CVD: Primary Care Intelligence Packs NHS Dudley 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 Dudley CCG are: NHS Havering CCG NHS Stockport CCG NHS North Tyneside CCG NHS Solihull CCG NHS Nottingham North and East CCG NHS Wigan Borough CCG NHS Trafford CCG NHS South East Staffordshire and Seisdon Peninsula CCG NHS Erewash CCG NHS Mansfield and Ashfield 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 Mansfield and Ashfield CCG 21.6%

NHS Wigan Borough CCG 19.0% • prevalence of 18.3% in NHS Dudley CCG NHS Erewash CCG 18.8%

NHS Dudley CCG 18.3%

NHS North Tyneside CCG 17.8%

NHS Nottingham North and East CCG 17.6%

NHS Stockport CCG 17.3%

NHS Havering CCG 16.4% Note: It has been found that the proportion of patients recorded as smokers correlates well NHS South East Staffordshire and Seisdon Peninsula CCG 16.3% with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, NHS Trafford CCG 15.9% http://bmjopen.bmj.com/content/4/7/e005217.abs tract

NHS Solihull CCG 15.7% Definition: denominator of QOF clinical indicator SMOKE004 ( number of patients 15+ who are 0% 5% 10% 15% 20% 25% 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

HIGH OAK SURGERY Y02653 29.4% BEAN MEDICAL PRACTICE M87036 27.9% QUARRY BANK MEDICAL CENTRE M87027 26.9% KEELINGE HOUSE M87601 26.8% THE WATERFRONT SURGERY M87010 26.3% DR PD GUPTA & PARTNERS M87617 26.0% • 47,930 people who are recorded as THE GREENS HEALTH CENTRE M87012 25.9% CENTRAL CLINIC M87605 25.6% smokers in NHS Dudley CCG BILSTON STREET SURGERY M87629 24.9% DUDLEY P'SHIPS FOR HEALTH LLP Y02212 24.7% • GP practice range: 11.0% to 29.4% CROSS STREET HEALTH CENTRE M87025 24.0% STEPPINGSTONES MEDICAL PRACTICE M87017 23.6% BATH STREET MEDICAL CENTRE M87621 23.2% NETHERTON HEALTH CENTRE M87028 23.0% PEDMORE MEDICAL PRACTICE M87030 21.4% DR. R. M. SHAH M87638 21.3% ST JAMES MEDICAL PRACTICE1 M87612 21.3% WYCHBURY MEDICAL GROUP M87024 21.2% THE LIMES SURGERY MEDICAL CENTRE M87019 20.9% AW SURGERIES M87009 20.5% COSELEY MEDICAL CENTRE M87021 20.3% CRESTFIELD SURGERY M87625 18.9% ST JAMES MEDICAL PRACTICE2 M87026 18.8% EVE HILL MEDICAL PRACTICE M87006 18.7% CLEMENT ROAD MEDICAL PRACTICE M87034 18.0% STOURSIDE MEDICAL PRACTICE Y01756 18.0% THREE VILLAGES MEDICAL PRACTICE M87005 17.5% DR. B. K. PRASHARA M87628 17.3% WORDSLEY GREEN HEALTH CENTRE M87023 17.0% LOWER GORNAL MEDICAL PRACTICE M87015 16.9% ALEXANDRA MEDICAL CENTRE M87623 16.1% WOODSETTON MEDICAL CENTRE M87016 16.0% RANGEWAYS ROAD SURGERY M87041 16.0% CASTLE MEADOWS SURGERY M87620 15.7% LION HEALTH M87011 15.3% FELDON LANE PRACTICE M87020 15.1% KINGSWINFORD MEDICAL PRACTICE M87008 14.7% HALESOWEN MEDICAL PRACTICE M87602 14.2% QUINCY RISE SURGERY M87618 13.6% Note: This method is thought to be a reasonably THE RIDGEWAY SURGERY M87007 13.6% robust method in estimating smoking prevalence LAPAL MEDICAL PRACTICE M87014 12.9% THE SUMMERHILL SURGERY M87018 11.5% for the majority of GP practices. However, MOSS GROVE SURGERY M87003 11.4% caution is advised for extreme estimates of NORTHWAY MEDICAL CENTRE M87037 11.4% NORTON MEDICAL PRACTICE M87002 11.1% smoking prevalence and those with high MEADOWBROOK SURGERY M87001 11.0% numbers of smoking status not recorded and 0% 5% 10% 15% 20% 25% 30% 35% 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 Dudley CCG 0.64

• the ratio of those diagnosed with hypertension versus those expected NHS Walsall CCG 0.61 to have hypertension is 0.64. This compares to 0.59 for England • this suggests that 64% of people with hypertension have been diagnosed NHS Sandwell And West Birmingham CCG 0.59

NHS Wolverhampton CCG 0.59

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 Dudley CCG 0.64

NHS Wigan Borough CCG 0.61

NHS Solihull CCG 0.60

NHS North Tyneside CCG 0.60

NHS Erewash CCG 0.60

NHS Mansfield and Ashfield CCG 0.60

NHS Stockport CCG 0.60

NHS Trafford CCG 0.60

NHS South East Staffordshire and Seisdon Peninsula 0.59 CCG

NHS Nottingham North and East CCG 0.58

NHS Havering CCG 0.58

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

COSELEY MEDICAL CENTRE M87021 0.82 LOWER GORNAL MEDICAL PRACTICE M87015 0.81 THE SUMMERHILL SURGERY M87018 0.78 EVE HILL MEDICAL PRACTICE M87006 0.77 NORTHWAY MEDICAL CENTRE M87037 0.75 DR. R. M. SHAH M87638 0.74 • it is estimated that there are 32,185 CRESTFIELD SURGERY M87625 0.74 QUARRY BANK MEDICAL CENTRE M87027 0.74 people with undiagnosed THE LIMES SURGERY MEDICAL CENTRE M87019 0.73 BATH STREET MEDICAL CENTRE M87621 0.73 ALEXANDRA MEDICAL CENTRE M87623 0.71 hypertension in NHS Dudley CCG THREE VILLAGES MEDICAL PRACTICE M87005 0.70 RANGEWAYS ROAD SURGERY M87041 0.70 • GP practice range of observed to WYCHBURY MEDICAL GROUP M87024 0.69 PEDMORE MEDICAL PRACTICE M87030 0.68 expected hypertension prevalence KEELINGE HOUSE M87601 0.68 DR PD GUPTA & PARTNERS M87617 0.68 0.44 to 0.82 THE WATERFRONT SURGERY M87010 0.68 QUINCY RISE SURGERY M87618 0.67 THE RIDGEWAY SURGERY M87007 0.67 NORTON MEDICAL PRACTICE M87002 0.67 MOSS GROVE SURGERY M87003 0.67 AW SURGERIES M87009 0.67 CASTLE MEADOWS SURGERY M87620 0.66 CROSS STREET HEALTH CENTRE M87025 0.65 BILSTON STREET SURGERY M87629 0.65 KINGSWINFORD MEDICAL PRACTICE M87008 0.65 WOODSETTON MEDICAL CENTRE M87016 0.65 DUDLEY P'SHIPS FOR HEALTH LLP Y02212 0.64 NETHERTON HEALTH CENTRE M87028 0.64 WORDSLEY GREEN HEALTH CENTRE M87023 0.63 HIGH OAK SURGERY Y02653 0.63 MEADOWBROOK SURGERY M87001 0.63 LAPAL MEDICAL PRACTICE M87014 0.62 CLEMENT ROAD MEDICAL PRACTICE M87034 0.62 LION HEALTH M87011 0.62 STOURSIDE MEDICAL PRACTICE Y01756 0.62 HALESOWEN MEDICAL PRACTICE M87602 0.61 FELDON LANE PRACTICE M87020 0.59 DR. B. K. PRASHARA M87628 0.58 BEAN MEDICAL PRACTICE M87036 0.58 ST JAMES MEDICAL PRACTICE2 M87026 0.57 STEPPINGSTONES MEDICAL PRACTICE M87017 0.57 THE GREENS HEALTH CENTRE M87012 0.55 CENTRAL CLINIC M87605 0.51 ST JAMES MEDICAL PRACTICE1 M87612 0.44 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 Walsall CCG 81.6%

• 56,387 people with hypertension (diagnosed)* in NHS Dudley CCG NHS Sandwell And West Birmingham CCG 78.5% • 43,827 (77.7%) people whose blood pressure is <= 150/90 • 1,388 (2.5%) people who are excepted from optimal control NHS Wolverhampton CCG 78.4% • 11,172 (19.8%) additional people whose blood pressure is not <= 150/90

NHS Dudley CCG 77.7%

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 Erewash CCG 82.0%

NHS Wigan Borough CCG 82.0%

NHS Stockport CCG 81.9%

NHS North Tyneside CCG 81.5%

NHS Nottingham North and East CCG 81.1%

NHS Mansfield and Ashfield CCG 80.5%

NHS Solihull CCG 80.2%

NHS Trafford CCG 79.7%

NHS Havering CCG 79.6%

NHS South East Staffordshire and Seisdon Peninsula 79.4% CCG

NHS Dudley CCG 77.7%

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

CRESTFIELD SURGERY M87625 126 DUDLEY P'SHIPS FOR HEALTH LLP Y02212 174 ST JAMES MEDICAL PRACTICE1 M87612 102 STEPPINGSTONES MEDICAL PRACTICE M87017 471 BATH STREET MEDICAL CENTRE M87621 135 THE WATERFRONT SURGERY M87010 464 • in total, including exceptions, there AW SURGERIES M87009 862 HIGH OAK SURGERY Y02653 181 are 12,560 people whose blood DR PD GUPTA & PARTNERS M87617 112 PEDMORE MEDICAL PRACTICE M87030 247 pressure is not <= 150/90 NETHERTON HEALTH CENTRE M87028 331 KINGSWINFORD MEDICAL PRACTICE M87008 382 • GP practice range: 11.2% to 40.8% WYCHBURY MEDICAL GROUP M87024 1094 CENTRAL CLINIC M87605 143 KEELINGE HOUSE M87601 254 LOWER GORNAL MEDICAL PRACTICE M87015 530 THE GREENS HEALTH CENTRE M87012 243 HALESOWEN MEDICAL PRACTICE M87602 373 CASTLE MEADOWS SURGERY M87620 138 WORDSLEY GREEN HEALTH CENTRE M87023 381 CROSS STREET HEALTH CENTRE M87025 194 STOURSIDE MEDICAL PRACTICE Y01756 245 MOSS GROVE SURGERY M87003 585 BEAN MEDICAL PRACTICE M87036 102 COSELEY MEDICAL CENTRE M87021 317 DR. B. K. PRASHARA M87628 40 CLEMENT ROAD MEDICAL PRACTICE M87034 114 THE RIDGEWAY SURGERY M87007 394 ALEXANDRA MEDICAL CENTRE M87623 69 MEADOWBROOK SURGERY M87001 296 ST JAMES MEDICAL PRACTICE2 M87026 157 WOODSETTON MEDICAL CENTRE M87016 240 NORTHWAY MEDICAL CENTRE M87037 218 QUINCY RISE SURGERY M87618 81 THE SUMMERHILL SURGERY M87018 298 EVE HILL MEDICAL PRACTICE M87006 250 THE LIMES SURGERY MEDICAL CENTRE M87019 228 LION HEALTH M87011 775 NORTON MEDICAL PRACTICE M87002 194 LAPAL MEDICAL PRACTICE M87014 207 RANGEWAYS ROAD SURGERY M87041 151 BILSTON STREET SURGERY M87629 59 DR. R. M. SHAH M87638 102 FELDON LANE PRACTICE M87020 194 QUARRY BANK MEDICAL CENTRE M87027 95 THREE VILLAGES MEDICAL PRACTICE M87005 212 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 Sandwell And West Birmingham CCG 79.4%

• 177 people with a new diagnosis* of hypertension with a CVD risk of 20% NHS Walsall CCG 75.1% or higher in NHS Dudley CCG • 113 (63.8%) people who are currently treated with statins • 43 (24.3%) people who are exempted NHS Wolverhampton CCG 75.0% from treatment with statins • 21 (11.9%) additional people who are not currently treated with statins

NHS Dudley CCG 63.8%

England 66.5%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% *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 Erewash CCG 72.2%

NHS Trafford CCG 71.8%

NHS Havering CCG 69.8%

NHS Solihull CCG 69.6%

NHS Nottingham North and East CCG 67.2%

NHS Mansfield and Ashfield CCG 65.5%

NHS North Tyneside CCG 64.3%

NHS Dudley CCG 63.8%

NHS South East Staffordshire and Seisdon Peninsula 61.8% CCG

NHS Wigan Borough CCG 61.0%

NHS Stockport CCG 60.1%

0% 10% 20% 30% 40% 50% 60% 70% 80%

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

THE RIDGEWAY SURGERY M87007 1 LOWER GORNAL MEDICAL PRACTICE M87015 1 WORDSLEY GREEN HEALTH CENTRE M87023 4 FELDON LANE PRACTICE M87020 3 WOODSETTON MEDICAL CENTRE M87016 2 CRESTFIELD SURGERY M87625 2 • in total, including exceptions, there THREE VILLAGES MEDICAL PRACTICE M87005 4 MEADOWBROOK SURGERY M87001 1 are 64 people who are not treated STEPPINGSTONES MEDICAL PRACTICE M87017 2 THE SUMMERHILL SURGERY M87018 1 with statins THE LIMES SURGERY MEDICAL CENTRE M87019 2 ST JAMES MEDICAL PRACTICE2 M87026 2 • GP practice range: 0.0% to 100.0% NETHERTON HEALTH CENTRE M87028 1 CLEMENT ROAD MEDICAL PRACTICE M87034 4 NORTHWAY MEDICAL CENTRE M87037 1 KEELINGE HOUSE M87601 1 CENTRAL CLINIC M87605 1 LION HEALTH M87011 9 MOSS GROVE SURGERY M87003 3 PEDMORE MEDICAL PRACTICE M87030 3 COSELEY MEDICAL CENTRE M87021 3 HALESOWEN MEDICAL PRACTICE M87602 3 KINGSWINFORD MEDICAL PRACTICE M87008 1 DR. R. M. SHAH M87638 1 AW SURGERIES M87009 3 WYCHBURY MEDICAL GROUP M87024 4 NORTON MEDICAL PRACTICE M87002 1 EVE HILL MEDICAL PRACTICE M87006 THE WATERFRONT SURGERY M87010 THE GREENS HEALTH CENTRE M87012 CROSS STREET HEALTH CENTRE M87025 QUARRY BANK MEDICAL CENTRE M87027 BEAN MEDICAL PRACTICE M87036 RANGEWAYS ROAD SURGERY M87041 ST JAMES MEDICAL PRACTICE1 M87612 DR PD GUPTA & PARTNERS M87617 CASTLE MEADOWS SURGERY M87620 BATH STREET MEDICAL CENTRE M87621 DR. B. K. PRASHARA M87628 STOURSIDE MEDICAL PRACTICE Y01756 DUDLEY P'SHIPS FOR HEALTH LLP Y02212 HIGH OAK SURGERY Y02653 BILSTON STREET SURGERY M87629 ALEXANDRA MEDICAL CENTRE M87623 QUINCY RISE SURGERY M87618 LAPAL MEDICAL PRACTICE M87014 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 Dudley CCG 0.76

• the ratio of those diagnosed with atrial fibrillation versus those expected to NHS Walsall CCG 0.72 have atrial fibrillation is 0.76. This compares to 0.7 for England • this suggests that 76% of people with atrial fibrillation have been diagnosed. NHS Wolverhampton CCG 0.65

NHS Sandwell And West Birmingham CCG 0.60

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 Wigan Borough CCG 0.79

NHS Dudley CCG 0.76

NHS Trafford CCG 0.75

NHS Stockport CCG 0.74

NHS Erewash CCG 0.71

NHS South East Staffordshire and Seisdon Peninsula 0.71 CCG

NHS North Tyneside CCG 0.70

NHS Solihull CCG 0.68

NHS Mansfield and Ashfield CCG 0.68

NHS Nottingham North and East CCG 0.65

NHS Havering CCG 0.61

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

THE SUMMERHILL SURGERY M87018 1.0 EVE HILL MEDICAL PRACTICE M87006 0.9 THE RIDGEWAY SURGERY M87007 0.9 KINGSWINFORD MEDICAL PRACTICE M87008 0.9 PEDMORE MEDICAL PRACTICE M87030 0.9 NORTHWAY MEDICAL CENTRE M87037 0.9 • it is estimated that there are 8,886 ST JAMES MEDICAL PRACTICE1 M87612 0.9 MOSS GROVE SURGERY M87003 0.8 people with undiagnosed atrial AW SURGERIES M87009 0.8 LION HEALTH M87011 0.8 LOWER GORNAL MEDICAL PRACTICE M87015 0.8 fibrillation in NHS Dudley CCG THE LIMES SURGERY MEDICAL CENTRE M87019 0.8 WYCHBURY MEDICAL GROUP M87024 0.8 • GP practice range of observed to CROSS STREET HEALTH CENTRE M87025 0.8 QUARRY BANK MEDICAL CENTRE M87027 0.8 expected atrial fibrillation prevalence NETHERTON HEALTH CENTRE M87028 0.8 BEAN MEDICAL PRACTICE M87036 0.8 0.2 to 1 RANGEWAYS ROAD SURGERY M87041 0.8 KEELINGE HOUSE M87601 0.8 BILSTON STREET SURGERY M87629 0.8 DUDLEY P'SHIPS FOR HEALTH LLP Y02212 0.8 HIGH OAK SURGERY Y02653 0.8 THREE VILLAGES MEDICAL PRACTICE M87005 0.7 THE WATERFRONT SURGERY M87010 0.7 THE GREENS HEALTH CENTRE M87012 0.7 LAPAL MEDICAL PRACTICE M87014 0.7 WOODSETTON MEDICAL CENTRE M87016 0.7 STEPPINGSTONES MEDICAL PRACTICE M87017 0.7 FELDON LANE PRACTICE M87020 0.7 WORDSLEY GREEN HEALTH CENTRE M87023 0.7 ST JAMES MEDICAL PRACTICE2 M87026 0.7 CLEMENT ROAD MEDICAL PRACTICE M87034 0.7 HALESOWEN MEDICAL PRACTICE M87602 0.7 CENTRAL CLINIC M87605 0.7 STOURSIDE MEDICAL PRACTICE Y01756 0.7 NORTON MEDICAL PRACTICE M87002 0.6 COSELEY MEDICAL CENTRE M87021 0.6 QUINCY RISE SURGERY M87618 0.6 BATH STREET MEDICAL CENTRE M87621 0.6 CRESTFIELD SURGERY M87625 0.6 DR. R. M. SHAH M87638 0.6 MEADOWBROOK SURGERY M87001 0.5 DR PD GUPTA & PARTNERS M87617 0.5 CASTLE MEADOWS SURGERY M87620 0.5 ALEXANDRA MEDICAL CENTRE M87623 0.4 DR. B. K. PRASHARA M87628 0.2 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 Dudley CCG 82.8% • 5,516 people with atrial fibrillation* with a CHA2DS2-VASc score >= 2 in NHS Dudley CCG NHS Walsall CCG 80.3% • 4,566 (82.8%) people treated with anti-coagulation therapy • 319 (5.8%) people who are exceptions NHS Sandwell And West Birmingham CCG 79.5% • 631 (11.4%) additional people with a recorded CHA2DS2-VASc score >= 2 who are not treated

NHS Wolverhampton CCG 73.9%

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 Dudley CCG 82.8%

NHS Erewash CCG 81.7%

NHS Wigan Borough CCG 80.4%

NHS Stockport CCG 79.2%

NHS Mansfield and Ashfield CCG 78.9%

NHS Trafford CCG 77.6%

NHS South East Staffordshire and Seisdon Peninsula CCG 77.4%

NHS Solihull CCG 77.0%

NHS Havering CCG 75.2%

NHS Nottingham North and East CCG 74.8%

NHS North Tyneside CCG 73.8%

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

THE SUMMERHILL SURGERY M87018 111 PEDMORE MEDICAL PRACTICE M87030 26 FELDON LANE PRACTICE M87020 39 DR. R. M. SHAH M87638 14 CENTRAL CLINIC M87605 11 DR PD GUPTA & PARTNERS M87617 4 • in total, including exceptions, there ST JAMES MEDICAL PRACTICE1 M87612 9 THREE VILLAGES MEDICAL PRACTICE M87005 37 are 950 people with a recorded LAPAL MEDICAL PRACTICE M87014 27 MEADOWBROOK SURGERY M87001 24 CHA2DS2-VASc score >= 2 who are WORDSLEY GREEN HEALTH CENTRE M87023 32 BILSTON STREET SURGERY M87629 8 not treated LION HEALTH M87011 96 CRESTFIELD SURGERY M87625 4 • GP practice range: 0.0% to 38.1% COSELEY MEDICAL CENTRE M87021 17 ALEXANDRA MEDICAL CENTRE M87623 2 WYCHBURY MEDICAL GROUP M87024 71 KINGSWINFORD MEDICAL PRACTICE M87008 29 QUARRY BANK MEDICAL CENTRE M87027 11 MOSS GROVE SURGERY M87003 58 AW SURGERIES M87009 42 NORTON MEDICAL PRACTICE M87002 17 THE LIMES SURGERY MEDICAL CENTRE M87019 14 EVE HILL MEDICAL PRACTICE M87006 20 LOWER GORNAL MEDICAL PRACTICE M87015 30 KEELINGE HOUSE M87601 13 CLEMENT ROAD MEDICAL PRACTICE M87034 8 THE GREENS HEALTH CENTRE M87012 11 STOURSIDE MEDICAL PRACTICE Y01756 14 BEAN MEDICAL PRACTICE M87036 5 BATH STREET MEDICAL CENTRE M87621 3 THE RIDGEWAY SURGERY M87007 36 DUDLEY P'SHIPS FOR HEALTH LLP Y02212 2 THE WATERFRONT SURGERY M87010 14 STEPPINGSTONES MEDICAL PRACTICE M87017 10 NORTHWAY MEDICAL CENTRE M87037 10 WOODSETTON MEDICAL CENTRE M87016 13 HIGH OAK SURGERY Y02653 7 HALESOWEN MEDICAL PRACTICE M87602 14 CASTLE MEADOWS SURGERY M87620 3 NETHERTON HEALTH CENTRE M87028 11 QUINCY RISE SURGERY M87618 2 ST JAMES MEDICAL PRACTICE2 M87026 6 RANGEWAYS ROAD SURGERY M87041 8 CROSS STREET HEALTH CENTRE M87025 7 DR. B. K. PRASHARA M87628 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

20% 15% 10% 5% 0% -5% -10% -15% -20% -25%

THE SUMMERHILL SURGERY 56

PEDMORE MEDICAL PRACTICE 11

CENTRAL CLINIC 5 • using the GP cluster method of FELDON LANE PRACTICE 15 calculating potential gains, if each DR PD GUPTA & PARTNERS 2 practice was to achieve as well as the DR. R. M. SHAH 5 upper quartile of its national cluster, then an additional 135 people would ST JAMES MEDICAL PRACTICE1 3 be treated MEADOWBROOK SURGERY 7

THREE VILLAGES MEDICAL PRACTICE 9

LAPAL MEDICAL PRACTICE 6

WOODSETTON MEDICAL CENTRE

HALESOWEN MEDICAL PRACTICE

CASTLE MEADOWS SURGERY

HIGH OAK SURGERY

QUINCY RISE SURGERY

NETHERTON HEALTH CENTRE

ST JAMES MEDICAL PRACTICE2

RANGEWAYS ROAD SURGERY

CROSS STREET HEALTH CENTRE

DR. B. K. PRASHARA 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 Walsall CCG 86.2% • 6,513 people with a history of stroke or TIA* in NHS Dudley CCG • 5,362 (82.3%) people whose blood NHS Sandwell And West Birmingham CCG 83.6% pressure is <= 150 / 90 • 201 (3.1%) people who are exceptions • 950 (14.6%) additional people whose NHS Wolverhampton CCG 83.1% blood pressure is not <= 150 / 90

NHS Dudley CCG 82.3%

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 Stockport CCG 87.1%

NHS Wigan Borough CCG 86.1%

NHS Mansfield and Ashfield CCG 85.5%

NHS Erewash CCG 85.5%

NHS Nottingham North and East CCG 85.0%

NHS North Tyneside CCG 84.5%

NHS Havering CCG 84.4%

NHS Trafford CCG 84.2%

NHS Solihull CCG 83.9%

NHS South East Staffordshire and Seisdon Peninsula CCG 83.1%

NHS Dudley CCG 82.3%

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

DUDLEY P'SHIPS FOR HEALTH LLP Y02212 25 CRESTFIELD SURGERY M87625 10 QUINCY RISE SURGERY M87618 10 STEPPINGSTONES MEDICAL PRACTICE M87017 45 HIGH OAK SURGERY Y02653 25 DR PD GUPTA & PARTNERS M87617 16 • in total, including exceptions, there NORTHWAY MEDICAL CENTRE M87037 32 KINGSWINFORD MEDICAL PRACTICE M87008 42 are 1,151 people whose blood THE WATERFRONT SURGERY M87010 26 LOWER GORNAL MEDICAL PRACTICE M87015 50 pressure is not <= 150 / 90 NETHERTON HEALTH CENTRE M87028 24 CASTLE MEADOWS SURGERY M87620 16 • GP practice range: 4.6% to 50.0% KEELINGE HOUSE M87601 21 THE LIMES SURGERY MEDICAL CENTRE M87019 32 THE SUMMERHILL SURGERY M87018 74 WORDSLEY GREEN HEALTH CENTRE M87023 41 CENTRAL CLINIC M87605 13 HALESOWEN MEDICAL PRACTICE M87602 31 PEDMORE MEDICAL PRACTICE M87030 20 WYCHBURY MEDICAL GROUP M87024 98 THE GREENS HEALTH CENTRE M87012 20 DR. R. M. SHAH M87638 14 BATH STREET MEDICAL CENTRE M87621 7 AW SURGERIES M87009 55 COSELEY MEDICAL CENTRE M87021 21 ST JAMES MEDICAL PRACTICE1 M87612 9 DR. B. K. PRASHARA M87628 3 MOSS GROVE SURGERY M87003 61 LAPAL MEDICAL PRACTICE M87014 24 STOURSIDE MEDICAL PRACTICE Y01756 20 CROSS STREET HEALTH CENTRE M87025 22 EVE HILL MEDICAL PRACTICE M87006 23 NORTON MEDICAL PRACTICE M87002 18 RANGEWAYS ROAD SURGERY M87041 12 THREE VILLAGES MEDICAL PRACTICE M87005 25 MEADOWBROOK SURGERY M87001 17 BEAN MEDICAL PRACTICE M87036 5 WOODSETTON MEDICAL CENTRE M87016 15 THE RIDGEWAY SURGERY M87007 28 ST JAMES MEDICAL PRACTICE2 M87026 10 LION HEALTH M87011 54 CLEMENT ROAD MEDICAL PRACTICE M87034 6 FELDON LANE PRACTICE M87020 21 BILSTON STREET SURGERY M87629 4 ALEXANDRA MEDICAL CENTRE M87623 2 QUARRY BANK MEDICAL CENTRE M87027 4 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 Walsall CCG 93.6% • 5,254 people with a stroke shown to be non-haemorrhagic* in NHS Dudley CCG NHS Wolverhampton CCG 92.1% • 4,777 (90.9%) people who are taking an anti-platetet agent or anti- coagulant • 131 (2.5%) people who are NHS Sandwell And West Birmingham CCG 91.3% exceptions • 346 (6.6%) additional people with no treatment

NHS Dudley CCG 90.9%

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 Stockport CCG 93.7%

NHS Nottingham North and East CCG 92.9%

NHS Solihull CCG 92.9%

NHS North Tyneside CCG 92.8%

NHS Wigan Borough CCG 92.6%

NHS Mansfield and Ashfield CCG 92.5%

NHS Trafford CCG 92.4%

NHS South East Staffordshire and Seisdon Peninsula CCG 91.8%

NHS Erewash CCG 91.6%

NHS Havering CCG 91.0%

NHS Dudley CCG 90.9%

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

QUINCY RISE SURGERY M87618 4 DR. R. M. SHAH M87638 10 THE LIMES SURGERY MEDICAL CENTRE M87019 26 CRESTFIELD SURGERY M87625 4 KEELINGE HOUSE M87601 12 DUDLEY P'SHIPS FOR HEALTH LLP Y02212 6 • in total, including exceptions, there THE SUMMERHILL SURGERY M87018 33 BILSTON STREET SURGERY M87629 5 are 477 people who are not taking an THREE VILLAGES MEDICAL PRACTICE M87005 21 ST JAMES MEDICAL PRACTICE1 M87612 5 anti-platelet agent or anti-coagulant NETHERTON HEALTH CENTRE M87028 10 MOSS GROVE SURGERY M87003 31 • GP practice range: 0.0% to 20.0% AW SURGERIES M87009 29 CASTLE MEADOWS SURGERY M87620 6 WOODSETTON MEDICAL CENTRE M87016 10 NORTON MEDICAL PRACTICE M87002 12 COSELEY MEDICAL CENTRE M87021 9 WYCHBURY MEDICAL GROUP M87024 47 ST JAMES MEDICAL PRACTICE2 M87026 8 DR PD GUPTA & PARTNERS M87617 4 LION HEALTH M87011 31 LAPAL MEDICAL PRACTICE M87014 11 LOWER GORNAL MEDICAL PRACTICE M87015 14 PEDMORE MEDICAL PRACTICE M87030 7 EVE HILL MEDICAL PRACTICE M87006 11 CROSS STREET HEALTH CENTRE M87025 11 WORDSLEY GREEN HEALTH CENTRE M87023 12 BATH STREET MEDICAL CENTRE M87621 2 HIGH OAK SURGERY Y02653 6 NORTHWAY MEDICAL CENTRE M87037 7 QUARRY BANK MEDICAL CENTRE M87027 5 FELDON LANE PRACTICE M87020 12 RANGEWAYS ROAD SURGERY M87041 4 STEPPINGSTONES MEDICAL PRACTICE M87017 7 THE RIDGEWAY SURGERY M87007 15 MEADOWBROOK SURGERY M87001 7 STOURSIDE MEDICAL PRACTICE Y01756 5 KINGSWINFORD MEDICAL PRACTICE M87008 8 ALEXANDRA MEDICAL CENTRE M87623 1 CENTRAL CLINIC M87605 2 THE GREENS HEALTH CENTRE M87012 2 CLEMENT ROAD MEDICAL PRACTICE M87034 1 HALESOWEN MEDICAL PRACTICE M87602 3 THE WATERFRONT SURGERY M87010 1 BEAN MEDICAL PRACTICE M87036 DR. B. K. PRASHARA M87628 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 Walsall CCG 0.87 • 0.79 ratio of observed to expected diabetes prevalence in NHS Dudley CCG, compared to 0.77 in England NHS Sandwell And West Birmingham CCG 0.81 • this suggests 79% of people have been diagnosed

NHS Dudley CCG 0.79

NHS Wolverhampton CCG 0.74

Note: This slide compares the prevalence of Diabetes recorded in QOF in 2015/16 to the expected prevalence of Diabetes in 2016 taken England 0.77 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 1.0

43 CVD: Primary Care Intelligence Packs Diabetes observed prevalence compared with expected prevalence by CCG Comparison with demographically similar CCGs

NHS Wigan Borough CCG 0.85

NHS North Tyneside CCG 0.84

NHS Solihull CCG 0.83

NHS South East Staffordshire and Seisdon Peninsula CCG 0.82

NHS Mansfield and Ashfield CCG 0.82

NHS Erewash CCG 0.81

NHS Trafford CCG 0.79

NHS Dudley CCG 0.79

NHS Nottingham North and East CCG 0.78

NHS Stockport CCG 0.74

NHS Havering CCG 0.73

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

44 CVD: Primary Care Intelligence Packs Diabetes prevalence by GP practice

GP practice CCG

DR. B. K. PRASHARA M87628 10.6% ALEXANDRA MEDICAL CENTRE M87623 10.1% CRESTFIELD SURGERY M87625 10.0% STEPPINGSTONES MEDICAL PRACTICE M87017 9.3% CROSS STREET HEALTH CENTRE M87025 9.2% ST JAMES MEDICAL PRACTICE2 M87026 9.2% • GP practice range of observed PEDMORE MEDICAL PRACTICE M87030 9.1% DR PD GUPTA & PARTNERS M87617 9.0% diabetes 4.4% to 10.6% CLEMENT ROAD MEDICAL PRACTICE M87034 8.9% THE SUMMERHILL SURGERY M87018 8.7% • there are an estimated 5,079 people THE WATERFRONT SURGERY M87010 8.6% KEELINGE HOUSE M87601 8.4% with undiagnosed diabetes in NHS EVE HILL MEDICAL PRACTICE M87006 8.3% COSELEY MEDICAL CENTRE M87021 8.2% Dudley CCG WYCHBURY MEDICAL GROUP M87024 8.1% DR. R. M. SHAH M87638 7.9% NETHERTON HEALTH CENTRE M87028 7.9% THE LIMES SURGERY MEDICAL CENTRE M87019 7.8% QUARRY BANK MEDICAL CENTRE M87027 7.8% HIGH OAK SURGERY Y02653 7.7% DUDLEY P'SHIPS FOR HEALTH LLP Y02212 7.6% LOWER GORNAL MEDICAL PRACTICE M87015 7.6% WORDSLEY GREEN HEALTH CENTRE M87023 7.6% THE RIDGEWAY SURGERY M87007 7.6% BEAN MEDICAL PRACTICE M87036 7.6% ST JAMES MEDICAL PRACTICE1 M87612 7.6% WOODSETTON MEDICAL CENTRE M87016 7.5% CENTRAL CLINIC M87605 7.3% RANGEWAYS ROAD SURGERY M87041 7.2% THREE VILLAGES MEDICAL PRACTICE M87005 7.1% AW SURGERIES M87009 6.8% FELDON LANE PRACTICE M87020 6.7% THE GREENS HEALTH CENTRE M87012 6.6% BATH STREET MEDICAL CENTRE M87621 6.6% LION HEALTH M87011 6.4% LAPAL MEDICAL PRACTICE M87014 6.3% MEADOWBROOK SURGERY M87001 6.3% NORTHWAY MEDICAL CENTRE M87037 6.3% HALESOWEN MEDICAL PRACTICE M87602 6.3% MOSS GROVE SURGERY M87003 6.2% NORTON MEDICAL PRACTICE M87002 6.0% STOURSIDE MEDICAL PRACTICE Y01756 5.9% KINGSWINFORD MEDICAL PRACTICE M87008 5.8% Note: The estimated number of undiagnosed CASTLE MEADOWS SURGERY M87620 5.5% BILSTON STREET SURGERY M87629 5.4% people with diabetes has been calculated by QUINCY RISE SURGERY M87618 4.4% multiplying the estimated prevalence rate to the 0% 2% 4% 6% 8% 10% 12% 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 Wolverhampton CCG 8.2% 2.9% 13.0% diabetes in NHS Dudley CCG is 9.3% (diagnosed and undiagnosed)

• in addition, there are an estimated NHS Sandwell And West Birmingham CCG 9.2% 2.1% 12.4% 12.4% of people in NHS Dudley CCG who are at increased risk of developing diabetes (i.e. with non- NHS Walsall CCG 8.8% 1.3% 12.6% diabetic hyperglycaemia)

• this means that 21.7% of the population in NHS Dudley CCG are NHS Dudley CCG 7.3% 2.0% 12.4% estimated to have diabetes, or at high risk of developing of diabetes

Note: Prevalence estimates of non-diabetic hyperglycaemia were developed using Health Survey for England (HSE) data. Five years of England 6.5% 1.9% 11.2% 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% 30% 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 Dudley CCG 57.7% • data on care processes and treatment targets are taken from the National Diabetes Audit (NDA) NHS Walsall CCG 57.6% • overall practice participation in the 2015/16 audit was 81.4% in England

• in NHS Dudley CCG, 27 out of 46 NHS Sandwell And West Birmingham CCG 45.6% practices (58.7%) participated in the NDA. Data is not available for the remaining practices

NHS Wolverhampton CCG 45.5%

• 57.7% of people with diabetes (of practices who participated in the audit) had the eight recommended care processes in NHS Dudley 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

THREE VILLAGES MEDICAL PRACTICE M87005 90.4% MEADOWBROOK SURGERY M87001 89.7% EVE HILL MEDICAL PRACTICE M87006 85.9% LOWER GORNAL MEDICAL PRACTICE M87015 79.2% • achievement - 8 care processes: in NORTHWAY MEDICAL CENTRE M87037 78.2% FELDON LANE PRACTICE M87020 76.0% practices who provided data via the THE RIDGEWAY SURGERY M87007 74.6% LION HEALTH M87011 67.7% NDA, between 12.8% and 90.4% of AW SURGERIES M87009 66.9% RANGEWAYS ROAD SURGERY M87041 66.9% patients received all 8 care processes THE WATERFRONT SURGERY M87010 62.1% LAPAL MEDICAL PRACTICE M87014 61.7% CASTLE MEADOWS SURGERY M87620 61.7% HIGH OAK SURGERY Y02653 60.4% BEAN MEDICAL PRACTICE M87036 55.7% • at least 4,865 people did not receive CLEMENT ROAD MEDICAL PRACTICE M87034 50.6% WOODSETTON MEDICAL CENTRE M87016 41.8% the eight care processes NETHERTON HEALTH CENTRE M87028 40.5% CRESTFIELD SURGERY M87625 38.1% DR. R. M. SHAH M87638 31.8% STEPPINGSTONES MEDICAL PRACTICE M87017 30.7% PEDMORE MEDICAL PRACTICE M87030 30.1% THE SUMMERHILL SURGERY M87018 27.6% HALESOWEN MEDICAL PRACTICE M87602 25.8% COSELEY MEDICAL CENTRE M87021 21.2% QUARRY BANK MEDICAL CENTRE M87027 20.7% ALEXANDRA MEDICAL CENTRE M87623 12.8% DUDLEY P'SHIPS FOR HEALTH LLP Y02212 STOURSIDE MEDICAL PRACTICE Y01756 BILSTON STREET SURGERY M87629 DR. B. K. PRASHARA M87628 BATH STREET MEDICAL CENTRE M87621 QUINCY RISE SURGERY M87618 DR PD GUPTA & PARTNERS M87617 ST JAMES MEDICAL PRACTICE1 M87612 CENTRAL CLINIC M87605 KEELINGE HOUSE M87601 ST JAMES MEDICAL PRACTICE2 M87026 CROSS STREET HEALTH CENTRE M87025 WYCHBURY MEDICAL GROUP M87024 WORDSLEY GREEN HEALTH CENTRE M87023 THE LIMES SURGERY MEDICAL CENTRE M87019 THE GREENS HEALTH CENTRE M87012 KINGSWINFORD MEDICAL PRACTICE M87008 MOSS GROVE SURGERY M87003 NORTON MEDICAL PRACTICE M87002 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 Walsall CCG 43.3% • 41.6% of people with diabetes (of practices who participated in the audit) met the three treatment targets NHS Sandwell And West Birmingham CCG 42.7% in NHS Dudley CCG, compared to 39.0% in England

NHS Dudley CCG 41.6%

NHS Wolverhampton CCG 35.7%

England 39.0%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

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

RANGEWAYS ROAD SURGERY M87041 61.7% THREE VILLAGES MEDICAL PRACTICE M87005 54.1% QUARRY BANK MEDICAL CENTRE M87027 49.5% LOWER GORNAL MEDICAL PRACTICE M87015 49.0% • achievement - 3 treatment targets: in NETHERTON HEALTH CENTRE M87028 48.0% CRESTFIELD SURGERY M87625 47.8% practices who provided data via the FELDON LANE PRACTICE M87020 46.8% LION HEALTH M87011 46.5% NDA, between 24.4% and 61.7% of CLEMENT ROAD MEDICAL PRACTICE M87034 45.5% NORTHWAY MEDICAL CENTRE M87037 44.1% patients achieved all 3 treatment MEADOWBROOK SURGERY M87001 43.4% AW SURGERIES M87009 42.5% targets THE SUMMERHILL SURGERY M87018 41.4% ALEXANDRA MEDICAL CENTRE M87623 39.3% THE RIDGEWAY SURGERY M87007 39.2% • at least 5,964 people did not meet the EVE HILL MEDICAL PRACTICE M87006 38.6% THE WATERFRONT SURGERY M87010 38.6% three treatment targets DR. R. M. SHAH M87638 37.3% BEAN MEDICAL PRACTICE M87036 36.5% LAPAL MEDICAL PRACTICE M87014 36.2% HALESOWEN MEDICAL PRACTICE M87602 35.8% WOODSETTON MEDICAL CENTRE M87016 33.5% PEDMORE MEDICAL PRACTICE M87030 32.4% STEPPINGSTONES MEDICAL PRACTICE M87017 30.9% COSELEY MEDICAL CENTRE M87021 30.9% CASTLE MEADOWS SURGERY M87620 27.0% HIGH OAK SURGERY Y02653 24.4% DUDLEY P'SHIPS FOR HEALTH LLP Y02212 STOURSIDE MEDICAL PRACTICE Y01756 BILSTON STREET SURGERY M87629 DR. B. K. PRASHARA M87628 BATH STREET MEDICAL CENTRE M87621 QUINCY RISE SURGERY M87618 DR PD GUPTA & PARTNERS M87617 ST JAMES MEDICAL PRACTICE1 M87612 CENTRAL CLINIC M87605 KEELINGE HOUSE M87601 ST JAMES MEDICAL PRACTICE2 M87026 CROSS STREET HEALTH CENTRE M87025 WYCHBURY MEDICAL GROUP M87024 WORDSLEY GREEN HEALTH CENTRE M87023 THE LIMES SURGERY MEDICAL CENTRE M87019 THE GREENS HEALTH CENTRE M87012 KINGSWINFORD MEDICAL PRACTICE M87008 MOSS GROVE SURGERY M87003 NORTON MEDICAL PRACTICE M87002 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

20% 15% 10% 5% 0% -5% -10% -15% -20% -25%

HIGH OAK SURGERY 42

CASTLE MEADOWS SURGERY 39

COSELEY MEDICAL CENTRE 63 • using the GP cluster method of STEPPINGSTONES MEDICAL PRACTICE 80 calculating potential gains, if each PEDMORE MEDICAL PRACTICE 29 practice was to achieve as well as the WOODSETTON MEDICAL CENTRE 37 upper quartile of its national cluster, then an additional 531 people would DR. R. M. SHAH 20 be treated HALESOWEN MEDICAL PRACTICE 43

THE WATERFRONT SURGERY 43

EVE HILL MEDICAL PRACTICE 39

NORTHWAY MEDICAL CENTRE 4

AW SURGERIES 0

FELDON LANE PRACTICE

QUARRY BANK MEDICAL CENTRE

CRESTFIELD SURGERY

NETHERTON HEALTH CENTRE

LOWER GORNAL MEDICAL PRACTICE

LION HEALTH

THREE VILLAGES MEDICAL PRACTICE

RANGEWAYS ROAD SURGERY 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 Dudley CCG 0.93

• the ratio of those diagnosed with chronic kidney disease versus those NHS Walsall CCG 0.82 expected to have chronic kidney disease is 0.93. This compares to 0.68 for England • this suggests that 93% of people with NHS Sandwell And West Birmingham CCG 0.69 chronic kidney disease have been diagnosed

NHS Wolverhampton CCG 0.67

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 Erewash CCG 1.07

NHS Nottingham North and East CCG 1.00

NHS Dudley CCG 0.93

NHS Wigan Borough CCG 0.87

NHS North Tyneside CCG 0.86

NHS Mansfield and Ashfield CCG 0.83

NHS South East Staffordshire and Seisdon 0.69 Peninsula CCG

NHS Trafford CCG 0.68

NHS Solihull CCG 0.57

NHS Havering CCG 0.48

NHS Stockport CCG 0.47

0.0 0.2 0.4 0.6 0.8 1.0 1.2 Ratio

55 CVD: Primary Care Intelligence Packs CKD prevalence by GP practice, 2015/16

GP practice CCG

THE SUMMERHILL SURGERY M87018 14.5% LOWER GORNAL MEDICAL PRACTICE M87015 10.3% DR. R. M. SHAH M87638 8.7% THE RIDGEWAY SURGERY M87007 8.4% WOODSETTON MEDICAL CENTRE M87016 8.2% HIGH OAK SURGERY Y02653 7.9% • it is estimated that there are 1,211 WYCHBURY MEDICAL GROUP M87024 7.9% MOSS GROVE SURGERY M87003 7.9% people with undiagnosed chronic COSELEY MEDICAL CENTRE M87021 7.8% PEDMORE MEDICAL PRACTICE M87030 7.7% kidney disease in NHS Dudley CCG NORTON MEDICAL PRACTICE M87002 7.1% CRESTFIELD SURGERY M87625 7.1% • GP practice range of observed CKD: ST JAMES MEDICAL PRACTICE1 M87612 7.1% EVE HILL MEDICAL PRACTICE M87006 6.9% 1.8% to 14.5% STOURSIDE MEDICAL PRACTICE Y01756 6.8% QUARRY BANK MEDICAL CENTRE M87027 6.7% CROSS STREET HEALTH CENTRE M87025 6.7% LION HEALTH M87011 6.5% KINGSWINFORD MEDICAL PRACTICE M87008 6.4% NORTHWAY MEDICAL CENTRE M87037 6.3% WORDSLEY GREEN HEALTH CENTRE M87023 6.2% MEADOWBROOK SURGERY M87001 6.2% NETHERTON HEALTH CENTRE M87028 6.0% HALESOWEN MEDICAL PRACTICE M87602 5.8% THREE VILLAGES MEDICAL PRACTICE M87005 5.7% LAPAL MEDICAL PRACTICE M87014 5.5% RANGEWAYS ROAD SURGERY M87041 5.3% ST JAMES MEDICAL PRACTICE2 M87026 5.3% CLEMENT ROAD MEDICAL PRACTICE M87034 5.1% DUDLEY P'SHIPS FOR HEALTH LLP Y02212 5.0% DR PD GUPTA & PARTNERS M87617 4.7% THE WATERFRONT SURGERY M87010 4.2% BILSTON STREET SURGERY M87629 4.2% THE LIMES SURGERY MEDICAL CENTRE M87019 4.1% KEELINGE HOUSE M87601 4.1% AW SURGERIES M87009 4.1% STEPPINGSTONES MEDICAL PRACTICE M87017 4.1% THE GREENS HEALTH CENTRE M87012 3.9% QUINCY RISE SURGERY M87618 3.9% BATH STREET MEDICAL CENTRE M87621 3.9% FELDON LANE PRACTICE M87020 3.7% Note: CCG estimates for the estimated CENTRAL CLINIC M87605 3.5% number of people with CKD are based on BEAN MEDICAL PRACTICE M87036 3.5% CASTLE MEADOWS SURGERY M87620 3.4% applying a proportion from a resident based ALEXANDRA MEDICAL CENTRE M87623 3.3% population estimate to a GP registered DR. B. K. PRASHARA M87628 1.8% population. The characteristics of registered 0% 2% 4% 6% 8% 10% 12% 14% 16% 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 Walsall CCG 79.2% • 15,623 people with CKD (diagnosed*) in NHS Dudley CCG • 11,657 (74.6%) people whose blood NHS Dudley CCG 74.6% pressure is <= 140 /85 • 991 (6.3%) people who are exceptions • 2,975 (19%) additional people whose NHS Sandwell And West Birmingham CCG 74.5% blood pressure is not <= 140 / 85

NHS Wolverhampton CCG 73.0%

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 Wigan Borough CCG 81.1%

NHS Stockport CCG 79.4%

NHS Havering CCG 77.8%

NHS Trafford CCG 76.2%

NHS Mansfield and Ashfield CCG 74.8%

NHS Dudley CCG 74.6%

NHS Nottingham North and East CCG 74.0%

NHS Erewash CCG 73.9%

NHS North Tyneside CCG 73.7%

NHS South East Staffordshire and Seisdon Peninsula CCG 72.3%

NHS Solihull CCG 72.2%

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

COSELEY MEDICAL CENTRE M87021 173 DR BASU, ST THOMAS'S MEDICAL CENTRE M87634 3 STEPPINGSTONES MEDICAL PRACTICE M87017 123 PEDMORE MEDICAL PRACTICE M87030 87 HIGH OAK SURGERY Y02653 77 MOSS GROVE SURGERY - KINGSWINFORD M87003 267 • in total, including exceptions, there DR'S PARRY & COX M87025 73 BEAN MEDICAL CENTRE M87036 22 are 3,966 people whose blood THE GREENS HEALTH CENTRE M87012 81 KEELINGE HOUSE SURGERY M87601 66 pressure is not <= 140 / 85 LOWER GORNAL HEALTH CENTRE M87015 243 CENTRAL CLINIC M87605 28 • GP practice range: 10.9% to 46.6% CLEMENT ROAD MEDICAL PRACTICE M87034 29 THE WATERFRONT SURGERY M87010 82 DUDLEY PARTNERSHIPS FOR HEALTH LLP Y02212 31 LAPAL MEDICAL PRACTICE M87014 84 BATH STREET SURGERY M87621 23 SUMMERHILL SURGERY M87018 208 WOODSETTON MEDICAL CENTRE M87016 102 HALESOWEN MEDICAL PRACTICE M87602 114 EVE HILL MEDICAL PRACTICE M87006 105 DR. R. M. SHAH M87638 56 WYCHBURY MEDICAL GROUP M87024 362 ST JAMES MEDICAL PRACTICE2 M87026 54 MEADOWBROOK SURGERY M87001 96 ST JAMES MEDICAL PRACTICE1 M87612 33 LION HEALTH M87011 313 THE RIDGEWAY SURGERY M87007 162 QUARRY BANK MEDICAL CENTRE M87027 45 NETHERTON HEALTH CENTRE M87028 77 AW SURGERIES M87009 122 STOURSIDE MEDICAL PRACTICE Y01756 77 CASTLE MEADOWS SURGERY M87620 25 THE LIMES SURGERY MEDICAL CENTRE M87019 51 THE NORTHWAY SURGERY M87037 58 KINGSWINFORD MEDICAL PRACTICE M87008 82 NETHERTON SURGERY M87617 18 ALEXANDRA MEDICAL CENTRE M87623 10 CRESTFIELD SURGERY M87625 15 NORTON MEDICAL PRACTICE M87002 57 FELDON LANE PRACTICE M87020 43 WORDSLEY GREEN HEALTH CENTRE M87023 79 QUINCY RISE SURGERY M87618 16 DR. B. K. PRASHARA M87628 4 THREE VILLAGES MEDICAL PRACTICE M87005 54 BILSTON STREET SURGERY M87629 12 RANGEWAYS ROAD SURGERY M87041 24 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% -30% -35%

COSELEY MEDICAL CENTRE 110

STEPPINGSTONES MEDICAL PRACTICE 73

HIGH OAK SURGERY 39 • using the GP cluster method of BEAN MEDICAL CENTRE 11 calculating potential gains, if each THE GREENS HEALTH CENTRE 42 practice was to achieve as well as the PEDMORE MEDICAL PRACTICE 42 upper quartile of its national cluster, then an additional 1,067 people would DR'S PARRY & COX 35 be treated KEELINGE HOUSE SURGERY 30

LOWER GORNAL HEALTH CENTRE 102

CENTRAL CLINIC 13

CRESTFIELD SURGERY

AW SURGERIES

NORTON MEDICAL PRACTICE

DR. B. K. PRASHARA

QUINCY RISE SURGERY

FELDON LANE PRACTICE

WORDSLEY GREEN HEALTH CENTRE

BILSTON STREET SURGERY

THREE VILLAGES MEDICAL PRACTICE

RANGEWAYS ROAD SURGERY 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 Walsall CCG 81.2% • 15,623 people with CKD (diagnosed*) in NHS Dudley CCG • 11,852 (75.9%) people who have a NHS Sandwell And West Birmingham CCG 76.8% record of urine albumin:creatinine ratio test • 912 (5.8%) people who are exceptions NHS Wolverhampton CCG 76.6% • 2,859 (18.3%) additional people who have no record of urine albumin:creatinine ratio test

NHS Dudley CCG 75.9%

*Using the QOF clinical indicator CKD004 England 75.4% 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 Wigan Borough CCG 80.4%

NHS Stockport CCG 79.9%

NHS Trafford CCG 78.2%

NHS Solihull CCG 78.2%

NHS Erewash CCG 77.6%

NHS North Tyneside CCG 76.4%

NHS Dudley CCG 75.9%

NHS Nottingham North and East CCG 75.3%

NHS South East Staffordshire and Seisdon Peninsula CCG 74.9%

NHS Mansfield and Ashfield CCG 72.4%

NHS Havering CCG 70.4%

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

DR BASU, ST THOMAS'S MEDICAL CENTRE M87634 4 COSELEY MEDICAL CENTRE M87021 199 STEPPINGSTONES MEDICAL PRACTICE M87017 138 SUMMERHILL SURGERY M87018 352 WOODSETTON MEDICAL CENTRE M87016 164 THE GREENS HEALTH CENTRE M87012 108 • in total, including exceptions, there ALEXANDRA MEDICAL CENTRE M87623 24 THE WATERFRONT SURGERY M87010 116 are 3,771 people who have no record CLEMENT ROAD MEDICAL PRACTICE M87034 34 LION HEALTH M87011 415 of urine albumin:creatinine ratio test KEELINGE HOUSE SURGERY M87601 68 BATH STREET SURGERY M87621 26 • GP practice range: 7.0% to 57.1% THE LIMES SURGERY MEDICAL CENTRE M87019 77 DR. R. M. SHAH M87638 62 CENTRAL CLINIC M87605 27 ST JAMES MEDICAL PRACTICE1 M87612 36 BEAN MEDICAL CENTRE M87036 18 KINGSWINFORD MEDICAL PRACTICE M87008 109 DR'S PARRY & COX M87025 55 LOWER GORNAL HEALTH CENTRE M87015 180 EVE HILL MEDICAL PRACTICE M87006 92 QUARRY BANK MEDICAL CENTRE M87027 46 PEDMORE MEDICAL PRACTICE M87030 56 QUINCY RISE SURGERY M87618 23 STOURSIDE MEDICAL PRACTICE Y01756 82 THE RIDGEWAY SURGERY M87007 137 DUDLEY PARTNERSHIPS FOR HEALTH LLP Y02212 23 MOSS GROVE SURGERY - KINGSWINFORD M87003 161 WYCHBURY MEDICAL GROUP M87024 276 AW SURGERIES M87009 110 MEADOWBROOK SURGERY M87001 69 ST JAMES MEDICAL PRACTICE2 M87026 36 CRESTFIELD SURGERY M87625 14 NETHERTON HEALTH CENTRE M87028 57 BILSTON STREET SURGERY M87629 15 HIGH OAK SURGERY Y02653 34 WORDSLEY GREEN HEALTH CENTRE M87023 66 FELDON LANE PRACTICE M87020 33 THE NORTHWAY SURGERY M87037 36 NORTON MEDICAL PRACTICE M87002 39 RANGEWAYS ROAD SURGERY M87041 24 THREE VILLAGES MEDICAL PRACTICE M87005 44 NETHERTON SURGERY M87617 10 LAPAL MEDICAL PRACTICE M87014 30 HALESOWEN MEDICAL PRACTICE M87602 35 DR. B. K. PRASHARA M87628 2 CASTLE MEADOWS SURGERY M87620 9 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 Walsall CCG 1.00%

• prevalence of 0.84% in NHS Dudley CCG compared to 0.76% in England NHS Wolverhampton CCG 0.88%

NHS Dudley CCG 0.84%

NHS Sandwell And West Birmingham CCG 0.68%

England 0.76%

0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2%

66 CVD: Primary Care Intelligence Packs Heart failure prevalence by CCG Comparison with demographically similar CCGs

NHS North Tyneside CCG 1.18%

NHS Wigan Borough CCG 1.03%

NHS Stockport CCG 0.94%

NHS Trafford CCG 0.87%

NHS Mansfield and Ashfield CCG 0.84%

NHS Dudley CCG 0.84%

NHS South East Staffordshire and Seisdon Peninsula CCG 0.79%

NHS Erewash CCG 0.75%

NHS Solihull CCG 0.72%

NHS Nottingham North and East CCG 0.63%

NHS Havering CCG 0.59%

0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4%

67 CVD: Primary Care Intelligence Packs Heart failure prevalence by GP practice

GP practice CCG

THE SUMMERHILL SURGERY M87018 2.6% LOWER GORNAL MEDICAL PRACTICE M87015 1.6% PEDMORE MEDICAL PRACTICE M87030 1.4% THE RIDGEWAY SURGERY M87007 1.2% BILSTON STREET SURGERY M87629 1.2% CRESTFIELD SURGERY M87625 1.2% • 2,638 people with diagnosed heart NORTON MEDICAL PRACTICE M87002 1.0% WYCHBURY MEDICAL GROUP M87024 1.0% failure in NHS Dudley CCG FELDON LANE PRACTICE M87020 0.9% STOURSIDE MEDICAL PRACTICE Y01756 0.9% • GP practice range: 0.2% to 2.6% HIGH OAK SURGERY Y02653 0.9% LION HEALTH M87011 0.9% THREE VILLAGES MEDICAL PRACTICE M87005 0.9% THE LIMES SURGERY MEDICAL CENTRE M87019 0.9% DR. R. M. SHAH M87638 0.9% STEPPINGSTONES MEDICAL PRACTICE M87017 0.8% DUDLEY P'SHIPS FOR HEALTH LLP Y02212 0.8% MOSS GROVE SURGERY M87003 0.8% KINGSWINFORD MEDICAL PRACTICE M87008 0.8% QUARRY BANK MEDICAL CENTRE M87027 0.8% CENTRAL CLINIC M87605 0.8% NETHERTON HEALTH CENTRE M87028 0.8% CROSS STREET HEALTH CENTRE M87025 0.8% LAPAL MEDICAL PRACTICE M87014 0.8% COSELEY MEDICAL CENTRE M87021 0.8% CLEMENT ROAD MEDICAL PRACTICE M87034 0.7% WORDSLEY GREEN HEALTH CENTRE M87023 0.7% KEELINGE HOUSE M87601 0.7% NORTHWAY MEDICAL CENTRE M87037 0.7% EVE HILL MEDICAL PRACTICE M87006 0.7% WOODSETTON MEDICAL CENTRE M87016 0.7% RANGEWAYS ROAD SURGERY M87041 0.7% ALEXANDRA MEDICAL CENTRE M87623 0.7% HALESOWEN MEDICAL PRACTICE M87602 0.6% AW SURGERIES M87009 0.6% MEADOWBROOK SURGERY M87001 0.6% DR PD GUPTA & PARTNERS M87617 0.6% THE GREENS HEALTH CENTRE M87012 0.6% ST JAMES MEDICAL PRACTICE1 M87612 0.5% BEAN MEDICAL PRACTICE M87036 0.5% ST JAMES MEDICAL PRACTICE2 M87026 0.5% THE WATERFRONT SURGERY M87010 0.5% BATH STREET MEDICAL CENTRE M87621 0.5% CASTLE MEADOWS SURGERY M87620 0.3% DR. B. K. PRASHARA M87628 0.2% QUINCY RISE SURGERY M87618 0.2% 0.0% 0.5% 1.0% 1.5% 2.0% 2.5% 3.0%

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 Sandwell And West Birmingham CCG 87.2% • 940 people with heart failure* with LVSD in NHS Dudley CCG • 803 (85.4%) people treated with ACE- NHS Dudley CCG 85.4% I or ARB • 88 (9.4%) people who are exceptions • 49 (5.2%) additional people who are not treated with ACE-I or ARB NHS Walsall CCG 84.3%

NHS Wolverhampton CCG 81.7%

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 Nottingham North and East CCG 89.5%

NHS Havering CCG 88.9%

NHS North Tyneside CCG 87.4%

NHS Wigan Borough CCG 86.0%

NHS Stockport CCG 85.5%

NHS Solihull CCG 85.4%

NHS Dudley CCG 85.4%

NHS Trafford CCG 84.8%

NHS Erewash CCG 83.9%

NHS South East Staffordshire and Seisdon Peninsula CCG 83.0%

NHS Mansfield and Ashfield CCG 81.8%

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

CASTLE MEADOWS SURGERY M87620 2 THE SUMMERHILL SURGERY M87018 29 BATH STREET MEDICAL CENTRE M87621 1 KINGSWINFORD MEDICAL PRACTICE M87008 7 THREE VILLAGES MEDICAL PRACTICE M87005 7 PEDMORE MEDICAL PRACTICE M87030 3 • in total, including exceptions, there DR PD GUPTA & PARTNERS M87617 1 ALEXANDRA MEDICAL CENTRE M87623 1 are 137 people who are not treated STEPPINGSTONES MEDICAL PRACTICE M87017 2 LAPAL MEDICAL PRACTICE M87014 2 with ACE-I or ARB COSELEY MEDICAL CENTRE M87021 2 CLEMENT ROAD MEDICAL PRACTICE M87034 1 • GP practice range: 0.0% to 50.0% LION HEALTH M87011 18 CROSS STREET HEALTH CENTRE M87025 5 WYCHBURY MEDICAL GROUP M87024 11 CENTRAL CLINIC M87605 1 FELDON LANE PRACTICE M87020 5 EVE HILL MEDICAL PRACTICE M87006 2 AW SURGERIES M87009 5 NORTHWAY MEDICAL CENTRE M87037 1 LOWER GORNAL MEDICAL PRACTICE M87015 4 BEAN MEDICAL PRACTICE M87036 1 KEELINGE HOUSE M87601 1 HIGH OAK SURGERY Y02653 1 THE RIDGEWAY SURGERY M87007 8 THE LIMES SURGERY MEDICAL CENTRE M87019 2 NORTON MEDICAL PRACTICE M87002 3 MEADOWBROOK SURGERY M87001 1 WOODSETTON MEDICAL CENTRE M87016 1 ST JAMES MEDICAL PRACTICE2 M87026 1 CRESTFIELD SURGERY M87625 1 THE GREENS HEALTH CENTRE M87012 2 HALESOWEN MEDICAL PRACTICE M87602 2 WORDSLEY GREEN HEALTH CENTRE M87023 1 RANGEWAYS ROAD SURGERY M87041 1 MOSS GROVE SURGERY M87003 1 THE WATERFRONT SURGERY M87010 QUARRY BANK MEDICAL CENTRE M87027 NETHERTON HEALTH CENTRE M87028 ST JAMES MEDICAL PRACTICE1 M87612 QUINCY RISE SURGERY M87618 DR. B. K. PRASHARA M87628 BILSTON STREET SURGERY M87629 DR. R. M. SHAH M87638 STOURSIDE MEDICAL PRACTICE Y01756 DUDLEY P'SHIPS FOR HEALTH LLP Y02212 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 Walsall CCG 81.7% • 803 people with heart failure* with LVSD treated with ACE-I/ARB in NHS Dudley CCG NHS Dudley CCG 78.0% • 626 (78%) people treated with ACE- I/ARB and BB • 119 (14.8%) people who are exceptions NHS Wolverhampton CCG 75.7% • 58 (7.2%) additional people who are not treated with ACE-I/ARB and BB

NHS Sandwell And West Birmingham CCG 70.6%

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 Wigan Borough CCG 87.5%

NHS Trafford CCG 83.0%

NHS Stockport CCG 81.3%

NHS Havering CCG 81.1%

NHS Solihull CCG 80.4%

NHS North Tyneside CCG 79.8%

NHS Mansfield and Ashfield CCG 79.2%

NHS Dudley CCG 78.0%

NHS Nottingham North and East CCG 75.0%

NHS Erewash CCG 74.1%

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

QUINCY RISE SURGERY M87618 1 LAPAL MEDICAL PRACTICE M87014 5 HIGH OAK SURGERY Y02653 4 CROSS STREET HEALTH CENTRE M87025 10 KEELINGE HOUSE M87601 3 NETHERTON HEALTH CENTRE M87028 5 • in total, including exceptions, there THE SUMMERHILL SURGERY M87018 20 QUARRY BANK MEDICAL CENTRE M87027 4 are 177 people who are not treated ST JAMES MEDICAL PRACTICE1 M87612 3 BILSTON STREET SURGERY M87629 2 with ACE-I or ARB THE LIMES SURGERY MEDICAL CENTRE M87019 6 HALESOWEN MEDICAL PRACTICE M87602 7 • GP practice range: 0.0% to 100.0% STOURSIDE MEDICAL PRACTICE Y01756 7 NORTON MEDICAL PRACTICE M87002 8 LION HEALTH M87011 23 FELDON LANE PRACTICE M87020 8 BEAN MEDICAL PRACTICE M87036 2 MEADOWBROOK SURGERY M87001 2 COSELEY MEDICAL CENTRE M87021 2 CLEMENT ROAD MEDICAL PRACTICE M87034 1 THREE VILLAGES MEDICAL PRACTICE M87005 4 THE RIDGEWAY SURGERY M87007 12 WYCHBURY MEDICAL GROUP M87024 10 RANGEWAYS ROAD SURGERY M87041 3 CENTRAL CLINIC M87605 1 DUDLEY P'SHIPS FOR HEALTH LLP Y02212 1 LOWER GORNAL MEDICAL PRACTICE M87015 5 WORDSLEY GREEN HEALTH CENTRE M87023 2 EVE HILL MEDICAL PRACTICE M87006 2 NORTHWAY MEDICAL CENTRE M87037 1 THE GREENS HEALTH CENTRE M87012 3 STEPPINGSTONES MEDICAL PRACTICE M87017 1 AW SURGERIES M87009 4 MOSS GROVE SURGERY M87003 2 WOODSETTON MEDICAL CENTRE M87016 1 ST JAMES MEDICAL PRACTICE2 M87026 1 KINGSWINFORD MEDICAL PRACTICE M87008 1 THE WATERFRONT SURGERY M87010 PEDMORE MEDICAL PRACTICE M87030 DR PD GUPTA & PARTNERS M87617 CASTLE MEADOWS SURGERY M87620 BATH STREET MEDICAL CENTRE M87621 ALEXANDRA MEDICAL CENTRE M87623 CRESTFIELD SURGERY M87625 DR. B. K. PRASHARA M87628 DR. R. M. SHAH M87638 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 Walsall CCG 90.8% • 12,572 people with coronary heart disease* in NHS Dudley CCG • 10,832 (86.2%) people whose blood NHS Sandwell And West Birmingham CCG 87.0% pressure <= 150 / 90 • 287 (2.3%) people who are exceptions • 1,453 (11.6%) additional people NHS Wolverhampton CCG 86.8% whose blood pressure is not <= 150 / 90

NHS Dudley CCG 86.2%

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 Stockport CCG 91.1%

NHS Wigan Borough CCG 90.6%

NHS Havering CCG 88.6%

NHS Trafford CCG 88.4%

NHS Nottingham North and East CCG 88.3%

NHS Erewash CCG 88.2%

NHS North Tyneside CCG 88.1%

NHS Solihull CCG 88.1%

NHS Mansfield and Ashfield CCG 87.3%

NHS South East Staffordshire and Seisdon Peninsula CCG 87.3%

NHS Dudley CCG 86.2%

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

CRESTFIELD SURGERY M87625 25 DUDLEY P'SHIPS FOR HEALTH LLP Y02212 32 THE WATERFRONT SURGERY M87010 66 BATH STREET MEDICAL CENTRE M87621 23 QUINCY RISE SURGERY M87618 17 KINGSWINFORD MEDICAL PRACTICE M87008 77 • in total, including exceptions, there STEPPINGSTONES MEDICAL PRACTICE M87017 72 PEDMORE MEDICAL PRACTICE M87030 44 are 1,740 people whose blood DR PD GUPTA & PARTNERS M87617 22 HIGH OAK SURGERY Y02653 24 pressure is not <= 150 / 90 AW SURGERIES M87009 120 STOURSIDE MEDICAL PRACTICE Y01756 47 • GP practice range: 5.6% to 29.4% LOWER GORNAL MEDICAL PRACTICE M87015 73 NETHERTON HEALTH CENTRE M87028 46 CENTRAL CLINIC M87605 24 NORTHWAY MEDICAL CENTRE M87037 35 CASTLE MEADOWS SURGERY M87620 17 ALEXANDRA MEDICAL CENTRE M87623 12 WORDSLEY GREEN HEALTH CENTRE M87023 49 KEELINGE HOUSE M87601 35 THE SUMMERHILL SURGERY M87018 59 LAPAL MEDICAL PRACTICE M87014 40 WYCHBURY MEDICAL GROUP M87024 132 MOSS GROVE SURGERY M87003 79 THE LIMES SURGERY MEDICAL CENTRE M87019 33 WOODSETTON MEDICAL CENTRE M87016 33 COSELEY MEDICAL CENTRE M87021 32 CROSS STREET HEALTH CENTRE M87025 27 LION HEALTH M87011 122 THE RIDGEWAY SURGERY M87007 50 EVE HILL MEDICAL PRACTICE M87006 35 ST JAMES MEDICAL PRACTICE2 M87026 21 BILSTON STREET SURGERY M87629 14 DR. B. K. PRASHARA M87628 6 CLEMENT ROAD MEDICAL PRACTICE M87034 10 DR. R. M. SHAH M87638 17 NORTON MEDICAL PRACTICE M87002 24 BEAN MEDICAL PRACTICE M87036 6 HALESOWEN MEDICAL PRACTICE M87602 26 FELDON LANE PRACTICE M87020 30 ST JAMES MEDICAL PRACTICE1 M87612 8 THE GREENS HEALTH CENTRE M87012 16 MEADOWBROOK SURGERY M87001 20 THREE VILLAGES MEDICAL PRACTICE M87005 21 QUARRY BANK MEDICAL CENTRE M87027 8 RANGEWAYS ROAD SURGERY M87041 11 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

5% 0% -5% -10% -15% -20% -25%

CRESTFIELD SURGERY 19

DUDLEY P'SHIPS FOR HEALTH LLP 24

THE WATERFRONT SURGERY 48 • using the GP cluster method of BATH STREET MEDICAL CENTRE 17 calculating potential gains, if each QUINCY RISE SURGERY 12 practice was to achieve as well as the KINGSWINFORD MEDICAL PRACTICE 52 upper quartile of its national cluster, then an additional 783 people would STEPPINGSTONES MEDICAL PRACTICE 48 be treated PEDMORE MEDICAL PRACTICE 29

DR PD GUPTA & PARTNERS 14

HIGH OAK SURGERY 15

NORTON MEDICAL PRACTICE 5

BEAN MEDICAL PRACTICE 1

HALESOWEN MEDICAL PRACTICE 4

FELDON LANE PRACTICE 4

ST JAMES MEDICAL PRACTICE1 1

THE GREENS HEALTH CENTRE 0

MEADOWBROOK SURGERY

QUARRY BANK MEDICAL CENTRE

RANGEWAYS ROAD SURGERY

THREE VILLAGES MEDICAL PRACTICE 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 Walsall CCG 93.5% • 12,572 people with coronary heart disease* in NHS Dudley CCG • 11,389 (90.6%) people who are taking NHS Wolverhampton CCG 91.6% aspirin, an alternative anti-platelet therapy, or an anti-coagulant • 284 (2.3%) people who are exceptions NHS Sandwell And West Birmingham CCG 90.7% • 899 (7.2%) additional people who are not taking aspirin, an alternative anti- platelet therapy, or an anti-coagulant

NHS Dudley CCG 90.6%

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 Solihull CCG 93.8%

NHS Stockport CCG 93.0%

NHS Trafford CCG 92.6%

NHS Havering CCG 92.5%

NHS North Tyneside CCG 92.2%

NHS South East Staffordshire and Seisdon Peninsula CCG 92.1%

NHS Nottingham North and East CCG 91.8%

NHS Wigan Borough CCG 91.6%

NHS Mansfield and Ashfield CCG 91.6%

NHS Dudley CCG 90.6%

NHS Erewash CCG 90.5%

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

QUINCY RISE SURGERY M87618 22 BILSTON STREET SURGERY M87629 40 THE LIMES SURGERY MEDICAL CENTRE M87019 50 ALEXANDRA MEDICAL CENTRE M87623 14 THE SUMMERHILL SURGERY M87018 60 WOODSETTON MEDICAL CENTRE M87016 36 • in total, including exceptions, there MOSS GROVE SURGERY M87003 84 FELDON LANE PRACTICE M87020 48 are 1,183 people are not taking CRESTFIELD SURGERY M87625 11 HIGH OAK SURGERY Y02653 16 aspirin, an alternative anti-platelet ST JAMES MEDICAL PRACTICE1 M87612 13 COSELEY MEDICAL CENTRE M87021 32 therapy, or an anti-coagulant WYCHBURY MEDICAL GROUP M87024 115 BATH STREET MEDICAL CENTRE M87621 10 • GP practice range: 2.5% to 31.0% NORTON MEDICAL PRACTICE M87002 28 NORTHWAY MEDICAL CENTRE M87037 22 NETHERTON HEALTH CENTRE M87028 27 THE WATERFRONT SURGERY M87010 25 LION HEALTH M87011 101 LAPAL MEDICAL PRACTICE M87014 26 STEPPINGSTONES MEDICAL PRACTICE M87017 29 KEELINGE HOUSE M87601 20 WORDSLEY GREEN HEALTH CENTRE M87023 27 DR. R. M. SHAH M87638 15 AW SURGERIES M87009 51 DUDLEY P'SHIPS FOR HEALTH LLP Y02212 9 THREE VILLAGES MEDICAL PRACTICE M87005 27 LOWER GORNAL MEDICAL PRACTICE M87015 31 DR PD GUPTA & PARTNERS M87617 8 EVE HILL MEDICAL PRACTICE M87006 21 CROSS STREET HEALTH CENTRE M87025 15 HALESOWEN MEDICAL PRACTICE M87602 20 PEDMORE MEDICAL PRACTICE M87030 13 MEADOWBROOK SURGERY M87001 18 ST JAMES MEDICAL PRACTICE2 M87026 11 THE RIDGEWAY SURGERY M87007 23 STOURSIDE MEDICAL PRACTICE Y01756 13 THE GREENS HEALTH CENTRE M87012 11 CASTLE MEADOWS SURGERY M87620 5 QUARRY BANK MEDICAL CENTRE M87027 6 KINGSWINFORD MEDICAL PRACTICE M87008 14 DR. B. K. PRASHARA M87628 2 BEAN MEDICAL PRACTICE M87036 2 CLEMENT ROAD MEDICAL PRACTICE M87034 3 CENTRAL CLINIC M87605 4 RANGEWAYS ROAD SURGERY M87041 5 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 Dudley CCG England 800

700 • in NHS Dudley CCG, the hospital admission rate for coronary heart disease in 2015/16 was 461.4 (1,453) 600 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 Dudley CCG England 200

180 • in NHS Dudley CCG, the hospital admission rate for stroke in 2015/16 160 was 165 (518) compared to 172.8 for England 140

120

100

80

60 Age standardised standardised Age (per rate 100,000)

40

20

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 Dudley CCG England

127.7% Angina 136.8% • The risk of a stroke was 64.1% higher and the risk of a heart attack was 126.0% 126% higher compared to people Heart Attack 108.6% without diabetes. The risk of a major amputation was 379.5% higher. 125.7% Heart failure 150.0%

64.1% Stroke 81.3%

379.5% Major amputation 445.8%

559.9% Minor amputation 753.5%

268.7% RRT 293.0%

0% 100% 200% 300% 400% 500% 600% 700% 800% 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 Dudley CCG England 90

80 • in NHS Dudley CCG, the early mortality rate for coronary heart 70 disease in 2013-15 was 41.3, 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 Dudley CCG England 30

• in NHS Dudley CCG, the early 25 mortality rate for stroke in 2013-15 was 12.5, 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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