs as practices with significant outlying population characteristics e.g. university populations or care home practices will need further contextualisation. Further detailed information including full technical methodology and a full PDF report on each of the 15 practice clusters is available here: https://github.com/julianflowers/geopractice.
8 CVD: Primary Care Intelligence Packs Cluster methodology: calculating potential gains
The performance of every practice in the GP cluster contributes to the average of the top performing 50% of practices to form a benchmark.
5% 0% -5% -10% -15% -20%
WELLINGTON ROAD SURGERY 7
EMERSONS GREEN MEDICAL CENTRE 9
LEAP VALLEY MEDICAL CENTRE 22
CHRISTCHURCH FAMILY MEDICAL CENTRE 21
CONISTON MEDICAL PRACTICE 17
FROME VALLEY MEDICAL CENTRE 31
ST MARY STREET SURGERY 14 KINGSWOODRaw HEALTH difference CENTRE between the Potential opportunity if 15 Potential opportunity if the CONCORDpractice MEDICAL CENTRE value the practice value was 12 CCG value were to move KENNEDYand WAY the SURGERY average of the to move to the average 9 to the average of the top 5 highest or lowest 50% of of the highest 50% of performing closest CCGs similar cluster practices similar cluster practices BRADLEY STOKE SURGERY 3
THE WILLOW SURGERY 5
CLOSE FARM SURGERY 1 The difference between the benchmark and the selected practices is displayed on this chart. The benchmark will most likelyPILNING be SURGERY different for different practices as they are in different clusters, so1 the difference is the key measure here. IfCOURTSIDE the practice SURGERY performance is below the benchmark, the difference is applied1 to the denominator plus exceptionsALMONDSBURY to SURGERY demonstrate potential gains on a practice basis. The potential gains on a CCG basis are calculated
STOKEbased GIFFORD on MEDICAL the CENTREdifference between the top 5 performing closest CCGs and the selected CCG, applied to the
denominatorORCHARD MEDICAL plus CENTRE exceptions.
WEST WALK SURGERY
THORNBURY9 CVD: HEALTH PrimaryCENTRE - BURNEY Care Intelligence Packs CVD prevention
10 CVD: Primary Care Intelligence Packs CVD prevention
The size of the prevention problem “The NHS needs a radical upgrade • 2/3 of adults are obese or overweight in prevention if it is to be • 1/3 of adults are physically inactive sustainable” • average smoking prevalence is 17% but is much 5 year Forward View 2014 higher in some communities • in high risk conditions like atrial fibrillation, high blood pressure, diabetes and high ten year CVD risk score, This is because England faces an epidemic of largely up to half of all people do not receive preventive preventable non-communicable diseases, such as heart treatments that are known to be highly effective at disease and stroke, cancer, Type 2 diabetes and liver disease. preventing heart attacks and strokes
Dietary risks • around 90% of people with familial hypercholestero- Tobacco smoke High body-mass index laemia are undiagnosed and untreated despite their High systolic blood pressure Alcohol and drug use average 10 year reduction in life expectancy HIV/AIDS and tuberculosis High fasting plasma glucose Diarrhea, lower respiratory & other common infectious diseases High total cholesterol Neglected tropical diseases & malaria Maternal disorders Low glomerular filtration rate Neonatal disorders Nutritional deficiencies Low physical activity Other communicable, maternal, neonatal, & nutritional diseases Neoplasms Occupational risks Social prescribing and wellbeing hubs offer new Cardiovascular diseases Air pollution Chronic respiratory diseases Cirrhosis Low bone mineral density Digestive diseases models for supporting behaviour change while reducing Neurological disorders Child and maternal malnutrition Mental & substance use disorders Diabetes, urogenital, blood, & endocrine diseases Sexual abuse and violence burden on general practice. Musculoskeletal disorders Other environmental risks Other non-communicable diseases Transport injuries Unsafe sex Unintentional injuries The NHS Health Check is a systematic approach to Self-harm and interpersonal violence Unsafe water/ sanitation/ handwashing Forces of nature, war, & legal intervention 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 11% 12% identifying local people at high risk of CVD, offering Percent of total disability-adjusted life-years (DALYs) behaviour change support and early detection of the The Global Burden of Disease Study (next slide) shows us that high risk but often undiagnosed conditions such as the leading causes of premature mortality include diet, hypertension, atrial fibrillation, CKD, diabetes and pre- tobacco, obesity, raised blood pressure, physical inactivity and diabetes. raised cholesterol. The radical upgrade in prevention needs Question: What proportion of our local eligible population-level approaches. But it also needs interventions in population is receiving the NHS Health Check and how primary care for individuals with behavioural and clinical risk effective is the follow-up management of their clinical factors. risk factors in primary care?
11 11 CVD: Primary Care Intelligence Packs Global Burden of Disease Study 2015 Risk Factors for premature death and disability caused by CVD in England, expressed as a percentage of total disability-adjusted life-years
High systolic blood pressure
Dietary risks
High total cholesterol
High body-mass index
Tobacco smoke
High fasting plasma glucose
Low physical activity
Air pollution
Low glomerular filtration rate
Other environmental risks
0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10%
Percentage of total CVD disability-adjusted life-years (DALYs)
12 CVD: Primary Care Intelligence Packs Estimated smoking prevalence (QOF) by CCG Comparison with demographically similar CCGs
NHS Swindon CCG 17.8%
NHS Basildon and Brentwood CCG 17.3% • prevalence of 15.3% in NHS South Gloucestershire CCG NHS South East Staffordshire and Seisdon Peninsula CCG 16.3%
NHS Fareham and Gosport CCG 15.7%
NHS North Hampshire CCG 15.7%
NHS Bracknell and Ascot CCG 15.6%
NHS South Gloucestershire CCG 15.3%
NHS East Surrey CCG 14.7% Note: It has been found that the proportion of patients recorded as smokers correlates well NHS North West Surrey CCG 14.4% with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, NHS Horsham and Mid Sussex CCG 12.4% http://bmjopen.bmj.com/content/4/7/e005217.abs tract
NHS Surrey Downs CCG 12.4% Definition: denominator of QOF clinical indicator SMOKE004 ( number of patients 15+ who are 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% recorded as current smokers) divided by GP practice’s estimated number of patients 15+
13 CVD: Primary Care Intelligence Packs Estimated smoking prevalence (QOF) by GP practice
GP Practice CCG
CONISTON MEDICAL PRACTICE L81036 24.0%
NORTHVILLE FAMILY PRACTICE L81028 22.1% KINGSWOOD HEALTH CENTRE L81063 21.9% • 33,395 people who are recorded as ORCHARD MEDICAL CENTRE L81055 21.9% smokers in NHS South CHRISTCHURCH FAMILY MEDICAL CENTRE L81026 17.1% Gloucestershire CCG KENNEDY WAY SURGERY L81042 16.7% • GP practice range: 10.3% to 24.0% CADBURY HEATH HEALTHCARE L81130 16.5%
WEST WALK SURGERY L81047 15.6%
CONCORD MEDICAL CENTRE L81019 15.3%
COURTSIDE SURGERY L81024 15.2%
CLOSE FARM SURGERY L81050 15.1%
STOKE GIFFORD MEDICAL CENTRE L81118 14.6%
THE WILLOW SURGERY L81052 14.4%
PILNING SURGERY L81117 14.3%
HANHAM HEALTH L81079 14.1%
BRADLEY STOKE SURGERY L81649 13.7%
WELLINGTON ROAD SURGERY L81642 13.2%
LEAP VALLEY MEDICAL CENTRE L81046 13.2%
ST MARY STREET SURGERY L81103 12.7%
THORNBURY HEALTH CENTRE - BURNEY L81018 11.6% EMERSONS GREEN MEDICAL CENTRE L81632 11.6% Note: This method is thought to be a reasonably THREE SHIRES MEDICAL PRACTICE L81029 11.2% robust method in estimating smoking prevalence FROME VALLEY MEDICAL CENTRE L81014 11.1% for the majority of GP practices. However,
THORNBURY HEALTH CENTRE - MALE L81106 10.5% caution is advised for extreme estimates of smoking prevalence and those with high ALMONDSBURY SURGERY L81127 10.3% numbers of smoking status not recorded and 0% 5% 10% 15% 20% 25% 30% exceptions.
14 CVD: Primary Care Intelligence Packs Hypertension
15 CVD: Primary Care Intelligence Packs Hypertension
The Missing Millions On average, each CCG in England has 26,000 residents with The Global Burden of Disease undiagnosed hypertension – these individuals are unaware of Study confirmed high blood pressure as their increased cardiovascular risk and are untreated. a leading cause of premature death and disability What questions should we ask in our CCG? 1. for each indicator how wide is the variation in achievement and exception reporting? 2. how many people would benefit if all practices performed High blood pressure is common and costly as well as the best? • it affects around a quarter of all adults 3. how can we support practices who are average or below • the NHS costs of hypertension are around £2bn average to perform as well as the best in: • social costs are probably considerably higher • detection of hypertension • management of hypertension What do we know? • at least half of all heart attacks and strokes are caused by high blood pressure and it is a major risk What might help? factor for chronic kidney disease and cognitive decline • support practices to share audit data and systematically • treatment is very effective – every 10mmHg reduction identify gaps and opportunities for improved detection and in systolic blood pressure lowers risk of heart attack management of hypertension and stroke by 20% • work with practices and local authorities to maximise • despite this 4 out of 10 adults with hypertension, over uptake and follow up in the NHS Health Check 5 and a half million people in England, remain • support access to self-test BP stations in waiting rooms undiagnosed and to ambulatory blood pressure monitoring. • and even when the condition is identified, treatment is • commission community pharmacists to offer blood often suboptimal, with blood pressure poorly pressure measurement, diagnosis and management controlled in about 1 out of 3 individuals support, including support for adherence to medication
16 CVD: Primary Care Intelligence Packs Hypertension observed prevalence compared with expected prevalence by CCG Comparison with CCGs in the STP
NHS North Somerset CCG 0.61
• the ratio of those diagnosed with hypertension versus those expected to have hypertension is 0.59. This NHS South Gloucestershire CCG 0.59 compares to 0.59 for England • this suggests that 59% of people with hypertension have been diagnosed
NHS Bristol CCG 0.54
England 0.59 Note: this slide shows Hypertension prevalence estimates created using data from QOF hypertension registers 2014/15 and Undiagnosed hypertension estimates for adults 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 16 years and older. 2014. Department of Primary Ratio Care & Public Health, Imperial College London
17 CVD: Primary Care Intelligence Packs Hypertension observed prevalence compared with expected prevalence by CCG Comparison with demographically similar CCGs
NHS Fareham and Gosport CCG 0.60
NHS Basildon and Brentwood CCG 0.60
NHS South East Staffordshire and Seisdon Peninsula 0.59 CCG
NHS Surrey Downs CCG 0.59
NHS Swindon CCG 0.59
NHS South Gloucestershire CCG 0.59
NHS Horsham and Mid Sussex CCG 0.59
NHS North Hampshire CCG 0.57
NHS North West Surrey CCG 0.57
NHS East Surrey CCG 0.56
NHS Bracknell and Ascot CCG 0.56
0% 10% 20% 30% 40% 50% 60% 70%
18 CVD: Primary Care Intelligence Packs Hypertension observed prevalence compared with expected prevalence by GP practice
GP practice CCG
PILNING SURGERY L81117 0.70 WELLINGTON ROAD SURGERY L81642 0.66 HANHAM HEALTH L81079 0.65 • it is estimated that there are 25,310 CADBURY HEATH HEALTHCARE L81130 0.64 COURTSIDE SURGERY L81024 0.62 people with undiagnosed ORCHARD MEDICAL CENTRE L81055 0.62 hypertension in NHS South ST MARY STREET SURGERY L81103 0.62 Gloucestershire CCG CONCORD MEDICAL CENTRE L81019 0.61 • GP practice range of observed to THORNBURY HEALTH CENTRE - BURNEY L81018 0.61 expected hypertension prevalence THORNBURY HEALTH CENTRE - MALE L81106 0.61 0.49 to 0.7 STOKE GIFFORD MEDICAL CENTRE L81118 0.60 FROME VALLEY MEDICAL CENTRE L81014 0.60 WEST WALK SURGERY L81047 0.59 CONISTON MEDICAL PRACTICE L81036 0.59 NORTHVILLE FAMILY PRACTICE L81028 0.58 CHRISTCHURCH FAMILY MEDICAL CENTRE L81026 0.57 CLOSE FARM SURGERY L81050 0.57 THREE SHIRES MEDICAL PRACTICE L81029 0.56 BRADLEY STOKE SURGERY L81649 0.56 ALMONDSBURY SURGERY L81127 0.56 LEAP VALLEY MEDICAL CENTRE L81046 0.55 KINGSWOOD HEALTH CENTRE L81063 0.55 THE WILLOW SURGERY L81052 0.55 KENNEDY WAY SURGERY L81042 0.51 EMERSONS GREEN MEDICAL CENTRE L81632 0.49 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Ratio
19 CVD: Primary Care Intelligence Packs Percentage of patients with hypertension whose last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less by CCG Comparison with CCGs in the STP
NHS North Somerset CCG 79.8%
• 36,908 people with hypertension (diagnosed)* in NHS South Gloucestershire CCG NHS South Gloucestershire CCG 79.0% • 29,150 (79%) people whose blood pressure is <= 150/90 • 1,511 (4.1%) people who are excepted from optimal control • 6,247 (16.9%) additional people NHS Bristol CCG 77.8% whose blood pressure is not <= 150/90
England 79.6%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% *Using QOF clinical indicator HYP006 denominator plus exceptions
20 CVD: Primary Care Intelligence Packs Percentage of patients with hypertension whose last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less by CCG Comparison with demographically similar CCGs
NHS Swindon CCG 80.5%
NHS Horsham and Mid Sussex CCG 80.3%
NHS South East Staffordshire and Seisdon Peninsula 79.4% CCG
NHS South Gloucestershire CCG 79.0%
NHS North Hampshire CCG 78.6%
NHS North West Surrey CCG 78.6%
NHS Basildon and Brentwood CCG 78.2%
NHS Bracknell and Ascot CCG 77.7%
NHS East Surrey CCG 77.2%
NHS Fareham and Gosport CCG 75.7%
NHS Surrey Downs CCG 75.3%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
21 CVD: Primary Care Intelligence Packs Percentage of patients with hypertension whose last blood pressure reading (measured in the preceding 12 months) is not 150/90 mmHg or less by GP practice
No treatment Exceptions reported
CHRISTCHURCH FAMILY MEDICAL CENTRE L81026 589 NORTHVILLE FAMILY PRACTICE L81028 222 LEAP VALLEY MEDICAL CENTRE L81046 443 • in total, including exceptions, there BRADLEY STOKE SURGERY L81649 327 are 7,758 people whose blood CONISTON MEDICAL PRACTICE L81036 351 pressure is not <= 150/90 ORCHARD MEDICAL CENTRE L81055 478 • GP practice range: 11.6% to 31.4% CONCORD MEDICAL CENTRE L81019 437 THREE SHIRES MEDICAL PRACTICE L81029 305 ST MARY STREET SURGERY L81103 267 THE WILLOW SURGERY L81052 377 KINGSWOOD HEALTH CENTRE L81063 363 HANHAM HEALTH L81079 727 THORNBURY HEALTH CENTRE - MALE L81106 157 FROME VALLEY MEDICAL CENTRE L81014 468 CADBURY HEATH HEALTHCARE L81130 280 THORNBURY HEALTH CENTRE - BURNEY L81018 301 COURTSIDE SURGERY L81024 403 EMERSONS GREEN MEDICAL CENTRE L81632 168 PILNING SURGERY L81117 142 ALMONDSBURY SURGERY L81127 124 STOKE GIFFORD MEDICAL CENTRE L81118 261 WELLINGTON ROAD SURGERY L81642 59 CLOSE FARM SURGERY L81050 121 KENNEDY WAY SURGERY L81042 153 WEST WALK SURGERY L81047 235
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
22 CVD: Primary Care Intelligence Packs New diagnosis of hypertension who have been given a CVD risk assessment whose CVD risk exceeds 20% and treated with statins by CCG Comparison with CCGs in the STP
NHS South Gloucestershire CCG 70.3%
• 128 people with a new diagnosis* of hypertension with a CVD risk of 20% or higher in NHS South NHS Bristol CCG 68.1% Gloucestershire CCG • 90 (70.3%) people who are currently treated with statins • 37 (28.9%) people who are exempted from treatment with statins NHS North Somerset CCG 53.9% • 1 (0.8%) additional people who are not currently treated with statins
England 66.5%
0% 10% 20% 30% 40% 50% 60% 70% 80% *Using the QOF clinical indicator CVD-PP001 denominator plus exceptions
23 CVD: Primary Care Intelligence Packs New diagnosis of hypertension who have been given a CVD risk assessment whose CVD risk exceeds 20% and treated with statins by CCG Comparison with demographically similar CCGs
NHS Swindon CCG 76.8%
NHS North West Surrey CCG 72.1%
NHS South Gloucestershire CCG 70.3%
NHS Bracknell and Ascot CCG 67.3%
NHS North Hampshire CCG 66.0%
NHS Fareham and Gosport CCG 64.7%
NHS Surrey Downs CCG 63.4%
NHS South East Staffordshire and Seisdon Peninsula 61.8% CCG
NHS Horsham and Mid Sussex CCG 61.6%
NHS Basildon and Brentwood CCG 61.6%
NHS East Surrey CCG 59.7%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
24 CVD: Primary Care Intelligence Packs New diagnosis of hypertension who have been given a CVD risk assessment whose CVD risk exceeds 20% and not treated with statins by GP practice
No treatment Exceptions reported
NORTHVILLE FAMILY PRACTICE L81028 1 THREE SHIRES MEDICAL PRACTICE L81029 2 CONISTON MEDICAL PRACTICE L81036 1 • in total, including exceptions, there KENNEDY WAY SURGERY L81042 3 are 38 people who are not treated WEST WALK SURGERY L81047 7 with statins THE WILLOW SURGERY L81052 4 • GP practice range: 0.0% to 100.0% ST MARY STREET SURGERY L81103 1 PILNING SURGERY L81117 2 STOKE GIFFORD MEDICAL CENTRE L81118 1 LEAP VALLEY MEDICAL CENTRE L81046 4 COURTSIDE SURGERY L81024 5 THORNBURY HEALTH CENTRE - BURNEY L81018 1 THORNBURY HEALTH CENTRE - MALE L81106 1 CADBURY HEATH HEALTHCARE L81130 1 FROME VALLEY MEDICAL CENTRE L81014 1 HANHAM HEALTH L81079 2 ORCHARD MEDICAL CENTRE L81055 1 CONCORD MEDICAL CENTRE L81019 CHRISTCHURCH FAMILY MEDICAL CENTRE L81026 CLOSE FARM SURGERY L81050 KINGSWOOD HEALTH CENTRE L81063 ALMONDSBURY SURGERY L81127 EMERSONS GREEN MEDICAL CENTRE L81632 WELLINGTON ROAD SURGERY L81642 BRADLEY STOKE SURGERY L81649
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
25 CVD: Primary Care Intelligence Packs Stroke
26 CVD: Primary Care Intelligence Packs Stroke prevention
What questions should we ask in our CCG? Only a half of people with known 1. for each indicator how wide is the variation in detection, treatment and exception reporting? AF who then suffer a stroke have been 2. how many people would benefit if all practices anticoagulated before their stroke. performed as well as the best? 3. how can we support practices who are average and below average to perform as well as the best in detection of atrial fibrillation and stroke prevention with anticoagulation. Stroke is one of the leading causes of premature death and disability. Stroke is What might help? devastating for individuals and families, and • increase opportunistic pulse checking especially in over 65s accounts for a substantial proportion of health • support practices to share audit data and systematically and social care expenditure. identify gaps and opportunities for improved detection and management of AF - eg GRASP-AF Atrial fibrillation increases the risk of stroke • promote systematic use of CHADS-VASC and HASBLED to by a factor of 5, and strokes caused by AF are ensure those at high risk are offered stroke prevention often more severe, with higher mortality and • promote systematic use of Warfarin Patient Safety Audit Tool greater disability. to ensure optimal time in therapeutic range for people on Anticoagulation reduces the risk of stroke in warfarin people with AF by two thirds. • develop local consensus statement on risk-benefit balance for Despite this, AF is underdiagnosed and under anticoagulants, including the newer treatments (NOACs) treated: up to a third of people with AF are • work with practices and local authorities to maximise uptake unaware they have the condition and even when and clinical follow up in the NHS Health Check diagnosed inadequate treatment is common – • commission community pharmacists to offer pulse checks, large numbers do not receive anticoagulants or anticoagulant monitoring, and support for adherence to have poor anticoagulant control. medication
27 CVD: Primary Care Intelligence Packs Atrial fibrillation observed prevalence compared to expected prevalence by CCG Comparison with CCGs in the STP
NHS North Somerset CCG 0.80
• the ratio of those diagnosed with atrial fibrillation versus those expected to have atrial fibrillation is 0.76. This NHS South Gloucestershire CCG 0.76 compares to 0.7 for England • this suggests that 76% of people with atrial fibrillation have been diagnosed.
NHS Bristol CCG 0.74
Note: This slide compares the prevalence of atrial fibrillation recorded in QOF in 2015/16 to the estimated prevalence of atrial fibrillation, taken from National Cardiovascular Intelligence Network estimates produced in 2017. The England 0.70 estimates were developed by applying age-sex specific prevalence rates as reported by Norberg et al (2013) to GP population estimates from 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 NHS Digital. Estimates reported are adjusted for age and sex of the local population.
28 CVD: Primary Care Intelligence Packs Atrial fibrillation observed prevalence compared to expected prevalence by CCG Comparison with demographically similar CCGs
NHS East Surrey CCG 0.78
NHS South Gloucestershire CCG 0.76
NHS Fareham and Gosport CCG 0.71
NHS South East Staffordshire and Seisdon Peninsula 0.71 CCG
NHS Horsham and Mid Sussex CCG 0.70
NHS Swindon CCG 0.68
NHS North West Surrey CCG 0.68
NHS Surrey Downs CCG 0.67
NHS Basildon and Brentwood CCG 0.66
NHS North Hampshire CCG 0.66
NHS Bracknell and Ascot CCG 0.65
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
29 CVD: Primary Care Intelligence Packs Atrial fibrillation observed prevalence compared with expected prevalence by GP practice
GP practice CCG
COURTSIDE SURGERY L81024 0.9 PILNING SURGERY L81117 0.9 FROME VALLEY MEDICAL CENTRE L81014 0.8 • it is estimated that there are 6,838 THORNBURY HEALTH CENTRE - BURNEY L81018 0.8 NORTHVILLE FAMILY PRACTICE L81028 0.8 people with undiagnosed atrial THREE SHIRES MEDICAL PRACTICE L81029 0.8 fibrillation in NHS South CONISTON MEDICAL PRACTICE L81036 0.8 Gloucestershire CCG WEST WALK SURGERY L81047 0.8 • GP practice range of observed to CLOSE FARM SURGERY L81050 0.8 expected atrial fibrillation prevalence ORCHARD MEDICAL CENTRE L81055 0.8 0.6 to 0.9 HANHAM HEALTH L81079 0.8 ST MARY STREET SURGERY L81103 0.8 THORNBURY HEALTH CENTRE - MALE L81106 0.8 WELLINGTON ROAD SURGERY L81642 0.8 CONCORD MEDICAL CENTRE L81019 0.7 CHRISTCHURCH FAMILY MEDICAL CENTRE L81026 0.7 KENNEDY WAY SURGERY L81042 0.7 THE WILLOW SURGERY L81052 0.7 KINGSWOOD HEALTH CENTRE L81063 0.7 STOKE GIFFORD MEDICAL CENTRE L81118 0.7 CADBURY HEATH HEALTHCARE L81130 0.7 BRADLEY STOKE SURGERY L81649 0.7 LEAP VALLEY MEDICAL CENTRE L81046 0.6 ALMONDSBURY SURGERY L81127 0.6 EMERSONS GREEN MEDICAL CENTRE L81632 0.6 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Ratio
30 CVD: Primary Care Intelligence Packs In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage treated with anti-coagulation therapy by CCG Comparison with CCGs in the STP Optimal management No treatment Exceptions reported
NHS South Gloucestershire CCG 79.7% • 4,247 people with atrial fibrillation* with a CHA2DS2-VASc score >= 2 in NHS South Gloucestershire CCG • 3,383 (79.7%) people treated with anti-coagulation therapy NHS Bristol CCG 79.1% • 350 (8.2%) people who are exceptions • 514 (12.1%) additional people with a recorded CHA2DS2-VASc score >= 2 NHS North Somerset CCG 77.8% who are not treated
England 77.9%
0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator AF007 denominator plus exceptions
31 CVD: Primary Care Intelligence Packs In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage treated with anti-coagulation therapy by CCG Comparison with demographically similar CCGs Optimal management No treatment Exceptions reported
NHS Surrey Downs CCG 81.0%
NHS North Hampshire CCG 79.9%
NHS South Gloucestershire CCG 79.7%
NHS Swindon CCG 78.9%
NHS Bracknell and Ascot CCG 78.6%
NHS South East Staffordshire and Seisdon Peninsula CCG 77.4%
NHS North West Surrey CCG 77.1%
NHS Basildon and Brentwood CCG 76.6%
NHS East Surrey CCG 76.5%
NHS Horsham and Mid Sussex CCG 75.3%
NHS Fareham and Gosport CCG 75.2%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
32 CVD: Primary Care Intelligence Packs In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage treated with anti-coagulation therapy by GP practice
No treatment Exceptions reported
WELLINGTON ROAD SURGERY L81642 18 CHRISTCHURCH FAMILY MEDICAL CENTRE L81026 57 KENNEDY WAY SURGERY L81042 44 • in total, including exceptions, there KINGSWOOD HEALTH CENTRE L81063 52 are 864 people with a recorded EMERSONS GREEN MEDICAL CENTRE L81632 17 CHA2DS2-VASc score >= 2 who are CONISTON MEDICAL PRACTICE L81036 33 not treated ST MARY STREET SURGERY L81103 42 • GP practice range: 9.4% to 38.3% FROME VALLEY MEDICAL CENTRE L81014 75 LEAP VALLEY MEDICAL CENTRE L81046 35 HANHAM HEALTH L81079 97 CADBURY HEATH HEALTHCARE L81130 28 NORTHVILLE FAMILY PRACTICE L81028 16 STOKE GIFFORD MEDICAL CENTRE L81118 33 THREE SHIRES MEDICAL PRACTICE L81029 35 COURTSIDE SURGERY L81024 47 THE WILLOW SURGERY L81052 40 ALMONDSBURY SURGERY L81127 12 CONCORD MEDICAL CENTRE L81019 26 ORCHARD MEDICAL CENTRE L81055 39 THORNBURY HEALTH CENTRE - MALE L81106 16 CLOSE FARM SURGERY L81050 18 BRADLEY STOKE SURGERY L81649 13 WEST WALK SURGERY L81047 41 PILNING SURGERY L81117 10 THORNBURY HEALTH CENTRE - BURNEY L81018 20
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
33 CVD: Primary Care Intelligence Packs In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage treated with anti-coagulation therapy by GP practice – opportunities compared to GP cluster
10% 5% 0% -5% -10% -15% -20% -25%
WELLINGTON ROAD SURGERY 11
CHRISTCHURCH FAMILY MEDICAL CENTRE 26
KENNEDY WAY SURGERY 19 • using the GP cluster method of KINGSWOOD HEALTH CENTRE 19 calculating potential gains, if each ST MARY STREET SURGERY 16 practice was to achieve as well as the CONISTON MEDICAL PRACTICE 10 upper quartile of its national cluster, then an additional 178 people would EMERSONS GREEN MEDICAL CENTRE 5 be treated FROME VALLEY MEDICAL CENTRE 20
NORTHVILLE FAMILY PRACTICE 4
THREE SHIRES MEDICAL PRACTICE 9
THORNBURY HEALTH CENTRE - MALE 1
THE WILLOW SURGERY 2
COURTSIDE SURGERY 2
CLOSE FARM SURGERY
CONCORD MEDICAL CENTRE
ORCHARD MEDICAL CENTRE
WEST WALK SURGERY
PILNING SURGERY
BRADLEY STOKE SURGERY
THORNBURY HEALTH CENTRE - BURNEY Details of this methodology are available on slide 9. Click here to view them.
34 CVD: Primary Care Intelligence Packs Percentage of patients with a history of stroke whose last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less by CCG Comparison with CCGs in the STP
Below 150/90 Not below 150/90 Exceptions reported
NHS North Somerset CCG 85.0% • 4,688 people with a history of stroke or TIA* in NHS South Gloucestershire CCG • 3,942 (84.1%) people whose blood pressure is <= 150 / 90 NHS South Gloucestershire CCG 84.1% • 162 (3.5%) people who are exceptions • 584 (12.5%) additional people whose blood pressure is not <= 150 / 90 NHS Bristol CCG 81.9%
England 83.8%
0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator STIA003 denominator plus exceptions
35 CVD: Primary Care Intelligence Packs Percentage of patients with a history of stroke whose last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less by CCG Comparison with demographically similar CCGs Below 150/90 Not below 150/90 Exceptions reported
NHS Bracknell and Ascot CCG 84.6%
NHS Horsham and Mid Sussex CCG 84.2%
NHS South Gloucestershire CCG 84.1%
NHS Swindon CCG 83.9%
NHS North Hampshire CCG 83.3%
NHS South East Staffordshire and Seisdon Peninsula CCG 83.1%
NHS North West Surrey CCG 83.1%
NHS East Surrey CCG 82.8%
NHS Fareham and Gosport CCG 82.2%
NHS Basildon and Brentwood CCG 81.9%
NHS Surrey Downs CCG 80.3%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
36 CVD: Primary Care Intelligence Packs Percentage of patients with a history of stroke whose last blood pressure reading (measured in the preceding 12 months) is not 150/90 mmHg or less by GP practice
No treatment Exceptions reported
NORTHVILLE FAMILY PRACTICE L81028 28 CHRISTCHURCH FAMILY MEDICAL CENTRE L81026 65 LEAP VALLEY MEDICAL CENTRE L81046 45 • in total, including exceptions, there BRADLEY STOKE SURGERY L81649 24 are 746 people whose blood pressure CONISTON MEDICAL PRACTICE L81036 37 is not <= 150 / 90 ALMONDSBURY SURGERY L81127 17 • GP practice range: 8.7% to 29.8% EMERSONS GREEN MEDICAL CENTRE L81632 16 CONCORD MEDICAL CENTRE L81019 35 THORNBURY HEALTH CENTRE - MALE L81106 20 PILNING SURGERY L81117 14 FROME VALLEY MEDICAL CENTRE L81014 55 THE WILLOW SURGERY L81052 40 HANHAM HEALTH L81079 72 THREE SHIRES MEDICAL PRACTICE L81029 30 ORCHARD MEDICAL CENTRE L81055 36 WELLINGTON ROAD SURGERY L81642 7 COURTSIDE SURGERY L81024 38 KINGSWOOD HEALTH CENTRE L81063 31 CADBURY HEATH HEALTHCARE L81130 21 THORNBURY HEALTH CENTRE - BURNEY L81018 22 CLOSE FARM SURGERY L81050 12 STOKE GIFFORD MEDICAL CENTRE L81118 21 WEST WALK SURGERY L81047 26 ST MARY STREET SURGERY L81103 18 KENNEDY WAY SURGERY L81042 16
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
37 CVD: Primary Care Intelligence Packs Percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record in the preceding 12 months that an anti-platelet agent, or an anti-coagulant is being taken by CCG Comparison with CCGs in the STP Below 150/90 Not below 150/90 Exceptions reported
NHS South Gloucestershire CCG 92.4% • 3,075 people with a stroke shown to be non-haemorrhagic* in NHS South Gloucestershire CCG • 2,840 (92.4%) people who are taking an anti-platetet agent or anti- NHS North Somerset CCG 91.4% coagulant • 157 (5.1%) people who are exceptions • 78 (2.5%) additional people with no NHS Bristol CCG 90.8% treatment
England 91.8%
0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator STIA007 denominator plus exceptions
38 CVD: Primary Care Intelligence Packs Percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record in the preceding 12 months that an anti-platelet agent, or an anti-coagulant is being taken by CCG Comparison with demographically similar CCGs Below 150/90 Not below 150/90 Exceptions reported
NHS South Gloucestershire CCG 92.4%
NHS North West Surrey CCG 92.3%
NHS South East Staffordshire and Seisdon Peninsula CCG 91.8%
NHS Fareham and Gosport CCG 91.6%
NHS Horsham and Mid Sussex CCG 91.4%
NHS North Hampshire CCG 91.2%
NHS Swindon CCG 91.2%
NHS East Surrey CCG 90.7%
NHS Basildon and Brentwood CCG 90.7%
NHS Bracknell and Ascot CCG 90.0%
NHS Surrey Downs CCG 89.9%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
39 CVD: Primary Care Intelligence Packs Percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who do not have a record in the preceding 12 months that an anti-platelet agent, or an anti-coagulant is being taken by GP practice
No treatment Exceptions reported
CHRISTCHURCH FAMILY MEDICAL CENTRE L81026 30 BRADLEY STOKE SURGERY L81649 11 PILNING SURGERY L81117 8 • in total, including exceptions, there ALMONDSBURY SURGERY L81127 8 are 235 people who are not taking an CLOSE FARM SURGERY L81050 9 anti-platelet agent or anti-coagulant THREE SHIRES MEDICAL PRACTICE L81029 14 • GP practice range: 0.0% to 16.7% CADBURY HEATH HEALTHCARE L81130 10 THORNBURY HEALTH CENTRE - MALE L81106 6 STOKE GIFFORD MEDICAL CENTRE L81118 12 WEST WALK SURGERY L81047 14 KENNEDY WAY SURGERY L81042 10 CONISTON MEDICAL PRACTICE L81036 7 HANHAM HEALTH L81079 20 KINGSWOOD HEALTH CENTRE L81063 10 THE WILLOW SURGERY L81052 9 CONCORD MEDICAL CENTRE L81019 7 ST MARY STREET SURGERY L81103 9 THORNBURY HEALTH CENTRE - BURNEY L81018 8 NORTHVILLE FAMILY PRACTICE L81028 3 EMERSONS GREEN MEDICAL CENTRE L81632 3 COURTSIDE SURGERY L81024 8 ORCHARD MEDICAL CENTRE L81055 6 FROME VALLEY MEDICAL CENTRE L81014 13 LEAP VALLEY MEDICAL CENTRE L81046 WELLINGTON ROAD SURGERY L81642
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
40 CVD: Primary Care Intelligence Packs Diabetes
41 CVD: Primary Care Intelligence Packs Diabetes prevention and management
Type 2 Diabetes in numbers Diabetes costs the NHS • diagnosed prevalence – 3.0 million £9.8 billion per year – and the • undiagnosed diabetes – 900,000 • non-diabetic hyperglycaemia (high risk of diabetes) – 5 million prevalence is rising What questions should we ask in our CCG? 1. for each indicator how wide is the variation in achievement and exception reporting? Type 2 diabetes is often preventable 2. how many people would benefit if all practices performed as well People at high risk of developing type 2 diabetes as the best? can be identified through the NHS Health Check, 3. how can we support practices who are average and below and the disease can be prevented or delayed in average to perform as well as the best in: many through intensive behaviour change support. • detection of diabetes • delivery of the 8 care processes and achievement of the 3 treatment targets Complications of diabetes are preventable • identification and management of Non-diabetic hyperglycaemia Diabetes is a major cause of premature death and disability and greatly increases the risk of heart disease and stroke, kidney failure, amputations and What might help blindness. 80% of NHS spending on diabetes goes • ensure universal participation by practices in the National on managing these complications, most of which Diabetes Audit (NDA) could be prevented. There are 8 essential care • benchmark practice level data from the NDA – and support processes, in addition to retinal screening, that practices to explore variation together substantially reduce complication rates. • increase support for patient education and shared Despite this, around a half of people with diabetes management do not receive all 8 care processes, and there is • maximise uptake of the NHS Health Check to aid detection of widespread variation between CCGs and practices diabetes and Non Diabetic Hyperglycaemia in levels of achievement • maximise uptake of the NHS Diabetes Prevention Programme
42 CVD: Primary Care Intelligence Packs Diabetes observed prevalence compared with expected prevalence by CCG Comparison with CCGs in the STP
NHS South Gloucestershire CCG 0.78 • 0.78 ratio of observed to expected diabetes prevalence in NHS South Gloucestershire CCG, compared to 0.77 in England
NHS Bristol CCG 0.71 • this suggests 78% of people have been diagnosed
NHS North Somerset CCG 0.71
Note: This slide compares the prevalence of Diabetes recorded in QOF in 2015/16 to the England 0.77 expected prevalence of Diabetes in 2016 taken from the NCVIN diabetes prevalence model produced in 2015.
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
43 CVD: Primary Care Intelligence Packs Diabetes observed prevalence compared with expected prevalence by CCG Comparison with demographically similar CCGs
NHS Swindon CCG 0.94
NHS South East Staffordshire and Seisdon Peninsula CCG 0.82
NHS Fareham and Gosport CCG 0.81
NHS North Hampshire CCG 0.78
NHS South Gloucestershire CCG 0.78
NHS Bracknell and Ascot CCG 0.78
NHS North West Surrey CCG 0.75
NHS Basildon and Brentwood CCG 0.75
NHS East Surrey CCG 0.70
NHS Horsham and Mid Sussex CCG 0.69
NHS Surrey Downs CCG 0.67
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
44 CVD: Primary Care Intelligence Packs Diabetes prevalence by GP practice
GP practice CCG
CONISTON MEDICAL PRACTICE L81036 7.4% NORTHVILLE FAMILY PRACTICE L81028 7.2% COURTSIDE SURGERY L81024 7.0% • GP practice range of observed PILNING SURGERY L81117 6.6% diabetes 3.6% to 7.4% LEAP VALLEY MEDICAL CENTRE L81046 6.5% • there are an estimated 3,563 people WEST WALK SURGERY L81047 6.5% with undiagnosed diabetes in NHS KINGSWOOD HEALTH CENTRE L81063 6.4% South Gloucestershire CCG CHRISTCHURCH FAMILY MEDICAL CENTRE L81026 6.4% ORCHARD MEDICAL CENTRE L81055 6.4% CONCORD MEDICAL CENTRE L81019 6.3% FROME VALLEY MEDICAL CENTRE L81014 6.0% KENNEDY WAY SURGERY L81042 6.0% HANHAM HEALTH L81079 6.0% THORNBURY HEALTH CENTRE - MALE L81106 5.9% THE WILLOW SURGERY L81052 5.6% CADBURY HEATH HEALTHCARE L81130 5.5% THORNBURY HEALTH CENTRE - BURNEY L81018 5.5% CLOSE FARM SURGERY L81050 5.5% WELLINGTON ROAD SURGERY L81642 5.5% STOKE GIFFORD MEDICAL CENTRE L81118 5.4% ST MARY STREET SURGERY L81103 5.2% THREE SHIRES MEDICAL PRACTICE L81029 5.1% ALMONDSBURY SURGERY L81127 4.9% EMERSONS GREEN MEDICAL CENTRE L81632 4.1% Note: The estimated number of undiagnosed people with diabetes has been calculated by BRADLEY STOKE SURGERY L81649 3.6% multiplying the estimated prevalence rate to the 0% 1% 2% 3% 4% 5% 6% 7% 8% 2015/16 QOF list size and subtracting the number of people on the diabetes register.
45 CVD: Primary Care Intelligence Packs Expected total prevalence of diabetes and non-diabetic hyperglycaemia
Diabetes prevalence Undiagnosed diabetes prevalence Expected non-diabetic hyperglycaemia prevalence
• the estimated total prevalence of NHS North Somerset CCG 6.1% 2.5% 12.0% diabetes in NHS South Gloucestershire CCG is 7.5% (diagnosed and undiagnosed) • in addition, there are an estimated 10.7% of people in NHS South NHS South Gloucestershire CCG 5.9% 1.7% 10.7% Gloucestershire CCG who are at increased risk of developing diabetes (i.e. with non-diabetic hyperglycaemia) NHS Bristol CCG 5.2% 2.1% 9.5% • this means that 18.2% of the population in NHS South Gloucestershire CCG are estimated to have diabetes, or at high risk of developing of diabetes
Note: Prevalence estimates of non-diabetic hyperglycaemia were developed using Health England 6.5% 1.9% 11.2% Survey for England (HSE) data. Five years of HSE data were combined, 2009- 2013. The estimates take into account the age, ethnic group and estimated body mass index of the population. 0% 5% 10% 15% 20% 25% These estimates were produced using the GP registered population.
46 CVD: Primary Care Intelligence Packs People with diabetes who had eight care processes by CCG 2015/16
NHS South Gloucestershire CCG 61.7% • data on care processes and treatment targets are taken from the National Diabetes Audit (NDA) • overall practice participation in the NHS North Somerset CCG 56.7% 2015/16 audit was 81.4% in England
• in NHS South Gloucestershire CCG, 22 out of 25 practices (88.0%) participated in the NDA. Data is not NHS Bristol CCG 51.4% available for the remaining practices
• 61.7% of people with diabetes (of practices who participated in the audit) had the eight recommended care processes in NHS South Gloucestershire CCG, compared to 52.6% in England
England 52.6%
0% 10% 20% 30% 40% 50% 60% 70%
47 CVD: Primary Care Intelligence Packs People with diabetes who had eight care processes by GP practice, 2015/16
GP practice Average of practices in the CCG who participated in the audit
LEAP VALLEY MEDICAL CENTRE L81046 79.4% KENNEDY WAY SURGERY L81042 77.5% • achievement - 8 care processes: in WEST WALK SURGERY L81047 70.1% practices who provided data via the CHRISTCHURCH FAMILY MEDICAL CENTRE L81026 68.9% CONISTON MEDICAL PRACTICE L81036 68.9% NDA, between 23.2% and 79.4% of KINGSWOOD HEALTH CENTRE L81063 66.8% patients received all 8 care processes ALMONDSBURY SURGERY L81127 66.1% FROME VALLEY MEDICAL CENTRE L81014 66.1% • at least 4,162 people did not receive THE WILLOW SURGERY L81052 65.9% the eight care processes HANHAM HEALTH L81079 65.9% ORCHARD MEDICAL CENTRE L81055 62.9% PILNING SURGERY L81117 62.9% STOKE GIFFORD MEDICAL CENTRE L81118 61.6% NORTHVILLE FAMILY PRACTICE L81028 57.8% COURTSIDE SURGERY L81024 57.3% THORNBURY HEALTH CENTRE - BURNEY L81018 55.2% THORNBURY HEALTH CENTRE - MALE L81106 53.5% THREE SHIRES MEDICAL PRACTICE L81029 45.0% CADBURY HEATH HEALTHCARE L81130 44.7% WELLINGTON ROAD SURGERY L81642 42.5% CLOSE FARM SURGERY L81050 37.7% EMERSONS GREEN MEDICAL CENTRE L81632 23.2% BRADLEY STOKE SURGERY L81649 ST MARY STREET SURGERY L81103 CONCORD MEDICAL CENTRE L81019
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
48 CVD: Primary Care Intelligence Packs People with diabetes who met all 3 treatment targets by CCG, 2015/16
NHS North Somerset CCG 33.4% • 33.2% of people with diabetes (of practices who participated in the audit) met the three treatment targets in NHS South Gloucestershire CCG, NHS South Gloucestershire CCG 33.2% compared to 39.0% in England
NHS Bristol CCG 31.3%
England 39.0%
0% 5% 10% 15% 20% 25% 30% 35% 40% 45%
49 CVD: Primary Care Intelligence Packs People with diabetes who met all 3 treatment targets by GP practice, 2015/16
GP practice Average of practices in the CCG who participated in the audit
COURTSIDE SURGERY L81024 40.1% WEST WALK SURGERY L81047 39.9% • achievement - 3 treatment targets: in WELLINGTON ROAD SURGERY L81642 38.7% practices who provided data via the CONISTON MEDICAL PRACTICE L81036 37.7% CLOSE FARM SURGERY L81050 37.2% NDA, between 24.0% and 40.1% of THORNBURY HEALTH CENTRE - MALE L81106 37.1% patients achieved all 3 treatment EMERSONS GREEN MEDICAL CENTRE L81632 36.3% targets CHRISTCHURCH FAMILY MEDICAL CENTRE L81026 36.2% • at least 6,527 people did not meet the CADBURY HEATH HEALTHCARE L81130 34.5% three treatment targets HANHAM HEALTH L81079 34.0% ALMONDSBURY SURGERY L81127 33.5% STOKE GIFFORD MEDICAL CENTRE L81118 31.6% THORNBURY HEALTH CENTRE - BURNEY L81018 31.4% FROME VALLEY MEDICAL CENTRE L81014 31.2% KENNEDY WAY SURGERY L81042 30.6% ORCHARD MEDICAL CENTRE L81055 29.9% LEAP VALLEY MEDICAL CENTRE L81046 29.9% KINGSWOOD HEALTH CENTRE L81063 29.5% THE WILLOW SURGERY L81052 28.8% PILNING SURGERY L81117 27.5% THREE SHIRES MEDICAL PRACTICE L81029 25.5% NORTHVILLE FAMILY PRACTICE L81028 24.0% BRADLEY STOKE SURGERY L81649 ST MARY STREET SURGERY L81103 CONCORD MEDICAL CENTRE L81019
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
50 CVD: Primary Care Intelligence Packs People with diabetes who met all 3 treatment targets by GP practice, 2015/16 - opportunities compared to GP cluster
0% -5% -10% -15% -20% -25%
NORTHVILLE FAMILY PRACTICE 62
THREE SHIRES MEDICAL PRACTICE 67
PILNING SURGERY 40 • using the GP cluster method of THE WILLOW SURGERY 78 calculating potential gains, if each KINGSWOOD HEALTH CENTRE 83 practice was to achieve as well as the ORCHARD MEDICAL CENTRE 83 upper quartile of its national cluster, then an additional 1,101 people would LEAP VALLEY MEDICAL CENTRE 67 be treated KENNEDY WAY SURGERY 67
FROME VALLEY MEDICAL CENTRE 83
STOKE GIFFORD MEDICAL CENTRE 69
CADBURY HEATH HEALTHCARE 45
THORNBURY HEALTH CENTRE - MALE 20
CLOSE FARM SURGERY 25
HANHAM HEALTH 77
CHRISTCHURCH FAMILY MEDICAL CENTRE 45
WELLINGTON ROAD SURGERY 8
CONISTON MEDICAL PRACTICE 33
EMERSONS GREEN MEDICAL CENTRE 18
WEST WALK SURGERY 29
COURTSIDE SURGERY 32 Details of this methodology are available on slide 9. Click here to view them.
51 CVD: Primary Care Intelligence Packs Kidney
52 CVD: Primary Care Intelligence Packs Management of chronic kidney disease
Chronic Kidney Disease can progress to kidney failure and it Late diagnosis of CKD is common. substantially increases the risk Around a third of people with CKD are undiagnosed. More of heart attack and stroke. opportunistic testing and improved uptake of the NHS Health Check will increase detection rates.
Chronic Kidney Disease (CKD) is common. What questions should we ask in our CCG? It is one of the commonest co-morbidities and affects a third 1. for each indicator how wide is the variation in of people over 75. In 2010 it was estimated to cost the NHS achievement and exception reporting? around £1.5bn. Average length of stay in hospital tends to 2. how many people would benefit if all practices be longer and outcomes are considerably worse: performed as well as the best? approximately 7,000 excess strokes and 12,000 excess 3. how can we support practices who are average and heart attacks occur each year in people with CKD below average to perform as well as the best in: compared to those without. • detection of CKD Individuals with CKD are also at much higher risk of • more systematic delivery of evidence based care developing acute kidney injury when they have an intercurrent illness such as pneumonia What might help • Support practices to share audit data and systematically Evidence based guidance from NICE highlights CVD identify gaps and opportunities for improved detection risk reduction, good blood pressure control and and management of CKD. management of proteinuria as essential steps to reduce the • Promote uptake of and follow up from the NHS Health risk of cardiovascular events and progression to kidney Check to aid detection and management of CKD failure. Despite this there is often significant variation • Offer local training and education in the detection and between practices in achievement and exception reporting. management of CKD
53 CVD: Primary Care Intelligence Packs Chronic kidney disease (CKD) observed prevalence (2015/16) compared with expected prevalence (2011) by CCG Comparison with CCGs in the STP
NHS Bristol CCG 0.87
• the ratio of those diagnosed with chronic kidney disease versus those expected to have chronic kidney NHS South Gloucestershire CCG 0.86 disease is 0.86. This compares to 0.68 for England • this suggests that 86% of people with chronic kidney disease have been diagnosed NHS North Somerset CCG 0.73
Note: This slide compares the prevalence of CKD recorded in QOF in 2015/16 to the expected prevalence of CKD produced by the University of Southampton in 2011. A small number of CCGs England 0.68 have a ratio greater than 1. It is unlikely that all people with CKD will be diagnosed in any CCG and therefore a ratio greater than 1 suggests that 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 the figures are underestimating the true CKD Ratio prevalence in the area. These ratios should be taken as an indication of the comparative scale of undiagnosed CKD rather than absolute figures.
54 CVD: Primary Care Intelligence Packs Chronic kidney disease (CKD) observed prevalence (2015/16) compared with expected prevalence (2011) by CCG Comparison with demographically similar CCGs
NHS Basildon and Brentwood CCG 0.89
NHS South Gloucestershire CCG 0.86
NHS South East Staffordshire and Seisdon 0.69 Peninsula CCG
NHS East Surrey CCG 0.66
NHS Horsham and Mid Sussex CCG 0.65
NHS Fareham and Gosport CCG 0.57
NHS North West Surrey CCG 0.56
NHS Swindon CCG 0.56
NHS North Hampshire CCG 0.56
NHS Surrey Downs CCG 0.55
NHS Bracknell and Ascot CCG 0.51
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Ratio
55 CVD: Primary Care Intelligence Packs CKD prevalence by GP practice, 2015/16
GP practice CCG
ST MARY STREET SURGERY L81103 9.0% FROME VALLEY MEDICAL CENTRE L81014 8.9% COURTSIDE SURGERY L81024 7.8% • it is estimated that there are 1,822 WELLINGTON ROAD SURGERY L81642 7.6% people with undiagnosed chronic ORCHARD MEDICAL CENTRE L81055 7.3% kidney disease in NHS South WEST WALK SURGERY L81047 7.2% Gloucestershire CCG HANHAM HEALTH L81079 7.1% • GP practice range of observed CKD: PILNING SURGERY L81117 7.0% CONISTON MEDICAL PRACTICE L81036 6.8% 1.7% to 9.0% THORNBURY HEALTH CENTRE - BURNEY L81018 6.5% KINGSWOOD HEALTH CENTRE L81063 6.1% ALMONDSBURY SURGERY L81127 5.3% THORNBURY HEALTH CENTRE - MALE L81106 5.3% STOKE GIFFORD MEDICAL CENTRE L81118 5.0% NORTHVILLE FAMILY PRACTICE L81028 4.8% CONCORD MEDICAL CENTRE L81019 4.8% THE WILLOW SURGERY L81052 4.5% CLOSE FARM SURGERY L81050 4.4% KENNEDY WAY SURGERY L81042 4.1% CADBURY HEATH HEALTHCARE L81130 3.8% LEAP VALLEY MEDICAL CENTRE L81046 2.8% EMERSONS GREEN MEDICAL CENTRE L81632 2.6% Note: CCG estimates for the estimated CHRISTCHURCH FAMILY MEDICAL CENTRE L81026 2.5% number of people with CKD are based on THREE SHIRES MEDICAL PRACTICE L81029 2.0% applying a proportion from a resident based BRADLEY STOKE SURGERY L81649 1.7% population estimate to a GP registered population. The characteristics of registered 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% and resident populations may vary in some CCGs, and local interpretation is required.
56 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding 12 months) is 140/85 mmHg or less by CCG, 2014/15 Comparison with CCGs in the STP Below 140/85 Not below 140/85 Exceptions reported
NHS South Gloucestershire CCG 76.6% • 11,022 people with CKD (diagnosed*) in NHS South Gloucestershire CCG • 8,446 (76.6%) people whose blood pressure is <= 140 /85 • 869 (7.9%) people who are NHS North Somerset CCG 75.5% exceptions • 1,707 (15.5%) additional people whose blood pressure is not <= 140 / 85 NHS Bristol CCG 74.4%
England 74.4% *Using the QOF clinical indicator CKD002 denominator plus exceptions. Note: as the CKD002 indicator was removed from 0% 20% 40% 60% 80% 100% the QOF in 15/16 this is historic data taken from the 2014/15 QOF.
57 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding 12 months) is 140/85 mmHg or less by CCG, 2014/15 Comparison with demographically similar CCGs Below 140/85 Not below 140/85 Exceptions reported
NHS Bracknell and Ascot CCG 79.2%
NHS North West Surrey CCG 77.7%
NHS South Gloucestershire CCG 76.6%
NHS Swindon CCG 76.3%
NHS Fareham and Gosport CCG 74.6%
NHS East Surrey CCG 73.9%
NHS Basildon and Brentwood CCG 73.3%
NHS South East Staffordshire and Seisdon Peninsula CCG 72.3%
NHS Horsham and Mid Sussex CCG 72.2%
NHS Surrey Downs CCG 71.9%
NHS North Hampshire CCG 71.2%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
58 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding 12 months) is not 140/85 mmHg or less by GP practice, 2014/15
Not below 140/85 Exceptions reported
LEAP VALLEY SURGERY L81046 101 STOKE GIFFORD MEDICAL CENTRE L81118 161 CADBURY HEATH HEALTHCARE L81130 89 • in total, including exceptions, there THE WILLOW SURGERY L81052 102 are 2,576 people whose blood CHRISTCHURCH FAMILY MEDICAL CENTRE L81026 63 pressure is not <= 140 / 85 CONISTON MEDICAL PRACTICE L81036 134 • GP practice range: 12.9% to 40.6% THREE SHIRES MEDICAL PRACTICE L81029 36 ST MARY STREET SURGERY L81103 130 HANHAM SURGERY L81079 307 ORCHARD MEDICAL CENTRE L81055 190 COURTSIDE SURGERY L81024 210 WELLINGTON ROAD SURGERY L81642 32 KINGSWOOD HEALTH CENTRE L81063 141 FROME VALLEY MEDICAL CENTRE L81014 228 THORNBURY HEALTH CENTRE - BURNEY L81018 106 THE CONCORD MEDICAL CENTRE L81019 105 NORTHVILLE FAMILY PRACTICE L81028 45 BRADLEY STOKE SURGERY L81649 39 ALMONDSBURY SURGERY L81127 38 PILNING SURGERY L81117 48 CLOSE FARM SURGERY L81050 41 EMERSONS GREEN MEDICAL CENTRE L81632 32 WEST WALK SURGERY L81047 117 KENNEDY WAY SURGERY L81042 56 THORNBURY HEALTH CENTRE - MALE L81106 25
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
59 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding 12 months) is not 140/85 mmHg or less by GP practice, 2014/15 – opportunities compared to GP cluster
10% 5% 0% -5% -10% -15% -20% -25%
LEAP VALLEY SURGERY 47
STOKE GIFFORD MEDICAL CENTRE 43
ST MARY STREET SURGERY 38 • using the GP cluster method of CADBURY HEATH HEALTHCARE 23 calculating potential gains, if each THREE SHIRES MEDICAL PRACTICE 10 practice was to achieve as well as the WELLINGTON ROAD SURGERY 8 upper quartile of its national cluster, then an additional 403 people would CHRISTCHURCH FAMILY MEDICAL CENTRE 14 be treated CONISTON MEDICAL PRACTICE 29
THE WILLOW SURGERY 18
ORCHARD MEDICAL CENTRE 34
FROME VALLEY MEDICAL CENTRE 15
ALMONDSBURY SURGERY 1
PILNING SURGERY 1
THORNBURY HEALTH CENTRE - BURNEY 2
CLOSE FARM SURGERY 0
BRADLEY STOKE SURGERY
EMERSONS GREEN MEDICAL CENTRE
WEST WALK SURGERY
KENNEDY WAY SURGERY
THORNBURY HEALTH CENTRE - MALE Details of this methodology are available on slide 9. Click here to view them.
60 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose notes have a record of a urine albumin: creatinine ratio test in the preceding 12 months by CCG, 2014/15 Comparison with CCGs in the STP Recorded Not recorded Exceptions reported
NHS South Gloucestershire CCG 80.2% • 11,022 people with CKD (diagnosed*) in NHS South Gloucestershire CCG • 8,835 (80.2%) people who have a record of urine albumin:creatinine ratio test NHS Bristol CCG 76.8% • 517 (4.7%) people who are exceptions • 1,670 (15.2%) additional people who have no record of urine NHS North Somerset CCG 74.8% albumin:creatinine ratio test
England 75.4% *Using the QOF clinical indicator CKD004 denominator plus exceptions. Note: as the CKD004 indicator was removed from the QOF in 15/16 this is historic data 0% 20% 40% 60% 80% 100% taken from the 2014/15 QOF.
61 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose notes have a record of a urine albumin: creatinine ratio test in the preceding 12 months by CCG, 2014/15 Comparison with demographically similar CCGs Recorded Not recorded Exceptions reported
NHS South Gloucestershire CCG 80.2%
NHS North Hampshire CCG 77.2%
NHS Bracknell and Ascot CCG 77.2%
NHS Fareham and Gosport CCG 76.6%
NHS Swindon CCG 75.3%
NHS South East Staffordshire and Seisdon Peninsula CCG 74.9%
NHS North West Surrey CCG 74.6%
NHS East Surrey CCG 73.2%
NHS Horsham and Mid Sussex CCG 71.4%
NHS Basildon and Brentwood CCG 67.5%
NHS Surrey Downs CCG 66.6%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
62 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose notes do not have a record of a urine albumin: creatinine ratio test in the preceding 12 months by GP practice, 2014/15
Not recorded Exceptions reported
CHRISTCHURCH FAMILY MEDICAL CENTRE L81026 135 LEAP VALLEY SURGERY L81046 89 HANHAM SURGERY L81079 340 • in total, including exceptions, there ORCHARD MEDICAL CENTRE L81055 212 are 2,187 people who have no record CADBURY HEATH HEALTHCARE L81130 73 of urine albumin:creatinine ratio test BRADLEY STOKE SURGERY L81649 43 • GP practice range: 2.4% to 55.3% KINGSWOOD HEALTH CENTRE L81063 130 ALMONDSBURY SURGERY L81127 43 THE WILLOW SURGERY L81052 82 EMERSONS GREEN MEDICAL CENTRE L81632 40 THE CONCORD MEDICAL CENTRE L81019 98 FROME VALLEY MEDICAL CENTRE L81014 196 CONISTON MEDICAL PRACTICE L81036 102 ST MARY STREET SURGERY L81103 95 WELLINGTON ROAD SURGERY L81642 24 THORNBURY HEALTH CENTRE - MALE L81106 32 WEST WALK SURGERY L81047 113 CLOSE FARM SURGERY L81050 33 PILNING SURGERY L81117 35 THREE SHIRES MEDICAL PRACTICE L81029 19 THORNBURY HEALTH CENTRE - BURNEY L81018 61 COURTSIDE SURGERY L81024 105 STOKE GIFFORD MEDICAL CENTRE L81118 56 KENNEDY WAY SURGERY L81042 26 NORTHVILLE FAMILY PRACTICE L81028 5
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
63 CVD: Primary Care Intelligence Packs Heart
64 CVD: Primary Care Intelligence Packs Management of Heart Disease
Premature death and disability in people with What questions should we ask in our CCG? CHD can be reduced significantly by systematic 1. for each indicator how wide is the variation in evidence based management in primary care achievement and exception reporting? 2. how many people would benefit if all practices performed as well as the best? 3. how can we support practices who are Coronary Heart Disease is one of the principal causes of average and below average to perform as premature death and disability. The key elements of management for well as the best in: an individual who has already had a heart attack or angina are • more systematic delivery of evidence symptom control and secondary prevention of further cardiovascular based care for people with CHD events and premature mortality. There is robust evidence to support the • improved detection and management use of anti-platelet treatment, statins, beta-blockers and angiotensin of heart failure converting enzyme inhibitors or angiotensin receptor blockers. There is also robust evidence to support good control of blood pressure. Each of these interventions is incentivised in QOF but variation in achievement What might help and exception reporting at practice level shows that there is often 1. roll out of GRASP-Heart Failure audit tool considerable potential for improving management and outcomes. that identifies people with heart failure who are undiagnosed or under treated 2. education for health professionals to Heart failure is a common and an important complication of promote evidence based management of coronary heart disease and other conditions. Appropriate treatment CHD and high quality measurement of including up-titration of ace inhibitors and beta blockers in heart failure blood pressure due to LVSD can significantly improve symptom control and quality of 3. ensure access to rapid access diagnostic life, and improve outcomes for patients. Despite this, around a quarter clinics and specialist support for of people with heart failure are undetected and untreated. And amongst management of angina and heart failure those who are diagnosed, there is significant variation in the quality of 4. ensure access to cardiac rehab for care. individuals with CHD and heart failure
65 CVD: Primary Care Intelligence Packs Heart failure prevalence by CCG Comparison with CCGs in the STP
NHS North Somerset CCG 0.88%
• prevalence of 0.7% in NHS South Gloucestershire CCG compared to 0.76% in England
NHS South Gloucestershire CCG 0.70%
NHS Bristol CCG 0.64%
England 0.76%
0.0% 0.1% 0.2% 0.3% 0.4% 0.5% 0.6% 0.7% 0.8% 0.9% 1.0%
66 CVD: Primary Care Intelligence Packs Heart failure prevalence by CCG Comparison with demographically similar CCGs
NHS Fareham and Gosport CCG 0.80%
NHS South East Staffordshire and Seisdon Peninsula CCG 0.79%
NHS Basildon and Brentwood CCG 0.77%
NHS Horsham and Mid Sussex CCG 0.72%
NHS South Gloucestershire CCG 0.70%
NHS East Surrey CCG 0.61%
NHS Swindon CCG 0.61%
NHS Bracknell and Ascot CCG 0.58%
NHS North West Surrey CCG 0.53%
NHS Surrey Downs CCG 0.52%
NHS North Hampshire CCG 0.46%
0.0% 0.1% 0.2% 0.3% 0.4% 0.5% 0.6% 0.7% 0.8% 0.9%
67 CVD: Primary Care Intelligence Packs Heart failure prevalence by GP practice
GP practice CCG
THORNBURY HEALTH CENTRE - MALE L81106 1.3% WEST WALK SURGERY L81047 1.1% ORCHARD MEDICAL CENTRE L81055 1.0% • 1,846 people with diagnosed heart HANHAM HEALTH L81079 1.0% failure in NHS South Gloucestershire WELLINGTON ROAD SURGERY L81642 0.9% CCG FROME VALLEY MEDICAL CENTRE L81014 0.9% • GP practice range: 0.3% to 1.3% KENNEDY WAY SURGERY L81042 0.8% THORNBURY HEALTH CENTRE - BURNEY L81018 0.8% COURTSIDE SURGERY L81024 0.8% CADBURY HEATH HEALTHCARE L81130 0.7% STOKE GIFFORD MEDICAL CENTRE L81118 0.7% ST MARY STREET SURGERY L81103 0.7% KINGSWOOD HEALTH CENTRE L81063 0.7% THREE SHIRES MEDICAL PRACTICE L81029 0.7% THE WILLOW SURGERY L81052 0.7% NORTHVILLE FAMILY PRACTICE L81028 0.6% PILNING SURGERY L81117 0.6% LEAP VALLEY MEDICAL CENTRE L81046 0.6% CHRISTCHURCH FAMILY MEDICAL CENTRE L81026 0.6% ALMONDSBURY SURGERY L81127 0.5% CLOSE FARM SURGERY L81050 0.5% CONCORD MEDICAL CENTRE L81019 0.5% CONISTON MEDICAL PRACTICE L81036 0.4% BRADLEY STOKE SURGERY L81649 0.3% EMERSONS GREEN MEDICAL CENTRE L81632 0.3%
0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4%
68 CVD: Primary Care Intelligence Packs Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who are treated with ACE-I / ARB by CCG Comparison with CCGs in the STP Treatment No treatment Exceptions reported
NHS South Gloucestershire CCG 85.3% • 469 people with heart failure* with LVSD in NHS South Gloucestershire CCG • 400 (85.3%) people treated with ACE- I or ARB NHS North Somerset CCG 84.2% • 67 (14.3%) people who are exceptions • 2 (0.4%) additional people who are not treated with ACE-I or ARB NHS Bristol CCG 83.6%
England 84.7%
0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator HF003 denominator plus exceptions
69 CVD: Primary Care Intelligence Packs Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who are treated with ACE-I / ARB by CCG Comparison with demographically similar CCGs Treatment No treatment Exceptions reported
NHS Bracknell and Ascot CCG 88.4%
NHS Basildon and Brentwood CCG 86.9%
NHS North Hampshire CCG 85.3%
NHS Swindon CCG 85.3%
NHS South Gloucestershire CCG 85.3%
NHS North West Surrey CCG 84.9%
NHS Fareham and Gosport CCG 84.8%
NHS South East Staffordshire and Seisdon Peninsula CCG 83.0%
NHS Horsham and Mid Sussex CCG 82.6%
NHS Surrey Downs CCG 82.1%
NHS East Surrey CCG 81.5%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
70 CVD: Primary Care Intelligence Packs Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who are not treated with ACE-I / ARB by GP practice
No treatment Exceptions reported
NORTHVILLE FAMILY PRACTICE L81028 1 PILNING SURGERY L81117 2 LEAP VALLEY MEDICAL CENTRE L81046 6 • in total, including exceptions, there THORNBURY HEALTH CENTRE - BURNEY L81018 7 are 69 people who are not treated KINGSWOOD HEALTH CENTRE L81063 3 with ACE-I or ARB CONCORD MEDICAL CENTRE L81019 2 • GP practice range: 0.0% to 50.0% HANHAM HEALTH L81079 3 ORCHARD MEDICAL CENTRE L81055 10 STOKE GIFFORD MEDICAL CENTRE L81118 6 CADBURY HEATH HEALTHCARE L81130 4 EMERSONS GREEN MEDICAL CENTRE L81632 1 THORNBURY HEALTH CENTRE - MALE L81106 2 CONISTON MEDICAL PRACTICE L81036 3 COURTSIDE SURGERY L81024 5 CHRISTCHURCH FAMILY MEDICAL CENTRE L81026 1 BRADLEY STOKE SURGERY L81649 1 WEST WALK SURGERY L81047 8 KENNEDY WAY SURGERY L81042 1 THREE SHIRES MEDICAL PRACTICE L81029 2 FROME VALLEY MEDICAL CENTRE L81014 1 CLOSE FARM SURGERY L81050 THE WILLOW SURGERY L81052 ST MARY STREET SURGERY L81103 ALMONDSBURY SURGERY L81127 WELLINGTON ROAD SURGERY L81642
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
71 CVD: Primary Care Intelligence Packs Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who are treated with ACE-I / ARB and BB by CCG Comparison with CCGs in the STP Treatment No treatment Exceptions reported
NHS South Gloucestershire CCG 81.3% • 400 people with heart failure* with LVSD treated with ACE-I/ARB in NHS South Gloucestershire CCG • 325 (81.3%) people treated with ACE- I/ARB and BB NHS Bristol CCG 81.2% • 49 (12.3%) people who are exceptions • 26 (6.5%) additional people who are not treated with ACE-I/ARB and BB NHS North Somerset CCG 79.9%
England 77.7%
0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator HF004 denominator plus exceptions
72 CVD: Primary Care Intelligence Packs Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who are treated with ACE-I / ARB and BB by CCG Comparison with demographically similar CCGs Treatment No treatment Exceptions reported
NHS Bracknell and Ascot CCG 83.2%
NHS North West Surrey CCG 82.9%
NHS Basildon and Brentwood CCG 82.3%
NHS South Gloucestershire CCG 81.3%
NHS Fareham and Gosport CCG 81.2%
NHS East Surrey CCG 77.8%
NHS Horsham and Mid Sussex CCG 76.9%
NHS North Hampshire CCG 74.2%
NHS Swindon CCG 71.2%
NHS Surrey Downs CCG 71.2%
NHS South East Staffordshire and Seisdon Peninsula CCG 66.8%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
73 CVD: Primary Care Intelligence Packs Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who are not treated with ACE-I / ARB and BB by GP practice
No treatment Exceptions reported
CHRISTCHURCH FAMILY MEDICAL CENTRE L81026 4 PILNING SURGERY L81117 1 FROME VALLEY MEDICAL CENTRE L81014 12 • in total, including exceptions, there HANHAM HEALTH L81079 4 are 75 people who are not treated THREE SHIRES MEDICAL PRACTICE L81029 5 with ACE-I or ARB CLOSE FARM SURGERY L81050 1 • GP practice range: 0.0% to 50.0% BRADLEY STOKE SURGERY L81649 2 KENNEDY WAY SURGERY L81042 2 CONISTON MEDICAL PRACTICE L81036 4 KINGSWOOD HEALTH CENTRE L81063 2 EMERSONS GREEN MEDICAL CENTRE L81632 1 WEST WALK SURGERY L81047 12 THORNBURY HEALTH CENTRE - BURNEY L81018 4 THORNBURY HEALTH CENTRE - MALE L81106 2 CADBURY HEATH HEALTHCARE L81130 3 STOKE GIFFORD MEDICAL CENTRE L81118 4 ST MARY STREET SURGERY L81103 2 LEAP VALLEY MEDICAL CENTRE L81046 1 COURTSIDE SURGERY L81024 4 THE WILLOW SURGERY L81052 1 ORCHARD MEDICAL CENTRE L81055 4 CONCORD MEDICAL CENTRE L81019 NORTHVILLE FAMILY PRACTICE L81028 ALMONDSBURY SURGERY L81127 WELLINGTON ROAD SURGERY L81642
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
74 CVD: Primary Care Intelligence Packs Percentage of patients with CHD whose blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less by CCG Comparison with CCGs in the STP Below 150/90 Not below 150/90 Exceptions reported
NHS North Somerset CCG 89.6% • 7,877 people with coronary heart disease* in NHS South Gloucestershire CCG • 6,914 (87.8%) people whose blood pressure <= 150 / 90 NHS South Gloucestershire CCG 87.8% • 283 (3.6%) people who are exceptions • 680 (8.6%) additional people whose blood pressure is not <= 150 / 90 NHS Bristol CCG 86.9%
England 88.2%
0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator CHD002 denominator plus exceptions
75 CVD: Primary Care Intelligence Packs Percentage of patients with CHD whose blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less by CCG Comparison with demographically similar CCGs Below 150/90 Not below 150/90 Exceptions reported
NHS Horsham and Mid Sussex CCG 89.3%
NHS North West Surrey CCG 88.5%
NHS Bracknell and Ascot CCG 88.4%
NHS Swindon CCG 88.0%
NHS North Hampshire CCG 88.0%
NHS South Gloucestershire CCG 87.8%
NHS South East Staffordshire and Seisdon Peninsula CCG 87.3%
NHS Basildon and Brentwood CCG 86.9%
NHS Fareham and Gosport CCG 86.6%
NHS East Surrey CCG 86.6%
NHS Surrey Downs CCG 84.8%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
76 CVD: Primary Care Intelligence Packs Percentage of patients with CHD whose blood pressure reading (measured in the preceding 12 months) is not 150/90 mmHg or less by GP practice
Not below 150/90 Exceptions reported
CHRISTCHURCH FAMILY MEDICAL CENTRE L81026 93 CONISTON MEDICAL PRACTICE L81036 64 LEAP VALLEY MEDICAL CENTRE L81046 53 • in total, including exceptions, there NORTHVILLE FAMILY PRACTICE L81028 28 are 963 people whose blood pressure THE WILLOW SURGERY L81052 64 is not <= 150 / 90 THREE SHIRES MEDICAL PRACTICE L81029 45 • GP practice range: 5.1% to 22.7% BRADLEY STOKE SURGERY L81649 31 CONCORD MEDICAL CENTRE L81019 46 ST MARY STREET SURGERY L81103 34 STOKE GIFFORD MEDICAL CENTRE L81118 49 ORCHARD MEDICAL CENTRE L81055 55 HANHAM HEALTH L81079 92 FROME VALLEY MEDICAL CENTRE L81014 59 ALMONDSBURY SURGERY L81127 15 PILNING SURGERY L81117 15 COURTSIDE SURGERY L81024 45 EMERSONS GREEN MEDICAL CENTRE L81632 15 KINGSWOOD HEALTH CENTRE L81063 39 CADBURY HEATH HEALTHCARE L81130 24 WELLINGTON ROAD SURGERY L81642 6 WEST WALK SURGERY L81047 33 CLOSE FARM SURGERY L81050 12 THORNBURY HEALTH CENTRE - BURNEY L81018 22 KENNEDY WAY SURGERY L81042 16 THORNBURY HEALTH CENTRE - MALE L81106 8
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
77 CVD: Primary Care Intelligence Packs Percentage of patients with CHD whose blood pressure reading (measured in the preceding 12 months) is not 150/90 mmHg or less by GP practice – opportunities compared to GP cluster
6% 4% 2% 0% -2% -4% -6% -8% -10% -12% -14% -16%
CHRISTCHURCH FAMILY MEDICAL CENTRE 59
CONISTON MEDICAL PRACTICE 39
LEAP VALLEY MEDICAL CENTRE 29 • using the GP cluster method of NORTHVILLE FAMILY PRACTICE 16 calculating potential gains, if each THREE SHIRES MEDICAL PRACTICE 23 practice was to achieve as well as the THE WILLOW SURGERY 30 upper quartile of its national cluster, then an additional 339 people would ST MARY STREET SURGERY 16 be treated BRADLEY STOKE SURGERY 13
CONCORD MEDICAL CENTRE 17
STOKE GIFFORD MEDICAL CENTRE 17
COURTSIDE SURGERY 8
KINGSWOOD HEALTH CENTRE 5
EMERSONS GREEN MEDICAL CENTRE 2
WELLINGTON ROAD SURGERY 0
CADBURY HEATH HEALTHCARE
CLOSE FARM SURGERY
WEST WALK SURGERY
THORNBURY HEALTH CENTRE - MALE
THORNBURY HEALTH CENTRE - BURNEY
KENNEDY WAY SURGERY Details of this methodology are available on slide 9. Click here to view them.
78 CVD: Primary Care Intelligence Packs Percentage of patients with CHD with a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken by CCG Comparison with CCGs in the STP Optimal management No treatment Exceptions reported
NHS South Gloucestershire CCG 92.8% • 7,877 people with coronary heart disease* in NHS South Gloucestershire CCG • 7,312 (92.8%) people who are taking aspirin, an alternative anti-platelet NHS North Somerset CCG 92.3% therapy, or an anti-coagulant • 283 (3.6%) people who are exceptions • 282 (3.6%) additional people who are NHS Bristol CCG 91.8% not taking aspirin, an alternative anti- platelet therapy, or an anti-coagulant
England 91.8%
0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator CHD005 denominator plus exceptions
79 CVD: Primary Care Intelligence Packs Percentage of patients with CHD with a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken by CCG Comparison with demographically similar CCGs Optimal management No treatment Exceptions reported
NHS North West Surrey CCG 92.9%
NHS South Gloucestershire CCG 92.8%
NHS Fareham and Gosport CCG 92.2%
NHS North Hampshire CCG 92.1%
NHS South East Staffordshire and Seisdon Peninsula CCG 92.1%
NHS Horsham and Mid Sussex CCG 91.7%
NHS Bracknell and Ascot CCG 91.3%
NHS East Surrey CCG 91.1%
NHS Swindon CCG 90.9%
NHS Surrey Downs CCG 90.8%
NHS Basildon and Brentwood CCG 90.3%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
80 CVD: Primary Care Intelligence Packs Percentage of patients with CHD without a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken by GP practice
No treatment Exceptions reported
CHRISTCHURCH FAMILY MEDICAL CENTRE L81026 70 BRADLEY STOKE SURGERY L81649 26 PILNING SURGERY L81117 17 • in total, including exceptions, there THREE SHIRES MEDICAL PRACTICE L81029 31 are 565 people are not taking aspirin, CONISTON MEDICAL PRACTICE L81036 28 an alternative anti-platelet therapy, or NORTHVILLE FAMILY PRACTICE L81028 15 an anti-coagulant STOKE GIFFORD MEDICAL CENTRE L81118 34 • GP practice range: 0.0% to 17.1% CADBURY HEATH HEALTHCARE L81130 25 KINGSWOOD HEALTH CENTRE L81063 30 HANHAM HEALTH L81079 51 COURTSIDE SURGERY L81024 29 CONCORD MEDICAL CENTRE L81019 22 EMERSONS GREEN MEDICAL CENTRE L81632 10 WEST WALK SURGERY L81047 27 ORCHARD MEDICAL CENTRE L81055 26 ALMONDSBURY SURGERY L81127 8 FROME VALLEY MEDICAL CENTRE L81014 30 CLOSE FARM SURGERY L81050 11 THE WILLOW SURGERY L81052 21 KENNEDY WAY SURGERY L81042 16 THORNBURY HEALTH CENTRE - MALE L81106 8 WELLINGTON ROAD SURGERY L81642 4 THORNBURY HEALTH CENTRE - BURNEY L81018 16 ST MARY STREET SURGERY L81103 10 LEAP VALLEY MEDICAL CENTRE L81046
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
81 CVD: Primary Care Intelligence Packs Some data on outcomes for people with cardiovascular disease
82 CVD: Primary Care Intelligence Packs Hospital admissions for coronary heart disease for all ages 2002/03 – 2015/16
NHS South Gloucestershire CCG England 800
700 • in NHS South Gloucestershire CCG, the hospital admission rate for coronary heart disease in 2015/16 600 was 374.1 (968) compared to 527.9 for England
500
400
300
Age Age standardised (per rate 100,000) 200
100
0 2002/032003/042004/052005/062006/072007/082008/092009/102010/112011/122012/132013/142014/152015/16 Source: Hospital Episode Statistics (HES), 2002/03 - 2015/16, Copyright © 2017, Re‐used with the permission of NHS Digital. All rights reserved
83 CVD: Primary Care Intelligence Packs Hospital admissions for stroke for all ages 2002/03 – 2015/16
NHS South Gloucestershire CCG England 250
• in NHS South Gloucestershire CCG, the hospital admission rate for stroke 200 in 2015/16 was 126.6 (329) compared to 172.8 for England
150
100 Age standardised standardised Age (per rate 100,000)
50
0 2002/032003/042004/052005/062006/072007/082008/092009/102010/112011/122012/132013/142014/152015/16 Source: Hospital Episode Statistics (HES), 2002/03 - 2015/16, Copyright © 2017, Re‐used with the permission of NHS Digital. All rights reserved
84 CVD: Primary Care Intelligence Packs Additional risk of complications for people with diabetes, three year follow up, 2013/14
NHS South Gloucestershire CCG England
171.6% Angina 136.8% • The risk of a stroke was 112.2% higher and the risk of a heart attack 146.3% was 146.3% higher compared to Heart Attack 108.6% people without diabetes. The risk of a major amputation was 1224.9% 196.4% higher. Heart failure 150.0%
112.2% Stroke 81.3%
1224.9% Major amputation 445.8%
1388.9% Minor amputation 753.5%
447.9% RRT 293.0%
0% 200% 400% 600% 800% 1000% 1200% 1400% 1600% Note: This slide uses data from the National Diabetes Audit (NDA)
85 CVD: Primary Care Intelligence Packs Deaths from coronary heart disease, under 75s
NHS South Gloucestershire CCG England 90
80 • in NHS South Gloucestershire CCG, the early mortality rate for coronary 70 heart disease in 2013-15 was 33.3, compared to 40.6 for England
60
50
40
30 Age Age standardised (per rate 1000,000) 20
10
0 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11 2010-12 2011-13 2012-14 2013-15
Source: Office for National Statistics (ONS) mortality data 2002 - 2015
86 CVD: Primary Care Intelligence Packs Deaths from stroke, under 75s
NHS South Gloucestershire CCG England 30
• in NHS South Gloucestershire CCG, 25 the early mortality rate for stroke in 2013-15 was 10.5, compared to 13.6 for England
20
15
10 Age Age standardised (per rate 100,000)
5
0 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11 2010-12 2011-13 2012-14 2013-15
Source: Office for National Statistics (ONS) mortality data 2002 - 2015
87 CVD: Primary Care Intelligence Packs Appendix Data sources
• Quality and Outcomes Framework (QOF), 2015/16, Copyright © 2016, re-used with the permission of NHS Digital. All rights reserved
• Non-diabetic hyperglycaemia prevalence estimates, NCVIN, PHE: https://www.gov.uk/government/publications/nhs-diabetes- prevention-programme-non-diabetic-hyperglycaemia
• Diabetes prevalence estimates, NCVIN, PHE: https://www.gov.uk/government/publications/diabetes-prevalence-estimates-for- local-populations
• CKD Prevalence model, G.Aitken, University of Southampton , 2014 https://www.gov.uk/government/publications/ckd- prevalence-estimates-for-local-and-regional-populations
• Hypertension prevalence estimates for local CCG populations. Created using data from: QOF hypertension registers 2014/15 and; Undiagnosed hypertension estimates for adults 16 years and older. 2014. Department of Primary Care & Public Health, Imperial College London https://www.gov.uk/government/publications/hypertension-prevalence-estimates-for-local-populations
• NHS Stop smoking services Copyright © 2014, NHS Digital
• Norberg J, Bäckström S , Jansson J-H, Johansson L. Estimating the prevalence of atrial fibrillation in a general population using validated electronic health data. Clin Epidemiol 2013 ; 5 475 – 81.
• National Diabetes Audit, 2013/14 and 2015/16, Copyright © 2016, re-used with the permission of NHS Digital. All rights reserved
• Hospital Episode Statistics (HES), 2002/03 - 2015/16, Copyright © 2017, Re‐used with the permission of NHS Digital. All rights reserved
• Office for National Statistics (ONS) mortality data 2002 – 2015, Copyright © 2017, Re-used with the permission of the Office for National Statistics. All rights reserved
88 CVD: Primary Care Intelligence Packs About Public Health England
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Published June 2017 Gateway number 2017095
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