CVD: Primary Care Intelligence Packs NHS Kernow 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 Kernow CCG are: NHS Somerset CCG NHS Cumbria CCG NHS Coastal West Sussex CCG NHS Gloucestershire CCG NHS Dorset CCG NHS West Hampshire CCG NHS Northumberland CCG NHS East Riding of Yorkshire CCG NHS North East Essex CCG NHS Ipswich and East Suffolk 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 North East Essex CCG 18.6%
NHS Kernow CCG 18.0% • prevalence of 18% in NHS Kernow CCG NHS Somerset CCG 17.7%
NHS Cumbria CCG 17.1%
NHS Ipswich and East Suffolk CCG 16.8%
NHS Coastal West Sussex CCG 16.8%
NHS Dorset CCG 16.5%
NHS Northumberland CCG 16.2% Note: It has been found that the proportion of patients recorded as smokers correlates well NHS Gloucestershire CCG 15.9% with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, NHS East Riding of Yorkshire CCG 15.2% http://bmjopen.bmj.com/content/4/7/e005217.abs tract
NHS West Hampshire CCG 14.0% Definition: denominator of QOF clinical indicator SMOKE004 ( number of patients 15+ who are 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% recorded as current smokers) divided by GP practice’s estimated number of patients 15+
13 CVD: Primary Care Intelligence Packs Estimated smoking prevalence (QOF) by GP practice
GP Practice CCG
CARDREW HEALTH CENTRE Y02596 28.2% TREVITHICK SURGERY L82014 26.4% NEWQUAY HEALTH CENTRE Y02517 24.7% MORRAB SURGERY Y01051 24.3% CLAYS PRACTICE L82051 23.8% STILLMOOR HOUSE L82010 23.3% ALVERTON PRACTICE L82021 23.2% PENALVERNE SURGERY L82053 22.2% • 85,264 people who are recorded as CARN TO COAST HEALTH CENTRES L82041 22.1% VEOR SURGERY L82044 21.5% MANOR SURGERY L82042 21.2% smokers in NHS Kernow CCG ROSMELLYN SURGERY Y01050 20.8% MIDDLEWAY SURGERY L82026 20.6% • GP practice range: 10.1% to 28.2% FALMOUTH HEALTH CENTRE L82049 20.3% NARROWCLIFF SURGERY L82029 20.3% CLINTON ROAD SURGERY L82024 20.0% ROSEDEAN SURGERY L82050 19.8% ST AUSTELL HEALTH GROUP Y04957 19.5% PETROC GROUP PRACTICE L82023 19.2% CARNEWATER PRACTICE L82009 19.2% MEDICAL CENTRE CAMELFORD (DR GARROD) L82618 19.1% NEETSIDE SURGERY Y01127 19.1% LAUNCESTON MEDICAL CENTRE L82030 18.8% HARRIS MEMORIAL SURGERY L82620 18.8% PHOENIX SURGERY L82617 18.7% ST MARY'S HEALTH CENTRE L82017 18.7% OLD BRIDGE SURGERY L82022 18.5% SUNNYSIDE SURGERY L82070 18.2% CAPE CORNWALL SURGERY L82038 18.2% BRANNEL SURGERY L82011 18.2% FOWEY RIVER PRACTICE L82035 17.7% OAK TREE SURGERY L82016 17.6% WESTOVER SURGERY L82622 17.6% ST.AGNES SURGERY L82054 17.5% BOTTREAUX SURGERY L82058 17.0% PENRYN SURGERY L82006 16.9% PRAZE-AN-BEEBLE SURGERY L82068 16.8% TRESCOBEAS SURGERY L82052 16.5% MEDICAL CENTRE CAMELFORD (DR NASH) L82007 16.5% HELSTON MEDICAL CENTRE L82018 16.5% STENNACK SURGERY Y01922 16.4% BODRIGGY HEALTH CENTRE L82036 16.3% PERRANPORTH SURGERY L82013 16.1% ST KEVERNE HEALTH CENTRE L82057 15.8% MEVAGISSEY SURGERY L82025 15.7% SALTASH HEALTH CENTRE L82046 15.6% LANDER MEDICAL PRACTICE L82001 15.6% CHACEWATER HEALTH CENTRE L82015 15.5% STRATTON MEDICAL CENTRE L82008 15.5% RAME GROUP PRACTICE Y00969 15.4% TAMAR VALLEY HEALTH L82012 15.2% MENEAGE STREET SURGERY L82059 15.0% PENSILVA HEALTH CENTRE L82037 14.8% THREE SPIRES MEDICAL PRACTICE L82028 14.7% PORT ISAAC SURGERY L82003 14.7% Note: This method is thought to be a reasonably MARAZION SURGERY L82047 14.5% MULLION HEALTH CENTRE L82056 14.0% robust method in estimating smoking prevalence ROSELAND SURGERIES L82048 13.8% QUAY LANE SURGERY L82043 13.6% for the majority of GP practices. However, LOSTWITHIEL SURGERY L82039 13.4% PORT VIEW SURGERY L82066 12.7% caution is advised for extreme estimates of WADEBRIDGE & CAMEL ESTUARY PRACTICE L82004 12.1% PROBUS SURGERY L82045 11.8% smoking prevalence and those with high CARNON DOWNS SURGERY L82061 10.1% MILLBROOK SURGERY Y05021 numbers of smoking status not recorded and 0% 5% 10% 15% 20% 25% 30% exceptions.
14 CVD: Primary Care Intelligence Packs Hypertension
15 CVD: Primary Care Intelligence Packs Hypertension
The Missing Millions On average, each CCG in England has 26,000 residents with The Global Burden of Disease undiagnosed hypertension – these individuals are unaware of Study confirmed high blood pressure as their increased cardiovascular risk and are untreated. a leading cause of premature death and disability What questions should we ask in our CCG? 1. for each indicator how wide is the variation in achievement and exception reporting? 2. how many people would benefit if all practices performed High blood pressure is common and costly as well as the best? • it affects around a quarter of all adults 3. how can we support practices who are average or below • the NHS costs of hypertension are around £2bn average to perform as well as the best in: • social costs are probably considerably higher • detection of hypertension • management of hypertension What do we know? • at least half of all heart attacks and strokes are caused by high blood pressure and it is a major risk What might help? factor for chronic kidney disease and cognitive decline • support practices to share audit data and systematically • treatment is very effective – every 10mmHg reduction identify gaps and opportunities for improved detection and in systolic blood pressure lowers risk of heart attack management of hypertension and stroke by 20% • work with practices and local authorities to maximise • despite this 4 out of 10 adults with hypertension, over uptake and follow up in the NHS Health Check 5 and a half million people in England, remain • support access to self-test BP stations in waiting rooms undiagnosed and to ambulatory blood pressure monitoring. • and even when the condition is identified, treatment is • commission community pharmacists to offer blood often suboptimal, with blood pressure poorly pressure measurement, diagnosis and management controlled in about 1 out of 3 individuals support, including support for adherence to medication
16 CVD: Primary Care Intelligence Packs Hypertension observed prevalence compared with expected prevalence by CCG Comparison with CCGs in the STP
NHS Kernow CCG 0.58 • the ratio of those diagnosed with hypertension versus those expected to have hypertension is 0.58. This compares to 0.59 for England • this suggests that 58% of people with hypertension have been diagnosed
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 East Riding of Yorkshire CCG 0.62
NHS Northumberland CCG 0.61
NHS Somerset CCG 0.60
NHS North East Essex CCG 0.60
NHS Coastal West Sussex CCG 0.60
NHS Cumbria CCG 0.59
NHS West Hampshire CCG 0.59
NHS Dorset CCG 0.59
NHS Ipswich and East Suffolk CCG 0.59
NHS Kernow CCG 0.58
NHS Gloucestershire 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
OLD BRIDGE SURGERY L82022 0.69 ALVERTON PRACTICE L82021 0.69 CAPE CORNWALL SURGERY L82038 0.63 PENSILVA HEALTH CENTRE L82037 0.62 MARAZION SURGERY L82047 0.61 PENALVERNE SURGERY L82053 0.61 PHOENIX SURGERY L82617 0.60 CARN TO COAST HEALTH CENTRES L82041 0.59 VEOR SURGERY L82044 0.59 • it is estimated that there are 62,033 PRAZE-AN-BEEBLE SURGERY L82068 0.58 MULLION HEALTH CENTRE L82056 0.58 people with undiagnosed OAK TREE SURGERY L82016 0.58 TAMAR VALLEY HEALTH L82012 0.58 MANOR SURGERY L82042 0.58 hypertension in NHS Kernow CCG HARRIS MEMORIAL SURGERY L82620 0.58 STRATTON MEDICAL CENTRE L82008 0.58 CARNON DOWNS SURGERY L82061 0.58 • GP practice range of observed to CARNEWATER PRACTICE L82009 0.58 ROSEDEAN SURGERY L82050 0.57 MENEAGE STREET SURGERY L82059 0.56 expected hypertension prevalence WADEBRIDGE & CAMEL ESTUARY PRACTICE L82004 0.56 PROBUS SURGERY L82045 0.56 TREVITHICK SURGERY L82014 0.56 0.33 to 0.69 PERRANPORTH SURGERY L82013 0.56 LAUNCESTON MEDICAL CENTRE L82030 0.55 BOTTREAUX SURGERY L82058 0.55 BODRIGGY HEALTH CENTRE L82036 0.55 MIDDLEWAY SURGERY L82026 0.55 STENNACK SURGERY Y01922 0.55 CHACEWATER HEALTH CENTRE L82015 0.54 CLINTON ROAD SURGERY L82024 0.53 ROSELAND SURGERIES L82048 0.53 PETROC GROUP PRACTICE L82023 0.53 STILLMOOR HOUSE L82010 0.53 PORT VIEW SURGERY L82066 0.53 RAME GROUP PRACTICE Y00969 0.53 ST KEVERNE HEALTH CENTRE L82057 0.52 THREE SPIRES MEDICAL PRACTICE L82028 0.52 SALTASH HEALTH CENTRE L82046 0.52 HELSTON MEDICAL CENTRE L82018 0.51 WESTOVER SURGERY L82622 0.51 FALMOUTH HEALTH CENTRE L82049 0.50 FOWEY RIVER PRACTICE L82035 0.50 SUNNYSIDE SURGERY L82070 0.50 ROSMELLYN SURGERY Y01050 0.50 BRANNEL SURGERY L82011 0.50 MEDICAL CENTRE CAMELFORD (DR NASH) L82007 0.49 NEWQUAY HEALTH CENTRE Y02517 0.49 TRESCOBEAS SURGERY L82052 0.49 NEETSIDE SURGERY Y01127 0.48 NARROWCLIFF SURGERY L82029 0.47 LANDER MEDICAL PRACTICE L82001 0.46 PENRYN SURGERY L82006 0.46 MORRAB SURGERY Y01051 0.45 ST MARY'S HEALTH CENTRE L82017 0.45 PORT ISAAC SURGERY L82003 0.43 MEDICAL CENTRE CAMELFORD (DR GARROD) L82618 0.43 QUAY LANE SURGERY L82043 0.43 ST.AGNES SURGERY L82054 0.43 MEVAGISSEY SURGERY L82025 0.41 CLAYS PRACTICE L82051 0.40 LOSTWITHIEL SURGERY L82039 0.39 CARDREW HEALTH CENTRE Y02596 0.33 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 Kernow CCG 79.7% • 86,817 people with hypertension (diagnosed)* in NHS Kernow CCG • 69,213 (79.7%) people whose blood pressure is <= 150/90 • 4,057 (4.7%) people who are excepted from optimal control • 13,547 (15.6%) additional people whose blood pressure is not <= 150/90
England 79.6%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% *Using QOF clinical indicator HYP006 denominator plus exceptions
20 CVD: Primary Care Intelligence Packs Percentage of patients with hypertension whose last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less by CCG Comparison with demographically similar CCGs
NHS Northumberland CCG 81.8%
NHS Cumbria CCG 80.9%
NHS Gloucestershire CCG 80.1%
NHS Ipswich and East Suffolk CCG 80.0%
NHS North East Essex CCG 79.9%
NHS Kernow CCG 79.7%
NHS East Riding of Yorkshire CCG 79.4%
NHS Dorset CCG 79.2%
NHS West Hampshire CCG 78.3%
NHS Coastal West Sussex CCG 76.1%
NHS Somerset CCG 74.8%
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
CARDREW HEALTH CENTRE Y02596 45 ST AUSTELL HEALTH GROUP Y04957 1779 PORT VIEW SURGERY L82066 311 VEOR SURGERY L82044 412 RAME GROUP PRACTICE Y00969 414 ROSELAND SURGERIES L82048 185 PETROC GROUP PRACTICE L82023 636 ROSMELLYN SURGERY Y01050 244 • in total, including exceptions, there PENRYN SURGERY L82006 553 CHACEWATER HEALTH CENTRE L82015 239 TREVITHICK SURGERY L82014 181 are 17,604 people whose blood LANDER MEDICAL PRACTICE L82001 475 THREE SPIRES MEDICAL PRACTICE L82028 488 PORT ISAAC SURGERY L82003 265 pressure is not <= 150/90 PERRANPORTH SURGERY L82013 269 NEWQUAY HEALTH CENTRE Y02517 432 • GP practice range: 12.3% to 37.5% WADEBRIDGE & CAMEL ESTUARY PRACTICE L82004 290 ST.AGNES SURGERY L82054 226 MANOR SURGERY L82042 428 ROSEDEAN SURGERY L82050 301 MEVAGISSEY SURGERY L82025 146 CLINTON ROAD SURGERY L82024 135 ALVERTON PRACTICE L82021 274 LAUNCESTON MEDICAL CENTRE L82030 549 PRAZE-AN-BEEBLE SURGERY L82068 191 BRANNEL SURGERY L82011 131 SUNNYSIDE SURGERY L82070 182 NARROWCLIFF SURGERY L82029 324 LOSTWITHIEL SURGERY L82039 115 CARNEWATER PRACTICE L82009 340 QUAY LANE SURGERY L82043 114 PROBUS SURGERY L82045 269 STENNACK SURGERY Y01922 393 STILLMOOR HOUSE L82010 277 MIDDLEWAY SURGERY L82026 192 BODRIGGY HEALTH CENTRE L82036 300 TRESCOBEAS SURGERY L82052 251 CARN TO COAST HEALTH CENTRES L82041 501 MORRAB SURGERY Y01051 154 FOWEY RIVER PRACTICE L82035 210 BOTTREAUX SURGERY L82058 157 ST KEVERNE HEALTH CENTRE L82057 90 MENEAGE STREET SURGERY L82059 155 PHOENIX SURGERY L82617 152 SALTASH HEALTH CENTRE L82046 302 PENSILVA HEALTH CENTRE L82037 156 FALMOUTH HEALTH CENTRE L82049 213 MARAZION SURGERY L82047 234 ST MARY'S HEALTH CENTRE L82017 46 PENALVERNE SURGERY L82053 144 MULLION HEALTH CENTRE L82056 237 TAMAR VALLEY HEALTH L82012 435 NEETSIDE SURGERY Y01127 100 HARRIS MEMORIAL SURGERY L82620 139 MEDICAL CENTRE CAMELFORD (DR GARROD) L82618 61 CARNON DOWNS SURGERY L82061 157 OLD BRIDGE SURGERY L82022 342 MEDICAL CENTRE CAMELFORD (DR NASH) L82007 68 HELSTON MEDICAL CENTRE L82018 281 OAK TREE SURGERY L82016 248 CAPE CORNWALL SURGERY L82038 134 CLAYS PRACTICE L82051 160 STRATTON MEDICAL CENTRE L82008 251 WESTOVER SURGERY L82622 121 MILLBROOK SURGERY Y05021 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 Kernow CCG 62.0% • 287 people with a new diagnosis* of hypertension with a CVD risk of 20% or higher in NHS Kernow CCG • 178 (62%) people who are currently treated with statins • 103 (35.9%) people who are exempted from treatment with statins • 6 (2.1%) additional people who are not currently treated with statins
England 66.5%
0% 10% 20% 30% 40% 50% 60% 70% *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 Gloucestershire CCG 65.1%
NHS North East Essex CCG 64.8%
NHS Cumbria CCG 64.0%
NHS East Riding of Yorkshire CCG 64.0%
NHS Ipswich and East Suffolk CCG 62.1%
NHS Kernow CCG 62.0%
NHS Northumberland CCG 61.9%
NHS Coastal West Sussex CCG 59.6%
NHS Dorset CCG 56.6%
NHS West Hampshire CCG 55.9%
NHS Somerset CCG 55.1%
0% 10% 20% 30% 40% 50% 60% 70%
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
MEVAGISSEY SURGERY L82025 2 NEETSIDE SURGERY Y01127 2 PENSILVA HEALTH CENTRE L82037 4 STENNACK SURGERY Y01922 3 MANOR SURGERY L82042 5 MULLION HEALTH CENTRE L82056 4 PERRANPORTH SURGERY L82013 5 CHACEWATER HEALTH CENTRE L82015 3 • in total, including exceptions, there THREE SPIRES MEDICAL PRACTICE L82028 3 WESTOVER SURGERY L82622 6 PROBUS SURGERY L82045 4 are 109 people who are not treated ST.AGNES SURGERY L82054 4 CARNEWATER PRACTICE L82009 9 STILLMOOR HOUSE L82010 1 with statins TREVITHICK SURGERY L82014 1 CLINTON ROAD SURGERY L82024 2 • GP practice range: 0.0% to 100.0% MIDDLEWAY SURGERY L82026 1 NARROWCLIFF SURGERY L82029 4 FOWEY RIVER PRACTICE L82035 2 QUAY LANE SURGERY L82043 1 MARAZION SURGERY L82047 1 TRESCOBEAS SURGERY L82052 1 PENALVERNE SURGERY L82053 2 PORT VIEW SURGERY L82066 1 FALMOUTH HEALTH CENTRE L82049 4 ST AUSTELL HEALTH GROUP Y04957 14 ROSMELLYN SURGERY Y01050 2 MEDICAL CENTRE CAMELFORD (DR NASH) L82007 1 PRAZE-AN-BEEBLE SURGERY L82068 2 STRATTON MEDICAL CENTRE L82008 3 OLD BRIDGE SURGERY L82022 3 CARN TO COAST HEALTH CENTRES L82041 2 LANDER MEDICAL PRACTICE L82001 3 CARNON DOWNS SURGERY L82061 1 RAME GROUP PRACTICE Y00969 1 BODRIGGY HEALTH CENTRE L82036 1 LAUNCESTON MEDICAL CENTRE L82030 1 PORT ISAAC SURGERY L82003 WADEBRIDGE & CAMEL ESTUARY PRACTICE L82004 PENRYN SURGERY L82006 BRANNEL SURGERY L82011 TAMAR VALLEY HEALTH L82012 OAK TREE SURGERY L82016 ST MARY'S HEALTH CENTRE L82017 HELSTON MEDICAL CENTRE L82018 ALVERTON PRACTICE L82021 PETROC GROUP PRACTICE L82023 CAPE CORNWALL SURGERY L82038 VEOR SURGERY L82044 SALTASH HEALTH CENTRE L82046 ROSELAND SURGERIES L82048 ROSEDEAN SURGERY L82050 CLAYS PRACTICE L82051 ST KEVERNE HEALTH CENTRE L82057 BOTTREAUX SURGERY L82058 MENEAGE STREET SURGERY L82059 PHOENIX SURGERY L82617 HARRIS MEMORIAL SURGERY L82620 MORRAB SURGERY Y01051 NEWQUAY HEALTH CENTRE Y02517 MILLBROOK SURGERY Y05021 CARDREW HEALTH CENTRE Y02596 MEDICAL CENTRE CAMELFORD (DR GARROD) L82618 SUNNYSIDE SURGERY L82070 LOSTWITHIEL SURGERY L82039 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 Kernow CCG 0.72 • the ratio of those diagnosed with atrial fibrillation versus those expected to have atrial fibrillation is 0.72. This compares to 0.7 for England • this suggests that 72% of people with atrial fibrillation have been diagnosed.
Note: This slide compares the prevalence of atrial fibrillation recorded in QOF in 2015/16 to the estimated prevalence of atrial fibrillation, England 0.70 taken from National Cardiovascular Intelligence Network estimates produced in 2017. The 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 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 Somerset CCG 0.78
NHS Dorset CCG 0.77
NHS Gloucestershire CCG 0.74
NHS Northumberland CCG 0.73
NHS Coastal West Sussex CCG 0.72
NHS Ipswich and East Suffolk CCG 0.72
NHS Kernow CCG 0.72
NHS Cumbria CCG 0.71
NHS East Riding of Yorkshire CCG 0.71
NHS North East Essex CCG 0.71
NHS West Hampshire CCG 0.70
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
ROSELAND SURGERIES L82048 0.9 WADEBRIDGE & CAMEL ESTUARY PRACTICE L82004 0.8 PENRYN SURGERY L82006 0.8 STRATTON MEDICAL CENTRE L82008 0.8 CARNEWATER PRACTICE L82009 0.8 CHACEWATER HEALTH CENTRE L82015 0.8 ALVERTON PRACTICE L82021 0.8 OLD BRIDGE SURGERY L82022 0.8 PETROC GROUP PRACTICE L82023 0.8 • it is estimated that there are 17,945 NARROWCLIFF SURGERY L82029 0.8 LAUNCESTON MEDICAL CENTRE L82030 0.8 people with undiagnosed atrial PENSILVA HEALTH CENTRE L82037 0.8 SALTASH HEALTH CENTRE L82046 0.8 MARAZION SURGERY L82047 0.8 fibrillation in NHS Kernow CCG FALMOUTH HEALTH CENTRE L82049 0.8 ROSEDEAN SURGERY L82050 0.8 MULLION HEALTH CENTRE L82056 0.8 • GP practice range of observed to MENEAGE STREET SURGERY L82059 0.8 CARNON DOWNS SURGERY L82061 0.8 PRAZE-AN-BEEBLE SURGERY L82068 0.8 expected atrial fibrillation prevalence WESTOVER SURGERY L82622 0.8 STENNACK SURGERY Y01922 0.8 NEWQUAY HEALTH CENTRE Y02517 0.8 0.5 to 0.9 ST AUSTELL HEALTH GROUP Y04957 0.8 LANDER MEDICAL PRACTICE L82001 0.7 PORT ISAAC SURGERY L82003 0.7 TAMAR VALLEY HEALTH L82012 0.7 PERRANPORTH SURGERY L82013 0.7 TREVITHICK SURGERY L82014 0.7 OAK TREE SURGERY L82016 0.7 MEVAGISSEY SURGERY L82025 0.7 MIDDLEWAY SURGERY L82026 0.7 THREE SPIRES MEDICAL PRACTICE L82028 0.7 BODRIGGY HEALTH CENTRE L82036 0.7 CAPE CORNWALL SURGERY L82038 0.7 CARN TO COAST HEALTH CENTRES L82041 0.7 QUAY LANE SURGERY L82043 0.7 VEOR SURGERY L82044 0.7 PROBUS SURGERY L82045 0.7 TRESCOBEAS SURGERY L82052 0.7 PENALVERNE SURGERY L82053 0.7 ST.AGNES SURGERY L82054 0.7 PORT VIEW SURGERY L82066 0.7 SUNNYSIDE SURGERY L82070 0.7 PHOENIX SURGERY L82617 0.7 STILLMOOR HOUSE L82010 0.6 ST MARY'S HEALTH CENTRE L82017 0.6 HELSTON MEDICAL CENTRE L82018 0.6 CLINTON ROAD SURGERY L82024 0.6 FOWEY RIVER PRACTICE L82035 0.6 MANOR SURGERY L82042 0.6 CLAYS PRACTICE L82051 0.6 ST KEVERNE HEALTH CENTRE L82057 0.6 BOTTREAUX SURGERY L82058 0.6 MEDICAL CENTRE CAMELFORD (DR GARROD) L82618 0.6 HARRIS MEMORIAL SURGERY L82620 0.6 ROSMELLYN SURGERY Y01050 0.6 NEETSIDE SURGERY Y01127 0.6 MEDICAL CENTRE CAMELFORD (DR NASH) L82007 0.5 BRANNEL SURGERY L82011 0.5 LOSTWITHIEL SURGERY L82039 0.5 RAME GROUP PRACTICE Y00969 0.5 MORRAB SURGERY Y01051 0.5 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
• 10,088 people with atrial fibrillation* NHS Kernow CCG 80.2% with a CHA2DS2-VASc score >= 2 in NHS Kernow CCG • 8,089 (80.2%) people treated with anti-coagulation therapy • 886 (8.8%) people who are exceptions • 1,113 (11%) additional people with a recorded CHA2DS2-VASc score >= 2 who are not treated
England 77.9%
0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator AF007 denominator plus exceptions
31 CVD: Primary Care Intelligence Packs In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage treated with anti-coagulation therapy by CCG Comparison with demographically similar CCGs Optimal management No treatment Exceptions reported
NHS Gloucestershire CCG 82.0%
NHS West Hampshire CCG 81.0%
NHS Kernow CCG 80.2%
NHS Ipswich and East Suffolk CCG 79.8%
NHS Somerset CCG 79.5%
NHS East Riding of Yorkshire CCG 76.6%
NHS Dorset CCG 75.5%
NHS Coastal West Sussex CCG 74.7%
NHS North East Essex CCG 74.6%
NHS Cumbria CCG 73.7%
NHS Northumberland CCG 72.3%
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
PRAZE-AN-BEEBLE SURGERY L82068 38 LOSTWITHIEL SURGERY L82039 19 TREVITHICK SURGERY L82014 19 PHOENIX SURGERY L82617 25 RAME GROUP PRACTICE Y00969 40 PETROC GROUP PRACTICE L82023 73 SALTASH HEALTH CENTRE L82046 60 HARRIS MEMORIAL SURGERY L82620 20 • in total, including exceptions, there ST.AGNES SURGERY L82054 35 ST MARY'S HEALTH CENTRE L82017 10 ALVERTON PRACTICE L82021 18 are 1,999 people with a recorded MEDICAL CENTRE CAMELFORD (DR GARROD) L82618 13 LAUNCESTON MEDICAL CENTRE L82030 81 STENNACK SURGERY Y01922 71 CHA2DS2-VASc score >= 2 who are BODRIGGY HEALTH CENTRE L82036 46 PORT VIEW SURGERY L82066 25 not treated STRATTON MEDICAL CENTRE L82008 65 CARN TO COAST HEALTH CENTRES L82041 69 ST AUSTELL HEALTH GROUP Y04957 132 • GP practice range: 0.0% to 33.3% ROSMELLYN SURGERY Y01050 20 BRANNEL SURGERY L82011 11 VEOR SURGERY L82044 41 CARNEWATER PRACTICE L82009 48 HELSTON MEDICAL CENTRE L82018 48 ROSELAND SURGERIES L82048 21 CLINTON ROAD SURGERY L82024 14 PORT ISAAC SURGERY L82003 40 MARAZION SURGERY L82047 35 OLD BRIDGE SURGERY L82022 53 WESTOVER SURGERY L82622 32 THREE SPIRES MEDICAL PRACTICE L82028 57 ROSEDEAN SURGERY L82050 38 CARNON DOWNS SURGERY L82061 34 FALMOUTH HEALTH CENTRE L82049 37 PENALVERNE SURGERY L82053 21 STILLMOOR HOUSE L82010 25 SUNNYSIDE SURGERY L82070 24 NEETSIDE SURGERY Y01127 14 PENRYN SURGERY L82006 48 QUAY LANE SURGERY L82043 17 PENSILVA HEALTH CENTRE L82037 15 NARROWCLIFF SURGERY L82029 41 LANDER MEDICAL PRACTICE L82001 40 PROBUS SURGERY L82045 26 FOWEY RIVER PRACTICE L82035 21 MULLION HEALTH CENTRE L82056 31 PERRANPORTH SURGERY L82013 21 TAMAR VALLEY HEALTH L82012 56 BOTTREAUX SURGERY L82058 14 OAK TREE SURGERY L82016 31 NEWQUAY HEALTH CENTRE Y02517 36 MANOR SURGERY L82042 29 WADEBRIDGE & CAMEL ESTUARY PRACTICE L82004 23 MIDDLEWAY SURGERY L82026 14 MORRAB SURGERY Y01051 8 CAPE CORNWALL SURGERY L82038 13 ST KEVERNE HEALTH CENTRE L82057 7 CHACEWATER HEALTH CENTRE L82015 4 CLAYS PRACTICE L82051 14 MEDICAL CENTRE CAMELFORD (DR NASH) L82007 4 TRESCOBEAS SURGERY L82052 7 MENEAGE STREET SURGERY L82059 7 MEVAGISSEY SURGERY L82025 CARDREW HEALTH CENTRE Y02596 MILLBROOK SURGERY Y05021 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%
PRAZE-AN-BEEBLE SURGERY 21
LOSTWITHIEL SURGERY 9
TREVITHICK SURGERY 9 • using the GP cluster method of PHOENIX SURGERY 11 calculating potential gains, if each HARRIS MEMORIAL SURGERY 8 practice was to achieve as well as the ST MARY'S HEALTH CENTRE 4 upper quartile of its national cluster, then an additional 366 people would ALVERTON PRACTICE 7 be treated RAME GROUP PRACTICE 15
MEDICAL CENTRE CAMELFORD (DR GARROD) 5
PETROC GROUP PRACTICE 26
MORRAB SURGERY
CAPE CORNWALL SURGERY
CHACEWATER HEALTH CENTRE
MEDICAL CENTRE CAMELFORD (DR NASH)
CLAYS PRACTICE
ST KEVERNE HEALTH CENTRE
MENEAGE STREET SURGERY
TRESCOBEAS SURGERY
CARDREW HEALTH CENTRE
MEVAGISSEY SURGERY 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
• 14,190 people with a history of stroke NHS Kernow CCG 82.6% or TIA* in NHS Kernow CCG • 11,724 (82.6%) people whose blood pressure is <= 150 / 90 • 738 (5.2%) people who are exceptions • 1,728 (12.2%) additional people whose blood pressure is not <= 150 / 90
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 Northumberland CCG 84.7%
NHS Cumbria CCG 84.4%
NHS Gloucestershire CCG 84.2%
NHS Ipswich and East Suffolk CCG 84.0%
NHS North East Essex CCG 83.9%
NHS East Riding of Yorkshire CCG 82.9%
NHS Kernow CCG 82.6%
NHS Dorset CCG 82.3%
NHS West Hampshire CCG 82.3%
NHS Coastal West Sussex CCG 79.7%
NHS Somerset CCG 77.5%
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
CARDREW HEALTH CENTRE Y02596 7 ST AUSTELL HEALTH GROUP Y04957 242 VEOR SURGERY L82044 84 PENRYN SURGERY L82006 104 ROSELAND SURGERIES L82048 34 PORT VIEW SURGERY L82066 40 RAME GROUP PRACTICE Y00969 60 ROSMELLYN SURGERY Y01050 44 • in total, including exceptions, there BRANNEL SURGERY L82011 20 PETROC GROUP PRACTICE L82023 89 TREVITHICK SURGERY L82014 26 are 2,466 people whose blood MIDDLEWAY SURGERY L82026 33 MORRAB SURGERY Y01051 32 PROBUS SURGERY L82045 34 pressure is not <= 150 / 90 NARROWCLIFF SURGERY L82029 65 HARRIS MEMORIAL SURGERY L82620 30 • GP practice range: 6.0% to 46.7% ST KEVERNE HEALTH CENTRE L82057 16 CHACEWATER HEALTH CENTRE L82015 37 MANOR SURGERY L82042 61 STRATTON MEDICAL CENTRE L82008 65 ROSEDEAN SURGERY L82050 41 PERRANPORTH SURGERY L82013 35 ST.AGNES SURGERY L82054 34 THREE SPIRES MEDICAL PRACTICE L82028 60 PORT ISAAC SURGERY L82003 40 CARN TO COAST HEALTH CENTRES L82041 81 BODRIGGY HEALTH CENTRE L82036 51 MEVAGISSEY SURGERY L82025 28 STILLMOOR HOUSE L82010 44 STENNACK SURGERY Y01922 68 SALTASH HEALTH CENTRE L82046 40 LOSTWITHIEL SURGERY L82039 24 LAUNCESTON MEDICAL CENTRE L82030 59 BOTTREAUX SURGERY L82058 19 MARAZION SURGERY L82047 36 MENEAGE STREET SURGERY L82059 26 NEWQUAY HEALTH CENTRE Y02517 42 SUNNYSIDE SURGERY L82070 27 NEETSIDE SURGERY Y01127 16 WADEBRIDGE & CAMEL ESTUARY PRACTICE L82004 34 PENSILVA HEALTH CENTRE L82037 18 PENALVERNE SURGERY L82053 20 TAMAR VALLEY HEALTH L82012 57 PRAZE-AN-BEEBLE SURGERY L82068 13 CLINTON ROAD SURGERY L82024 12 OAK TREE SURGERY L82016 32 CLAYS PRACTICE L82051 28 ST MARY'S HEALTH CENTRE L82017 5 PHOENIX SURGERY L82617 24 FALMOUTH HEALTH CENTRE L82049 30 MULLION HEALTH CENTRE L82056 36 LANDER MEDICAL PRACTICE L82001 34 FOWEY RIVER PRACTICE L82035 26 CARNEWATER PRACTICE L82009 28 TRESCOBEAS SURGERY L82052 28 HELSTON MEDICAL CENTRE L82018 35 CARNON DOWNS SURGERY L82061 21 OLD BRIDGE SURGERY L82022 33 MEDICAL CENTRE CAMELFORD (DR NASH) L82007 6 QUAY LANE SURGERY L82043 7 ALVERTON PRACTICE L82021 15 MEDICAL CENTRE CAMELFORD (DR GARROD) L82618 7 WESTOVER SURGERY L82622 16 CAPE CORNWALL SURGERY L82038 7 MILLBROOK SURGERY Y05021 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
• 10,296 people with a stroke shown to NHS Kernow CCG 92.3% be non-haemorrhagic* in NHS Kernow CCG • 9,501 (92.3%) people who are taking an anti-platetet agent or anti- coagulant • 557 (5.4%) people who are exceptions • 238 (2.3%) additional people with no treatment
England 91.8%
0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator STIA007 denominator plus exceptions
38 CVD: Primary Care Intelligence Packs Percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record in the preceding 12 months that an anti-platelet agent, or an anti-coagulant is being taken by CCG Comparison with demographically similar CCGs Below 150/90 Not below 150/90 Exceptions reported
NHS Northumberland CCG 92.3%
NHS Kernow CCG 92.3%
NHS West Hampshire CCG 91.9%
NHS Ipswich and East Suffolk CCG 91.8%
NHS East Riding of Yorkshire CCG 91.7%
NHS Gloucestershire CCG 91.7%
NHS Dorset CCG 91.6%
NHS Cumbria CCG 91.1%
NHS North East Essex CCG 91.0%
NHS Coastal West Sussex CCG 90.2%
NHS Somerset CCG 88.9%
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
CARDREW HEALTH CENTRE Y02596 3 PRAZE-AN-BEEBLE SURGERY L82068 9 PORT ISAAC SURGERY L82003 29 MEDICAL CENTRE CAMELFORD (DR NASH) L82007 5 VEOR SURGERY L82044 20 TREVITHICK SURGERY L82014 9 PERRANPORTH SURGERY L82013 17 BODRIGGY HEALTH CENTRE L82036 21 • in total, including exceptions, there MANOR SURGERY L82042 27 STILLMOOR HOUSE L82010 16 ST AUSTELL HEALTH GROUP Y04957 57 are 795 people who are not taking an OLD BRIDGE SURGERY L82022 26 MEVAGISSEY SURGERY L82025 15 CHACEWATER HEALTH CENTRE L82015 16 anti-platelet agent or anti-coagulant PETROC GROUP PRACTICE L82023 29 STRATTON MEDICAL CENTRE L82008 18 • GP practice range: 2.7% to 33.3% CAPE CORNWALL SURGERY L82038 8 RAME GROUP PRACTICE Y00969 18 STENNACK SURGERY Y01922 32 ROSEDEAN SURGERY L82050 16 ST MARY'S HEALTH CENTRE L82017 3 ROSMELLYN SURGERY Y01050 11 SALTASH HEALTH CENTRE L82046 12 MIDDLEWAY SURGERY L82026 12 LOSTWITHIEL SURGERY L82039 9 PORT VIEW SURGERY L82066 8 PENALVERNE SURGERY L82053 11 PROBUS SURGERY L82045 10 HELSTON MEDICAL CENTRE L82018 20 LAUNCESTON MEDICAL CENTRE L82030 22 PENRYN SURGERY L82006 23 TAMAR VALLEY HEALTH L82012 23 WADEBRIDGE & CAMEL ESTUARY PRACTICE L82004 13 QUAY LANE SURGERY L82043 4 CLAYS PRACTICE L82051 10 FALMOUTH HEALTH CENTRE L82049 12 CARNEWATER PRACTICE L82009 10 MULLION HEALTH CENTRE L82056 14 ROSELAND SURGERIES L82048 6 THREE SPIRES MEDICAL PRACTICE L82028 14 BOTTREAUX SURGERY L82058 4 MARAZION SURGERY L82047 12 ST.AGNES SURGERY L82054 10 SUNNYSIDE SURGERY L82070 10 MORRAB SURGERY Y01051 7 NEETSIDE SURGERY Y01127 6 FOWEY RIVER PRACTICE L82035 9 WESTOVER SURGERY L82622 7 CARN TO COAST HEALTH CENTRES L82041 18 NARROWCLIFF SURGERY L82029 10 MENEAGE STREET SURGERY L82059 6 LANDER MEDICAL PRACTICE L82001 9 CLINTON ROAD SURGERY L82024 3 PENSILVA HEALTH CENTRE L82037 5 TRESCOBEAS SURGERY L82052 7 NEWQUAY HEALTH CENTRE Y02517 7 BRANNEL SURGERY L82011 2 ST KEVERNE HEALTH CENTRE L82057 2 HARRIS MEMORIAL SURGERY L82620 3 CARNON DOWNS SURGERY L82061 5 PHOENIX SURGERY L82617 4 OAK TREE SURGERY L82016 5 ALVERTON PRACTICE L82021 4 MEDICAL CENTRE CAMELFORD (DR GARROD) L82618 2 MILLBROOK SURGERY Y05021 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
• 0.65 ratio of observed to expected NHS Kernow CCG 0.65 diabetes prevalence in NHS Kernow CCG, compared to 0.77 in England
• this suggests 65% of people have been diagnosed
England 0.77 Note: This slide compares the prevalence of Diabetes recorded in QOF in 2015/16 to the expected prevalence of Diabetes in 2016 taken from the NCVIN diabetes prevalence model produced in 2015.
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
43 CVD: Primary Care Intelligence Packs Diabetes observed prevalence compared with expected prevalence by CCG Comparison with demographically similar CCGs
NHS Northumberland CCG 0.83
NHS East Riding of Yorkshire CCG 0.82
NHS Cumbria CCG 0.79
NHS Gloucestershire CCG 0.77
NHS North East Essex CCG 0.77
NHS Coastal West Sussex CCG 0.76
NHS Somerset CCG 0.74
NHS Dorset CCG 0.69
NHS Ipswich and East Suffolk CCG 0.68
NHS West Hampshire CCG 0.66
NHS Kernow CCG 0.65
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
STRATTON MEDICAL CENTRE L82008 9.0% TREVITHICK SURGERY L82014 9.0% MEDICAL CENTRE CAMELFORD (DR GARROD) L82618 8.6% HARRIS MEMORIAL SURGERY L82620 8.5% CAPE CORNWALL SURGERY L82038 8.5% VEOR SURGERY L82044 8.1% MIDDLEWAY SURGERY L82026 8.0% OAK TREE SURGERY L82016 7.5% • GP practice range of observed BRANNEL SURGERY L82011 7.5% PENSILVA HEALTH CENTRE L82037 7.4% CLINTON ROAD SURGERY L82024 7.4% diabetes 0.0% to 9.0% CLAYS PRACTICE L82051 7.4% OLD BRIDGE SURGERY L82022 7.3% MENEAGE STREET SURGERY L82059 7.3% • there are an estimated 15,684 people MEDICAL CENTRE CAMELFORD (DR NASH) L82007 7.2% PHOENIX SURGERY L82617 7.1% STILLMOOR HOUSE L82010 7.1% with undiagnosed diabetes in NHS CARN TO COAST HEALTH CENTRES L82041 6.9% MEVAGISSEY SURGERY L82025 6.9% Kernow CCG MULLION HEALTH CENTRE L82056 6.8% PENALVERNE SURGERY L82053 6.8% MARAZION SURGERY L82047 6.7% ROSEDEAN SURGERY L82050 6.7% PORT VIEW SURGERY L82066 6.6% PRAZE-AN-BEEBLE SURGERY L82068 6.6% TAMAR VALLEY HEALTH L82012 6.6% LAUNCESTON MEDICAL CENTRE L82030 6.6% BODRIGGY HEALTH CENTRE L82036 6.6% PETROC GROUP PRACTICE L82023 6.6% SUNNYSIDE SURGERY L82070 6.5% ALVERTON PRACTICE L82021 6.5% ST AUSTELL HEALTH GROUP Y04957 6.5% WADEBRIDGE & CAMEL ESTUARY PRACTICE L82004 6.5% MANOR SURGERY L82042 6.4% BOTTREAUX SURGERY L82058 6.4% HELSTON MEDICAL CENTRE L82018 6.4% PERRANPORTH SURGERY L82013 6.3% ROSELAND SURGERIES L82048 6.3% RAME GROUP PRACTICE Y00969 6.3% FOWEY RIVER PRACTICE L82035 6.2% CARNON DOWNS SURGERY L82061 6.1% ST KEVERNE HEALTH CENTRE L82057 6.1% PROBUS SURGERY L82045 6.1% CARNEWATER PRACTICE L82009 6.0% SALTASH HEALTH CENTRE L82046 6.0% STENNACK SURGERY Y01922 6.0% ST.AGNES SURGERY L82054 5.8% CHACEWATER HEALTH CENTRE L82015 5.7% ROSMELLYN SURGERY Y01050 5.7% LOSTWITHIEL SURGERY L82039 5.6% LANDER MEDICAL PRACTICE L82001 5.6% FALMOUTH HEALTH CENTRE L82049 5.5% THREE SPIRES MEDICAL PRACTICE L82028 5.4% PORT ISAAC SURGERY L82003 5.4% TRESCOBEAS SURGERY L82052 5.4% QUAY LANE SURGERY L82043 5.3% NARROWCLIFF SURGERY L82029 5.2% MORRAB SURGERY Y01051 5.1% NEWQUAY HEALTH CENTRE Y02517 5.0% NEETSIDE SURGERY Y01127 4.8% ST MARY'S HEALTH CENTRE L82017 4.6% Note: The estimated number of undiagnosed PENRYN SURGERY L82006 4.5% WESTOVER SURGERY L82622 4.1% CARDREW HEALTH CENTRE Y02596 3.2% people with diabetes has been calculated by MILLBROOK SURGERY Y05021 multiplying the estimated prevalence rate to the 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 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 diabetes in NHS Kernow CCG is 9.7% (diagnosed and undiagnosed) NHS Kernow CCG 6.3% 3.4% 12.5% • in addition, there are an estimated 12.5% of people in NHS Kernow CCG who are at increased risk of developing diabetes (i.e. with non- diabetic hyperglycaemia)
• this means that 22.2% of the population in NHS Kernow CCG are estimated to have diabetes, or at high risk of developing of diabetes
Note: Prevalence estimates of non-diabetic England 6.5% 1.9% 11.2% hyperglycaemia were developed using Health Survey for England (HSE) data. Five years of HSE data were combined, 2009- 2013. The estimates take into account the age, ethnic group and estimated body mass index of the population. 0% 5% 10% 15% 20% 25% These estimates were produced using the GP registered population.
46 CVD: Primary Care Intelligence Packs People with diabetes who had eight care processes by CCG 2015/16
• data on care processes and treatment NHS Kernow CCG 56.4% targets are taken from the National Diabetes Audit (NDA) • overall practice participation in the 2015/16 audit was 81.4% in England
• in NHS Kernow CCG, 59 out of 64 practices (92.2%) participated in the NDA. Data is not available for the remaining practices
• 56.4% of people with diabetes (of practices who participated in the audit) had the eight recommended care processes in NHS Kernow CCG, compared to 52.6% in England England 52.6%
0% 10% 20% 30% 40% 50% 60%
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
QUAY LANE SURGERY L82043 84.7% MULLION HEALTH CENTRE L82056 78.1% PENALVERNE SURGERY L82053 78.0% FALMOUTH HEALTH CENTRE L82049 76.8% CHACEWATER HEALTH CENTRE L82015 76.0% FOWEY RIVER PRACTICE L82035 76.0% • achievement - 8 care processes: in STILLMOOR HOUSE L82010 75.2% MENEAGE STREET SURGERY L82059 73.9% HELSTON MEDICAL CENTRE L82018 72.4% practices who provided data via the TRESCOBEAS SURGERY L82052 72.2% ALVERTON PRACTICE L82021 70.2% ST.AGNES SURGERY L82054 70.1% NDA, between 7.5% and 84.7% of PORT VIEW SURGERY L82066 69.4% LOSTWITHIEL SURGERY L82039 67.7% patients received all 8 care processes PERRANPORTH SURGERY L82013 67.4% PRAZE-AN-BEEBLE SURGERY L82068 67.2% SALTASH HEALTH CENTRE L82046 65.2% OLD BRIDGE SURGERY L82022 65.0% STENNACK SURGERY Y01922 64.8% MARAZION SURGERY L82047 64.7% CAPE CORNWALL SURGERY L82038 64.6% • at least 11,401 people did not receive MEVAGISSEY SURGERY L82025 64.2% OAK TREE SURGERY L82016 63.9% MEDICAL CENTRE CAMELFORD (DR GARROD) L82618 63.6% the eight care processes NEWQUAY HEALTH CENTRE Y02517 63.6% ROSEDEAN SURGERY L82050 63.6% LANDER MEDICAL PRACTICE L82001 62.7% ST KEVERNE HEALTH CENTRE L82057 62.6% MORRAB SURGERY Y01051 62.5% PROBUS SURGERY L82045 62.3% BRANNEL SURGERY L82011 61.9% CLAYS PRACTICE L82051 61.6% HARRIS MEMORIAL SURGERY L82620 61.5% WADEBRIDGE & CAMEL ESTUARY PRACTICE L82004 61.1% MIDDLEWAY SURGERY L82026 59.9% SUNNYSIDE SURGERY L82070 59.6% ST MARY'S HEALTH CENTRE L82017 59.3% WESTOVER SURGERY L82622 59.2% NARROWCLIFF SURGERY L82029 59.1% LAUNCESTON MEDICAL CENTRE L82030 56.6% CARNEWATER PRACTICE L82009 55.4% PETROC GROUP PRACTICE L82023 55.2% PENRYN SURGERY L82006 54.8% NEETSIDE SURGERY Y01127 52.0% PORT ISAAC SURGERY L82003 50.6% THREE SPIRES MEDICAL PRACTICE L82028 50.5% CARN TO COAST HEALTH CENTRES L82041 45.9% CLINTON ROAD SURGERY L82024 44.9% ROSMELLYN SURGERY Y01050 39.7% MANOR SURGERY L82042 39.6% ST AUSTELL HEALTH GROUP Y04957 37.7% VEOR SURGERY L82044 35.6% BODRIGGY HEALTH CENTRE L82036 30.0% RAME GROUP PRACTICE Y00969 25.8% PHOENIX SURGERY L82617 24.6% TREVITHICK SURGERY L82014 22.5% MEDICAL CENTRE CAMELFORD (DR NASH) L82007 17.0% ROSELAND SURGERIES L82048 12.6% BOTTREAUX SURGERY L82058 7.5% MILLBROOK SURGERY Y05021 CARDREW HEALTH CENTRE Y02596 CARNON DOWNS SURGERY L82061 PENSILVA HEALTH CENTRE L82037 TAMAR VALLEY HEALTH L82012 STRATTON MEDICAL CENTRE L82008 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
• 33.8% of people with diabetes (of NHS Kernow CCG 33.8% practices who participated in the audit) met the three treatment targets in NHS Kernow CCG, compared to 39.0% in England
England 39.0%
0% 5% 10% 15% 20% 25% 30% 35% 40% 45%
49 CVD: Primary Care Intelligence Packs People with diabetes who met all 3 treatment targets by GP practice, 2015/16
GP practice Average of practices in the CCG who participated in the audit
ST MARY'S HEALTH CENTRE L82017 52.4% OAK TREE SURGERY L82016 48.9% ST KEVERNE HEALTH CENTRE L82057 47.1% CLINTON ROAD SURGERY L82024 45.2% CAPE CORNWALL SURGERY L82038 44.6% MEDICAL CENTRE CAMELFORD (DR GARROD) L82618 44.4% • achievement - 3 treatment targets: in BOTTREAUX SURGERY L82058 43.7% SUNNYSIDE SURGERY L82070 43.0% TRESCOBEAS SURGERY L82052 42.2% practices who provided data via the MULLION HEALTH CENTRE L82056 42.2% NEETSIDE SURGERY Y01127 41.2% FALMOUTH HEALTH CENTRE L82049 41.0% NDA, between 0.0% and 52.4% of MEDICAL CENTRE CAMELFORD (DR NASH) L82007 40.3% WESTOVER SURGERY L82622 38.9% patients achieved all 3 treatment PHOENIX SURGERY L82617 37.8% MEVAGISSEY SURGERY L82025 37.7% LAUNCESTON MEDICAL CENTRE L82030 37.7% targets STENNACK SURGERY Y01922 37.6% OLD BRIDGE SURGERY L82022 37.6% LANDER MEDICAL PRACTICE L82001 37.2% FOWEY RIVER PRACTICE L82035 37.2% • at least 13,868 people did not meet MARAZION SURGERY L82047 36.5% PENALVERNE SURGERY L82053 35.5% CARN TO COAST HEALTH CENTRES L82041 35.5% the three treatment targets LOSTWITHIEL SURGERY L82039 35.4% HARRIS MEMORIAL SURGERY L82620 34.7% THREE SPIRES MEDICAL PRACTICE L82028 34.5% NARROWCLIFF SURGERY L82029 34.2% STILLMOOR HOUSE L82010 34.2% ST.AGNES SURGERY L82054 34.1% ROSEDEAN SURGERY L82050 33.7% WADEBRIDGE & CAMEL ESTUARY PRACTICE L82004 33.4% ALVERTON PRACTICE L82021 33.3% QUAY LANE SURGERY L82043 33.3% MENEAGE STREET SURGERY L82059 32.3% MANOR SURGERY L82042 31.8% SALTASH HEALTH CENTRE L82046 31.6% RAME GROUP PRACTICE Y00969 31.5% TREVITHICK SURGERY L82014 31.0% NEWQUAY HEALTH CENTRE Y02517 30.6% PRAZE-AN-BEEBLE SURGERY L82068 30.6% PENRYN SURGERY L82006 30.6% VEOR SURGERY L82044 30.4% CARNEWATER PRACTICE L82009 29.4% PERRANPORTH SURGERY L82013 28.9% PORT VIEW SURGERY L82066 28.4% ST AUSTELL HEALTH GROUP Y04957 28.0% PROBUS SURGERY L82045 27.7% PORT ISAAC SURGERY L82003 27.5% CLAYS PRACTICE L82051 27.3% HELSTON MEDICAL CENTRE L82018 26.2% ROSMELLYN SURGERY Y01050 26.1% ROSELAND SURGERIES L82048 26.1% MORRAB SURGERY Y01051 25.7% BRANNEL SURGERY L82011 25.3% MIDDLEWAY SURGERY L82026 24.1% PETROC GROUP PRACTICE L82023 23.6% CHACEWATER HEALTH CENTRE L82015 21.7% BODRIGGY HEALTH CENTRE L82036 MILLBROOK SURGERY Y05021 CARDREW HEALTH CENTRE Y02596 CARNON DOWNS SURGERY L82061 PENSILVA HEALTH CENTRE L82037 TAMAR VALLEY HEALTH L82012 STRATTON MEDICAL CENTRE L82008 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
10% 0% -10% -20% -30% -40% -50%
BODRIGGY HEALTH CENTRE 2
CHACEWATER HEALTH CENTRE 51
MIDDLEWAY SURGERY 46 • using the GP cluster method of BRANNEL SURGERY 57 calculating potential gains, if each MORRAB SURGERY 38 practice was to achieve as well as the ROSMELLYN SURGERY 56 upper quartile of its national cluster, then an additional 2,138 people would PETROC GROUP PRACTICE 150 be treated HELSTON MEDICAL CENTRE 8
ROSELAND SURGERIES 28
CLAYS PRACTICE 104
MULLION HEALTH CENTRE 13
SUNNYSIDE SURGERY 7
CLINTON ROAD SURGERY 5
TRESCOBEAS SURGERY 8
BOTTREAUX SURGERY 4
MEDICAL CENTRE CAMELFORD (DR GARROD) 2
CAPE CORNWALL SURGERY 2
ST KEVERNE HEALTH CENTRE
OAK TREE SURGERY
ST MARY'S HEALTH CENTRE 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 Kernow CCG 0.72 • the ratio of those diagnosed with chronic kidney disease versus those expected to have chronic kidney disease is 0.72. This compares to 0.68 for England • this suggests that 72% of people with chronic kidney disease have been diagnosed
Note: This slide compares the prevalence of CKD recorded in QOF in 2015/16 to the expected England 0.68 prevalence of CKD produced by the University of Southampton in 2011. A small number of CCGs 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 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 Gloucestershire CCG 0.98
NHS Northumberland CCG 0.85
NHS Ipswich and East Suffolk CCG 0.78
NHS Dorset CCG 0.74
NHS Kernow CCG 0.72
NHS Cumbria CCG 0.71
NHS East Riding of Yorkshire CCG 0.71
NHS North East Essex CCG 0.66
NHS Somerset CCG 0.64
NHS Coastal West Sussex CCG 0.58
NHS West Hampshire CCG 0.50
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
CARNON DOWNS SURGERY L82061 9.7% CHACEWATER HEALTH CENTRE L82015 9.6% BOTTREAUX SURGERY L82058 9.3% STRATTON MEDICAL CENTRE L82008 8.5% PORT ISAAC SURGERY L82003 8.3% MIDDLEWAY SURGERY L82026 7.5% CAPE CORNWALL SURGERY L82038 7.4% VEOR SURGERY L82044 7.3% • it is estimated that there are 9,393 MULLION HEALTH CENTRE L82056 7.3% PROBUS SURGERY L82045 7.1% TREVITHICK SURGERY L82014 7.1% people with undiagnosed chronic STILLMOOR HOUSE L82010 7.0% MEDICAL CENTRE CAMELFORD (DR NASH) L82007 6.8% NEETSIDE SURGERY Y01127 6.6% kidney disease in NHS Kernow CCG NARROWCLIFF SURGERY L82029 6.6% STENNACK SURGERY Y01922 6.6% • GP practice range of observed CKD: PHOENIX SURGERY L82617 6.4% MENEAGE STREET SURGERY L82059 6.4% CLINTON ROAD SURGERY L82024 6.3% 0.0% to 9.7% FOWEY RIVER PRACTICE L82035 6.3% TRESCOBEAS SURGERY L82052 6.1% ST AUSTELL HEALTH GROUP Y04957 6.0% CARNEWATER PRACTICE L82009 5.9% THREE SPIRES MEDICAL PRACTICE L82028 5.8% FALMOUTH HEALTH CENTRE L82049 5.8% CARN TO COAST HEALTH CENTRES L82041 5.7% QUAY LANE SURGERY L82043 5.7% MANOR SURGERY L82042 5.6% ALVERTON PRACTICE L82021 5.6% PENALVERNE SURGERY L82053 5.5% ST KEVERNE HEALTH CENTRE L82057 5.5% SUNNYSIDE SURGERY L82070 5.5% BRANNEL SURGERY L82011 5.4% OLD BRIDGE SURGERY L82022 5.3% MEVAGISSEY SURGERY L82025 5.3% HELSTON MEDICAL CENTRE L82018 5.3% BODRIGGY HEALTH CENTRE L82036 5.2% LANDER MEDICAL PRACTICE L82001 5.0% MARAZION SURGERY L82047 4.9% MEDICAL CENTRE CAMELFORD (DR GARROD) L82618 4.9% TAMAR VALLEY HEALTH L82012 4.9% PETROC GROUP PRACTICE L82023 4.9% PORT VIEW SURGERY L82066 4.8% PENRYN SURGERY L82006 4.8% WADEBRIDGE & CAMEL ESTUARY PRACTICE L82004 4.8% ROSMELLYN SURGERY Y01050 4.2% WESTOVER SURGERY L82622 4.2% PRAZE-AN-BEEBLE SURGERY L82068 4.2% LAUNCESTON MEDICAL CENTRE L82030 3.9% ST MARY'S HEALTH CENTRE L82017 3.8% PENSILVA HEALTH CENTRE L82037 3.8% NEWQUAY HEALTH CENTRE Y02517 3.7% ROSEDEAN SURGERY L82050 3.5% PERRANPORTH SURGERY L82013 3.4% HARRIS MEMORIAL SURGERY L82620 3.4% SALTASH HEALTH CENTRE L82046 3.3% MORRAB SURGERY Y01051 3.3% Note: CCG estimates for the estimated RAME GROUP PRACTICE Y00969 3.1% LOSTWITHIEL SURGERY L82039 3.0% OAK TREE SURGERY L82016 2.9% number of people with CKD are based on CLAYS PRACTICE L82051 2.9% ST.AGNES SURGERY L82054 2.4% applying a proportion from a resident based ROSELAND SURGERIES L82048 2.4% CARDREW HEALTH CENTRE Y02596 0.6% population estimate to a GP registered MILLBROOK SURGERY Y05021 population. The characteristics of registered 0% 2% 4% 6% 8% 10% 12% 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
• 24,446 people with CKD (diagnosed*) NHS Kernow CCG 72.5% in NHS Kernow CCG • 17,721 (72.5%) people whose blood pressure is <= 140 /85 • 2,617 (10.7%) people who are exceptions • 4,108 (16.8%) additional people whose blood pressure is not <= 140 / 85
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 Northumberland CCG 76.5%
NHS Cumbria CCG 74.4%
NHS Gloucestershire CCG 74.4%
NHS North East Essex CCG 74.1%
NHS Dorset CCG 72.9%
NHS East Riding of Yorkshire CCG 72.7%
NHS Kernow CCG 72.5%
NHS Ipswich and East Suffolk CCG 72.0%
NHS West Hampshire CCG 69.6%
NHS Coastal West Sussex CCG 68.6%
NHS Somerset CCG 67.3%
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
POLKYTH SURGERY Y04694 109 QUAY LANE SURGERY L82043 99 VEOR SURGERY L82044 204 CARDREW HEALTH CENTRE Y02596 10 WHEAL NORTHEY SURGERY L82611 178 CARNON DOWNS SURGERY L82061 161 PETROC GROUP PRACTICE L82023 252 NEWQUAY HEALTH CENTRE Y02517 191 PENSILVA HEALTH CENTRE L82037 58 • in total, including exceptions, there ROSMELLYN SURGERY Y01050 80 CHACEWATER AND DEVORAN SURGERIES L82015 142 PORT VIEW SURGERY L82066 89 are 6,725 people whose blood THE CLAYS PRACTICE L82051 88 PERRANPORTH SURGERY L82013 68 pressure is not <= 140 / 85 MIDDLEWAY SURGERY L82026 126 PENALVERNE SURGERY L82053 66 TREVITHICK SURGERY L82014 83 • GP practice range: 16.1% to 47.0% TRESCOBEAS SURGERY L82052 157 ROSEDEAN HOUSE SURGERY L82050 84 WOODLAND ROAD SURGERY L82040 141 CHURCHFIELD PRACTICE L82618 43 WADEBRIDGE & CAMEL ESTUARY PRACTICE L82004 91 PENRYN SURGERY L82006 245 MILLBROOK SURGERY L82621 19 THE RAME GROUP PRACTICE Y00969 80 PORT ISAAC PRACTICE L82003 183 MORRAB SURGERY Y01051 55 MENEAGE STREET SURGERY L82059 102 NARROWCLIFF SURGERY L82029 186 MEVAGISSEY SURGERY L82025 68 OAK TREE SURGERY L82016 72 BRANNEL SURGERY L82011 62 ST AGNES & MOUNT HAWKE SURGERIES L82054 49 PROBUS & GRAMPOUND SURGERIES L82045 152 WESTOVER SURGERY L82622 78 CLINTON ROAD SURGERY L82024 50 SALTASH HEALTH CENTRE L82046 77 SUNNYSIDE SURGERY L82070 76 HARRIS MEMORIAL & LANNER SURGERIES L82620 41 THE PARK MEDICAL CENTRE L82019 113 PRAZE SURGERY L82068 50 ROSELAND SURGERIES L82048 19 BODRIGGY HEALTH CENTRE L82036 108 LAUNCESTON MEDICAL CENTRE L82030 140 LANDER MEDICAL PRACTICE L82001 167 TAMAR VALLEY HEALTH L82012 151 HOMECROFT SURGERY L82002 89 CAMELFORD MEDICAL CENTRE L82007 39 HELSTON MEDICAL CENTRE L82018 126 OLD BRIDGE SURGERY L82022 101 NEETSIDE SURGERY Y01127 56 CARNEWATER PRACTICE L82009 94 FALMOUTH HEALTH CENTRE L82049 89 STILLMOOR HOUSE MEDICAL PRACTICE L82010 127 FOWEY RIVER PRACTICE L82035 86 MULLION & CONSTANTINE GROUP PRACTICE L82056 68 MARAZION SURGERY L82047 65 LOSTWITHIEL MEDICAL PRACTICE L82039 26 THE STENNACK SURGERY Y01922 141 ISLES OF SCILLY HEALTH CENTRE L82017 15 MANOR SURGERY L82042 114 THREE SPIRES MEDICAL PRACTICE L82028 143 BOTTREAUX SURGERY L82058 78 CAPE CORNWALL SURGERY L82038 61 STRATTON MEDICAL CENTRE L82008 132 POOL HEALTH CENTRE L82041 87 ST KEVERNE HEALTH CENTRE L82057 26 THE ALVERTON PRACTICE L82021 51 PHOENIX SURGERY L82617 48 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
5% 0% -5% -10% -15% -20% -25% -30%
QUAY LANE SURGERY 59
CARDREW HEALTH CENTRE 6
VEOR SURGERY 113 • using the GP cluster method of CARNON DOWNS SURGERY 75 calculating potential gains, if each ROSMELLYN SURGERY 41 practice was to achieve as well as the PETROC GROUP PRACTICE 115 upper quartile of its national cluster, then an additional 1,655 people would PENSILVA HEALTH CENTRE 28 be treated CHACEWATER AND DEVORAN SURGERIES 67
PORT VIEW SURGERY 42
NEWQUAY HEALTH CENTRE 83
STILLMOOR HOUSE MEDICAL PRACTICE 9
FALMOUTH HEALTH CENTRE 2
THE ALVERTON PRACTICE
PHOENIX SURGERY
THE STENNACK SURGERY
POOL HEALTH CENTRE
MANOR SURGERY
THREE SPIRES MEDICAL PRACTICE
STRATTON MEDICAL CENTRE
ST KEVERNE HEALTH CENTRE 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
• 24,461 people with CKD (diagnosed*) NHS Kernow CCG 77.0% in NHS Kernow CCG • 18,836 (77%) people who have a record of urine albumin:creatinine ratio test • 1,636 (6.7%) people who are exceptions • 3,989 (16.3%) additional people who have no record of urine albumin:creatinine ratio test
England 75.4%
*Using the QOF clinical indicator CKD004 denominator plus exceptions. Note: as the CKD004 indicator was removed from the QOF in 15/16 this is historic data 0% 20% 40% 60% 80% 100% taken from the 2014/15 QOF.
61 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose notes have a record of a urine albumin: creatinine ratio test in the preceding 12 months by CCG, 2014/15 Comparison with demographically similar CCGs Recorded Not recorded Exceptions reported
NHS Northumberland CCG 78.9%
NHS Kernow CCG 77.0%
NHS Cumbria CCG 76.9%
NHS East Riding of Yorkshire CCG 74.7%
NHS Gloucestershire CCG 74.1%
NHS North East Essex CCG 73.8%
NHS Dorset CCG 73.1%
NHS Ipswich and East Suffolk CCG 71.5%
NHS West Hampshire CCG 71.2%
NHS Coastal West Sussex CCG 67.4%
NHS Somerset CCG 61.5%
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
PENSILVA HEALTH CENTRE L82037 85 THE RAME GROUP PRACTICE Y00969 107 BODRIGGY HEALTH CENTRE L82036 165 TREVITHICK SURGERY L82014 95 PHOENIX SURGERY L82617 105 PENRYN SURGERY L82006 272 CARNEWATER PRACTICE L82009 145 LANDER MEDICAL PRACTICE L82001 229 CARDREW HEALTH CENTRE Y02596 8 • in total, including exceptions, there MEVAGISSEY SURGERY L82025 75 VEOR SURGERY L82044 158 PORT ISAAC PRACTICE L82003 184 are 5,625 people who have no record PROBUS & GRAMPOUND SURGERIES L82045 154 WOODLAND ROAD SURGERY L82040 122 of urine albumin:creatinine ratio test WHEAL NORTHEY SURGERY L82611 122 LOSTWITHIEL MEDICAL PRACTICE L82039 33 POLKYTH SURGERY Y04694 66 • GP practice range: 10.6% to 51.2% ROSELAND SURGERIES L82048 20 NEWQUAY HEALTH CENTRE Y02517 140 MIDDLEWAY SURGERY L82026 101 PRAZE SURGERY L82068 50 THE STENNACK SURGERY Y01922 170 CAMELFORD MEDICAL CENTRE L82007 39 THREE SPIRES MEDICAL PRACTICE L82028 166 PETROC GROUP PRACTICE L82023 159 NARROWCLIFF SURGERY L82029 149 OAK TREE SURGERY L82016 56 QUAY LANE SURGERY L82043 47 WADEBRIDGE & CAMEL ESTUARY PRACTICE L82004 61 STRATTON MEDICAL CENTRE L82008 140 SUNNYSIDE SURGERY L82070 59 MANOR SURGERY L82042 115 THE PARK MEDICAL CENTRE L82019 89 FALMOUTH HEALTH CENTRE L82049 82 LAUNCESTON MEDICAL CENTRE L82030 115 CHACEWATER AND DEVORAN SURGERIES L82015 83 ROSEDEAN HOUSE SURGERY L82050 53 TRESCOBEAS SURGERY L82052 97 THE ALVERTON PRACTICE L82021 56 POOL HEALTH CENTRE L82041 87 PORT VIEW SURGERY L82066 50 MULLION & CONSTANTINE GROUP PRACTICE L82056 60 HOMECROFT SURGERY L82002 69 MENEAGE STREET SURGERY L82059 64 CHURCHFIELD PRACTICE L82618 25 CLINTON ROAD SURGERY L82024 33 PERRANPORTH SURGERY L82013 38 PENALVERNE SURGERY L82053 37 OLD BRIDGE SURGERY L82022 80 NEETSIDE SURGERY Y01127 44 CARNON DOWNS SURGERY L82061 73 BOTTREAUX SURGERY L82058 67 MORRAB SURGERY Y01051 32 CAPE CORNWALL SURGERY L82038 53 HELSTON MEDICAL CENTRE L82018 88 ROSMELLYN SURGERY Y01050 38 TAMAR VALLEY HEALTH L82012 102 ST KEVERNE HEALTH CENTRE L82057 23 HARRIS MEMORIAL & LANNER SURGERIES L82620 25 STILLMOOR HOUSE MEDICAL PRACTICE L82010 92 WESTOVER SURGERY L82622 43 ST AGNES & MOUNT HAWKE SURGERIES L82054 26 THE CLAYS PRACTICE L82051 38 SALTASH HEALTH CENTRE L82046 38 MILLBROOK SURGERY L82621 8 FOWEY RIVER PRACTICE L82035 51 ISLES OF SCILLY HEALTH CENTRE L82017 9 MARAZION SURGERY L82047 37 BRANNEL SURGERY L82011 23 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 Kernow CCG 1.03% • prevalence of 1.03% in NHS Kernow CCG compared to 0.76% in England
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 Cumbria CCG 1.13%
NHS Northumberland CCG 1.07%
NHS Kernow CCG 1.03%
NHS North East Essex CCG 0.94%
NHS Dorset CCG 0.91%
NHS Somerset CCG 0.89%
NHS East Riding of Yorkshire CCG 0.88%
NHS Coastal West Sussex CCG 0.88%
NHS Ipswich and East Suffolk CCG 0.87%
NHS West Hampshire CCG 0.78%
NHS Gloucestershire CCG 0.77%
0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2%
67 CVD: Primary Care Intelligence Packs Heart failure prevalence by GP practice
GP practice CCG
MENEAGE STREET SURGERY L82059 4.4% ROSELAND SURGERIES L82048 1.8% MULLION HEALTH CENTRE L82056 1.7% MARAZION SURGERY L82047 1.7% BODRIGGY HEALTH CENTRE L82036 1.6% FALMOUTH HEALTH CENTRE L82049 1.5% ST KEVERNE HEALTH CENTRE L82057 1.4% MANOR SURGERY L82042 1.4% • 5,788 people with diagnosed heart VEOR SURGERY L82044 1.4% ST AUSTELL HEALTH GROUP Y04957 1.4% ALVERTON PRACTICE L82021 1.3% failure in NHS Kernow CCG OLD BRIDGE SURGERY L82022 1.3% CHACEWATER HEALTH CENTRE L82015 1.3% MEVAGISSEY SURGERY L82025 1.3% • GP practice range: 0.0% to 4.4% PENALVERNE SURGERY L82053 1.2% BOTTREAUX SURGERY L82058 1.2% NARROWCLIFF SURGERY L82029 1.1% PRAZE-AN-BEEBLE SURGERY L82068 1.1% TREVITHICK SURGERY L82014 1.1% TAMAR VALLEY HEALTH L82012 1.1% PHOENIX SURGERY L82617 1.1% SUNNYSIDE SURGERY L82070 1.1% PORT ISAAC SURGERY L82003 1.1% WESTOVER SURGERY L82622 1.0% MIDDLEWAY SURGERY L82026 1.0% TRESCOBEAS SURGERY L82052 1.0% CAPE CORNWALL SURGERY L82038 1.0% PROBUS SURGERY L82045 1.0% PENRYN SURGERY L82006 1.0% CARN TO COAST HEALTH CENTRES L82041 1.0% PERRANPORTH SURGERY L82013 1.0% CARNEWATER PRACTICE L82009 0.9% CLINTON ROAD SURGERY L82024 0.9% OAK TREE SURGERY L82016 0.9% SALTASH HEALTH CENTRE L82046 0.9% PENSILVA HEALTH CENTRE L82037 0.9% CARNON DOWNS SURGERY L82061 0.9% ST.AGNES SURGERY L82054 0.9% HARRIS MEMORIAL SURGERY L82620 0.9% STILLMOOR HOUSE L82010 0.9% STRATTON MEDICAL CENTRE L82008 0.8% STENNACK SURGERY Y01922 0.8% ROSEDEAN SURGERY L82050 0.8% LANDER MEDICAL PRACTICE L82001 0.8% FOWEY RIVER PRACTICE L82035 0.8% BRANNEL SURGERY L82011 0.8% NEETSIDE SURGERY Y01127 0.8% THREE SPIRES MEDICAL PRACTICE L82028 0.8% QUAY LANE SURGERY L82043 0.8% PETROC GROUP PRACTICE L82023 0.8% ROSMELLYN SURGERY Y01050 0.8% WADEBRIDGE & CAMEL ESTUARY PRACTICE L82004 0.8% NEWQUAY HEALTH CENTRE Y02517 0.7% RAME GROUP PRACTICE Y00969 0.7% LAUNCESTON MEDICAL CENTRE L82030 0.7% CLAYS PRACTICE L82051 0.7% HELSTON MEDICAL CENTRE L82018 0.7% ST MARY'S HEALTH CENTRE L82017 0.7% PORT VIEW SURGERY L82066 0.7% MEDICAL CENTRE CAMELFORD (DR GARROD) L82618 0.7% MORRAB SURGERY Y01051 0.7% MEDICAL CENTRE CAMELFORD (DR NASH) L82007 0.7% LOSTWITHIEL SURGERY L82039 0.5% CARDREW HEALTH CENTRE Y02596 0.1% MILLBROOK SURGERY Y05021 0.0% 0.5% 1.0% 1.5% 2.0% 2.5% 3.0% 3.5% 4.0% 4.5% 5.0%
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
• 2,579 people with heart failure* with NHS Kernow CCG 81.0% LVSD in NHS Kernow CCG • 2,088 (81%) people treated with ACE- I or ARB • 483 (18.7%) people who are exceptions • 8 (0.3%) additional people who are not treated with ACE-I or ARB
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 East Riding of Yorkshire CCG 87.0%
NHS Cumbria CCG 86.5%
NHS Gloucestershire CCG 85.4%
NHS Northumberland CCG 85.1%
NHS West Hampshire CCG 84.0%
NHS North East Essex CCG 83.4%
NHS Ipswich and East Suffolk CCG 81.9%
NHS Kernow CCG 81.0%
NHS Dorset CCG 80.8%
NHS Somerset CCG 80.1%
NHS Coastal West Sussex CCG 79.4%
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
RAME GROUP PRACTICE Y00969 3 BOTTREAUX SURGERY L82058 2 ALVERTON PRACTICE L82021 9 OLD BRIDGE SURGERY L82022 23 CLINTON ROAD SURGERY L82024 7 PENSILVA HEALTH CENTRE L82037 5 ROSEDEAN SURGERY L82050 3 ST KEVERNE HEALTH CENTRE L82057 6 • in total, including exceptions, there PROBUS SURGERY L82045 9 TREVITHICK SURGERY L82014 4 ST.AGNES SURGERY L82054 9 are 491 people who are not treated PORT VIEW SURGERY L82066 2 PERRANPORTH SURGERY L82013 5 BRANNEL SURGERY L82011 4 with ACE-I or ARB NEETSIDE SURGERY Y01127 7 MANOR SURGERY L82042 25 • GP practice range: 0.0% to 50.0% SALTASH HEALTH CENTRE L82046 17 MENEAGE STREET SURGERY L82059 29 SUNNYSIDE SURGERY L82070 10 VEOR SURGERY L82044 12 BODRIGGY HEALTH CENTRE L82036 23 ST MARY'S HEALTH CENTRE L82017 3 PENRYN SURGERY L82006 22 PHOENIX SURGERY L82617 5 MARAZION SURGERY L82047 12 ROSELAND SURGERIES L82048 3 CAPE CORNWALL SURGERY L82038 5 PORT ISAAC SURGERY L82003 13 STENNACK SURGERY Y01922 12 MIDDLEWAY SURGERY L82026 8 CARNEWATER PRACTICE L82009 6 ROSMELLYN SURGERY Y01050 4 FALMOUTH HEALTH CENTRE L82049 16 CARNON DOWNS SURGERY L82061 5 WESTOVER SURGERY L82622 7 PENALVERNE SURGERY L82053 8 MEVAGISSEY SURGERY L82025 6 NEWQUAY HEALTH CENTRE Y02517 8 PRAZE-AN-BEEBLE SURGERY L82068 3 TRESCOBEAS SURGERY L82052 7 STRATTON MEDICAL CENTRE L82008 3 FOWEY RIVER PRACTICE L82035 4 CARN TO COAST HEALTH CENTRES L82041 15 THREE SPIRES MEDICAL PRACTICE L82028 7 LANDER MEDICAL PRACTICE L82001 12 MULLION HEALTH CENTRE L82056 7 ST AUSTELL HEALTH GROUP Y04957 29 CHACEWATER HEALTH CENTRE L82015 7 STILLMOOR HOUSE L82010 2 HELSTON MEDICAL CENTRE L82018 2 CLAYS PRACTICE L82051 5 TAMAR VALLEY HEALTH L82012 8 NARROWCLIFF SURGERY L82029 13 PETROC GROUP PRACTICE L82023 5 MORRAB SURGERY Y01051 3 HARRIS MEMORIAL SURGERY L82620 1 WADEBRIDGE & CAMEL ESTUARY PRACTICE L82004 1 MEDICAL CENTRE CAMELFORD (DR NASH) L82007 OAK TREE SURGERY L82016 LAUNCESTON MEDICAL CENTRE L82030 LOSTWITHIEL SURGERY L82039 QUAY LANE SURGERY L82043 MEDICAL CENTRE CAMELFORD (DR GARROD) L82618 MILLBROOK SURGERY Y05021 CARDREW HEALTH CENTRE Y02596 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
• 2,086 people with heart failure* with NHS Kernow CCG 73.4% LVSD treated with ACE-I/ARB in NHS Kernow CCG • 1,532 (73.4%) people treated with ACE-I/ARB and BB • 397 (19%) people who are exceptions • 157 (7.5%) additional people who are not treated with ACE-I/ARB and BB
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 East Riding of Yorkshire CCG 82.2%
NHS Northumberland CCG 78.8%
NHS Cumbria CCG 77.4%
NHS West Hampshire CCG 77.4%
NHS Ipswich and East Suffolk CCG 77.4%
NHS North East Essex CCG 77.1%
NHS Dorset CCG 76.5%
NHS Gloucestershire CCG 75.9%
NHS Coastal West Sussex CCG 73.8%
NHS Kernow CCG 73.4%
NHS Somerset CCG 72.5%
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
TREVITHICK SURGERY L82014 6 QUAY LANE SURGERY L82043 2 MEDICAL CENTRE CAMELFORD (DR GARROD) L82618 2 NEETSIDE SURGERY Y01127 9 CAPE CORNWALL SURGERY L82038 8 BRANNEL SURGERY L82011 5 CARNON DOWNS SURGERY L82061 9 MIDDLEWAY SURGERY L82026 12 • in total, including exceptions, there PETROC GROUP PRACTICE L82023 14 MENEAGE STREET SURGERY L82059 31 LOSTWITHIEL SURGERY L82039 1 are 554 people who are not treated VEOR SURGERY L82044 13 ROSEDEAN SURGERY L82050 2 WESTOVER SURGERY L82622 11 with ACE-I or ARB RAME GROUP PRACTICE Y00969 1 BODRIGGY HEALTH CENTRE L82036 25 • GP practice range: 0.0% to 66.7% PENRYN SURGERY L82006 24 PERRANPORTH SURGERY L82013 4 ST KEVERNE HEALTH CENTRE L82057 4 WADEBRIDGE & CAMEL ESTUARY PRACTICE L82004 7 ST MARY'S HEALTH CENTRE L82017 3 PENSILVA HEALTH CENTRE L82037 3 NARROWCLIFF SURGERY L82029 29 CLINTON ROAD SURGERY L82024 4 MEVAGISSEY SURGERY L82025 8 FALMOUTH HEALTH CENTRE L82049 19 FOWEY RIVER PRACTICE L82035 6 ROSELAND SURGERIES L82048 3 HARRIS MEMORIAL SURGERY L82620 6 CHACEWATER HEALTH CENTRE L82015 14 THREE SPIRES MEDICAL PRACTICE L82028 11 STILLMOOR HOUSE L82010 4 HELSTON MEDICAL CENTRE L82018 4 STENNACK SURGERY Y01922 13 PENALVERNE SURGERY L82053 10 TAMAR VALLEY HEALTH L82012 16 ST AUSTELL HEALTH GROUP Y04957 46 CARN TO COAST HEALTH CENTRES L82041 22 STRATTON MEDICAL CENTRE L82008 4 SALTASH HEALTH CENTRE L82046 13 TRESCOBEAS SURGERY L82052 9 MORRAB SURGERY Y01051 6 OLD BRIDGE SURGERY L82022 11 LANDER MEDICAL PRACTICE L82001 16 MULLION HEALTH CENTRE L82056 9 MARAZION SURGERY L82047 9 PORT ISAAC SURGERY L82003 11 CARNEWATER PRACTICE L82009 5 PROBUS SURGERY L82045 4 MANOR SURGERY L82042 15 ALVERTON PRACTICE L82021 3 ST.AGNES SURGERY L82054 4 PHOENIX SURGERY L82617 3 ROSMELLYN SURGERY Y01050 3 MEDICAL CENTRE CAMELFORD (DR NASH) L82007 1 LAUNCESTON MEDICAL CENTRE L82030 1 CLAYS PRACTICE L82051 6 SUNNYSIDE SURGERY L82070 5 PRAZE-AN-BEEBLE SURGERY L82068 2 NEWQUAY HEALTH CENTRE Y02517 3 OAK TREE SURGERY L82016 BOTTREAUX SURGERY L82058 PORT VIEW SURGERY L82066 MILLBROOK SURGERY Y05021 CARDREW HEALTH CENTRE Y02596 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
• 22,457 people with coronary heart NHS Kernow CCG 88.5% disease* in NHS Kernow CCG • 19,882 (88.5%) people whose blood pressure <= 150 / 90 • 1,080 (4.8%) people who are exceptions • 1,495 (6.7%) additional people whose blood pressure is not <= 150 / 90
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 Cumbria CCG 89.2%
NHS Northumberland CCG 88.8%
NHS Kernow CCG 88.5%
NHS Gloucestershire CCG 88.2%
NHS North East Essex CCG 88.2%
NHS Ipswich and East Suffolk CCG 87.7%
NHS Dorset CCG 87.1%
NHS East Riding of Yorkshire CCG 87.0%
NHS West Hampshire CCG 86.8%
NHS Coastal West Sussex CCG 84.3%
NHS Somerset CCG 82.4%
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
CARDREW HEALTH CENTRE Y02596 5 ST AUSTELL HEALTH GROUP Y04957 309 ROSELAND SURGERIES L82048 39 PENRYN SURGERY L82006 114 ST KEVERNE HEALTH CENTRE L82057 30 VEOR SURGERY L82044 97 TREVITHICK SURGERY L82014 40 ROSMELLYN SURGERY Y01050 38 • in total, including exceptions, there PORT VIEW SURGERY L82066 47 WADEBRIDGE & CAMEL ESTUARY PRACTICE L82004 55 MIDDLEWAY SURGERY L82026 38 are 2,575 people whose blood PETROC GROUP PRACTICE L82023 101 CHACEWATER HEALTH CENTRE L82015 39 BODRIGGY HEALTH CENTRE L82036 62 pressure is not <= 150 / 90 PRAZE-AN-BEEBLE SURGERY L82068 31 PERRANPORTH SURGERY L82013 37 • GP practice range: 3.9% to 31.3% ST.AGNES SURGERY L82054 38 RAME GROUP PRACTICE Y00969 45 ROSEDEAN SURGERY L82050 40 NEETSIDE SURGERY Y01127 22 NARROWCLIFF SURGERY L82029 54 MORRAB SURGERY Y01051 26 SALTASH HEALTH CENTRE L82046 50 ST MARY'S HEALTH CENTRE L82017 8 CARNON DOWNS SURGERY L82061 30 CARNEWATER PRACTICE L82009 46 MANOR SURGERY L82042 69 CLAYS PRACTICE L82051 41 MARAZION SURGERY L82047 42 BRANNEL SURGERY L82011 16 PROBUS SURGERY L82045 34 MENEAGE STREET SURGERY L82059 23 PORT ISAAC SURGERY L82003 30 LANDER MEDICAL PRACTICE L82001 49 THREE SPIRES MEDICAL PRACTICE L82028 53 TRESCOBEAS SURGERY L82052 35 STRATTON MEDICAL CENTRE L82008 45 HELSTON MEDICAL CENTRE L82018 42 CAPE CORNWALL SURGERY L82038 20 OLD BRIDGE SURGERY L82022 47 CARN TO COAST HEALTH CENTRES L82041 61 LAUNCESTON MEDICAL CENTRE L82030 55 FALMOUTH HEALTH CENTRE L82049 29 MEVAGISSEY SURGERY L82025 20 FOWEY RIVER PRACTICE L82035 27 PENSILVA HEALTH CENTRE L82037 17 PENALVERNE SURGERY L82053 21 CLINTON ROAD SURGERY L82024 16 STENNACK SURGERY Y01922 45 QUAY LANE SURGERY L82043 12 MEDICAL CENTRE CAMELFORD (DR NASH) L82007 8 TAMAR VALLEY HEALTH L82012 53 BOTTREAUX SURGERY L82058 15 STILLMOOR HOUSE L82010 28 LOSTWITHIEL SURGERY L82039 10 SUNNYSIDE SURGERY L82070 18 MULLION HEALTH CENTRE L82056 28 NEWQUAY HEALTH CENTRE Y02517 33 MEDICAL CENTRE CAMELFORD (DR GARROD) L82618 9 PHOENIX SURGERY L82617 14 OAK TREE SURGERY L82016 26 ALVERTON PRACTICE L82021 18 HARRIS MEMORIAL SURGERY L82620 15 WESTOVER SURGERY L82622 10 MILLBROOK SURGERY Y05021 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% -30%
CARDREW HEALTH CENTRE 4
VEOR SURGERY 66
ROSELAND SURGERIES 24 • using the GP cluster method of ST KEVERNE HEALTH CENTRE 19 calculating potential gains, if each TREVITHICK SURGERY 26 practice was to achieve as well as the PENRYN SURGERY 65 upper quartile of its national cluster, then an additional 647 people would ROSMELLYN SURGERY 23 be treated PORT VIEW SURGERY 27
WADEBRIDGE & CAMEL ESTUARY PRACTICE 30
MIDDLEWAY SURGERY 20
STENNACK SURGERY
LAUNCESTON MEDICAL CENTRE
PHOENIX SURGERY
TAMAR VALLEY HEALTH
ALVERTON PRACTICE
STILLMOOR HOUSE
NEWQUAY HEALTH CENTRE
HARRIS MEMORIAL SURGERY
OAK TREE SURGERY
WESTOVER SURGERY Details of this methodology are available on slide 9. Click here to view them.
78 CVD: Primary Care Intelligence Packs Percentage of patients with CHD with a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken by CCG Comparison with CCGs in the STP Optimal management No treatment Exceptions reported
• 22,458 people with coronary heart NHS Kernow CCG 92.6% disease* in NHS Kernow CCG • 20,791 (92.6%) people who are taking aspirin, an alternative anti- platelet therapy, or an anti-coagulant • 967 (4.3%) people who are exceptions • 700 (3.1%) additional people who are not taking aspirin, an alternative anti- platelet therapy, or an anti-coagulant
England 91.8%
0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator CHD005 denominator plus exceptions
79 CVD: Primary Care Intelligence Packs Percentage of patients with CHD with a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken by CCG Comparison with demographically similar CCGs Optimal management No treatment Exceptions reported
NHS Kernow CCG 92.6%
NHS West Hampshire CCG 92.6%
NHS Northumberland CCG 92.2%
NHS Cumbria CCG 91.9%
NHS Dorset CCG 91.6%
NHS Gloucestershire CCG 91.5%
NHS East Riding of Yorkshire CCG 90.6%
NHS Ipswich and East Suffolk CCG 90.5%
NHS North East Essex CCG 90.4%
NHS Coastal West Sussex CCG 89.8%
NHS Somerset CCG 88.9%
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
CARDREW HEALTH CENTRE Y02596 3 LAUNCESTON MEDICAL CENTRE L82030 85 QUAY LANE SURGERY L82043 21 ST AUSTELL HEALTH GROUP Y04957 167 LOSTWITHIEL SURGERY L82039 18 MEVAGISSEY SURGERY L82025 28 PRAZE-AN-BEEBLE SURGERY L82068 27 TREVITHICK SURGERY L82014 23 • in total, including exceptions, there PENRYN SURGERY L82006 56 BODRIGGY HEALTH CENTRE L82036 46 RAME GROUP PRACTICE Y00969 36 are 1,667 people are not taking MEDICAL CENTRE CAMELFORD (DR GARROD) L82618 14 PORT ISAAC SURGERY L82003 29 PENSILVA HEALTH CENTRE L82037 19 aspirin, an alternative anti-platelet ROSMELLYN SURGERY Y01050 20 HELSTON MEDICAL CENTRE L82018 41 therapy, or an anti-coagulant SALTASH HEALTH CENTRE L82046 38 VEOR SURGERY L82044 37 HARRIS MEMORIAL SURGERY L82620 23 • GP practice range: 1.9% to 18.8% SUNNYSIDE SURGERY L82070 21 MANOR SURGERY L82042 50 ST.AGNES SURGERY L82054 23 STENNACK SURGERY Y01922 43 ST KEVERNE HEALTH CENTRE L82057 10 STRATTON MEDICAL CENTRE L82008 34 WADEBRIDGE & CAMEL ESTUARY PRACTICE L82004 25 PETROC GROUP PRACTICE L82023 47 PENALVERNE SURGERY L82053 18 MULLION HEALTH CENTRE L82056 29 ST MARY'S HEALTH CENTRE L82017 5 CHACEWATER HEALTH CENTRE L82015 18 ROSEDEAN SURGERY L82050 22 CARNON DOWNS SURGERY L82061 18 FOWEY RIVER PRACTICE L82035 21 CARN TO COAST HEALTH CENTRES L82041 44 ROSELAND SURGERIES L82048 11 MENEAGE STREET SURGERY L82059 14 OLD BRIDGE SURGERY L82022 33 NEWQUAY HEALTH CENTRE Y02517 30 PORT VIEW SURGERY L82066 17 TAMAR VALLEY HEALTH L82012 43 MIDDLEWAY SURGERY L82026 15 WESTOVER SURGERY L82622 15 PERRANPORTH SURGERY L82013 16 FALMOUTH HEALTH CENTRE L82049 19 NARROWCLIFF SURGERY L82029 25 PROBUS SURGERY L82045 18 THREE SPIRES MEDICAL PRACTICE L82028 30 BOTTREAUX SURGERY L82058 12 CARNEWATER PRACTICE L82009 23 MORRAB SURGERY Y01051 12 LANDER MEDICAL PRACTICE L82001 26 CLAYS PRACTICE L82051 20 ALVERTON PRACTICE L82021 17 STILLMOOR HOUSE L82010 21 MARAZION SURGERY L82047 20 TRESCOBEAS SURGERY L82052 18 CLINTON ROAD SURGERY L82024 10 MEDICAL CENTRE CAMELFORD (DR NASH) L82007 5 NEETSIDE SURGERY Y01127 8 CAPE CORNWALL SURGERY L82038 9 PHOENIX SURGERY L82617 9 BRANNEL SURGERY L82011 4 OAK TREE SURGERY L82016 8 MILLBROOK SURGERY Y05021 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 Kernow CCG England 900
800 • in NHS Kernow CCG, the hospital admission rate for coronary heart 700 disease in 2015/16 was 614.3 (3,931) compared to 527.9 for England
600
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 Kernow CCG England 300
• in NHS Kernow CCG, the hospital 250 admission rate for stroke in 2015/16 was 228.6 (1,476) compared to 172.8 for England
200
150
100 Age standardised standardised Age (per rate 100,000)
50
0 2002/032003/042004/052005/062006/072007/082008/092009/102010/112011/122012/132013/142014/152015/16 Source: Hospital Episode Statistics (HES), 2002/03 - 2015/16, Copyright © 2017, Re‐used with the permission of NHS Digital. All rights reserved
84 CVD: Primary Care Intelligence Packs Additional risk of complications for people with diabetes, three year follow up, 2013/14
NHS Kernow CCG England
115.0% Angina 136.8% • The risk of a stroke was 73.5% higher and the risk of a heart attack was 105.2% 105.2% higher compared to people Heart Attack 108.6% without diabetes. The risk of a major amputation was 353.1% higher. 123.8% Heart failure 150.0%
73.5% Stroke 81.3%
353.1% Major amputation 445.8%
571.9% Minor amputation 753.5%
196.1% 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 Kernow CCG England 90
80 • in NHS Kernow CCG, the early mortality rate for coronary heart 70 disease in 2013-15 was 37.4, 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 Kernow CCG England 30
• in NHS Kernow CCG, the early 25 mortality rate for stroke in 2013-15 was 14.3, 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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