CVD: Primary Care Intelligence Packs NHS Warrington 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 Warrington CCG are: NHS Redditch and Bromsgrove CCG NHS Warwickshire North CCG NHS Chorley and South Ribble CCG NHS Barnsley CCG NHS Telford and Wrekin CCG NHS South Cheshire CCG NHS Wigan Borough CCG NHS South East Staffordshire and Seisdon Peninsula CCG NHS Hartlepool and Stockton-on-Tees CCG NHS Cannock Chase 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 Barnsley CCG 21.6%

NHS Telford and Wrekin CCG 20.1% • prevalence of 16.7% in NHS Warrington CCG NHS Hartlepool and Stockton-on-Tees CCG 19.3%

NHS Wigan Borough CCG 19.0%

NHS Warwickshire North CCG 18.7%

NHS Cannock Chase CCG 18.2%

NHS Chorley and South Ribble CCG 18.0%

NHS Redditch and Bromsgrove CCG 17.2% Note: It has been found that the proportion of patients recorded as smokers correlates well NHS South Cheshire CCG 16.9% with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, NHS Warrington CCG 16.7% http://bmjopen.bmj.com/content/4/7/e005217.abs tract

NHS South East Staffordshire and Seisdon Peninsula CCG 16.3% Definition: denominator of QOF clinical indicator SMOKE004 ( number of patients 15+ who are 0% 5% 10% 15% 20% 25% recorded as current smokers) divided by GP practice’s estimated number of patients 15+

13 CVD: Primary Care Intelligence Packs Estimated smoking prevalence (QOF) by GP practice

GP Practice CCG

4 SEASONS MEDICAL CENTRE N81645 29.7%

THE ERIC MOORE PARTNERSHIP N81628 27.6% COCKHEDGE MEDICAL CENTRE N81637 27.3% • 27,790 people who are recorded as LATCHFORD MEDICAL CENTRE N81065 26.7% smokers in NHS Warrington CCG FEARNHEAD CROSS MED.CTR. N81048 22.7% • GP practice range: 7.7% to 29.7% FOLLY LANE MEDICAL CENTRE N81056 21.7%

DALLAM LANE MEDICAL CENTRE N81097 21.1%

PARKVIEW MEDICAL CENTRE N81083 20.5%

CAUSEWAY MEDICAL CENTRE N81028 20.2%

MANCHESTER ROAD SURGERY N81107 19.8%

GUARDIAN STREET MED/CTR N81012 19.7%

FAIRFIELD SURGERY Y01108 18.9%

BIRCHWOOD MEDICAL CENTRE N81114 18.0%

HELSBY STREET MED/CTR N81041 17.9%

SPRINGFIELDS MEDICAL CENTRE N81036 17.6%

GREENBANK SURGERY N81089 17.1%

PADGATE MEDICAL CENTRE N81109 16.5%

HOLES LANE MEDICAL CENTRE N81007 16.5%

CULCHETH MEDICAL CENTRE N81059 12.3%

WESTBROOK MEDICAL CENTRE N81122 10.6% PENKETH HEALTH CENTRE N81020 10.5% Note: This method is thought to be a reasonably STOCKTON HEATH MED.CENTRE N81075 10.0% robust method in estimating smoking prevalence BROOKFIELD SURGERY N81014 9.2% for the majority of GP practices. However,

STRETTON MEDICAL CENTRE N81623 8.4% caution is advised for extreme estimates of smoking prevalence and those with high THE LAKESIDE SURGERY N81108 7.7% numbers of smoking status not recorded and 0% 5% 10% 15% 20% 25% 30% 35% exceptions.

14 CVD: Primary Care Intelligence Packs Hypertension

15 CVD: Primary Care Intelligence Packs Hypertension

The Missing Millions On average, each CCG in England has 26,000 residents with The Global Burden of Disease undiagnosed hypertension – these individuals are unaware of Study confirmed high blood pressure as their increased cardiovascular risk and are untreated. a leading cause of premature death and disability What questions should we ask in our CCG? 1. for each indicator how wide is the variation in achievement and exception reporting? 2. how many people would benefit if all practices performed High blood pressure is common and costly as well as the best? • it affects around a quarter of all adults 3. how can we support practices who are average or below • the NHS costs of hypertension are around £2bn average to perform as well as the best in: • social costs are probably considerably higher • detection of hypertension • management of hypertension What do we know? • at least half of all heart attacks and strokes are caused by high blood pressure and it is a major risk What might help? factor for chronic kidney disease and cognitive decline • support practices to share audit data and systematically • treatment is very effective – every 10mmHg reduction identify gaps and opportunities for improved detection and in systolic blood pressure lowers risk of heart attack management of hypertension and stroke by 20% • work with practices and local authorities to maximise • despite this 4 out of 10 adults with hypertension, over uptake and follow up in the NHS Health Check 5 and a half million people in England, remain • support access to self-test BP stations in waiting rooms undiagnosed and to ambulatory blood pressure monitoring. • and even when the condition is identified, treatment is • commission community pharmacists to offer blood often suboptimal, with blood pressure poorly pressure measurement, diagnosis and management controlled in about 1 out of 3 individuals support, including support for adherence to medication

16 CVD: Primary Care Intelligence Packs Hypertension observed prevalence compared with expected prevalence by CCG Comparison with CCGs in the STP

NHS St Helens CCG 0.64

NHS South Sefton CCG 0.63

NHS Knowsley CCG 0.61 • the ratio of those diagnosed with hypertension versus those expected NHS Vale Royal CCG 0.61 to have hypertension is 0.59. This compares to 0.59 for England NHS South Cheshire CCG 0.61 • this suggests that 59% of people with hypertension have been diagnosed NHS Halton CCG 0.61

NHS Wirral CCG 0.60

NHS Southport And Formby CCG 0.60

NHS Eastern Cheshire CCG 0.59

NHS Warrington CCG 0.59

NHS West Cheshire CCG 0.59

NHS Liverpool CCG 0.58

Note: this slide shows Hypertension prevalence estimates created using data from QOF England 0.59 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 Cannock Chase CCG 0.62

NHS Warwickshire North CCG 0.62

NHS Wigan Borough CCG 0.61

NHS Hartlepool and Stockton-on-Tees CCG 0.61

NHS South Cheshire CCG 0.61

NHS Barnsley CCG 0.61

NHS Chorley and South Ribble CCG 0.60

NHS Redditch and Bromsgrove CCG 0.60

NHS South East Staffordshire and Seisdon Peninsula 0.59 CCG

NHS Warrington CCG 0.59

NHS Telford and Wrekin 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

FOLLY LANE MEDICAL CENTRE N81056 0.67 STRETTON MEDICAL CENTRE N81623 0.65 PENKETH HEALTH CENTRE N81020 0.65 • it is estimated that there are 20,592 CULCHETH MEDICAL CENTRE N81059 0.64 PARKVIEW MEDICAL CENTRE N81083 0.64 people with undiagnosed PADGATE MEDICAL CENTRE N81109 0.64 hypertension in NHS Warrington CCG HOLES LANE MEDICAL CENTRE N81007 0.61 • GP practice range of observed to FEARNHEAD CROSS MED.CTR. N81048 0.61 expected hypertension prevalence GREENBANK SURGERY N81089 0.60 0.39 to 0.67 WESTBROOK MEDICAL CENTRE N81122 0.59 HELSBY STREET MED/CTR N81041 0.57 GUARDIAN STREET MED/CTR N81012 0.57 CAUSEWAY MEDICAL CENTRE N81028 0.56 BIRCHWOOD MEDICAL CENTRE N81114 0.55 MANCHESTER ROAD SURGERY N81107 0.55 SPRINGFIELDS MEDICAL CENTRE N81036 0.55 DALLAM LANE MEDICAL CENTRE N81097 0.54 4 SEASONS MEDICAL CENTRE N81645 0.53 FAIRFIELD SURGERY Y01108 0.53 STOCKTON HEATH MED.CENTRE N81075 0.52 THE LAKESIDE SURGERY N81108 0.50 LATCHFORD MEDICAL CENTRE N81065 0.49 BROOKFIELD SURGERY N81014 0.46 THE ERIC MOORE PARTNERSHIP N81628 0.44 COCKHEDGE MEDICAL CENTRE N81637 0.39 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 Knowsley CCG 82.4%

NHS Vale Royal CCG 82.1%

NHS West Cheshire CCG 81.6% • 28,063 people with hypertension (diagnosed)* in NHS Warrington CCG NHS Southport And Formby CCG 81.6% • 22,209 (79.1%) people whose blood pressure is <= 150/90 NHS St Helens CCG 80.5% • 947 (3.4%) people who are excepted from optimal control NHS South Cheshire CCG 80.3% • 4,907 (17.5%) additional people

NHS Halton CCG 80.3% whose blood pressure is not <= 150/90 NHS Liverpool CCG 80.3%

NHS Eastern Cheshire CCG 79.8%

NHS Wirral CCG 79.4%

NHS Warrington CCG 79.1%

NHS South Sefton CCG 77.5%

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 Warwickshire North CCG 82.3%

NHS Hartlepool and Stockton-on-Tees CCG 82.2%

NHS Wigan Borough CCG 82.0%

NHS Redditch and Bromsgrove CCG 81.9%

NHS Chorley and South Ribble CCG 80.6%

NHS South Cheshire CCG 80.3%

NHS South East Staffordshire and Seisdon Peninsula 79.4% CCG

NHS Cannock Chase CCG 79.4%

NHS Warrington CCG 79.1%

NHS Telford and Wrekin CCG 78.8%

NHS Barnsley CCG 78.8%

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

4 SEASONS MEDICAL CENTRE N81645 103 PADGATE MEDICAL CENTRE N81109 294 BROOKFIELD SURGERY N81014 283 • in total, including exceptions, there WESTBROOK MEDICAL CENTRE N81122 326 are 5,854 people whose blood CULCHETH MEDICAL CENTRE N81059 298 pressure is not <= 150/90 PENKETH HEALTH CENTRE N81020 619 • GP practice range: 10.9% to 32.6% STRETTON MEDICAL CENTRE N81623 127 GUARDIAN STREET MED/CTR N81012 310 HELSBY STREET MED/CTR N81041 286 FAIRFIELD SURGERY Y01108 73 MANCHESTER ROAD SURGERY N81107 79 GREENBANK SURGERY N81089 304 THE ERIC MOORE PARTNERSHIP N81628 183 HOLES LANE MEDICAL CENTRE N81007 342 BIRCHWOOD MEDICAL CENTRE N81114 295 PARKVIEW MEDICAL CENTRE N81083 158 STOCKTON HEATH MED.CENTRE N81075 448 THE LAKESIDE SURGERY N81108 232 FOLLY LANE MEDICAL CENTRE N81056 282 CAUSEWAY MEDICAL CENTRE N81028 163 LATCHFORD MEDICAL CENTRE N81065 118 FEARNHEAD CROSS MED.CTR. N81048 315 COCKHEDGE MEDICAL CENTRE N81637 37 SPRINGFIELDS MEDICAL CENTRE N81036 130 DALLAM LANE MEDICAL CENTRE N81097 49

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 Knowsley CCG 83.5%

NHS South Sefton CCG 71.1%

NHS Liverpool CCG 70.9% • 96 people with a new diagnosis* of hypertension with a CVD risk of 20% NHS St Helens CCG 70.2% or higher in NHS Warrington CCG • 59 (61.5%) people who are currently NHS Wirral CCG 69.2% treated with statins • 36 (37.5%) people who are exempted NHS Eastern Cheshire CCG 62.9% from treatment with statins

NHS Warrington CCG 61.5% • 1 (1%) additional people who are not currently treated with statins NHS West Cheshire CCG 61.0%

NHS South Cheshire CCG 60.8%

NHS Vale Royal CCG 60.0%

NHS Halton CCG 58.0%

NHS Southport And Formby CCG 47.6%

England 66.5%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% *Using the QOF clinical indicator CVD-PP001 denominator plus exceptions

23 CVD: Primary Care Intelligence Packs New diagnosis of hypertension who have been given a CVD risk assessment whose CVD risk exceeds 20% and treated with statins by CCG Comparison with demographically similar CCGs

NHS Warwickshire North CCG 80.8%

NHS Telford and Wrekin CCG 78.3%

NHS Cannock Chase CCG 76.6%

NHS Hartlepool and Stockton-on-Tees CCG 75.9%

NHS Redditch and Bromsgrove CCG 64.8%

NHS Chorley and South Ribble CCG 62.9%

NHS South East Staffordshire and Seisdon Peninsula 61.8% CCG

NHS Warrington CCG 61.5%

NHS Wigan Borough CCG 61.0%

NHS South Cheshire CCG 60.8%

NHS Barnsley CCG 60.3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

24 CVD: Primary Care Intelligence Packs New diagnosis of hypertension who have been given a CVD risk assessment whose CVD risk exceeds 20% and not treated with statins by GP practice

No treatment Exceptions reported

PADGATE MEDICAL CENTRE N81109 2 GUARDIAN STREET MED/CTR N81012 3 WESTBROOK MEDICAL CENTRE N81122 3 • in total, including exceptions, there SPRINGFIELDS MEDICAL CENTRE N81036 2 are 37 people who are not treated FOLLY LANE MEDICAL CENTRE N81056 5 with statins THE LAKESIDE SURGERY N81108 4 • GP practice range: 0.0% to 100.0% PENKETH HEALTH CENTRE N81020 4 HOLES LANE MEDICAL CENTRE N81007 4 HELSBY STREET MED/CTR N81041 3 BIRCHWOOD MEDICAL CENTRE N81114 4 LATCHFORD MEDICAL CENTRE N81065 1 THE ERIC MOORE PARTNERSHIP N81628 1 4 SEASONS MEDICAL CENTRE N81645 1 BROOKFIELD SURGERY N81014 CAUSEWAY MEDICAL CENTRE N81028 CULCHETH MEDICAL CENTRE N81059 STOCKTON HEATH MED.CENTRE N81075 PARKVIEW MEDICAL CENTRE N81083 GREENBANK SURGERY N81089 DALLAM LANE MEDICAL CENTRE N81097 MANCHESTER ROAD SURGERY N81107 STRETTON MEDICAL CENTRE N81623 COCKHEDGE MEDICAL CENTRE N81637 FAIRFIELD SURGERY Y01108 FEARNHEAD CROSS MED.CTR. N81048

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 Wirral CCG 0.86

NHS Halton CCG 0.85

NHS Vale Royal CCG 0.82 • the ratio of those diagnosed with atrial fibrillation versus those expected to NHS South Cheshire CCG 0.80 have atrial fibrillation is 0.67. This compares to 0.7 for England NHS West Cheshire CCG 0.80 • this suggests that 67% of people with atrial fibrillation have been diagnosed. NHS South Sefton CCG 0.80

NHS Liverpool CCG 0.79

NHS Knowsley CCG 0.77

NHS St Helens CCG 0.76

NHS Eastern Cheshire CCG 0.75

NHS Southport And Formby CCG 0.72 Note: This slide compares the prevalence of atrial fibrillation recorded in QOF in 2015/16 to NHS Warrington CCG 0.67 the estimated prevalence of atrial fibrillation, 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 England 0.70 et al (2013) to GP population estimates from 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 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 South Cheshire CCG 0.80

NHS Wigan Borough CCG 0.79

NHS Hartlepool and Stockton-on-Tees CCG 0.78

NHS Chorley and South Ribble CCG 0.73

NHS Barnsley CCG 0.72

NHS Cannock Chase CCG 0.72

NHS South East Staffordshire and Seisdon Peninsula 0.71 CCG

NHS Redditch and Bromsgrove CCG 0.69

NHS Telford and Wrekin CCG 0.69

NHS Warrington CCG 0.67

NHS Warwickshire North CCG 0.65

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

29 CVD: Primary Care Intelligence Packs Atrial fibrillation observed prevalence compared with expected prevalence by GP practice

GP practice CCG

FEARNHEAD CROSS MED.CTR. N81048 0.9 FOLLY LANE MEDICAL CENTRE N81056 0.9 FAIRFIELD SURGERY Y01108 0.9 • it is estimated that there are 5,235 HOLES LANE MEDICAL CENTRE N81007 0.8 GUARDIAN STREET MED/CTR N81012 0.8 people with undiagnosed atrial SPRINGFIELDS MEDICAL CENTRE N81036 0.8 fibrillation in NHS Warrington CCG STOCKTON HEATH MED.CENTRE N81075 0.8 • GP practice range of observed to GREENBANK SURGERY N81089 0.8 expected atrial fibrillation prevalence BIRCHWOOD MEDICAL CENTRE N81114 0.8 0.4 to 0.9 PENKETH HEALTH CENTRE N81020 0.7 HELSBY STREET MED/CTR N81041 0.7 LATCHFORD MEDICAL CENTRE N81065 0.7 DALLAM LANE MEDICAL CENTRE N81097 0.7 MANCHESTER ROAD SURGERY N81107 0.7 PADGATE MEDICAL CENTRE N81109 0.7 COCKHEDGE MEDICAL CENTRE N81637 0.7 BROOKFIELD SURGERY N81014 0.6 CULCHETH MEDICAL CENTRE N81059 0.6 THE LAKESIDE SURGERY N81108 0.6 WESTBROOK MEDICAL CENTRE N81122 0.6 STRETTON MEDICAL CENTRE N81623 0.6 THE ERIC MOORE PARTNERSHIP N81628 0.6 CAUSEWAY MEDICAL CENTRE N81028 0.5 PARKVIEW MEDICAL CENTRE N81083 0.5 4 SEASONS MEDICAL CENTRE N81645 0.4 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Ratio

30 CVD: Primary Care Intelligence Packs In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage treated with anti-coagulation therapy by CCG Comparison with CCGs in the STP Optimal management No treatment Exceptions reported

NHS Knowsley CCG 79.9%

NHS Vale Royal CCG 79.8% • 2,922 people with atrial fibrillation* with a CHA2DS2-VASc score >= 2 in NHS Wirral CCG 79.3% NHS Warrington CCG NHS Liverpool CCG 79.0% • 2,236 (76.5%) people treated with anti-coagulation therapy NHS Halton CCG 78.5% • 288 (9.9%) people who are exceptions NHS St Helens CCG 77.8% • 398 (13.6%) additional people with a

NHS Eastern Cheshire CCG 77.7% recorded CHA2DS2-VASc score >= 2 who are not treated NHS South Cheshire CCG 77.3%

NHS West Cheshire CCG 77.3%

NHS Southport And Formby CCG 76.9%

NHS Warrington CCG 76.5%

NHS South Sefton CCG 76.2%

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 Wigan Borough CCG 80.4%

NHS Barnsley CCG 79.1%

NHS Telford and Wrekin CCG 78.9%

NHS Cannock Chase CCG 78.2%

NHS Warwickshire North CCG 77.5%

NHS South East Staffordshire and Seisdon Peninsula CCG 77.4%

NHS South Cheshire CCG 77.3%

NHS Hartlepool and Stockton-on-Tees CCG 76.6%

NHS Warrington CCG 76.5%

NHS Redditch and Bromsgrove CCG 75.6%

NHS Chorley and South Ribble CCG 72.5%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

32 CVD: Primary Care Intelligence Packs In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage treated with anti-coagulation therapy by GP practice

No treatment Exceptions reported

THE ERIC MOORE PARTNERSHIP N81628 26 THE LAKESIDE SURGERY N81108 48 BROOKFIELD SURGERY N81014 34 • in total, including exceptions, there DALLAM LANE MEDICAL CENTRE N81097 14 are 686 people with a recorded HELSBY STREET MED/CTR N81041 42 CHA2DS2-VASc score >= 2 who are WESTBROOK MEDICAL CENTRE N81122 27 not treated STOCKTON HEATH MED.CENTRE N81075 95 • GP practice range: 8.6% to 38.2% FEARNHEAD CROSS MED.CTR. N81048 64 CAUSEWAY MEDICAL CENTRE N81028 20 COCKHEDGE MEDICAL CENTRE N81637 6 SPRINGFIELDS MEDICAL CENTRE N81036 29 LATCHFORD MEDICAL CENTRE N81065 19 CULCHETH MEDICAL CENTRE N81059 28 MANCHESTER ROAD SURGERY N81107 7 FOLLY LANE MEDICAL CENTRE N81056 35 GREENBANK SURGERY N81089 39 BIRCHWOOD MEDICAL CENTRE N81114 29 GUARDIAN STREET MED/CTR N81012 25 FAIRFIELD SURGERY Y01108 8 PARKVIEW MEDICAL CENTRE N81083 7 PADGATE MEDICAL CENTRE N81109 16 STRETTON MEDICAL CENTRE N81623 6 4 SEASONS MEDICAL CENTRE N81645 2 PENKETH HEALTH CENTRE N81020 45 HOLES LANE MEDICAL CENTRE N81007 15

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

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

THE ERIC MOORE PARTNERSHIP 16

BROOKFIELD SURGERY 18

THE LAKESIDE SURGERY 23 • using the GP cluster method of DALLAM LANE MEDICAL CENTRE 7 calculating potential gains, if each HELSBY STREET MED/CTR 20 practice was to achieve as well as the CAUSEWAY MEDICAL CENTRE 9 upper quartile of its national cluster, then an additional 233 people would COCKHEDGE MEDICAL CENTRE 3 be treated STOCKTON HEATH MED.CENTRE 38

WESTBROOK MEDICAL CENTRE 10

FEARNHEAD CROSS MED.CTR. 24

GUARDIAN STREET MED/CTR 7

FAIRFIELD SURGERY 2

GREENBANK SURGERY 8

BIRCHWOOD MEDICAL CENTRE 5

PARKVIEW MEDICAL CENTRE 1

PADGATE MEDICAL CENTRE 2

STRETTON MEDICAL CENTRE 0

4 SEASONS MEDICAL CENTRE

PENKETH HEALTH CENTRE

HOLES LANE MEDICAL CENTRE Details of this methodology are available on slide 9. Click here to view them.

34 CVD: Primary Care Intelligence Packs Percentage of patients with a history of stroke whose last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less by CCG Comparison with CCGs in the STP

Below 150/90 Not below 150/90 Exceptions reported

NHS Knowsley CCG 86.3%

NHS St Helens CCG 85.1% • 3,585 people with a history of stroke or TIA* in NHS Warrington CCG NHS Liverpool CCG 84.9% • 2,988 (83.3%) people whose blood NHS Southport And Formby CCG 84.9% pressure is <= 150 / 90 • 158 (4.4%) people who are NHS Vale Royal CCG 84.5% exceptions • 439 (12.2%) additional people whose NHS West Cheshire CCG 84.4% blood pressure is not <= 150 / 90

NHS Wirral CCG 84.3%

NHS Halton CCG 84.2%

NHS South Cheshire CCG 84.0%

NHS Warrington CCG 83.3%

NHS Eastern Cheshire CCG 82.5%

NHS South Sefton CCG 82.4%

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 Redditch and Bromsgrove CCG 86.4%

NHS Wigan Borough CCG 86.1%

NHS Warwickshire North CCG 85.1%

NHS Hartlepool and Stockton-on-Tees CCG 84.5%

NHS South Cheshire CCG 84.0%

NHS Chorley and South Ribble CCG 83.9%

NHS Warrington CCG 83.3%

NHS South East Staffordshire and Seisdon Peninsula CCG 83.1%

NHS Barnsley CCG 83.0%

NHS Cannock Chase CCG 82.9%

NHS Telford and Wrekin CCG 82.7%

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

4 SEASONS MEDICAL CENTRE N81645 12 FAIRFIELD SURGERY Y01108 8 BROOKFIELD SURGERY N81014 31 • in total, including exceptions, there PENKETH HEALTH CENTRE N81020 80 are 597 people whose blood pressure WESTBROOK MEDICAL CENTRE N81122 30 is not <= 150 / 90 PADGATE MEDICAL CENTRE N81109 26 • GP practice range: 3.4% to 27.9% FOLLY LANE MEDICAL CENTRE N81056 39 GREENBANK SURGERY N81089 40 THE ERIC MOORE PARTNERSHIP N81628 21 HOLES LANE MEDICAL CENTRE N81007 39 BIRCHWOOD MEDICAL CENTRE N81114 39 CAUSEWAY MEDICAL CENTRE N81028 13 THE LAKESIDE SURGERY N81108 21 LATCHFORD MEDICAL CENTRE N81065 16 HELSBY STREET MED/CTR N81041 23 PARKVIEW MEDICAL CENTRE N81083 11 STOCKTON HEATH MED.CENTRE N81075 49 GUARDIAN STREET MED/CTR N81012 25 MANCHESTER ROAD SURGERY N81107 7 STRETTON MEDICAL CENTRE N81623 8 FEARNHEAD CROSS MED.CTR. N81048 29 CULCHETH MEDICAL CENTRE N81059 15 SPRINGFIELDS MEDICAL CENTRE N81036 11 DALLAM LANE MEDICAL CENTRE N81097 3 COCKHEDGE MEDICAL CENTRE N81637 1

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

37 CVD: Primary Care Intelligence Packs Percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record in the preceding 12 months that an anti-platelet agent, or an anti-coagulant is being taken by CCG Comparison with CCGs in the STP Below 150/90 Not below 150/90 Exceptions reported

NHS Liverpool CCG 93.4%

NHS Knowsley CCG 92.9% • 2,291 people with a stroke shown to be non-haemorrhagic* in NHS NHS South Sefton CCG 92.6% Warrington CCG NHS Warrington CCG 92.3% • 2,115 (92.3%) people who are taking an anti-platetet agent or anti- NHS Southport And Formby CCG 92.0% coagulant • 101 (4.4%) people who are NHS Halton CCG 92.0% exceptions

NHS West Cheshire CCG 90.8% • 75 (3.3%) additional people with no treatment NHS St Helens CCG 90.0%

NHS Wirral CCG 89.7%

NHS Eastern Cheshire CCG 89.3%

NHS South Cheshire CCG 88.9%

NHS Vale Royal CCG 88.8%

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 Hartlepool and Stockton-on-Tees CCG 93.7%

NHS Redditch and Bromsgrove CCG 93.2%

NHS Wigan Borough CCG 92.6%

NHS Warwickshire North CCG 92.4%

NHS Warrington CCG 92.3%

NHS Telford and Wrekin CCG 92.0%

NHS South East Staffordshire and Seisdon Peninsula CCG 91.8%

NHS Cannock Chase CCG 91.4%

NHS Barnsley CCG 91.4%

NHS Chorley and South Ribble CCG 90.6%

NHS South Cheshire 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

BROOKFIELD SURGERY N81014 15 MANCHESTER ROAD SURGERY N81107 6 FOLLY LANE MEDICAL CENTRE N81056 19 • in total, including exceptions, there BIRCHWOOD MEDICAL CENTRE N81114 17 are 176 people who are not taking an CAUSEWAY MEDICAL CENTRE N81028 5 anti-platelet agent or anti-coagulant GUARDIAN STREET MED/CTR N81012 9 • GP practice range: 0.0% to 16.5% CULCHETH MEDICAL CENTRE N81059 7 PADGATE MEDICAL CENTRE N81109 7 COCKHEDGE MEDICAL CENTRE N81637 1 SPRINGFIELDS MEDICAL CENTRE N81036 5 STOCKTON HEATH MED.CENTRE N81075 15 HELSBY STREET MED/CTR N81041 7 LATCHFORD MEDICAL CENTRE N81065 5 4 SEASONS MEDICAL CENTRE N81645 2 GREENBANK SURGERY N81089 10 WESTBROOK MEDICAL CENTRE N81122 6 PENKETH HEALTH CENTRE N81020 14 THE ERIC MOORE PARTNERSHIP N81628 4 THE LAKESIDE SURGERY N81108 3 STRETTON MEDICAL CENTRE N81623 2 HOLES LANE MEDICAL CENTRE N81007 6 FEARNHEAD CROSS MED.CTR. N81048 8 PARKVIEW MEDICAL CENTRE N81083 2 DALLAM LANE MEDICAL CENTRE N81097 1 FAIRFIELD SURGERY Y01108

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

40 CVD: Primary Care Intelligence Packs Diabetes

41 CVD: Primary Care Intelligence Packs Diabetes prevention and management

Type 2 Diabetes in numbers Diabetes costs the NHS • diagnosed prevalence – 3.0 million £9.8 billion per year – and the • undiagnosed diabetes – 900,000 • non-diabetic hyperglycaemia (high risk of diabetes) – 5 million prevalence is rising What questions should we ask in our CCG? 1. for each indicator how wide is the variation in achievement and exception reporting? Type 2 diabetes is often preventable 2. how many people would benefit if all practices performed as well People at high risk of developing type 2 diabetes as the best? can be identified through the NHS Health Check, 3. how can we support practices who are average and below and the disease can be prevented or delayed in average to perform as well as the best in: many through intensive behaviour change support. • detection of diabetes • delivery of the 8 care processes and achievement of the 3 treatment targets Complications of diabetes are preventable • identification and management of Non-diabetic hyperglycaemia Diabetes is a major cause of premature death and disability and greatly increases the risk of heart disease and stroke, kidney failure, amputations and What might help blindness. 80% of NHS spending on diabetes goes • ensure universal participation by practices in the National on managing these complications, most of which Diabetes Audit (NDA) could be prevented. There are 8 essential care • benchmark practice level data from the NDA – and support processes, in addition to retinal screening, that practices to explore variation together substantially reduce complication rates. • increase support for patient education and shared Despite this, around a half of people with diabetes management do not receive all 8 care processes, and there is • maximise uptake of the NHS Health Check to aid detection of widespread variation between CCGs and practices diabetes and Non Diabetic Hyperglycaemia in levels of achievement • maximise uptake of the NHS Diabetes Prevention Programme

42 CVD: Primary Care Intelligence Packs Diabetes observed prevalence compared with expected prevalence by CCG Comparison with CCGs in the STP

NHS Halton CCG 0.97

NHS Warrington CCG 0.85 • 0.85 ratio of observed to expected diabetes prevalence in NHS NHS Knowsley CCG 0.85 Warrington CCG, compared to 0.77 in NHS St Helens CCG 0.83 England

NHS Vale Royal CCG 0.81 • this suggests 85% of people have been diagnosed NHS West Cheshire CCG 0.80

NHS South Cheshire CCG 0.80

NHS Wirral CCG 0.79

NHS South Sefton CCG 0.76

NHS Liverpool CCG 0.76

NHS Southport And Formby CCG 0.72

NHS Eastern Cheshire CCG 0.72 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 England 0.77 produced in 2015.

0.0 0.2 0.4 0.6 0.8 1.0 1.2

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

NHS Cannock Chase CCG 0.91

NHS Warrington CCG 0.85

NHS Wigan Borough CCG 0.85

NHS Warwickshire North CCG 0.84

NHS Telford and Wrekin CCG 0.84

NHS Chorley and South Ribble CCG 0.83

NHS Redditch and Bromsgrove CCG 0.83

NHS Barnsley CCG 0.83

NHS South East Staffordshire and Seisdon Peninsula CCG 0.82

NHS South Cheshire CCG 0.80

NHS Hartlepool and Stockton-on-Tees CCG 0.78

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

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

GP practice CCG

DALLAM LANE MEDICAL CENTRE N81097 10.0% PENKETH HEALTH CENTRE N81020 7.9% FOLLY LANE MEDICAL CENTRE N81056 7.8% • GP practice range of observed FEARNHEAD CROSS MED.CTR. N81048 7.7% diabetes 4.1% to 10.0% SPRINGFIELDS MEDICAL CENTRE N81036 7.7% • there are an estimated 1,842 people CAUSEWAY MEDICAL CENTRE N81028 7.6% with undiagnosed diabetes in NHS 4 SEASONS MEDICAL CENTRE N81645 7.1% Warrington CCG GREENBANK SURGERY N81089 7.1% GUARDIAN STREET MED/CTR N81012 6.9% BIRCHWOOD MEDICAL CENTRE N81114 6.9% HELSBY STREET MED/CTR N81041 6.8% HOLES LANE MEDICAL CENTRE N81007 6.8% THE ERIC MOORE PARTNERSHIP N81628 6.6% FAIRFIELD SURGERY Y01108 6.6% PARKVIEW MEDICAL CENTRE N81083 6.5% MANCHESTER ROAD SURGERY N81107 6.5% CULCHETH MEDICAL CENTRE N81059 6.5% STOCKTON HEATH MED.CENTRE N81075 6.2% WESTBROOK MEDICAL CENTRE N81122 6.0% STRETTON MEDICAL CENTRE N81623 5.9% PADGATE MEDICAL CENTRE N81109 5.8% COCKHEDGE MEDICAL CENTRE N81637 5.8% LATCHFORD MEDICAL CENTRE N81065 5.8% THE LAKESIDE SURGERY N81108 4.9% Note: The estimated number of undiagnosed people with diabetes has been calculated by BROOKFIELD SURGERY N81014 4.1% multiplying the estimated prevalence rate to the 0% 2% 4% 6% 8% 10% 12% 2015/16 QOF list size and subtracting the number of people on the diabetes register.

45 CVD: Primary Care Intelligence Packs Expected total prevalence of diabetes and non-diabetic hyperglycaemia

Diabetes prevalence Undiagnosed diabetes prevalence Expected non-diabetic hyperglycaemia prevalence

NHS Southport And Formby CCG 6.8% 2.6% 12.8% • the estimated total prevalence of diabetes in NHS Warrington CCG is NHS Eastern Cheshire CCG 6.1% 2.4% 12.0% 7.8% (diagnosed and undiagnosed) NHS St Helens CCG 7.4% 1.5% 11.5% • in addition, there are an estimated NHS Wirral CCG 7.0% 1.8% 11.2% 10.7% of people in NHS Warrington NHS South Sefton CCG 6.7% 2.1% 11.2% CCG who are at increased risk of developing diabetes (i.e. with non- NHS West Cheshire CCG 6.5% 1.6% 11.5% diabetic hyperglycaemia) NHS Vale Royal CCG 6.7% 1.6% 11.1% • this means that 18.5% of the NHS South Cheshire CCG 6.5% 1.7% 11.1% population in NHS Warrington CCG NHS Halton CCG 8.0% 0.3% 11.1% are estimated to have diabetes, or at high risk of developing of diabetes NHS Knowsley CCG 7.3% 1.3% 10.3%

NHS Warrington CCG 6.7% 1.1% 10.7%

NHS Liverpool CCG 6.1% 1.9% 10.0% Note: Prevalence estimates of non-diabetic hyperglycaemia were developed using Health Survey for England (HSE) data. Five years of HSE data were combined, 2009- 2013. The England 6.5% 1.9% 11.2% estimates take into account the age, ethnic group and estimated body mass index of the population. 0% 5% 10% 15% 20% 25% These estimates were produced using the GP registered population.

46 CVD: Primary Care Intelligence Packs People with diabetes who had eight care processes by CCG 2015/16

NHS Liverpool CCG 77.8%

NHS Southport And Formby CCG 64.7% • data on care processes and treatment NHS West Cheshire CCG 58.3% targets are taken from the National Diabetes Audit (NDA) NHS South Sefton CCG 56.5% • overall practice participation in the NHS Vale Royal CCG 56.1% 2015/16 audit was 81.4% in England

NHS Eastern Cheshire CCG 52.8% • in NHS Warrington CCG, 23 out of 26 practices (88.5%) participated in the NHS Warrington CCG 51.6% NDA. Data is not available for the remaining practices NHS Halton CCG 46.5%

NHS South Cheshire CCG 46.1% • 51.6% of people with diabetes (of NHS Wirral CCG 42.3% practices who participated in the audit) had the eight recommended NHS St Helens CCG 38.1% care processes in NHS Warrington

NHS Knowsley CCG 37.4% CCG, compared to 52.6% in England

England 52.6%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

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

SPRINGFIELDS MEDICAL CENTRE N81036 83.6% FEARNHEAD CROSS MED.CTR. N81048 65.4% • achievement - 8 care processes: in COCKHEDGE MEDICAL CENTRE N81637 64.9% practices who provided data via the GUARDIAN STREET MED/CTR N81012 64.1% WESTBROOK MEDICAL CENTRE N81122 59.9% NDA, between 4.0% and 83.6% of BIRCHWOOD MEDICAL CENTRE N81114 58.3% patients received all 8 care processes THE ERIC MOORE PARTNERSHIP N81628 58.1% GREENBANK SURGERY N81089 56.6% • at least 5,059 people did not receive STOCKTON HEATH MED.CENTRE N81075 55.8% the eight care processes CULCHETH MEDICAL CENTRE N81059 54.9% THE LAKESIDE SURGERY N81108 51.8% HOLES LANE MEDICAL CENTRE N81007 50.9% LATCHFORD MEDICAL CENTRE N81065 48.9% 4 SEASONS MEDICAL CENTRE N81645 48.6% PADGATE MEDICAL CENTRE N81109 47.1% PENKETH HEALTH CENTRE N81020 46.5% HELSBY STREET MED/CTR N81041 46.0% CAUSEWAY MEDICAL CENTRE N81028 41.4% FOLLY LANE MEDICAL CENTRE N81056 40.4% DALLAM LANE MEDICAL CENTRE N81097 26.6% FAIRFIELD SURGERY Y01108 5.2% PARKVIEW MEDICAL CENTRE N81083 4.0% STRETTON MEDICAL CENTRE N81623 MANCHESTER ROAD SURGERY N81107 BROOKFIELD SURGERY N81014

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

48 CVD: Primary Care Intelligence Packs People with diabetes who met all 3 treatment targets by CCG, 2015/16

NHS West Cheshire CCG 46.4%

NHS Wirral CCG 44.0% • 40.6% of people with diabetes (of NHS Knowsley CCG 44.0% practices who participated in the audit) met the three treatment targets NHS Liverpool CCG 43.7% in NHS Warrington CCG, compared to 39.0% in England NHS Southport And Formby CCG 43.2%

NHS St Helens CCG 41.9%

NHS Warrington CCG 40.6%

NHS South Sefton CCG 39.3%

NHS Vale Royal CCG 39.0%

NHS Eastern Cheshire CCG 38.7%

NHS Halton CCG 37.5%

NHS South Cheshire CCG 36.6%

England 39.0%

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

49 CVD: Primary Care Intelligence Packs People with diabetes who met all 3 treatment targets by GP practice, 2015/16

GP practice Average of practices in the CCG who participated in the audit

FAIRFIELD SURGERY Y01108 52.8% DALLAM LANE MEDICAL CENTRE N81097 52.0% • achievement - 3 treatment targets: in SPRINGFIELDS MEDICAL CENTRE N81036 51.5% practices who provided data via the HOLES LANE MEDICAL CENTRE N81007 48.9% CULCHETH MEDICAL CENTRE N81059 44.4% NDA, between 30.1% and 52.8% of GREENBANK SURGERY N81089 44.3% patients achieved all 3 treatment LATCHFORD MEDICAL CENTRE N81065 44.0% targets CAUSEWAY MEDICAL CENTRE N81028 42.1% • at least 5,363 people did not meet the HELSBY STREET MED/CTR N81041 41.8% three treatment targets FEARNHEAD CROSS MED.CTR. N81048 41.4% FOLLY LANE MEDICAL CENTRE N81056 40.9% THE ERIC MOORE PARTNERSHIP N81628 40.5% THE LAKESIDE SURGERY N81108 40.4% STOCKTON HEATH MED.CENTRE N81075 40.2% PENKETH HEALTH CENTRE N81020 39.8% PARKVIEW MEDICAL CENTRE N81083 39.3% COCKHEDGE MEDICAL CENTRE N81637 37.5% GUARDIAN STREET MED/CTR N81012 36.8% WESTBROOK MEDICAL CENTRE N81122 34.2% 4 SEASONS MEDICAL CENTRE N81645 33.1% BIRCHWOOD MEDICAL CENTRE N81114 31.6% PADGATE MEDICAL CENTRE N81109 30.1% STRETTON MEDICAL CENTRE N81623 MANCHESTER ROAD SURGERY N81107 BROOKFIELD SURGERY N81014

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

PADGATE MEDICAL CENTRE 42

BIRCHWOOD MEDICAL CENTRE 71

4 SEASONS MEDICAL CENTRE 15 • using the GP cluster method of WESTBROOK MEDICAL CENTRE 44 calculating potential gains, if each GUARDIAN STREET MED/CTR 42 practice was to achieve as well as the COCKHEDGE MEDICAL CENTRE 10 upper quartile of its national cluster, then an additional 429 people would PARKVIEW MEDICAL CENTRE 16 be treated HELSBY STREET MED/CTR 21

THE ERIC MOORE PARTNERSHIP 18

FOLLY LANE MEDICAL CENTRE 26

STOCKTON HEATH MED.CENTRE 30

CAUSEWAY MEDICAL CENTRE 13

FEARNHEAD CROSS MED.CTR. 24

LATCHFORD MEDICAL CENTRE 3

CULCHETH MEDICAL CENTRE 5

GREENBANK SURGERY 1

SPRINGFIELDS MEDICAL CENTRE

HOLES LANE MEDICAL CENTRE

DALLAM LANE MEDICAL CENTRE

FAIRFIELD SURGERY Details of this methodology are available on slide 9. Click here to view them.

51 CVD: Primary Care Intelligence Packs Kidney

52 CVD: Primary Care Intelligence Packs Management of chronic kidney disease

Chronic Kidney Disease can progress to kidney failure and it Late diagnosis of CKD is common. substantially increases the risk Around a third of people with CKD are undiagnosed. More of heart attack and stroke. opportunistic testing and improved uptake of the NHS Health Check will increase detection rates.

Chronic Kidney Disease (CKD) is common. What questions should we ask in our CCG? It is one of the commonest co-morbidities and affects a third 1. for each indicator how wide is the variation in of people over 75. In 2010 it was estimated to cost the NHS achievement and exception reporting? around £1.5bn. Average length of stay in hospital tends to 2. how many people would benefit if all practices be longer and outcomes are considerably worse: performed as well as the best? approximately 7,000 excess strokes and 12,000 excess 3. how can we support practices who are average and heart attacks occur each year in people with CKD below average to perform as well as the best in: compared to those without. • detection of CKD Individuals with CKD are also at much higher risk of • more systematic delivery of evidence based care developing acute kidney injury when they have an intercurrent illness such as pneumonia What might help • Support practices to share audit data and systematically Evidence based guidance from NICE highlights CVD identify gaps and opportunities for improved detection risk reduction, good blood pressure control and and management of CKD. management of proteinuria as essential steps to reduce the • Promote uptake of and follow up from the NHS Health risk of cardiovascular events and progression to kidney Check to aid detection and management of CKD failure. Despite this there is often significant variation • Offer local training and education in the detection and between practices in achievement and exception reporting. management of CKD

53 CVD: Primary Care Intelligence Packs Chronic kidney disease (CKD) observed prevalence (2015/16) compared with expected prevalence (2011) by CCG Comparison with CCGs in the STP

NHS Liverpool CCG 1.05

NHS South Sefton CCG 0.90

NHS Vale Royal CCG 0.79 • the ratio of those diagnosed with chronic kidney disease versus those NHS Knowsley CCG 0.78 expected to have chronic kidney disease is 0.62. This compares to NHS South Cheshire CCG 0.75 0.68 for England NHS Halton CCG 0.73 • this suggests that 62% of people with chronic kidney disease have been NHS Wirral CCG 0.71 diagnosed

NHS St Helens CCG 0.68

NHS Southport And Formby CCG 0.65

NHS Warrington CCG 0.62

NHS Eastern Cheshire CCG 0.62 Note: This slide compares the prevalence of CKD NHS West Cheshire CCG 0.55 recorded in QOF in 2015/16 to the expected prevalence of CKD produced by the University of Southampton in 2011. A small number of CCGs have a ratio greater than 1. It is unlikely that all England 0.68 people with CKD will be diagnosed in any CCG and therefore a ratio greater than 1 suggests that 0.0 0.2 0.4 0.6 0.8 1.0 1.2 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 Warwickshire North CCG 1.05

NHS Chorley and South Ribble CCG 1.02

NHS Wigan Borough CCG 0.87

NHS Barnsley CCG 0.82

NHS Telford and Wrekin CCG 0.79

NHS South Cheshire CCG 0.75

NHS Redditch and Bromsgrove CCG 0.74

NHS South East Staffordshire and Seisdon 0.69 Peninsula CCG

NHS Cannock Chase CCG 0.64

NHS Hartlepool and Stockton-on-Tees CCG 0.64

NHS Warrington CCG 0.62

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

GREENBANK SURGERY N81089 5.6% FOLLY LANE MEDICAL CENTRE N81056 5.5% STRETTON MEDICAL CENTRE N81623 5.1% • it is estimated that there are 3,585 HOLES LANE MEDICAL CENTRE N81007 4.9% people with undiagnosed chronic SPRINGFIELDS MEDICAL CENTRE N81036 4.9% kidney disease in NHS Warrington FEARNHEAD CROSS MED.CTR. N81048 4.8% CCG DALLAM LANE MEDICAL CENTRE N81097 4.5% • GP practice range of observed CKD: PADGATE MEDICAL CENTRE N81109 4.3% HELSBY STREET MED/CTR N81041 4.1% 1.5% to 5.6% STOCKTON HEATH MED.CENTRE N81075 4.1% FAIRFIELD SURGERY Y01108 4.0% GUARDIAN STREET MED/CTR N81012 3.9% MANCHESTER ROAD SURGERY N81107 3.9% LATCHFORD MEDICAL CENTRE N81065 3.8% PENKETH HEALTH CENTRE N81020 3.7% CAUSEWAY MEDICAL CENTRE N81028 3.4% THE LAKESIDE SURGERY N81108 3.4% CULCHETH MEDICAL CENTRE N81059 3.1% BIRCHWOOD MEDICAL CENTRE N81114 2.6% COCKHEDGE MEDICAL CENTRE N81637 2.2% 4 SEASONS MEDICAL CENTRE N81645 2.1% THE ERIC MOORE PARTNERSHIP N81628 2.1% Note: CCG estimates for the estimated WESTBROOK MEDICAL CENTRE N81122 2.0% number of people with CKD are based on PARKVIEW MEDICAL CENTRE N81083 1.9% applying a proportion from a resident based BROOKFIELD SURGERY N81014 1.5% population estimate to a GP registered population. The characteristics of registered 0% 1% 2% 3% 4% 5% 6% and resident populations may vary in some CCGs, and local interpretation is required.

56 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding 12 months) is 140/85 mmHg or less by CCG, 2014/15 Comparison with CCGs in the STP Below 140/85 Not below 140/85 Exceptions reported

NHS Knowsley CCG 79.6%

NHS St Helens CCG 78.9% • 6,360 people with CKD (diagnosed*) in NHS Warrington CCG NHS Vale Royal CCG 78.5% • 4,753 (74.7%) people whose blood NHS South Sefton CCG 78.4% pressure is <= 140 /85 • 419 (6.6%) people who are NHS West Cheshire CCG 77.8% exceptions • 1,188 (18.7%) additional people NHS Liverpool CCG 77.7% whose blood pressure is not <= 140 /

NHS Southport And Formby CCG 77.2% 85

NHS Wirral CCG 75.6%

NHS South Cheshire CCG 75.0%

NHS Halton CCG 74.9%

NHS Warrington CCG 74.7%

NHS Eastern Cheshire CCG 73.0%

*Using the QOF clinical indicator CKD002 England 74.4% denominator plus exceptions. Note: as the CKD002 indicator was removed from 0% 20% 40% 60% 80% 100% the QOF in 15/16 this is historic data taken from the 2014/15 QOF.

57 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding 12 months) is 140/85 mmHg or less by CCG, 2014/15 Comparison with demographically similar CCGs Below 140/85 Not below 140/85 Exceptions reported

NHS Wigan Borough CCG 81.1%

NHS Cannock Chase CCG 78.2%

NHS Hartlepool and Stockton-on-Tees CCG 78.1%

NHS Chorley and South Ribble CCG 77.4%

NHS Warwickshire North CCG 75.5%

NHS Redditch and Bromsgrove CCG 75.2%

NHS South Cheshire CCG 75.0%

NHS Warrington CCG 74.7%

NHS Telford and Wrekin CCG 74.5%

NHS Barnsley CCG 72.9%

NHS South East Staffordshire and Seisdon Peninsula CCG 72.3%

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

4 SEASONS MEDICAL CENTRE N81645 19 PADGATE MEDICAL CENTRE N81109 106 PENKETH MEDICAL CENTRE N81020 151 • in total, including exceptions, there CCA CARE PARTNERSHIP N81634 70 are 1,607 people whose blood LAKESIDE SURGERY N81108 85 BIRCHWOOD MEDICAL CENTRE N81114 76 pressure is not <= 140 / 85 GUARDIAN MEDICAL CENTRE N81012 91 • GP practice range: 9.4% to 51.4% STOCKTON HEATH MED.CENTRE N81075 167 WESTBROOK MEDICAL CENTRE N81122 51 BROOKFIELD SURGERY N81014 30 MANCHESTER ROAD PRACTICE N81089 112 HOLES LANE SURGERY N81007 108 ERIC MOORE PARTNERSHIP N81628 37 CAUSEWAY MEDICAL CENTRE N81028 46 LATCHFORD MEDICAL CENTRE N81065 40 FAIRFIELD SURGERY Y01108 21 SPRINGFIELDS MEDICAL CENTRE N81036 50 MANCHESTER ROAD SURGERY N81107 18 FOLLY LANE MEDICAL CENTRE N81056 89 CULCHETH MEDICAL CENTRE N81059 35 FEARNHEAD CROSS MEDICAL CENTRE N81048 97 HELSBY STREET SURGERY N81041 55 PARKVIEW MEDICAL PRACTICE N81083 13 STRETTON MEDICAL CENTRE N81623 21 COCKHEDGE MEDICAL CENTRE N81637 9 DALLAM LANE MEDICAL CENTRE N81097 10

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

59 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding 12 months) is not 140/85 mmHg or less by GP practice, 2014/15 – opportunities compared to GP cluster

10% 5% 0% -5% -10% -15% -20% -25% -30% -35% -40%

4 SEASONS MEDICAL CENTRE 13

PADGATE MEDICAL CENTRE 65

GUARDIAN MEDICAL CENTRE 40 • using the GP cluster method of PENKETH MEDICAL CENTRE 52 calculating potential gains, if each LAKESIDE SURGERY 29 practice was to achieve as well as the BIRCHWOOD MEDICAL CENTRE 25 upper quartile of its national cluster, then an additional 402 people would BROOKFIELD SURGERY 10 be treated WESTBROOK MEDICAL CENTRE 15

STOCKTON HEATH MED.CENTRE 44

ERIC MOORE PARTNERSHIP 11

MANCHESTER ROAD SURGERY 3

SPRINGFIELDS MEDICAL CENTRE 7

FOLLY LANE MEDICAL CENTRE 12

HELSBY STREET SURGERY 4

CULCHETH MEDICAL CENTRE 1

PARKVIEW MEDICAL PRACTICE

FEARNHEAD CROSS MEDICAL CENTRE

STRETTON MEDICAL CENTRE

COCKHEDGE MEDICAL CENTRE

DALLAM LANE MEDICAL 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

NHS Liverpool CCG 81.2%

NHS Southport And Formby CCG 79.2% • 6,360 people with CKD (diagnosed*) in NHS Warrington CCG NHS South Sefton CCG 78.6% • 4,530 (71.2%) people who have a NHS St Helens CCG 77.8% record of urine albumin:creatinine ratio test NHS Eastern Cheshire CCG 77.6% • 417 (6.6%) people who are exceptions NHS Vale Royal CCG 77.5% • 1,413 (22.2%) additional people who

NHS Halton CCG 77.0% have no record of urine albumin:creatinine ratio test NHS West Cheshire CCG 76.9%

NHS Knowsley CCG 76.7%

NHS South Cheshire CCG 75.3%

NHS Warrington CCG 71.2%

NHS Wirral CCG 71.1%

*Using the QOF clinical indicator CKD004 denominator plus exceptions. Note: as England 75.4% 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 Chorley and South Ribble CCG 81.0%

NHS Telford and Wrekin CCG 80.6%

NHS Wigan Borough CCG 80.4%

NHS Hartlepool and Stockton-on-Tees CCG 78.0%

NHS Warwickshire North CCG 76.8%

NHS Redditch and Bromsgrove CCG 76.5%

NHS South Cheshire CCG 75.3%

NHS South East Staffordshire and Seisdon Peninsula CCG 74.9%

NHS Cannock Chase CCG 73.6%

NHS Barnsley CCG 72.2%

NHS Warrington CCG 71.2%

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

PENKETH MEDICAL CENTRE N81020 227 BIRCHWOOD MEDICAL CENTRE N81114 120 HOLES LANE SURGERY N81007 202 • in total, including exceptions, there MANCHESTER ROAD PRACTICE N81089 154 are 1,830 people who have no record CAUSEWAY MEDICAL CENTRE N81028 72 WESTBROOK MEDICAL CENTRE N81122 62 of urine albumin:creatinine ratio test CCA CARE PARTNERSHIP N81634 65 • GP practice range: 10.7% to 49.5% LAKESIDE SURGERY N81108 82 STOCKTON HEATH MED.CENTRE N81075 164 GUARDIAN MEDICAL CENTRE N81012 87 PADGATE MEDICAL CENTRE N81109 67 FEARNHEAD CROSS MEDICAL CENTRE N81048 123 BROOKFIELD SURGERY N81014 24 DALLAM LANE MEDICAL CENTRE N81097 23 4 SEASONS MEDICAL CENTRE N81645 8 PARKVIEW MEDICAL PRACTICE N81083 18 ERIC MOORE PARTNERSHIP N81628 31 CULCHETH MEDICAL CENTRE N81059 35 FOLLY LANE MEDICAL CENTRE N81056 87 MANCHESTER ROAD SURGERY N81107 17 FAIRFIELD SURGERY Y01108 18 HELSBY STREET SURGERY N81041 51 LATCHFORD MEDICAL CENTRE N81065 32 STRETTON MEDICAL CENTRE N81623 23 COCKHEDGE MEDICAL CENTRE N81637 11 SPRINGFIELDS MEDICAL CENTRE N81036 27

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 South Sefton CCG 1.28%

NHS St Helens CCG 1.12%

NHS Southport And Formby CCG 1.07% • prevalence of 0.8% in NHS Warrington CCG compared to 0.76% NHS Halton CCG 0.98% in England

NHS South Cheshire CCG 0.98%

NHS Vale Royal CCG 0.96%

NHS Wirral CCG 0.94%

NHS Knowsley CCG 0.91%

NHS West Cheshire CCG 0.90%

NHS Liverpool CCG 0.84%

NHS Warrington CCG 0.80%

NHS Eastern Cheshire CCG 0.79%

England 0.76%

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

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

NHS Wigan Borough CCG 1.03%

NHS South Cheshire CCG 0.98%

NHS Chorley and South Ribble CCG 0.96%

NHS Redditch and Bromsgrove CCG 0.92%

NHS Cannock Chase CCG 0.92%

NHS Hartlepool and Stockton-on-Tees CCG 0.90%

NHS Barnsley CCG 0.89%

NHS Warwickshire North CCG 0.82%

NHS Warrington CCG 0.80%

NHS South East Staffordshire and Seisdon Peninsula CCG 0.79%

NHS Telford and Wrekin CCG 0.75%

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

GREENBANK SURGERY N81089 1.2% FEARNHEAD CROSS MED.CTR. N81048 1.2% HOLES LANE MEDICAL CENTRE N81007 1.2% • 1,614 people with diagnosed heart SPRINGFIELDS MEDICAL CENTRE N81036 1.1% failure in NHS Warrington CCG GUARDIAN STREET MED/CTR N81012 1.1% • GP practice range: 0.3% to 1.2% FAIRFIELD SURGERY Y01108 1.1% CULCHETH MEDICAL CENTRE N81059 1.0% PENKETH HEALTH CENTRE N81020 0.9% FOLLY LANE MEDICAL CENTRE N81056 0.9% HELSBY STREET MED/CTR N81041 0.9% DALLAM LANE MEDICAL CENTRE N81097 0.9% STRETTON MEDICAL CENTRE N81623 0.8% BIRCHWOOD MEDICAL CENTRE N81114 0.7% PADGATE MEDICAL CENTRE N81109 0.7% STOCKTON HEATH MED.CENTRE N81075 0.7% THE ERIC MOORE PARTNERSHIP N81628 0.6% LATCHFORD MEDICAL CENTRE N81065 0.6% WESTBROOK MEDICAL CENTRE N81122 0.6% MANCHESTER ROAD SURGERY N81107 0.5% 4 SEASONS MEDICAL CENTRE N81645 0.5% THE LAKESIDE SURGERY N81108 0.4% BROOKFIELD SURGERY N81014 0.4% CAUSEWAY MEDICAL CENTRE N81028 0.4% COCKHEDGE MEDICAL CENTRE N81637 0.3% PARKVIEW MEDICAL CENTRE N81083 0.3%

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

68 CVD: Primary Care Intelligence Packs Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who are treated with ACE-I / ARB by CCG Comparison with CCGs in the STP Treatment No treatment Exceptions reported

NHS Vale Royal CCG 89.8%

NHS South Cheshire CCG 87.5% • 687 people with heart failure* with LVSD in NHS Warrington CCG NHS West Cheshire CCG 85.8% • 585 (85.2%) people treated with ACE- NHS Warrington CCG 85.2% I or ARB • 99 (14.4%) people who are NHS St Helens CCG 84.6% exceptions • 3 (0.4%) additional people who are NHS Wirral CCG 82.4% not treated with ACE-I or ARB

NHS Halton CCG 81.5%

NHS Liverpool CCG 81.2%

NHS Eastern Cheshire CCG 80.3%

NHS Southport And Formby CCG 80.1%

NHS Knowsley CCG 79.1%

NHS South Sefton CCG 78.9%

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 Redditch and Bromsgrove CCG 88.9%

NHS Hartlepool and Stockton-on-Tees CCG 88.1%

NHS Warwickshire North CCG 87.6%

NHS South Cheshire CCG 87.5%

NHS Cannock Chase CCG 86.7%

NHS Barnsley CCG 86.7%

NHS Wigan Borough CCG 86.0%

NHS Telford and Wrekin CCG 85.6%

NHS Chorley and South Ribble CCG 85.3%

NHS Warrington CCG 85.2%

NHS South East Staffordshire and Seisdon Peninsula CCG 83.0%

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

BROOKFIELD SURGERY N81014 5 MANCHESTER ROAD SURGERY N81107 1 THE LAKESIDE SURGERY N81108 1 • in total, including exceptions, there DALLAM LANE MEDICAL CENTRE N81097 5 are 102 people who are not treated SPRINGFIELDS MEDICAL CENTRE N81036 9 with ACE-I or ARB CULCHETH MEDICAL CENTRE N81059 6 • GP practice range: 0.0% to 45.5% PENKETH HEALTH CENTRE N81020 7 GUARDIAN STREET MED/CTR N81012 15 FOLLY LANE MEDICAL CENTRE N81056 11 GREENBANK SURGERY N81089 8 HELSBY STREET MED/CTR N81041 3 BIRCHWOOD MEDICAL CENTRE N81114 3 FEARNHEAD CROSS MED.CTR. N81048 14 HOLES LANE MEDICAL CENTRE N81007 10 PADGATE MEDICAL CENTRE N81109 1 LATCHFORD MEDICAL CENTRE N81065 1 WESTBROOK MEDICAL CENTRE N81122 1 STOCKTON HEATH MED.CENTRE N81075 1 CAUSEWAY MEDICAL CENTRE N81028 PARKVIEW MEDICAL CENTRE N81083 STRETTON MEDICAL CENTRE N81623 THE ERIC MOORE PARTNERSHIP N81628 COCKHEDGE MEDICAL CENTRE N81637 4 SEASONS MEDICAL CENTRE N81645 FAIRFIELD SURGERY Y01108

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

71 CVD: Primary Care Intelligence Packs Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who are treated with ACE-I / ARB and BB by CCG Comparison with CCGs in the STP Treatment No treatment Exceptions reported

NHS West Cheshire CCG 85.3%

NHS Vale Royal CCG 84.2% • 585 people with heart failure* with LVSD treated with ACE-I/ARB in NHS NHS Liverpool CCG 80.5% Warrington CCG NHS Halton CCG 79.1% • 456 (77.9%) people treated with ACE- I/ARB and BB NHS Warrington CCG 77.9% • 95 (16.2%) people who are exceptions NHS Wirral CCG 77.1% • 34 (5.8%) additional people who are

NHS St Helens CCG 74.1% not treated with ACE-I/ARB and BB

NHS Eastern Cheshire CCG 73.0%

NHS Southport And Formby CCG 72.8%

NHS South Cheshire CCG 72.0%

NHS South Sefton CCG 71.5%

NHS Knowsley CCG 71.4%

England 77.7%

0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator HF004 denominator plus exceptions

72 CVD: Primary Care Intelligence Packs Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who are treated with ACE-I / ARB and BB by CCG Comparison with demographically similar CCGs Treatment No treatment Exceptions reported

NHS Wigan Borough CCG 87.5%

NHS Warwickshire North CCG 83.0%

NHS Chorley and South Ribble CCG 81.0%

NHS Redditch and Bromsgrove CCG 78.1%

NHS Warrington CCG 77.9%

NHS Cannock Chase CCG 77.4%

NHS Barnsley CCG 75.5%

NHS Hartlepool and Stockton-on-Tees CCG 75.4%

NHS Telford and Wrekin CCG 73.6%

NHS South Cheshire CCG 72.0%

NHS South East Staffordshire and Seisdon Peninsula CCG 66.8%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

73 CVD: Primary Care Intelligence Packs Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who are not treated with ACE-I / ARB and BB by GP practice

No treatment Exceptions reported

THE ERIC MOORE PARTNERSHIP N81628 1 PADGATE MEDICAL CENTRE N81109 4 CAUSEWAY MEDICAL CENTRE N81028 3 • in total, including exceptions, there SPRINGFIELDS MEDICAL CENTRE N81036 13 are 129 people who are not treated GREENBANK SURGERY N81089 14 with ACE-I or ARB BIRCHWOOD MEDICAL CENTRE N81114 5 • GP practice range: 0.0% to 50.0% PENKETH HEALTH CENTRE N81020 8 FEARNHEAD CROSS MED.CTR. N81048 26 STOCKTON HEATH MED.CENTRE N81075 7 WESTBROOK MEDICAL CENTRE N81122 3 HELSBY STREET MED/CTR N81041 4 HOLES LANE MEDICAL CENTRE N81007 18 FOLLY LANE MEDICAL CENTRE N81056 9 GUARDIAN STREET MED/CTR N81012 11 CULCHETH MEDICAL CENTRE N81059 2 DALLAM LANE MEDICAL CENTRE N81097 1 BROOKFIELD SURGERY N81014 LATCHFORD MEDICAL CENTRE N81065 PARKVIEW MEDICAL CENTRE N81083 MANCHESTER ROAD SURGERY N81107 THE LAKESIDE SURGERY N81108 STRETTON MEDICAL CENTRE N81623 COCKHEDGE MEDICAL CENTRE N81637 4 SEASONS MEDICAL CENTRE N81645 FAIRFIELD SURGERY Y01108

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

74 CVD: Primary Care Intelligence Packs Percentage of patients with CHD whose blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less by CCG Comparison with CCGs in the STP Below 150/90 Not below 150/90 Exceptions reported

NHS West Cheshire CCG 90.1%

NHS St Helens CCG 89.9% • 7,341 people with coronary heart disease* in NHS Warrington CCG NHS Knowsley CCG 89.7% • 6,419 (87.4%) people whose blood NHS Southport And Formby CCG 89.6% pressure <= 150 / 90 • 379 (5.2%) people who are NHS Halton CCG 89.1% exceptions • 543 (7.4%) additional people whose NHS Liverpool CCG 88.9% blood pressure is not <= 150 / 90

NHS Eastern Cheshire CCG 88.5%

NHS South Cheshire CCG 88.5%

NHS Wirral CCG 88.2%

NHS Vale Royal CCG 87.9%

NHS Warrington CCG 87.4%

NHS South Sefton CCG 86.8%

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 Redditch and Bromsgrove CCG 91.0%

NHS Wigan Borough CCG 90.6%

NHS Warwickshire North CCG 90.1%

NHS Hartlepool and Stockton-on-Tees CCG 89.0%

NHS Chorley and South Ribble CCG 88.8%

NHS South Cheshire CCG 88.5%

NHS Cannock Chase CCG 88.2%

NHS Telford and Wrekin CCG 87.8%

NHS Warrington CCG 87.4%

NHS South East Staffordshire and Seisdon Peninsula CCG 87.3%

NHS Barnsley CCG 86.1%

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

4 SEASONS MEDICAL CENTRE N81645 23 PADGATE MEDICAL CENTRE N81109 44 GUARDIAN STREET MED/CTR N81012 65 • in total, including exceptions, there GREENBANK SURGERY N81089 69 are 922 people whose blood pressure PENKETH HEALTH CENTRE N81020 116 is not <= 150 / 90 STRETTON MEDICAL CENTRE N81623 16 • GP practice range: 6.1% to 22.5% THE ERIC MOORE PARTNERSHIP N81628 43 BROOKFIELD SURGERY N81014 42 BIRCHWOOD MEDICAL CENTRE N81114 61 THE LAKESIDE SURGERY N81108 44 STOCKTON HEATH MED.CENTRE N81075 88 MANCHESTER ROAD SURGERY N81107 11 PARKVIEW MEDICAL CENTRE N81083 18 HOLES LANE MEDICAL CENTRE N81007 50 COCKHEDGE MEDICAL CENTRE N81637 7 WESTBROOK MEDICAL CENTRE N81122 31 HELSBY STREET MED/CTR N81041 35 FOLLY LANE MEDICAL CENTRE N81056 32 CAUSEWAY MEDICAL CENTRE N81028 21 SPRINGFIELDS MEDICAL CENTRE N81036 24 DALLAM LANE MEDICAL CENTRE N81097 10 FAIRFIELD SURGERY Y01108 9 FEARNHEAD CROSS MED.CTR. N81048 35 LATCHFORD MEDICAL CENTRE N81065 12 CULCHETH MEDICAL CENTRE N81059 16

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

4% 2% 0% -2% -4% -6% -8% -10% -12% -14% -16% -18%

4 SEASONS MEDICAL CENTRE 16

PADGATE MEDICAL CENTRE 30

GUARDIAN STREET MED/CTR 43 • using the GP cluster method of GREENBANK SURGERY 36 calculating potential gains, if each THE ERIC MOORE PARTNERSHIP 23 practice was to achieve as well as the STRETTON MEDICAL CENTRE 9 upper quartile of its national cluster, then an additional 371 people would BROOKFIELD SURGERY 22 be treated PENKETH HEALTH CENTRE 55

BIRCHWOOD MEDICAL CENTRE 25

MANCHESTER ROAD SURGERY 5

HOLES LANE MEDICAL CENTRE 12

CAUSEWAY MEDICAL CENTRE 6

WESTBROOK MEDICAL CENTRE 6

FOLLY LANE MEDICAL CENTRE 7

SPRINGFIELDS MEDICAL CENTRE 5

FAIRFIELD SURGERY 1

DALLAM LANE MEDICAL CENTRE 1

LATCHFORD MEDICAL CENTRE

CULCHETH MEDICAL CENTRE

FEARNHEAD CROSS MED.CTR. Details of this methodology are available on slide 9. Click here to view them.

78 CVD: Primary Care Intelligence Packs Percentage of patients with CHD with a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken by CCG Comparison with CCGs in the STP Optimal management No treatment Exceptions reported

NHS Knowsley CCG 93.5%

NHS Liverpool CCG 93.2% • 7,341 people with coronary heart disease* in NHS Warrington CCG NHS Halton CCG 92.8% • 6,676 (90.9%) people who are taking NHS South Sefton CCG 92.4% aspirin, an alternative anti-platelet therapy, or an anti-coagulant NHS Southport And Formby CCG 92.1% • 324 (4.4%) people who are exceptions NHS South Cheshire CCG 91.6% • 341 (4.6%) additional people who are

NHS West Cheshire CCG 91.5% not taking aspirin, an alternative anti- platelet therapy, or an anti-coagulant NHS Eastern Cheshire CCG 91.2%

NHS Vale Royal CCG 91.2%

NHS St Helens CCG 91.1%

NHS Warrington CCG 90.9%

NHS Wirral CCG 89.6%

England 91.8%

0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator CHD005 denominator plus exceptions

79 CVD: Primary Care Intelligence Packs Percentage of patients with CHD with a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken by CCG Comparison with demographically similar CCGs Optimal management No treatment Exceptions reported

NHS Warwickshire North CCG 93.7%

NHS Redditch and Bromsgrove CCG 93.4%

NHS Telford and Wrekin CCG 93.1%

NHS Hartlepool and Stockton-on-Tees CCG 92.4%

NHS South East Staffordshire and Seisdon Peninsula CCG 92.1%

NHS Cannock Chase CCG 91.6%

NHS Wigan Borough CCG 91.6%

NHS South Cheshire CCG 91.6%

NHS Barnsley CCG 91.4%

NHS Chorley and South Ribble CCG 91.3%

NHS Warrington CCG 90.9%

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

PENKETH HEALTH CENTRE N81020 91 HELSBY STREET MED/CTR N81041 42 4 SEASONS MEDICAL CENTRE N81645 12 • in total, including exceptions, there BIRCHWOOD MEDICAL CENTRE N81114 49 are 665 people are not taking aspirin, THE LAKESIDE SURGERY N81108 38 an alternative anti-platelet therapy, or STOCKTON HEATH MED.CENTRE N81075 75 an anti-coagulant GUARDIAN STREET MED/CTR N81012 37 • GP practice range: 4.2% to 12.6% BROOKFIELD SURGERY N81014 30 MANCHESTER ROAD SURGERY N81107 9 WESTBROOK MEDICAL CENTRE N81122 28 PADGATE MEDICAL CENTRE N81109 21 CULCHETH MEDICAL CENTRE N81059 24 LATCHFORD MEDICAL CENTRE N81065 16 FOLLY LANE MEDICAL CENTRE N81056 31 STRETTON MEDICAL CENTRE N81623 9 GREENBANK SURGERY N81089 31 COCKHEDGE MEDICAL CENTRE N81637 5 CAUSEWAY MEDICAL CENTRE N81028 17 THE ERIC MOORE PARTNERSHIP N81628 18 HOLES LANE MEDICAL CENTRE N81007 27 DALLAM LANE MEDICAL CENTRE N81097 7 SPRINGFIELDS MEDICAL CENTRE N81036 14 PARKVIEW MEDICAL CENTRE N81083 7 FEARNHEAD CROSS MED.CTR. N81048 22 FAIRFIELD SURGERY Y01108 5

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

81 CVD: Primary Care Intelligence Packs Some data on outcomes for people with cardiovascular disease

82 CVD: Primary Care Intelligence Packs Hospital admissions for coronary heart disease for all ages 2002/03 – 2015/16

NHS Warrington CCG England 1000

900 • in NHS Warrington CCG, the hospital admission rate for coronary heart 800 disease in 2015/16 was 604.6 (1,173) compared to 527.9 for England 700

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 Warrington CCG England 250

• in NHS Warrington CCG, the hospital admission rate for stroke in 2015/16 200 was 173.9 (323) compared to 172.8 for England

150

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

50

0 2002/032003/042004/052005/062006/072007/082008/092009/102010/112011/122012/132013/142014/152015/16 Source: Hospital Episode Statistics (HES), 2002/03 - 2015/16, Copyright © 2017, Re‐used with the permission of NHS Digital. All rights reserved

84 CVD: Primary Care Intelligence Packs Additional risk of complications for people with diabetes, three year follow up, 2013/14

NHS Warrington CCG England

141.3% Angina 136.8% • The risk of a stroke was 97.9% higher and the risk of a heart attack was 132.1% 132.1% higher compared to people Heart Attack 108.6% without diabetes. The risk of a major amputation was 355.6% higher. 136.2% Heart failure 150.0%

97.9% Stroke 81.3%

355.6% Major amputation 445.8%

677.5% Minor amputation 753.5%

216.2% 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 Warrington CCG England 120

• in NHS Warrington CCG, the early 100 mortality rate for coronary heart disease in 2013-15 was 43.9, compared to 40.6 for England

80

60

40 Age Age standardised (per rate 1000,000)

20

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 Warrington CCG England 30

• in NHS Warrington CCG, the early 25 mortality rate for stroke in 2013-15 was 15.6, 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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