CVD: Primary Care Intelligence Packs NHS Brent 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 Brent CCG are: NHS Waltham Forest CCG NHS Ealing CCG NHS Croydon CCG NHS Greenwich CCG NHS Haringey CCG NHS Hounslow CCG NHS Merton CCG NHS Lewisham CCG NHS Sandwell and West Birmingham CCG NHS Redbridge 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 Haringey CCG 21.1%

NHS Sandwell and West Birmingham CCG 19.8% • prevalence of 16.9% in NHS Brent CCG NHS Lewisham CCG 19.8%

NHS Waltham Forest CCG 19.7%

NHS Greenwich CCG 18.8%

NHS Croydon CCG 17.0%

NHS Brent CCG 16.9%

NHS Hounslow CCG 16.2% Note: It has been found that the proportion of patients recorded as smokers correlates well NHS Merton CCG 15.5% with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, NHS Ealing CCG 15.5% http://bmjopen.bmj.com/content/4/7/e005217.abs tract

NHS Redbridge CCG 13.6% 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

ST ANDREWS MEDICAL CENTRE E84011 27.8% PEEL PRECINCT SURGERY E84696 26.5% BURNLEY PRACTICE Y00206 25.5% THE VILLAGE MEDICAL CENTRE E84708 25.3% THE WILLESDEN MEDICAL CENTRE E84021 24.4% FREUCHEN MEDICAL CENTRE E84074 24.3% CHAMBERLAYNE RD SURGERY E84705 23.6% CHURCH END MEDICAL CENTRE E84013 23.6% • 50,929 people who are recorded as BLESSING MEDICAL CENTRE E84667 23.6% CHICHELE ROAD SURGERY E84674 23.4% BUCKINGHAM RD SURGERY E84026 22.1% smokers in NHS Brent CCG PARK ROAD SURGERY E84624 21.3% GLADSTONE MEDICAL CENTRE E84036 21.1% • GP practice range: 7.0% to 27.8% HILLTOP MEDICAL PRACTICE E84637 20.9% KILBURN PARK MEDICAL CENTRE E84042 20.9% NEASDEN MEDICAL CENTRE E84665 20.7% THE SHELDON PRACTICE E84077 20.0% WILLOW TREE FAMILY DOCTORS E84706 19.6% HARNESS HARLESDEN PRACTICE E84029 19.5% WALM LANE SURGERY E84086 19.4% THE TUDOR HOUSE MEDICAL CENTRE E84684 19.3% ACTON LANE SURGERY E84645 19.2% PARK HOUSE MEDICAL CENTRE E84023 19.2% BRENTFIELD MEDICAL CENTRE E84031 19.1% HARNESS WEMBLEY PRACTICE Y02692 19.0% STAVERTON SURGERY E84080 18.5% ROUNDWOOD PARK MEDICAL CENTRE E84656 18.4% THE STONEBRIDGE PRACTICE E84028 18.3% WEMBLEY PARK DRIVE MEDICAL CENTRE E84709 18.1% THE LAW MEDICAL GROUP PRACTICE E84006 17.8% CHALKHILL FAMILY PRACTICE E84033 17.4% THE CLARENCE MEDICAL CENTRE E84056 17.4% ELLIS PRACTICE E84032 17.2% THE LONSDALE MEDICAL CENTRE E84025 17.1% THE WINDMILL MEDICAL PRACTICE E84012 16.9% WILLOW TREE FAMILY DOCTORS E84015 16.5% CRICKLEWOOD BROADWAY SURGERY E83654 16.4% CREST MEDICAL CENTRE E84690 16.2% AKSYR MEDICAL PRACTICE E84030 16.1% OXGATE GARDENS SURGERY E84076 15.4% WILLESDEN GREEN SURGERY E84702 14.9% LANFRANC MEDICAL CENTRE E84083 14.7% FORTY WILLOWS SURGERY E84002 14.5% THE SUNFLOWER MEDICAL CENTRE E84626 14.2% THE BEECHCROFT MEDICAL CENTRE E84084 13.9% SUDBURY & ALPERTON MEDICAL CENTRE E84017 13.8% THE FRYENT WAY SURGERY E84048 13.3% HAZELDENE MEDICAL CENTRE E84066 13.2% INTERGRATED HEALTH CIC E84685 12.9% ST.GEORGES MEDICAL CENTRE E84704 12.9% PRESTON ROAD SURGERY E84620 12.7% CHURCH LANE SURGERY E84067 12.3% PRESTON MEDICAL CENTRE E84678 12.1% THE STAG - HOLLYROOD PRACTICE E84020 12.0% THE SURGERY E84635 11.5% Note: This method is thought to be a reasonably SMS MEDICAL PRACTICE Y01090 11.4% STANLEY CORNER MEDICAL CENTRE E84051 11.2% KINGS EDGE MEDICAL CENTRE E84699 11.0% robust method in estimating smoking prevalence KINGSBURY HEALTH AND WELLBEING E84078 10.7% BRAMPTON HEALTH CENTRE E84049 10.3% for the majority of GP practices. However, PEARL MEDICAL PRACTICE E84701 9.0% UXENDON CRESCENT SURGERY E84007 8.6% caution is advised for extreme estimates of THE EAGLE EYE E84669 8.6% LANCELOT MEDICAL CENTRE E84063 8.5% smoking prevalence and those with high PREMIER MEDICAL CENTRE E84003 8.0% ALPERTON MEDICAL CENTRE E84638 7.0% 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 Harrow CCG 0.59

NHS Hillingdon CCG 0.58 • the ratio of those diagnosed with hypertension versus those expected NHS Brent CCG 0.58 to have hypertension is 0.58. This compares to 0.59 for England • this suggests that 58% of people with NHS Hounslow CCG 0.57 hypertension have been diagnosed

NHS Ealing CCG 0.57

NHS Hammersmith And Fulham CCG 0.51

NHS West London CCG 0.49

NHS Central London (Westminster) CCG 0.48

Note: this slide shows Hypertension prevalence England 0.59 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 Greenwich CCG 0.60

NHS Sandwell and West Birmingham CCG 0.59

NHS Brent CCG 0.58

NHS Redbridge CCG 0.57

NHS Hounslow CCG 0.57

NHS Ealing CCG 0.57

NHS Croydon CCG 0.57

NHS Waltham Forest CCG 0.56

NHS Lewisham CCG 0.56

NHS Haringey CCG 0.55

NHS Merton CCG 0.53

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

KINGS EDGE MEDICAL CENTRE E84699 0.84 KINGSBURY HEALTH AND WELLBEING E84078 0.79 ST.GEORGES MEDICAL CENTRE E84704 0.75 ST ANDREWS MEDICAL CENTRE E84011 0.73 GLADSTONE MEDICAL CENTRE E84036 0.70 THE STAG - HOLLYROOD PRACTICE E84020 0.70 WILLOW TREE FAMILY DOCTORS E84015 0.70 HARNESS HARLESDEN PRACTICE E84029 0.65 STANLEY CORNER MEDICAL CENTRE E84051 0.65 • it is estimated that there are 31,986 PEEL PRECINCT SURGERY E84696 0.65 LANFRANC MEDICAL CENTRE E84083 0.64 THE BEECHCROFT MEDICAL CENTRE E84084 0.64 people with undiagnosed BRENTFIELD MEDICAL CENTRE E84031 0.64 PARK HOUSE MEDICAL CENTRE E84023 0.64 SUDBURY & ALPERTON MEDICAL CENTRE E84017 0.64 hypertension in NHS Brent CCG AKSYR MEDICAL PRACTICE E84030 0.63 THE WILLESDEN MEDICAL CENTRE E84021 0.63 CREST MEDICAL CENTRE E84690 0.63 • GP practice range of observed to THE SUNFLOWER MEDICAL CENTRE E84626 0.63 PARK ROAD SURGERY E84624 0.62 THE LAW MEDICAL GROUP PRACTICE E84006 0.62 expected hypertension prevalence WILLOW TREE FAMILY DOCTORS E84706 0.62 THE SHELDON PRACTICE E84077 0.60 THE EAGLE EYE E84669 0.60 0.35 to 0.84 THE CLARENCE MEDICAL CENTRE E84056 0.60 THE STONEBRIDGE PRACTICE E84028 0.59 THE VILLAGE MEDICAL CENTRE E84708 0.59 UXENDON CRESCENT SURGERY E84007 0.58 ROUNDWOOD PARK MEDICAL CENTRE E84656 0.58 ACTON LANE SURGERY E84645 0.58 PRESTON ROAD SURGERY E84620 0.58 HAZELDENE MEDICAL CENTRE E84066 0.58 PREMIER MEDICAL CENTRE E84003 0.56 THE FRYENT WAY SURGERY E84048 0.56 INTERGRATED HEALTH CIC E84685 0.56 THE TUDOR HOUSE MEDICAL CENTRE E84684 0.56 PRESTON MEDICAL CENTRE E84678 0.55 FREUCHEN MEDICAL CENTRE E84074 0.55 OXGATE GARDENS SURGERY E84076 0.55 NEASDEN MEDICAL CENTRE E84665 0.55 BLESSING MEDICAL CENTRE E84667 0.54 WEMBLEY PARK DRIVE MEDICAL CENTRE E84709 0.53 BUCKINGHAM RD SURGERY E84026 0.53 CHURCH END MEDICAL CENTRE E84013 0.53 FORTY WILLOWS SURGERY E84002 0.53 PEARL MEDICAL PRACTICE E84701 0.53 CRICKLEWOOD BROADWAY SURGERY E83654 0.51 THE SURGERY E84635 0.51 CHURCH LANE SURGERY E84067 0.51 SMS MEDICAL PRACTICE Y01090 0.50 CHAMBERLAYNE RD SURGERY E84705 0.50 ALPERTON MEDICAL CENTRE E84638 0.49 LANCELOT MEDICAL CENTRE E84063 0.49 CHICHELE ROAD SURGERY E84674 0.48 ELLIS PRACTICE E84032 0.47 KILBURN PARK MEDICAL CENTRE E84042 0.47 THE WINDMILL MEDICAL PRACTICE E84012 0.47 CHALKHILL FAMILY PRACTICE E84033 0.47 WILLESDEN GREEN SURGERY E84702 0.46 STAVERTON SURGERY E84080 0.46 BURNLEY PRACTICE Y00206 0.44 BRAMPTON HEALTH CENTRE E84049 0.42 HILLTOP MEDICAL PRACTICE E84637 0.41 WALM LANE SURGERY E84086 0.41 THE LONSDALE MEDICAL CENTRE E84025 0.40 HARNESS WEMBLEY PRACTICE Y02692 0.35 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 Harrow CCG 80.3%

NHS Brent CCG 79.8% • 44,731 people with hypertension (diagnosed)* in NHS Brent CCG NHS Hillingdon CCG 79.7% • 35,690 (79.8%) people whose blood pressure is <= 150/90 • 1,940 (4.3%) people who are NHS Hounslow CCG 78.8% excepted from optimal control • 7,101 (15.9%) additional people NHS Ealing CCG 78.7% whose blood pressure is not <= 150/90

NHS West London CCG 77.6%

NHS Central London (Westminster) CCG 75.3%

NHS Hammersmith And Fulham CCG 74.3%

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 Brent CCG 79.8%

NHS Hounslow CCG 78.8%

NHS Ealing CCG 78.7%

NHS Croydon CCG 78.5%

NHS Sandwell and West Birmingham CCG 78.5%

NHS Redbridge CCG 78.3%

NHS Waltham Forest CCG 77.7%

NHS Merton CCG 77.3%

NHS Greenwich CCG 76.0%

NHS Lewisham CCG 74.9%

NHS Haringey CCG 74.7%

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

21 CVD: Primary Care Intelligence Packs Percentage of patients with hypertension whose last blood pressure reading (measured in the preceding 12 months) is not 150/90 mmHg or less by GP practice

No treatment Exceptions reported

PARK ROAD SURGERY E84624 149 CRICKLEWOOD BROADWAY SURGERY E83654 121 THE SUNFLOWER MEDICAL CENTRE E84626 124 CHICHELE ROAD SURGERY E84674 174 THE VILLAGE MEDICAL CENTRE E84708 90 AKSYR MEDICAL PRACTICE E84030 271 KILBURN PARK MEDICAL CENTRE E84042 244 WALM LANE SURGERY E84086 165 • in total, including exceptions, there THE CLARENCE MEDICAL CENTRE E84056 86 ELLIS PRACTICE E84032 246 FORTY WILLOWS SURGERY E84002 208 are 9,041 people whose blood THE WILLESDEN MEDICAL CENTRE E84021 419 FREUCHEN MEDICAL CENTRE E84074 193 PARK HOUSE MEDICAL CENTRE E84023 170 pressure is not <= 150/90 ROUNDWOOD PARK MEDICAL CENTRE E84656 118 KINGS EDGE MEDICAL CENTRE E84699 177 PEEL PRECINCT SURGERY E84696 51 • GP practice range: 8.8% to 37.1% HARNESS WEMBLEY PRACTICE Y02692 93 INTERGRATED HEALTH CIC E84685 259 HAZELDENE MEDICAL CENTRE E84066 102 GLADSTONE MEDICAL CENTRE E84036 253 THE LAW MEDICAL GROUP PRACTICE E84006 446 BURNLEY PRACTICE Y00206 105 THE TUDOR HOUSE MEDICAL CENTRE E84684 93 THE STONEBRIDGE PRACTICE E84028 151 SMS MEDICAL PRACTICE Y01090 85 THE LONSDALE MEDICAL CENTRE E84025 229 BRENTFIELD MEDICAL CENTRE E84031 261 BUCKINGHAM RD SURGERY E84026 149 CHURCH LANE SURGERY E84067 131 WEMBLEY PARK DRIVE MEDICAL CENTRE E84709 209 PEARL MEDICAL PRACTICE E84701 84 THE WINDMILL MEDICAL PRACTICE E84012 138 CHALKHILL FAMILY PRACTICE E84033 94 THE SURGERY E84635 82 CREST MEDICAL CENTRE E84690 85 LANCELOT MEDICAL CENTRE E84063 80 STAVERTON SURGERY E84080 135 ACTON LANE SURGERY E84645 99 BRAMPTON HEALTH CENTRE E84049 74 HARNESS HARLESDEN PRACTICE E84029 74 HILLTOP MEDICAL PRACTICE E84637 49 THE FRYENT WAY SURGERY E84048 192 SUDBURY & ALPERTON MEDICAL CENTRE E84017 208 UXENDON CRESCENT SURGERY E84007 147 ALPERTON MEDICAL CENTRE E84638 107 STANLEY CORNER MEDICAL CENTRE E84051 138 CHAMBERLAYNE RD SURGERY E84705 39 PRESTON ROAD SURGERY E84620 103 THE EAGLE EYE E84669 57 ST ANDREWS MEDICAL CENTRE E84011 82 NEASDEN MEDICAL CENTRE E84665 164 THE BEECHCROFT MEDICAL CENTRE E84084 93 BLESSING MEDICAL CENTRE E84667 42 OXGATE GARDENS SURGERY E84076 119 CHURCH END MEDICAL CENTRE E84013 143 THE SHELDON PRACTICE E84077 43 LANFRANC MEDICAL CENTRE E84083 118 WILLOW TREE FAMILY DOCTORS E84015 231 THE STAG - HOLLYROOD PRACTICE E84020 67 WILLESDEN GREEN SURGERY E84702 38 KINGSBURY HEALTH AND WELLBEING E84078 131 WILLOW TREE FAMILY DOCTORS E84706 41 PREMIER MEDICAL CENTRE E84003 90 PRESTON MEDICAL CENTRE E84678 53 ST.GEORGES MEDICAL CENTRE E84704 29 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 Hammersmith And Fulham CCG 84.4%

NHS Ealing CCG 83.4% • 231 people with a new diagnosis* of hypertension with a CVD risk of 20% NHS Hounslow CCG 78.4% or higher in NHS Brent CCG • 162 (70.1%) people who are currently treated with statins NHS West London CCG 76.0% • 58 (25.1%) people who are exempted from treatment with statins NHS Central London (Westminster) CCG 73.4% • 11 (4.8%) additional people who are not currently treated with statins

NHS Hillingdon CCG 71.6%

NHS Brent CCG 70.1%

NHS Harrow CCG 65.4%

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 Ealing CCG 83.4%

NHS Redbridge CCG 80.2%

NHS Sandwell and West Birmingham CCG 79.4%

NHS Hounslow CCG 78.4%

NHS Lewisham CCG 76.8%

NHS Greenwich CCG 74.5%

NHS Haringey CCG 74.3%

NHS Waltham Forest CCG 72.5%

NHS Merton CCG 72.0%

NHS Croydon CCG 70.8%

NHS Brent CCG 70.1%

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

THE SUNFLOWER MEDICAL CENTRE E84626 1 PEEL PRECINCT SURGERY E84696 2 THE LONSDALE MEDICAL CENTRE E84025 10 THE FRYENT WAY SURGERY E84048 4 CREST MEDICAL CENTRE E84690 2 ST.GEORGES MEDICAL CENTRE E84704 4 THE VILLAGE MEDICAL CENTRE E84708 2 KILBURN PARK MEDICAL CENTRE E84042 5 • in total, including exceptions, there ST ANDREWS MEDICAL CENTRE E84011 1 AKSYR MEDICAL PRACTICE E84030 1 BRENTFIELD MEDICAL CENTRE E84031 1 are 69 people who are not treated ELLIS PRACTICE E84032 2 HAZELDENE MEDICAL CENTRE E84066 1 BURNLEY PRACTICE Y00206 1 with statins INTERGRATED HEALTH CIC E84685 7 THE LAW MEDICAL GROUP PRACTICE E84006 3 CHALKHILL FAMILY PRACTICE E84033 1 • GP practice range: 0.0% to 100.0% GLADSTONE MEDICAL CENTRE E84036 2 BRAMPTON HEALTH CENTRE E84049 1 THE SHELDON PRACTICE E84077 1 HILLTOP MEDICAL PRACTICE E84637 1 PRESTON MEDICAL CENTRE E84678 1 PEARL MEDICAL PRACTICE E84701 1 WEMBLEY PARK DRIVE MEDICAL CENTRE E84709 2 BLESSING MEDICAL CENTRE E84667 2 THE WILLESDEN MEDICAL CENTRE E84021 2 THE SURGERY E84635 2 ACTON LANE SURGERY E84645 1 NEASDEN MEDICAL CENTRE E84665 1 THE WINDMILL MEDICAL PRACTICE E84012 1 KINGS EDGE MEDICAL CENTRE E84699 1 THE STAG - HOLLYROOD PRACTICE E84020 1 WILLOW TREE FAMILY DOCTORS E84015 1 CRICKLEWOOD BROADWAY SURGERY E83654 FORTY WILLOWS SURGERY E84002 PREMIER MEDICAL CENTRE E84003 UXENDON CRESCENT SURGERY E84007 CHURCH END MEDICAL CENTRE E84013 SUDBURY & ALPERTON MEDICAL CENTRE E84017 PARK HOUSE MEDICAL CENTRE E84023 BUCKINGHAM RD SURGERY E84026 THE STONEBRIDGE PRACTICE E84028 STANLEY CORNER MEDICAL CENTRE E84051 THE CLARENCE MEDICAL CENTRE E84056 LANCELOT MEDICAL CENTRE E84063 CHURCH LANE SURGERY E84067 FREUCHEN MEDICAL CENTRE E84074 OXGATE GARDENS SURGERY E84076 KINGSBURY HEALTH AND WELLBEING E84078 STAVERTON SURGERY E84080 LANFRANC MEDICAL CENTRE E84083 THE BEECHCROFT MEDICAL CENTRE E84084 WALM LANE SURGERY E84086 PRESTON ROAD SURGERY E84620 ALPERTON MEDICAL CENTRE E84638 ROUNDWOOD PARK MEDICAL CENTRE E84656 THE EAGLE EYE E84669 CHICHELE ROAD SURGERY E84674 THE TUDOR HOUSE MEDICAL CENTRE E84684 WILLESDEN GREEN SURGERY E84702 CHAMBERLAYNE RD SURGERY E84705 WILLOW TREE FAMILY DOCTORS E84706 SMS MEDICAL PRACTICE Y01090 HARNESS WEMBLEY PRACTICE Y02692 PARK ROAD SURGERY E84624 HARNESS HARLESDEN PRACTICE E84029 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 Central London (Westminster) CCG 0.65

NHS Hammersmith And Fulham CCG 0.65 • the ratio of those diagnosed with atrial fibrillation versus those expected to NHS Hillingdon CCG 0.64 have atrial fibrillation is 0.47. This compares to 0.7 for England • this suggests that 47% of people with NHS Ealing CCG 0.61 atrial fibrillation have been diagnosed.

NHS Hounslow CCG 0.59

NHS Harrow CCG 0.58

NHS West London CCG 0.58

NHS Brent CCG 0.47 Note: This slide compares the prevalence of atrial fibrillation recorded in QOF in 2015/16 to the estimated prevalence of atrial fibrillation, taken from National Cardiovascular Intelligence Network estimates produced in 2017. The estimates were developed by applying age-sex England 0.70 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 Ealing CCG 0.61

NHS Sandwell and West Birmingham CCG 0.60

NHS Greenwich CCG 0.60

NHS Hounslow CCG 0.59

NHS Merton CCG 0.58

NHS Croydon CCG 0.54

NHS Lewisham CCG 0.53

NHS Haringey CCG 0.52

NHS Waltham Forest CCG 0.51

NHS Redbridge CCG 0.50

NHS Brent CCG 0.47

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7

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

GP practice CCG

THE VILLAGE MEDICAL CENTRE E84708 3.0 THE BEECHCROFT MEDICAL CENTRE E84084 1.4 STAVERTON SURGERY E84080 0.7 THE LAW MEDICAL GROUP PRACTICE E84006 0.6 ST ANDREWS MEDICAL CENTRE E84011 0.6 THE WINDMILL MEDICAL PRACTICE E84012 0.6 THE LONSDALE MEDICAL CENTRE E84025 0.6 BRENTFIELD MEDICAL CENTRE E84031 0.6 ELLIS PRACTICE E84032 0.6 • it is estimated that there are 5,843 CHALKHILL FAMILY PRACTICE E84033 0.6 GLADSTONE MEDICAL CENTRE E84036 0.6 OXGATE GARDENS SURGERY E84076 0.6 people with undiagnosed atrial THE SHELDON PRACTICE E84077 0.6 ROUNDWOOD PARK MEDICAL CENTRE E84656 0.6 fibrillation in NHS Brent CCG CRICKLEWOOD BROADWAY SURGERY E83654 0.5 FORTY WILLOWS SURGERY E84002 0.5 UXENDON CRESCENT SURGERY E84007 0.5 • GP practice range of observed to CHURCH END MEDICAL CENTRE E84013 0.5 WILLOW TREE FAMILY DOCTORS E84015 0.5 PARK HOUSE MEDICAL CENTRE E84023 0.5 expected atrial fibrillation prevalence KILBURN PARK MEDICAL CENTRE E84042 0.5 THE FRYENT WAY SURGERY E84048 0.5 WALM LANE SURGERY E84086 0.5 0.1 to 3 PRESTON ROAD SURGERY E84620 0.5 PARK ROAD SURGERY E84624 0.5 HILLTOP MEDICAL PRACTICE E84637 0.5 NEASDEN MEDICAL CENTRE E84665 0.5 BLESSING MEDICAL CENTRE E84667 0.5 CREST MEDICAL CENTRE E84690 0.5 KINGS EDGE MEDICAL CENTRE E84699 0.5 WEMBLEY PARK DRIVE MEDICAL CENTRE E84709 0.5 BURNLEY PRACTICE Y00206 0.5 PREMIER MEDICAL CENTRE E84003 0.4 SUDBURY & ALPERTON MEDICAL CENTRE E84017 0.4 THE STAG - HOLLYROOD PRACTICE E84020 0.4 THE WILLESDEN MEDICAL CENTRE E84021 0.4 KINGSBURY HEALTH AND WELLBEING E84078 0.4 LANFRANC MEDICAL CENTRE E84083 0.4 THE SUNFLOWER MEDICAL CENTRE E84626 0.4 THE SURGERY E84635 0.4 THE EAGLE EYE E84669 0.4 INTERGRATED HEALTH CIC E84685 0.4 ST.GEORGES MEDICAL CENTRE E84704 0.4 SMS MEDICAL PRACTICE Y01090 0.4 BUCKINGHAM RD SURGERY E84026 0.3 THE STONEBRIDGE PRACTICE E84028 0.3 HARNESS HARLESDEN PRACTICE E84029 0.3 AKSYR MEDICAL PRACTICE E84030 0.3 BRAMPTON HEALTH CENTRE E84049 0.3 STANLEY CORNER MEDICAL CENTRE E84051 0.3 LANCELOT MEDICAL CENTRE E84063 0.3 FREUCHEN MEDICAL CENTRE E84074 0.3 CHICHELE ROAD SURGERY E84674 0.3 THE TUDOR HOUSE MEDICAL CENTRE E84684 0.3 WILLESDEN GREEN SURGERY E84702 0.3 CHAMBERLAYNE RD SURGERY E84705 0.3 HAZELDENE MEDICAL CENTRE E84066 0.2 CHURCH LANE SURGERY E84067 0.2 ALPERTON MEDICAL CENTRE E84638 0.2 PRESTON MEDICAL CENTRE E84678 0.2 PEEL PRECINCT SURGERY E84696 0.2 PEARL MEDICAL PRACTICE E84701 0.2 HARNESS WEMBLEY PRACTICE Y02692 0.2 ACTON LANE SURGERY E84645 0.1 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 Hounslow CCG 76.9% • 2,266 people with atrial fibrillation* NHS Hammersmith And Fulham CCG 76.4% with a CHA2DS2-VASc score >= 2 in NHS Brent CCG NHS Central London (Westminster) CCG 76.1% • 1,547 (68.3%) people treated with anti-coagulation therapy • 375 (16.5%) people who are NHS Ealing CCG 75.9% exceptions • 344 (15.2%) additional people with a NHS West London CCG 75.9% recorded CHA2DS2-VASc score >= 2 who are not treated

NHS Hillingdon CCG 72.2%

NHS Harrow CCG 69.0%

NHS Brent CCG 68.3%

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 Sandwell and West Birmingham CCG 79.5%

NHS Merton CCG 77.3%

NHS Hounslow CCG 76.9%

NHS Ealing CCG 75.9%

NHS Waltham Forest CCG 75.7%

NHS Redbridge CCG 75.5%

NHS Croydon CCG 72.8%

NHS Lewisham CCG 71.1%

NHS Haringey CCG 71.1%

NHS Greenwich CCG 70.4%

NHS Brent CCG 68.3%

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

HARNESS HARLESDEN PRACTICE E84029 9 THE BEECHCROFT MEDICAL CENTRE E84084 33 PRESTON MEDICAL CENTRE E84678 8 CHICHELE ROAD SURGERY E84674 10 CHALKHILL FAMILY PRACTICE E84033 16 KINGSBURY HEALTH AND WELLBEING E84078 24 KINGS EDGE MEDICAL CENTRE E84699 10 PRESTON ROAD SURGERY E84620 12 • in total, including exceptions, there UXENDON CRESCENT SURGERY E84007 31 THE STONEBRIDGE PRACTICE E84028 10 THE LAW MEDICAL GROUP PRACTICE E84006 53 are 719 people with a recorded THE VILLAGE MEDICAL CENTRE E84708 7 WALM LANE SURGERY E84086 14 HARNESS WEMBLEY PRACTICE Y02692 2 CHA2DS2-VASc score >= 2 who are THE STAG - HOLLYROOD PRACTICE E84020 11 AKSYR MEDICAL PRACTICE E84030 14 BURNLEY PRACTICE Y00206 7 not treated BRENTFIELD MEDICAL CENTRE E84031 27 THE SHELDON PRACTICE E84077 6 • GP practice range: 0.0% to 60.0% WILLOW TREE FAMILY DOCTORS E84015 40 THE WILLESDEN MEDICAL CENTRE E84021 19 THE FRYENT WAY SURGERY E84048 23 WEMBLEY PARK DRIVE MEDICAL CENTRE E84709 18 BRAMPTON HEALTH CENTRE E84049 7 ACTON LANE SURGERY E84645 1 PEARL MEDICAL PRACTICE E84701 3 SMS MEDICAL PRACTICE Y01090 6 INTERGRATED HEALTH CIC E84685 19 THE SURGERY E84635 7 PARK ROAD SURGERY E84624 6 NEASDEN MEDICAL CENTRE E84665 12 GLADSTONE MEDICAL CENTRE E84036 16 CHURCH END MEDICAL CENTRE E84013 16 STANLEY CORNER MEDICAL CENTRE E84051 7 FREUCHEN MEDICAL CENTRE E84074 6 HILLTOP MEDICAL PRACTICE E84637 4 CHAMBERLAYNE RD SURGERY E84705 2 ELLIS PRACTICE E84032 16 THE SUNFLOWER MEDICAL CENTRE E84626 5 SUDBURY & ALPERTON MEDICAL CENTRE E84017 17 CHURCH LANE SURGERY E84067 3 STAVERTON SURGERY E84080 17 ST ANDREWS MEDICAL CENTRE E84011 8 PARK HOUSE MEDICAL CENTRE E84023 9 PREMIER MEDICAL CENTRE E84003 9 BUCKINGHAM RD SURGERY E84026 7 OXGATE GARDENS SURGERY E84076 16 BLESSING MEDICAL CENTRE E84667 3 CRICKLEWOOD BROADWAY SURGERY E83654 5 HAZELDENE MEDICAL CENTRE E84066 3 FORTY WILLOWS SURGERY E84002 14 THE WINDMILL MEDICAL PRACTICE E84012 14 THE TUDOR HOUSE MEDICAL CENTRE E84684 4 THE LONSDALE MEDICAL CENTRE E84025 20 ALPERTON MEDICAL CENTRE E84638 3 ST.GEORGES MEDICAL CENTRE E84704 2 CREST MEDICAL CENTRE E84690 3 ROUNDWOOD PARK MEDICAL CENTRE E84656 4 KILBURN PARK MEDICAL CENTRE E84042 7 LANFRANC MEDICAL CENTRE E84083 7 THE EAGLE EYE E84669 2 THE CLARENCE MEDICAL CENTRE E84056 2 LANCELOT MEDICAL CENTRE E84063 1 WILLESDEN GREEN SURGERY E84702 1 WILLOW TREE FAMILY DOCTORS E84706 1 PEEL PRECINCT SURGERY E84696 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% 10% 0% -10% -20% -30% -40% -50%

HARNESS HARLESDEN PRACTICE 7

THE BEECHCROFT MEDICAL CENTRE 24

PRESTON MEDICAL CENTRE 6 • using the GP cluster method of CHALKHILL FAMILY PRACTICE 11 calculating potential gains, if each CHICHELE ROAD SURGERY 7 practice was to achieve as well as the KINGSBURY HEALTH AND WELLBEING 15 upper quartile of its national cluster, then an additional 367 people would KINGS EDGE MEDICAL CENTRE 6 be treated PRESTON ROAD SURGERY 8

UXENDON CRESCENT SURGERY 20

THE STONEBRIDGE PRACTICE 6

THE LONSDALE MEDICAL CENTRE 3

ROUNDWOOD PARK MEDICAL CENTRE

KILBURN PARK MEDICAL CENTRE

LANFRANC MEDICAL CENTRE

THE EAGLE EYE

THE CLARENCE MEDICAL CENTRE

LANCELOT MEDICAL CENTRE

WILLESDEN GREEN SURGERY

WILLOW TREE FAMILY DOCTORS

PEEL PRECINCT 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

NHS Harrow CCG 84.8% • 3,921 people with a history of stroke NHS Hounslow CCG 84.6% or TIA* in NHS Brent CCG • 3,300 (84.2%) people whose blood NHS Brent CCG 84.2% pressure is <= 150 / 90 • 193 (4.9%) people who are exceptions NHS Hillingdon CCG 83.3% • 428 (10.9%) additional people whose blood pressure is not <= 150 / 90 NHS Central London (Westminster) CCG 82.9%

NHS Ealing CCG 82.9%

NHS West London CCG 81.3%

NHS Hammersmith And Fulham CCG 80.3%

England 83.8%

0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator STIA003 denominator plus exceptions

35 CVD: Primary Care Intelligence Packs Percentage of patients with a history of stroke whose last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less by CCG Comparison with demographically similar CCGs Below 150/90 Not below 150/90 Exceptions reported

NHS Redbridge CCG 84.6%

NHS Hounslow CCG 84.6%

NHS Brent CCG 84.2%

NHS Croydon CCG 83.6%

NHS Sandwell and West Birmingham CCG 83.6%

NHS Greenwich CCG 83.3%

NHS Ealing CCG 82.9%

NHS Waltham Forest CCG 82.9%

NHS Merton CCG 82.3%

NHS Lewisham CCG 80.8%

NHS Haringey CCG 78.9%

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

CHICHELE ROAD SURGERY E84674 13 THE WILLESDEN MEDICAL CENTRE E84021 33 SMS MEDICAL PRACTICE Y01090 9 THE SUNFLOWER MEDICAL CENTRE E84626 9 THE CLARENCE MEDICAL CENTRE E84056 6 CRICKLEWOOD BROADWAY SURGERY E83654 7 CHURCH LANE SURGERY E84067 10 PEARL MEDICAL PRACTICE E84701 5 • in total, including exceptions, there KILBURN PARK MEDICAL CENTRE E84042 25 ELLIS PRACTICE E84032 25 THE SURGERY E84635 8 are 621 people whose blood pressure GLADSTONE MEDICAL CENTRE E84036 22 STANLEY CORNER MEDICAL CENTRE E84051 14 BRENTFIELD MEDICAL CENTRE E84031 21 is not <= 150 / 90 WALM LANE SURGERY E84086 11 BRAMPTON HEALTH CENTRE E84049 5 THE EAGLE EYE E84669 5 • GP practice range: 0.0% to 36.1% ACTON LANE SURGERY E84645 6 THE BEECHCROFT MEDICAL CENTRE E84084 13 INTERGRATED HEALTH CIC E84685 18 THE LAW MEDICAL GROUP PRACTICE E84006 43 STAVERTON SURGERY E84080 17 PARK ROAD SURGERY E84624 5 THE VILLAGE MEDICAL CENTRE E84708 5 THE TUDOR HOUSE MEDICAL CENTRE E84684 6 AKSYR MEDICAL PRACTICE E84030 15 HARNESS HARLESDEN PRACTICE E84029 9 PEEL PRECINCT SURGERY E84696 2 HARNESS WEMBLEY PRACTICE Y02692 4 LANCELOT MEDICAL CENTRE E84063 4 FORTY WILLOWS SURGERY E84002 13 WEMBLEY PARK DRIVE MEDICAL CENTRE E84709 17 UXENDON CRESCENT SURGERY E84007 13 PRESTON ROAD SURGERY E84620 6 CHALKHILL FAMILY PRACTICE E84033 8 ST.GEORGES MEDICAL CENTRE E84704 5 BURNLEY PRACTICE Y00206 7 BUCKINGHAM RD SURGERY E84026 8 HAZELDENE MEDICAL CENTRE E84066 4 OXGATE GARDENS SURGERY E84076 13 WILLOW TREE FAMILY DOCTORS E84706 5 THE LONSDALE MEDICAL CENTRE E84025 17 ROUNDWOOD PARK MEDICAL CENTRE E84656 7 THE STONEBRIDGE PRACTICE E84028 7 THE WINDMILL MEDICAL PRACTICE E84012 8 CHURCH END MEDICAL CENTRE E84013 15 THE FRYENT WAY SURGERY E84048 13 WILLOW TREE FAMILY DOCTORS E84015 17 FREUCHEN MEDICAL CENTRE E84074 7 PARK HOUSE MEDICAL CENTRE E84023 5 ST ANDREWS MEDICAL CENTRE E84011 4 NEASDEN MEDICAL CENTRE E84665 7 KINGSBURY HEALTH AND WELLBEING E84078 12 HILLTOP MEDICAL PRACTICE E84637 2 BLESSING MEDICAL CENTRE E84667 2 THE SHELDON PRACTICE E84077 2 LANFRANC MEDICAL CENTRE E84083 6 CREST MEDICAL CENTRE E84690 2 PREMIER MEDICAL CENTRE E84003 5 THE STAG - HOLLYROOD PRACTICE E84020 3 PRESTON MEDICAL CENTRE E84678 2 CHAMBERLAYNE RD SURGERY E84705 1 SUDBURY & ALPERTON MEDICAL CENTRE E84017 2 ALPERTON MEDICAL CENTRE E84638 1 KINGS EDGE MEDICAL CENTRE E84699 WILLESDEN GREEN SURGERY E84702 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 Ealing CCG 93.0% • 2,093 people with a stroke shown to NHS Hounslow CCG 91.8% be non-haemorrhagic* in NHS Brent CCG NHS Central London (Westminster) CCG 90.8% • 1,892 (90.4%) people who are taking an anti-platetet agent or anti- coagulant NHS Hillingdon CCG 90.8% • 144 (6.9%) people who are exceptions NHS Brent CCG 90.4% • 57 (2.7%) additional people with no treatment

NHS Harrow CCG 90.3%

NHS Hammersmith And Fulham CCG 90.2%

NHS West London CCG 87.3%

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 Ealing CCG 93.0%

NHS Merton CCG 92.8%

NHS Hounslow CCG 91.8%

NHS Croydon CCG 91.3%

NHS Sandwell and West Birmingham CCG 91.3%

NHS Redbridge CCG 91.0%

NHS Lewisham CCG 91.0%

NHS Greenwich CCG 90.9%

NHS Waltham Forest CCG 90.9%

NHS Brent CCG 90.4%

NHS Haringey CCG 88.3%

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

CHALKHILL FAMILY PRACTICE E84033 6 INTERGRATED HEALTH CIC E84685 15 KILBURN PARK MEDICAL CENTRE E84042 11 PEEL PRECINCT SURGERY E84696 2 CREST MEDICAL CENTRE E84690 3 HARNESS HARLESDEN PRACTICE E84029 4 CHURCH LANE SURGERY E84067 4 CHICHELE ROAD SURGERY E84674 3 • in total, including exceptions, there GLADSTONE MEDICAL CENTRE E84036 10 THE LAW MEDICAL GROUP PRACTICE E84006 23 HILLTOP MEDICAL PRACTICE E84637 1 are 201 people who are not taking an STAVERTON SURGERY E84080 9 PARK ROAD SURGERY E84624 3 ST.GEORGES MEDICAL CENTRE E84704 3 anti-platelet agent or anti-coagulant WEMBLEY PARK DRIVE MEDICAL CENTRE E84709 7 THE BEECHCROFT MEDICAL CENTRE E84084 6 WILLOW TREE FAMILY DOCTORS E84015 12 • GP practice range: 0.0% to 28.6% BUCKINGHAM RD SURGERY E84026 4 FREUCHEN MEDICAL CENTRE E84074 4 THE SUNFLOWER MEDICAL CENTRE E84626 2 OXGATE GARDENS SURGERY E84076 7 PRESTON ROAD SURGERY E84620 3 HARNESS WEMBLEY PRACTICE Y02692 1 AKSYR MEDICAL PRACTICE E84030 4 THE SURGERY E84635 2 WALM LANE SURGERY E84086 3 ELLIS PRACTICE E84032 7 PEARL MEDICAL PRACTICE E84701 1 THE LONSDALE MEDICAL CENTRE E84025 7 SUDBURY & ALPERTON MEDICAL CENTRE E84017 3 BURNLEY PRACTICE Y00206 2 THE WINDMILL MEDICAL PRACTICE E84012 3 WILLOW TREE FAMILY DOCTORS E84706 2 ST ANDREWS MEDICAL CENTRE E84011 2 HAZELDENE MEDICAL CENTRE E84066 1 THE FRYENT WAY SURGERY E84048 4 THE WILLESDEN MEDICAL CENTRE E84021 3 CRICKLEWOOD BROADWAY SURGERY E83654 1 FORTY WILLOWS SURGERY E84002 3 UXENDON CRESCENT SURGERY E84007 2 THE STAG - HOLLYROOD PRACTICE E84020 1 ALPERTON MEDICAL CENTRE E84638 1 BRENTFIELD MEDICAL CENTRE E84031 2 CHURCH END MEDICAL CENTRE E84013 2 NEASDEN MEDICAL CENTRE E84665 1 LANFRANC MEDICAL CENTRE E84083 1 PREMIER MEDICAL CENTRE E84003 PARK HOUSE MEDICAL CENTRE E84023 THE STONEBRIDGE PRACTICE E84028 BRAMPTON HEALTH CENTRE E84049 STANLEY CORNER MEDICAL CENTRE E84051 THE CLARENCE MEDICAL CENTRE E84056 LANCELOT MEDICAL CENTRE E84063 THE SHELDON PRACTICE E84077 KINGSBURY HEALTH AND WELLBEING E84078 ACTON LANE SURGERY E84645 ROUNDWOOD PARK MEDICAL CENTRE E84656 BLESSING MEDICAL CENTRE E84667 THE EAGLE EYE E84669 PRESTON MEDICAL CENTRE E84678 THE TUDOR HOUSE MEDICAL CENTRE E84684 KINGS EDGE MEDICAL CENTRE E84699 WILLESDEN GREEN SURGERY E84702 CHAMBERLAYNE RD SURGERY E84705 THE VILLAGE MEDICAL CENTRE E84708 SMS MEDICAL PRACTICE Y01090 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 Harrow CCG 0.87

• 0.78 ratio of observed to expected NHS Hillingdon CCG 0.81 diabetes prevalence in NHS Brent CCG, compared to 0.77 in England NHS Hounslow CCG 0.79 • this suggests 78% of people have NHS Brent CCG 0.78 been diagnosed

NHS Ealing CCG 0.76

NHS Hammersmith And Fulham CCG 0.60

NHS Central London (Westminster) CCG 0.57

NHS West London CCG 0.56

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 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

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

NHS Sandwell and West Birmingham CCG 0.81

NHS Greenwich CCG 0.80

NHS Hounslow CCG 0.79

NHS Brent CCG 0.78

NHS Redbridge CCG 0.77

NHS Ealing CCG 0.76

NHS Merton CCG 0.74

NHS Waltham Forest CCG 0.67

NHS Lewisham CCG 0.66

NHS Haringey CCG 0.65

NHS Croydon 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

KINGSBURY HEALTH AND WELLBEING E84078 13.4% THE STAG - HOLLYROOD PRACTICE E84020 12.8% HARNESS HARLESDEN PRACTICE E84029 12.8% PREMIER MEDICAL CENTRE E84003 12.0% THE EAGLE EYE E84669 11.8% THE BEECHCROFT MEDICAL CENTRE E84084 11.7% AKSYR MEDICAL PRACTICE E84030 11.6% THE SUNFLOWER MEDICAL CENTRE E84626 11.6% • GP practice range of observed KINGS EDGE MEDICAL CENTRE E84699 11.2% THE SURGERY E84635 11.1% THE FRYENT WAY SURGERY E84048 11.1% diabetes 3.8% to 13.4% PARK ROAD SURGERY E84624 11.1% PRESTON ROAD SURGERY E84620 11.0% SUDBURY & ALPERTON MEDICAL CENTRE E84017 10.9% • there are an estimated 7,224 people ALPERTON MEDICAL CENTRE E84638 10.8% CHURCH LANE SURGERY E84067 10.5% ST.GEORGES MEDICAL CENTRE E84704 10.5% with undiagnosed diabetes in NHS WILLOW TREE FAMILY DOCTORS E84706 10.5% WILLESDEN GREEN SURGERY E84702 10.4% BRENTFIELD MEDICAL CENTRE E84031 10.4% Brent CCG THE STONEBRIDGE PRACTICE E84028 10.3% ROUNDWOOD PARK MEDICAL CENTRE E84656 10.3% THE TUDOR HOUSE MEDICAL CENTRE E84684 10.0% LANFRANC MEDICAL CENTRE E84083 10.0% PEARL MEDICAL PRACTICE E84701 9.8% FREUCHEN MEDICAL CENTRE E84074 9.6% THE SHELDON PRACTICE E84077 9.6% BRAMPTON HEALTH CENTRE E84049 9.6% CHURCH END MEDICAL CENTRE E84013 9.5% HAZELDENE MEDICAL CENTRE E84066 9.3% CRICKLEWOOD BROADWAY SURGERY E83654 9.3% WILLOW TREE FAMILY DOCTORS E84015 9.2% UXENDON CRESCENT SURGERY E84007 9.1% THE LAW MEDICAL GROUP PRACTICE E84006 9.1% INTERGRATED HEALTH CIC E84685 9.0% THE CLARENCE MEDICAL CENTRE E84056 8.9% STANLEY CORNER MEDICAL CENTRE E84051 8.9% BUCKINGHAM RD SURGERY E84026 8.8% SMS MEDICAL PRACTICE Y01090 8.8% CREST MEDICAL CENTRE E84690 8.7% PRESTON MEDICAL CENTRE E84678 8.7% ACTON LANE SURGERY E84645 8.4% HILLTOP MEDICAL PRACTICE E84637 8.4% NEASDEN MEDICAL CENTRE E84665 8.2% THE WILLESDEN MEDICAL CENTRE E84021 8.1% PEEL PRECINCT SURGERY E84696 8.1% FORTY WILLOWS SURGERY E84002 8.0% THE VILLAGE MEDICAL CENTRE E84708 7.9% ST ANDREWS MEDICAL CENTRE E84011 7.8% GLADSTONE MEDICAL CENTRE E84036 7.7% ELLIS PRACTICE E84032 7.7% CHALKHILL FAMILY PRACTICE E84033 7.2% LANCELOT MEDICAL CENTRE E84063 7.0% PARK HOUSE MEDICAL CENTRE E84023 6.9% WEMBLEY PARK DRIVE MEDICAL CENTRE E84709 6.9% OXGATE GARDENS SURGERY E84076 6.7% BLESSING MEDICAL CENTRE E84667 6.7% CHAMBERLAYNE RD SURGERY E84705 6.4% BURNLEY PRACTICE Y00206 6.1% KILBURN PARK MEDICAL CENTRE E84042 6.1% CHICHELE ROAD SURGERY E84674 5.7% STAVERTON SURGERY E84080 5.2% Note: The estimated number of undiagnosed THE WINDMILL MEDICAL PRACTICE E84012 4.7% HARNESS WEMBLEY PRACTICE Y02692 4.6% WALM LANE SURGERY E84086 4.0% people with diabetes has been calculated by THE LONSDALE MEDICAL CENTRE E84025 3.8% multiplying the estimated prevalence rate to the 0% 2% 4% 6% 8% 10% 12% 14% 16% 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 Harrow CCG 9.1% 1.3% 13.6% • the estimated total prevalence of diabetes in NHS Brent CCG is 11.0% (diagnosed and undiagnosed) NHS Brent CCG 8.6% 2.5% 12.4%

• in addition, there are an estimated NHS Ealing CCG 7.8% 2.5% 11.9% 12.4% of people in NHS Brent CCG who are at increased risk of NHS Hounslow CCG 7.3% 1.9% 11.2% developing diabetes (i.e. with non- diabetic hyperglycaemia) NHS Hillingdon CCG 7.0% 1.6% 11.6% • this means that 23.5% of the NHS West London CCG 4.6% 3.7% 9.4% population in NHS Brent CCG are estimated to have diabetes, or at high NHS Hammersmith And Fulham CCG 4.5% 2.9% 8.7% risk of developing of diabetes

NHS Central London (Westminster) CCG 4.0% 3.1% 8.8%

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% 30% These estimates were produced using the GP registered population.

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

NHS Ealing CCG 62.1%

NHS Hounslow CCG 59.5% • data on care processes and treatment targets are taken from the National Diabetes Audit (NDA) NHS West London CCG 50.5% • overall practice participation in the 2015/16 audit was 81.4% in England NHS Central London (Westminster) CCG 49.5% • in NHS Brent CCG, 20 out of 66 NHS Hammersmith And Fulham CCG 47.1% practices (30.3%) participated in the NDA. Data is not available for the remaining practices NHS Hillingdon CCG 39.6%

NHS Brent CCG 36.8% • 36.8% of people with diabetes (of practices who participated in the audit) had the eight recommended NHS Harrow CCG 31.9% care processes in NHS Brent CCG, compared to 52.6% in England

England 52.6%

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

47 CVD: Primary Care Intelligence Packs People with diabetes who had eight care processes by GP practice, 2015/16

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

THE STAG - HOLLYROOD PRACTICE E84020 69.8% GLADSTONE MEDICAL CENTRE E84036 65.1% THE LAW MEDICAL GROUP PRACTICE E84006 62.7% BLESSING MEDICAL CENTRE E84667 62.1% THE FRYENT WAY SURGERY E84048 55.3% LANCELOT MEDICAL CENTRE E84063 48.4% • achievement - 8 care processes: in THE SHELDON PRACTICE E84077 44.8% FREUCHEN MEDICAL CENTRE E84074 33.7% CHURCH END MEDICAL CENTRE E84013 30.2% practices who provided data via the THE EAGLE EYE E84669 29.8% WALM LANE SURGERY E84086 26.2% PRESTON ROAD SURGERY E84620 25.1% NDA, between 8.3% and 69.8% of HAZELDENE MEDICAL CENTRE E84066 23.3% THE WINDMILL MEDICAL PRACTICE E84012 22.6% THE WILLESDEN MEDICAL CENTRE E84021 19.1% patients received all 8 care processes HILLTOP MEDICAL PRACTICE E84637 17.1% FORTY WILLOWS SURGERY E84002 16.5% THE STONEBRIDGE PRACTICE E84028 13.6% CHICHELE ROAD SURGERY E84674 10.8% KILBURN PARK MEDICAL CENTRE E84042 8.3% HARNESS WEMBLEY PRACTICE Y02692 SMS MEDICAL PRACTICE Y01090 • at least 5,210 people did not receive BURNLEY PRACTICE Y00206 WEMBLEY PARK DRIVE MEDICAL CENTRE E84709 the eight care processes THE VILLAGE MEDICAL CENTRE E84708 WILLOW TREE FAMILY DOCTORS E84706 CHAMBERLAYNE RD SURGERY E84705 ST.GEORGES MEDICAL CENTRE E84704 WILLESDEN GREEN SURGERY E84702 PEARL MEDICAL PRACTICE E84701 KINGS EDGE MEDICAL CENTRE E84699 PEEL PRECINCT SURGERY E84696 CREST MEDICAL CENTRE E84690 INTERGRATED HEALTH CIC E84685 THE TUDOR HOUSE MEDICAL CENTRE E84684 PRESTON MEDICAL CENTRE E84678 NEASDEN MEDICAL CENTRE E84665 ROUNDWOOD PARK MEDICAL CENTRE E84656 ACTON LANE SURGERY E84645 ALPERTON MEDICAL CENTRE E84638 THE SURGERY E84635 THE SUNFLOWER MEDICAL CENTRE E84626 PARK ROAD SURGERY E84624 THE BEECHCROFT MEDICAL CENTRE E84084 LANFRANC MEDICAL CENTRE E84083 STAVERTON SURGERY E84080 KINGSBURY HEALTH AND WELLBEING E84078 OXGATE GARDENS SURGERY E84076 CHURCH LANE SURGERY E84067 THE CLARENCE MEDICAL CENTRE E84056 STANLEY CORNER MEDICAL CENTRE E84051 BRAMPTON HEALTH CENTRE E84049 CHALKHILL FAMILY PRACTICE E84033 ELLIS PRACTICE E84032 BRENTFIELD MEDICAL CENTRE E84031 AKSYR MEDICAL PRACTICE E84030 HARNESS HARLESDEN PRACTICE E84029 BUCKINGHAM RD SURGERY E84026 THE LONSDALE MEDICAL CENTRE E84025 PARK HOUSE MEDICAL CENTRE E84023 SUDBURY & ALPERTON MEDICAL CENTRE E84017 WILLOW TREE FAMILY DOCTORS E84015 ST ANDREWS MEDICAL CENTRE E84011 UXENDON CRESCENT SURGERY E84007 PREMIER MEDICAL CENTRE E84003 CRICKLEWOOD BROADWAY SURGERY E83654 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 Hillingdon CCG 42.8%

NHS Central London (Westminster) CCG 42.2% • 39.1% of people with diabetes (of practices who participated in the audit) met the three treatment targets NHS Harrow CCG 40.4% in NHS Brent CCG, compared to 39.0% in England

NHS Brent CCG 39.1%

NHS West London CCG 39.1%

NHS Hounslow CCG 38.6%

NHS Ealing CCG 37.2%

NHS Hammersmith And Fulham CCG 37.0%

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

HAZELDENE MEDICAL CENTRE E84066 49.8% THE STAG - HOLLYROOD PRACTICE E84020 49.5% BLESSING MEDICAL CENTRE E84667 49.2% THE SHELDON PRACTICE E84077 47.0% THE EAGLE EYE E84669 45.3% FREUCHEN MEDICAL CENTRE E84074 44.6% • achievement - 3 treatment targets: in LANCELOT MEDICAL CENTRE E84063 43.9% PRESTON ROAD SURGERY E84620 42.5% THE FRYENT WAY SURGERY E84048 40.1% practices who provided data via the THE LAW MEDICAL GROUP PRACTICE E84006 39.6% HILLTOP MEDICAL PRACTICE E84637 38.6% CHURCH END MEDICAL CENTRE E84013 38.5% NDA, between 17.3% and 49.8% of GLADSTONE MEDICAL CENTRE E84036 38.3% THE WINDMILL MEDICAL PRACTICE E84012 36.7% FORTY WILLOWS SURGERY E84002 36.0% patients achieved all 3 treatment THE WILLESDEN MEDICAL CENTRE E84021 35.8% WALM LANE SURGERY E84086 34.8% targets THE STONEBRIDGE PRACTICE E84028 33.8% CHICHELE ROAD SURGERY E84674 33.3% KILBURN PARK MEDICAL CENTRE E84042 17.3% HARNESS WEMBLEY PRACTICE Y02692 SMS MEDICAL PRACTICE Y01090 • at least 4,470 people did not meet the BURNLEY PRACTICE Y00206 WEMBLEY PARK DRIVE MEDICAL CENTRE E84709 three treatment targets THE VILLAGE MEDICAL CENTRE E84708 WILLOW TREE FAMILY DOCTORS E84706 CHAMBERLAYNE RD SURGERY E84705 ST.GEORGES MEDICAL CENTRE E84704 WILLESDEN GREEN SURGERY E84702 PEARL MEDICAL PRACTICE E84701 KINGS EDGE MEDICAL CENTRE E84699 PEEL PRECINCT SURGERY E84696 CREST MEDICAL CENTRE E84690 INTERGRATED HEALTH CIC E84685 THE TUDOR HOUSE MEDICAL CENTRE E84684 PRESTON MEDICAL CENTRE E84678 NEASDEN MEDICAL CENTRE E84665 ROUNDWOOD PARK MEDICAL CENTRE E84656 ACTON LANE SURGERY E84645 ALPERTON MEDICAL CENTRE E84638 THE SURGERY E84635 THE SUNFLOWER MEDICAL CENTRE E84626 PARK ROAD SURGERY E84624 THE BEECHCROFT MEDICAL CENTRE E84084 LANFRANC MEDICAL CENTRE E84083 STAVERTON SURGERY E84080 KINGSBURY HEALTH AND WELLBEING E84078 OXGATE GARDENS SURGERY E84076 CHURCH LANE SURGERY E84067 THE CLARENCE MEDICAL CENTRE E84056 STANLEY CORNER MEDICAL CENTRE E84051 BRAMPTON HEALTH CENTRE E84049 CHALKHILL FAMILY PRACTICE E84033 ELLIS PRACTICE E84032 BRENTFIELD MEDICAL CENTRE E84031 AKSYR MEDICAL PRACTICE E84030 HARNESS HARLESDEN PRACTICE E84029 BUCKINGHAM RD SURGERY E84026 THE LONSDALE MEDICAL CENTRE E84025 PARK HOUSE MEDICAL CENTRE E84023 SUDBURY & ALPERTON MEDICAL CENTRE E84017 WILLOW TREE FAMILY DOCTORS E84015 ST ANDREWS MEDICAL CENTRE E84011 UXENDON CRESCENT SURGERY E84007 PREMIER MEDICAL CENTRE E84003 CRICKLEWOOD BROADWAY SURGERY E83654 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% -25% -30%

KILBURN PARK MEDICAL CENTRE 92

CHICHELE ROAD SURGERY 30

WALM LANE SURGERY 24 • using the GP cluster method of THE STONEBRIDGE PRACTICE 33 calculating potential gains, if each THE WILLESDEN MEDICAL CENTRE 63 practice was to achieve as well as the THE WINDMILL MEDICAL PRACTICE 21 upper quartile of its national cluster, then an additional 421 people would FORTY WILLOWS SURGERY 29 be treated GLADSTONE MEDICAL CENTRE 27

CHURCH END MEDICAL CENTRE 27

HILLTOP MEDICAL PRACTICE 8

THE FRYENT WAY SURGERY 30

THE LAW MEDICAL GROUP PRACTICE 26

PRESTON ROAD SURGERY 8

LANCELOT MEDICAL CENTRE 4

THE EAGLE EYE

FREUCHEN MEDICAL CENTRE

THE SHELDON PRACTICE

BLESSING MEDICAL CENTRE

THE STAG - HOLLYROOD PRACTICE

HAZELDENE MEDICAL 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 Hounslow CCG 0.56

NHS Hammersmith And Fulham CCG 0.55 • the ratio of those diagnosed with chronic kidney disease versus those NHS Hillingdon CCG 0.50 expected to have chronic kidney disease is 0.49. This compares to NHS Brent CCG 0.49 0.68 for England • this suggests that 49% of people with chronic kidney disease have been NHS Ealing CCG 0.43 diagnosed

NHS Harrow CCG 0.41

NHS West London CCG 0.40

NHS Central London (Westminster) CCG 0.33 Note: This slide compares the prevalence of CKD recorded in QOF in 2015/16 to the expected prevalence of CKD produced by the University of Southampton in 2011. A small number of CCGs 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 0.1 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 Sandwell and West Birmingham CCG 0.69

NHS Greenwich CCG 0.67

NHS Croydon CCG 0.61

NHS Merton CCG 0.60

NHS Hounslow CCG 0.56

NHS Waltham Forest CCG 0.52

NHS Redbridge CCG 0.50

NHS Haringey CCG 0.50

NHS Brent CCG 0.49

NHS Lewisham CCG 0.49

NHS Ealing CCG 0.43

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 Ratio

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

GP practice CCG

BRAMPTON HEALTH CENTRE E84049 6.1% HAZELDENE MEDICAL CENTRE E84066 5.5% PREMIER MEDICAL CENTRE E84003 5.2% THE STAG - HOLLYROOD PRACTICE E84020 4.9% THE EAGLE EYE E84669 4.8% THE BEECHCROFT MEDICAL CENTRE E84084 4.8% KINGSBURY HEALTH AND WELLBEING E84078 4.7% GLADSTONE MEDICAL CENTRE E84036 4.5% • it is estimated that there are 6,839 CRICKLEWOOD BROADWAY SURGERY E83654 4.0% WILLOW TREE FAMILY DOCTORS E84706 3.5% ACTON LANE SURGERY E84645 3.5% people with undiagnosed chronic WILLOW TREE FAMILY DOCTORS E84015 3.3% PRESTON MEDICAL CENTRE E84678 3.3% STANLEY CORNER MEDICAL CENTRE E84051 3.2% kidney disease in NHS Brent CCG THE TUDOR HOUSE MEDICAL CENTRE E84684 3.2% STAVERTON SURGERY E84080 3.1% CHALKHILL FAMILY PRACTICE E84033 3.0% • GP practice range of observed CKD: UXENDON CRESCENT SURGERY E84007 2.9% LANFRANC MEDICAL CENTRE E84083 2.9% THE FRYENT WAY SURGERY E84048 2.9% 0.2% to 6.1% HARNESS HARLESDEN PRACTICE E84029 2.8% ROUNDWOOD PARK MEDICAL CENTRE E84656 2.8% THE LAW MEDICAL GROUP PRACTICE E84006 2.7% PARK ROAD SURGERY E84624 2.6% THE STONEBRIDGE PRACTICE E84028 2.5% PARK HOUSE MEDICAL CENTRE E84023 2.5% FREUCHEN MEDICAL CENTRE E84074 2.4% WILLESDEN GREEN SURGERY E84702 2.4% KINGS EDGE MEDICAL CENTRE E84699 2.3% FORTY WILLOWS SURGERY E84002 2.3% CHURCH END MEDICAL CENTRE E84013 2.2% THE SURGERY E84635 2.1% AKSYR MEDICAL PRACTICE E84030 2.1% BRENTFIELD MEDICAL CENTRE E84031 2.0% WEMBLEY PARK DRIVE MEDICAL CENTRE E84709 2.0% OXGATE GARDENS SURGERY E84076 2.0% KILBURN PARK MEDICAL CENTRE E84042 2.0% INTERGRATED HEALTH CIC E84685 1.9% THE SHELDON PRACTICE E84077 1.9% THE SUNFLOWER MEDICAL CENTRE E84626 1.9% BLESSING MEDICAL CENTRE E84667 1.9% THE WINDMILL MEDICAL PRACTICE E84012 1.8% ELLIS PRACTICE E84032 1.8% ST ANDREWS MEDICAL CENTRE E84011 1.7% PEARL MEDICAL PRACTICE E84701 1.7% THE LONSDALE MEDICAL CENTRE E84025 1.7% SUDBURY & ALPERTON MEDICAL CENTRE E84017 1.6% THE VILLAGE MEDICAL CENTRE E84708 1.5% CHICHELE ROAD SURGERY E84674 1.5% BURNLEY PRACTICE Y00206 1.4% THE WILLESDEN MEDICAL CENTRE E84021 1.4% LANCELOT MEDICAL CENTRE E84063 1.3% CREST MEDICAL CENTRE E84690 1.3% PRESTON ROAD SURGERY E84620 1.2% CHURCH LANE SURGERY E84067 1.2% SMS MEDICAL PRACTICE Y01090 1.2% ALPERTON MEDICAL CENTRE E84638 1.0% PEEL PRECINCT SURGERY E84696 1.0% Note: CCG estimates for the estimated HILLTOP MEDICAL PRACTICE E84637 0.9% BUCKINGHAM RD SURGERY E84026 0.9% NEASDEN MEDICAL CENTRE E84665 0.8% number of people with CKD are based on WALM LANE SURGERY E84086 0.8% CHAMBERLAYNE RD SURGERY E84705 0.8% applying a proportion from a resident based ST.GEORGES MEDICAL CENTRE E84704 0.8% HARNESS WEMBLEY PRACTICE Y02692 0.3% population estimate to a GP registered THE CLARENCE MEDICAL CENTRE E84056 0.2% population. The characteristics of registered 0% 1% 2% 3% 4% 5% 6% 7% 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 Hillingdon CCG 77.1% • 6,812 people with CKD (diagnosed*) NHS Ealing CCG 75.7% in NHS Brent CCG • 5,132 (75.3%) people whose blood NHS Brent CCG 75.3% pressure is <= 140 /85 • 767 (11.3%) people who are exceptions NHS Harrow CCG 75.1% • 913 (13.4%) additional people whose blood pressure is not <= 140 / 85 NHS Hounslow CCG 74.9%

NHS West London CCG 73.3%

NHS Central London (Westminster) CCG 73.3%

NHS Hammersmith And Fulham CCG 70.3%

*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 Merton CCG 78.3%

NHS Greenwich CCG 76.7%

NHS Waltham Forest CCG 75.8%

NHS Ealing CCG 75.7%

NHS Redbridge CCG 75.7%

NHS Croydon CCG 75.5%

NHS Brent CCG 75.3%

NHS Hounslow CCG 74.9%

NHS Sandwell and West Birmingham CCG 74.5%

NHS Lewisham CCG 74.0%

NHS Haringey CCG 71.7%

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

PARK ROAD SURGERY E84624 26 DR W T MAHESWARAN AND PARTNERS E83654 44 ST ANDREWS MEDICAL CENTRE E84011 17 FORTY WILLOWS SURGERY E84002 51 PARK HOUSE MEDICAL CENTRE E84023 42 HAZELDENE MEDICAL CENTRE E84066 59 DR ABRAHAMS & PARTNERS E84006 111 KILBURN PARK MEDICAL CENTRE E84042 44 • in total, including exceptions, there CHALKHILL FAMILY PRACTICE E84033 37 THE WILLESDEN MEDICAL CENTRE E84021 43 KINGS EDGE MEDICAL CENTRE E84699 36 are 1,680 people whose blood ROUNDWOOD PARK MEDICAL CENTRE E84656 24 DR U K SOBTI E84049 41 THE TUDOR HOUSE MEDICAL CENTRE E84684 23 pressure is not <= 140 / 85 THE SURGERY E84635 23 ELLIS PRACTICE E84032 38 ACTON LANE SURGERY E84645 27 • GP practice range: 0.0% to 51.0% GLADSTONE MEDICAL CENTRE E84036 92 THE EAGLE EYE E84669 31 FREUCHEN MEDICAL CENTRE E84074 32 DR LAT DAVID & PARTNERS E84025 53 AKSYR MEDICAL PRACTICE E84030 27 CHICHELE ROAD SURGERY E84674 25 CHURCH END MEDICAL CENTRE E84013 35 CREST MEDICAL CENTRE E84690 12 WALM LANE SURGERY E84086 13 DR CAE AMOBI & PARTNERS E84031 32 DR TARIQ KALEEM & PARTNERS E84007 34 THE FRYENT WAY SURGERY E84048 44 THE WINDMILL MEDICAL PRACTICE E84012 28 HARNESS HARLESDEN PRACTICE E84029 8 DR.RK GEORGE & PARTNERS E84026 9 FRYENT MEDICAL CENTRE E84706 15 DR MJR ROGERS AND PARTNERS E84620 12 WILLOW TREE FAMILY DOCTORS E84015 65 STANLEY CORNER MEDICAL CENTRE E84051 33 DR CRAIG & PARTNERS E84080 45 NEASDEN MEDICAL CENTRE E84665 12 WEMBLEY PARK DRIVE MEDICAL CENTRE E84709 31 ALPERTON MEDICAL CENTRE E84638 9 DR KG HAYNES & PARTNERS E84076 18 PEARL MEDICAL PRACTICE E84701 12 THE BEECHCROFT MEDICAL CENTRE E84084 34 LANFRANC MEDICAL CENTRE E84083 27 DR G THANKI & PTNRS E84017 19 THE STONEBRIDGE PRACTICE E84028 17 INTERGRATED HEALTH CIC-SUDBURY PRIMARY CARE CENTRE E84685 23 PEEL PRECINCT SURGERY E84696 2 DR KAMAL AND PARTNERS E84067 11 THE SUNFLOWER MEDICAL CENTRE E84626 6 PRIMARY CARE MEDICAL CENTRE E84661 18 BURNLEY PRACTICE Y00206 7 PREMIER MEDICAL CENTRE E84003 34 LANCELOT MEDICAL CENTRE E84063 9 KINGSBURY HEALTH & WELL BEING E84078 17 DR L WONG E84667 5 THE STAG - HOLLYROOD PRACTICE E84020 12 PRESTON MEDICAL CENTRE E84678 12 THE VILLAGE MEDICAL CENTRE E84708 4 CHAMBERLAYNE RD SURGERY E84705 2 HILLTOP MEDICAL PRACTICE - DR GHOSH-CHOWDHURY E84637 2 ST.GEORGES MEDICAL CENTRE E84704 1 BRENT GP ACCESS UNIT HARNESS-WEMBLEY Y02692 1 THE SHELDON PRACTICE E84077 2 SMS MEDICAL PRACTICE Y01090 1 WILLESDEN GREEN SURGERY E84702 1 THE CLARENCE MEDICAL CENTRE E84056 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

30% 20% 10% 0% -10% -20% -30% -40%

PARK ROAD SURGERY 18

DR W T MAHESWARAN AND PARTNERS 29

ST ANDREWS MEDICAL CENTRE 11 • using the GP cluster method of FORTY WILLOWS SURGERY 32 calculating potential gains, if each PARK HOUSE MEDICAL CENTRE 24 practice was to achieve as well as the HAZELDENE MEDICAL CENTRE 33 upper quartile of its national cluster, then an additional 628 people would KILBURN PARK MEDICAL CENTRE 24 be treated THE WILLESDEN MEDICAL CENTRE 23

KINGS EDGE MEDICAL CENTRE 19

CHALKHILL FAMILY PRACTICE 19

PRESTON MEDICAL CENTRE

THE VILLAGE MEDICAL CENTRE

CHAMBERLAYNE RD SURGERY

ST.GEORGES MEDICAL CENTRE

HILLTOP MEDICAL PRACTICE - DR GHOSH-CHOWDHURY

BRENT GP ACCESS UNIT HARNESS-WEMBLEY

THE SHELDON PRACTICE

SMS MEDICAL PRACTICE

WILLESDEN GREEN SURGERY

THE CLARENCE 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 Hillingdon CCG 78.6% • 6,812 people with CKD (diagnosed*) NHS Harrow CCG 76.0% in NHS Brent CCG • 5,069 (74.4%) people who have a NHS Ealing CCG 75.5% record of urine albumin:creatinine ratio test • 706 (10.4%) people who are NHS Brent CCG 74.4% exceptions • 1,037 (15.2%) additional people who NHS Hounslow CCG 74.1% have no record of urine albumin:creatinine ratio test

NHS Central London (Westminster) CCG 73.5%

NHS West London CCG 73.5%

NHS Hammersmith And Fulham CCG 69.6%

*Using the QOF clinical indicator CKD004 England 75.4% denominator plus exceptions. Note: as the CKD004 indicator was removed from the QOF in 15/16 this is historic data 0% 20% 40% 60% 80% 100% taken from the 2014/15 QOF.

61 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose notes have a record of a urine albumin: creatinine ratio test in the preceding 12 months by CCG, 2014/15 Comparison with demographically similar CCGs Recorded Not recorded Exceptions reported

NHS Sandwell and West Birmingham CCG 76.8%

NHS Haringey CCG 76.0%

NHS Ealing CCG 75.5%

NHS Lewisham CCG 74.9%

NHS Waltham Forest CCG 74.7%

NHS Brent CCG 74.4%

NHS Merton CCG 74.4%

NHS Hounslow CCG 74.1%

NHS Croydon CCG 73.9%

NHS Greenwich CCG 70.6%

NHS Redbridge CCG 61.6%

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

62 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose notes do not have a record of a urine albumin: creatinine ratio test in the preceding 12 months by GP practice, 2014/15

Not recorded Exceptions reported

THE CLARENCE MEDICAL CENTRE E84056 2 HAZELDENE MEDICAL CENTRE E84066 98 LANCELOT MEDICAL CENTRE E84063 40 PARK ROAD SURGERY E84624 28 INTERGRATED HEALTH CIC-SUDBURY PRIMARY CARE CENTRE E84685 69 THE WINDMILL MEDICAL PRACTICE E84012 54 DR W T MAHESWARAN AND PARTNERS E83654 44 ST ANDREWS MEDICAL CENTRE E84011 16 • in total, including exceptions, there LANFRANC MEDICAL CENTRE E84083 56 DR G THANKI & PTNRS E84017 37 ROUNDWOOD PARK MEDICAL CENTRE E84656 28 are 1,743 people who have no record CHICHELE ROAD SURGERY E84674 32 THE EAGLE EYE E84669 38 KINGS EDGE MEDICAL CENTRE E84699 38 of urine albumin:creatinine ratio test THE SUNFLOWER MEDICAL CENTRE E84626 14 AKSYR MEDICAL PRACTICE E84030 31 FREUCHEN MEDICAL CENTRE E84074 36 • GP practice range: 0.0% to 66.7% FORTY WILLOWS SURGERY E84002 37 DR CRAIG & PARTNERS E84080 64 DR MJR ROGERS AND PARTNERS E84620 16 DR TARIQ KALEEM & PARTNERS E84007 38 WALM LANE SURGERY E84086 14 THE STONEBRIDGE PRACTICE E84028 26 KILBURN PARK MEDICAL CENTRE E84042 34 THE VILLAGE MEDICAL CENTRE E84708 10 THE WILLESDEN MEDICAL CENTRE E84021 33 GLADSTONE MEDICAL CENTRE E84036 81 ELLIS PRACTICE E84032 32 PRIMARY CARE MEDICAL CENTRE E84661 32 CREST MEDICAL CENTRE E84690 11 THE FRYENT WAY SURGERY E84048 43 CHURCH END MEDICAL CENTRE E84013 31 HARNESS HARLESDEN PRACTICE E84029 8 PARK HOUSE MEDICAL CENTRE E84023 27 PEARL MEDICAL PRACTICE E84701 14 DR ABRAHAMS & PARTNERS E84006 70 PRESTON MEDICAL CENTRE E84678 24 FRYENT MEDICAL CENTRE E84706 15 CHALKHILL FAMILY PRACTICE E84033 24 DR.RK GEORGE & PARTNERS E84026 8 WILLOW TREE FAMILY DOCTORS E84015 62 ALPERTON MEDICAL CENTRE E84638 9 DR LAT DAVID & PARTNERS E84025 34 DR U K SOBTI E84049 23 WEMBLEY PARK DRIVE MEDICAL CENTRE E84709 27 DR KG HAYNES & PARTNERS E84076 16 STANLEY CORNER MEDICAL CENTRE E84051 26 HILLTOP MEDICAL PRACTICE - DR GHOSH-CHOWDHURY E84637 4 THE TUDOR HOUSE MEDICAL CENTRE E84684 12 BURNLEY PRACTICE Y00206 8 PEEL PRECINCT SURGERY E84696 2 DR CAE AMOBI & PARTNERS E84031 19 SMS MEDICAL PRACTICE Y01090 5 PREMIER MEDICAL CENTRE E84003 37 THE STAG - HOLLYROOD PRACTICE E84020 15 ACTON LANE SURGERY E84645 13 THE BEECHCROFT MEDICAL CENTRE E84084 25 THE SHELDON PRACTICE E84077 5 WILLESDEN GREEN SURGERY E84702 8 THE SURGERY E84635 10 BRENT GP ACCESS UNIT HARNESS-WEMBLEY Y02692 2 DR KAMAL AND PARTNERS E84067 9 NEASDEN MEDICAL CENTRE E84665 7 KINGSBURY HEALTH & WELL BEING E84078 9 DR L WONG E84667 2 CHAMBERLAYNE RD SURGERY E84705 1 ST.GEORGES MEDICAL CENTRE E84704 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 Harrow CCG 0.57%

NHS Brent CCG 0.54% • prevalence of 0.54% in NHS Brent CCG compared to 0.76% in England NHS Hounslow CCG 0.51%

NHS Hillingdon CCG 0.49%

NHS Ealing CCG 0.46%

NHS Central London (Westminster) CCG 0.44%

NHS Hammersmith And Fulham CCG 0.41%

NHS West London CCG 0.40%

England 0.76%

0.0% 0.1% 0.2% 0.3% 0.4% 0.5% 0.6% 0.7% 0.8%

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

NHS Sandwell and West Birmingham CCG 0.68%

NHS Greenwich CCG 0.61%

NHS Brent CCG 0.54%

NHS Hounslow CCG 0.51%

NHS Haringey CCG 0.50%

NHS Merton CCG 0.48%

NHS Croydon CCG 0.47%

NHS Lewisham CCG 0.47%

NHS Waltham Forest CCG 0.46%

NHS Ealing CCG 0.46%

NHS Redbridge CCG 0.45%

0.0% 0.1% 0.2% 0.3% 0.4% 0.5% 0.6% 0.7% 0.8%

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

GP practice CCG

KINGS EDGE MEDICAL CENTRE E84699 1.5% THE STAG - HOLLYROOD PRACTICE E84020 1.1% THE EAGLE EYE E84669 1.1% PREMIER MEDICAL CENTRE E84003 1.0% KINGSBURY HEALTH AND WELLBEING E84078 1.0% HARNESS HARLESDEN PRACTICE E84029 1.0% THE CLARENCE MEDICAL CENTRE E84056 0.9% ST ANDREWS MEDICAL CENTRE E84011 0.9% • 2,005 people with diagnosed heart THE VILLAGE MEDICAL CENTRE E84708 0.9% ST.GEORGES MEDICAL CENTRE E84704 0.9% THE LAW MEDICAL GROUP PRACTICE E84006 0.9% failure in NHS Brent CCG THE SUNFLOWER MEDICAL CENTRE E84626 0.8% GLADSTONE MEDICAL CENTRE E84036 0.8% PARK ROAD SURGERY E84624 0.8% • GP practice range: 0.1% to 1.5% THE SHELDON PRACTICE E84077 0.8% WILLOW TREE FAMILY DOCTORS E84015 0.7% OXGATE GARDENS SURGERY E84076 0.7% AKSYR MEDICAL PRACTICE E84030 0.6% KILBURN PARK MEDICAL CENTRE E84042 0.6% FORTY WILLOWS SURGERY E84002 0.6% THE STONEBRIDGE PRACTICE E84028 0.6% FREUCHEN MEDICAL CENTRE E84074 0.6% CHURCH END MEDICAL CENTRE E84013 0.6% UXENDON CRESCENT SURGERY E84007 0.6% THE FRYENT WAY SURGERY E84048 0.6% ROUNDWOOD PARK MEDICAL CENTRE E84656 0.6% LANFRANC MEDICAL CENTRE E84083 0.6% CHALKHILL FAMILY PRACTICE E84033 0.5% THE WINDMILL MEDICAL PRACTICE E84012 0.5% PRESTON ROAD SURGERY E84620 0.5% PEARL MEDICAL PRACTICE E84701 0.5% THE SURGERY E84635 0.5% WILLOW TREE FAMILY DOCTORS E84706 0.5% WEMBLEY PARK DRIVE MEDICAL CENTRE E84709 0.5% THE WILLESDEN MEDICAL CENTRE E84021 0.5% HILLTOP MEDICAL PRACTICE E84637 0.5% THE BEECHCROFT MEDICAL CENTRE E84084 0.5% PEEL PRECINCT SURGERY E84696 0.5% NEASDEN MEDICAL CENTRE E84665 0.5% HAZELDENE MEDICAL CENTRE E84066 0.5% ELLIS PRACTICE E84032 0.5% STAVERTON SURGERY E84080 0.5% SUDBURY & ALPERTON MEDICAL CENTRE E84017 0.5% BRAMPTON HEALTH CENTRE E84049 0.4% ACTON LANE SURGERY E84645 0.4% THE TUDOR HOUSE MEDICAL CENTRE E84684 0.4% THE LONSDALE MEDICAL CENTRE E84025 0.4% ALPERTON MEDICAL CENTRE E84638 0.4% BURNLEY PRACTICE Y00206 0.4% BRENTFIELD MEDICAL CENTRE E84031 0.4% PARK HOUSE MEDICAL CENTRE E84023 0.4% CREST MEDICAL CENTRE E84690 0.4% BUCKINGHAM RD SURGERY E84026 0.4% INTERGRATED HEALTH CIC E84685 0.4% STANLEY CORNER MEDICAL CENTRE E84051 0.4% SMS MEDICAL PRACTICE Y01090 0.4% PRESTON MEDICAL CENTRE E84678 0.3% CRICKLEWOOD BROADWAY SURGERY E83654 0.3% BLESSING MEDICAL CENTRE E84667 0.3% CHAMBERLAYNE RD SURGERY E84705 0.3% WALM LANE SURGERY E84086 0.3% LANCELOT MEDICAL CENTRE E84063 0.2% CHICHELE ROAD SURGERY E84674 0.2% WILLESDEN GREEN SURGERY E84702 0.2% CHURCH LANE SURGERY E84067 0.2% HARNESS WEMBLEY PRACTICE Y02692 0.1% 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6% 1.8%

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 Hounslow CCG 91.5% • 336 people with heart failure* with NHS Ealing CCG 91.5% LVSD in NHS Brent CCG • 297 (88.4%) people treated with ACE- NHS Brent CCG 88.4% I or ARB • 39 (11.6%) people who are exceptions NHS Hillingdon CCG 87.6% • 0 (0%) additional people who are not treated with ACE-I or ARB NHS Central London (Westminster) CCG 86.0%

NHS Harrow CCG 86.0%

NHS Hammersmith And Fulham CCG 84.8%

NHS West London CCG 82.7%

England 84.7%

0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator HF003 denominator plus exceptions

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

NHS Lewisham CCG 92.0%

NHS Hounslow CCG 91.5%

NHS Ealing CCG 91.5%

NHS Greenwich CCG 89.4%

NHS Redbridge CCG 89.3%

NHS Waltham Forest CCG 88.7%

NHS Brent CCG 88.4%

NHS Merton CCG 87.3%

NHS Sandwell and West Birmingham CCG 87.2%

NHS Croydon CCG 85.7%

NHS Haringey CCG 83.3%

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

THE SHELDON PRACTICE E84077 2 UXENDON CRESCENT SURGERY E84007 3 THE LONSDALE MEDICAL CENTRE E84025 3 THE WINDMILL MEDICAL PRACTICE E84012 2 STAVERTON SURGERY E84080 1 OXGATE GARDENS SURGERY E84076 2 WILLOW TREE FAMILY DOCTORS E84015 2 PRESTON ROAD SURGERY E84620 1 • in total, including exceptions, there THE LAW MEDICAL GROUP PRACTICE E84006 6 THE BEECHCROFT MEDICAL CENTRE E84084 2 FORTY WILLOWS SURGERY E84002 2 are 39 people who are not treated CHALKHILL FAMILY PRACTICE E84033 1 GLADSTONE MEDICAL CENTRE E84036 1 CHURCH END MEDICAL CENTRE E84013 1 with ACE-I or ARB THE SURGERY E84635 3 KILBURN PARK MEDICAL CENTRE E84042 2 THE EAGLE EYE E84669 1 • GP practice range: 0.0% to 50.0% PARK HOUSE MEDICAL CENTRE E84023 1 BRENTFIELD MEDICAL CENTRE E84031 1 LANFRANC MEDICAL CENTRE E84083 1 PREMIER MEDICAL CENTRE E84003 1 CRICKLEWOOD BROADWAY SURGERY E83654 ST ANDREWS MEDICAL CENTRE E84011 SUDBURY & ALPERTON MEDICAL CENTRE E84017 THE STAG - HOLLYROOD PRACTICE E84020 THE WILLESDEN MEDICAL CENTRE E84021 BUCKINGHAM RD SURGERY E84026 THE STONEBRIDGE PRACTICE E84028 HARNESS HARLESDEN PRACTICE E84029 AKSYR MEDICAL PRACTICE E84030 ELLIS PRACTICE E84032 THE FRYENT WAY SURGERY E84048 BRAMPTON HEALTH CENTRE E84049 STANLEY CORNER MEDICAL CENTRE E84051 THE CLARENCE MEDICAL CENTRE E84056 LANCELOT MEDICAL CENTRE E84063 HAZELDENE MEDICAL CENTRE E84066 CHURCH LANE SURGERY E84067 FREUCHEN MEDICAL CENTRE E84074 KINGSBURY HEALTH AND WELLBEING E84078 WALM LANE SURGERY E84086 PARK ROAD SURGERY E84624 THE SUNFLOWER MEDICAL CENTRE E84626 HILLTOP MEDICAL PRACTICE E84637 ALPERTON MEDICAL CENTRE E84638 ACTON LANE SURGERY E84645 ROUNDWOOD PARK MEDICAL CENTRE E84656 NEASDEN MEDICAL CENTRE E84665 BLESSING MEDICAL CENTRE E84667 CHICHELE ROAD SURGERY E84674 PRESTON MEDICAL CENTRE E84678 THE TUDOR HOUSE MEDICAL CENTRE E84684 INTERGRATED HEALTH CIC E84685 CREST MEDICAL CENTRE E84690 PEEL PRECINCT SURGERY E84696 KINGS EDGE MEDICAL CENTRE E84699 PEARL MEDICAL PRACTICE E84701 WILLESDEN GREEN SURGERY E84702 ST.GEORGES MEDICAL CENTRE E84704 CHAMBERLAYNE RD SURGERY E84705 WILLOW TREE FAMILY DOCTORS E84706 THE VILLAGE MEDICAL CENTRE E84708 WEMBLEY PARK DRIVE MEDICAL CENTRE E84709 BURNLEY PRACTICE Y00206 SMS MEDICAL PRACTICE Y01090 HARNESS WEMBLEY PRACTICE Y02692 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 Ealing CCG 83.6% • 297 people with heart failure* with NHS Hounslow CCG 82.8% LVSD treated with ACE-I/ARB in NHS Brent CCG NHS Brent CCG 82.5% • 245 (82.5%) people treated with ACE- I/ARB and BB • 43 (14.5%) people who are NHS Harrow CCG 77.4% exceptions • 9 (3%) additional people who are not NHS Hammersmith And Fulham CCG 74.0% treated with ACE-I/ARB and BB

NHS West London CCG 73.4%

NHS Hillingdon CCG 72.6%

NHS Central London (Westminster) CCG 71.7%

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 Lewisham CCG 88.8%

NHS Croydon CCG 84.6%

NHS Ealing CCG 83.6%

NHS Hounslow CCG 82.8%

NHS Brent CCG 82.5%

NHS Greenwich CCG 82.0%

NHS Haringey CCG 81.4%

NHS Merton CCG 79.9%

NHS Waltham Forest CCG 74.5%

NHS Redbridge CCG 73.5%

NHS Sandwell and West Birmingham CCG 70.6%

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

ST ANDREWS MEDICAL CENTRE E84011 1 AKSYR MEDICAL PRACTICE E84030 2 CRICKLEWOOD BROADWAY SURGERY E83654 1 THE LONSDALE MEDICAL CENTRE E84025 2 FREUCHEN MEDICAL CENTRE E84074 1 CREST MEDICAL CENTRE E84690 1 KINGS EDGE MEDICAL CENTRE E84699 1 WALM LANE SURGERY E84086 3 • in total, including exceptions, there THE SURGERY E84635 6 THE WINDMILL MEDICAL PRACTICE E84012 1 THE FRYENT WAY SURGERY E84048 1 are 52 people who are not treated PRESTON MEDICAL CENTRE E84678 1 BURNLEY PRACTICE Y00206 1 THE BEECHCROFT MEDICAL CENTRE E84084 2 with ACE-I or ARB KILBURN PARK MEDICAL CENTRE E84042 3 UXENDON CRESCENT SURGERY E84007 1 SUDBURY & ALPERTON MEDICAL CENTRE E84017 1 • GP practice range: 0.0% to 100.0% CHALKHILL FAMILY PRACTICE E84033 1 GLADSTONE MEDICAL CENTRE E84036 1 ACTON LANE SURGERY E84645 1 NEASDEN MEDICAL CENTRE E84665 1 PREMIER MEDICAL CENTRE E84003 5 OXGATE GARDENS SURGERY E84076 1 THE LAW MEDICAL GROUP PRACTICE E84006 4 WILLOW TREE FAMILY DOCTORS E84015 1 THE EAGLE EYE E84669 1 PARK HOUSE MEDICAL CENTRE E84023 1 BRENTFIELD MEDICAL CENTRE E84031 1 THE VILLAGE MEDICAL CENTRE E84708 1 WEMBLEY PARK DRIVE MEDICAL CENTRE E84709 2 FORTY WILLOWS SURGERY E84002 1 LANFRANC MEDICAL CENTRE E84083 1 CHURCH END MEDICAL CENTRE E84013 THE STAG - HOLLYROOD PRACTICE E84020 THE WILLESDEN MEDICAL CENTRE E84021 BUCKINGHAM RD SURGERY E84026 THE STONEBRIDGE PRACTICE E84028 HARNESS HARLESDEN PRACTICE E84029 ELLIS PRACTICE E84032 BRAMPTON HEALTH CENTRE E84049 STANLEY CORNER MEDICAL CENTRE E84051 THE CLARENCE MEDICAL CENTRE E84056 LANCELOT MEDICAL CENTRE E84063 HAZELDENE MEDICAL CENTRE E84066 CHURCH LANE SURGERY E84067 THE SHELDON PRACTICE E84077 KINGSBURY HEALTH AND WELLBEING E84078 STAVERTON SURGERY E84080 PRESTON ROAD SURGERY E84620 PARK ROAD SURGERY E84624 THE SUNFLOWER MEDICAL CENTRE E84626 HILLTOP MEDICAL PRACTICE E84637 ALPERTON MEDICAL CENTRE E84638 ROUNDWOOD PARK MEDICAL CENTRE E84656 BLESSING MEDICAL CENTRE E84667 CHICHELE ROAD SURGERY E84674 THE TUDOR HOUSE MEDICAL CENTRE E84684 INTERGRATED HEALTH CIC E84685 PEEL PRECINCT SURGERY E84696 PEARL MEDICAL PRACTICE E84701 WILLESDEN GREEN SURGERY E84702 ST.GEORGES MEDICAL CENTRE E84704 CHAMBERLAYNE RD SURGERY E84705 WILLOW TREE FAMILY DOCTORS E84706 SMS MEDICAL PRACTICE Y01090 HARNESS WEMBLEY PRACTICE Y02692 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 Brent CCG 89.8% • 7,803 people with coronary heart NHS Harrow CCG 89.5% disease* in NHS Brent CCG • 7,007 (89.8%) people whose blood NHS Hillingdon CCG 89.1% pressure <= 150 / 90 • 318 (4.1%) people who are exceptions NHS Ealing CCG 88.0% • 478 (6.1%) additional people whose blood pressure is not <= 150 / 90 NHS Hounslow CCG 87.9%

NHS West London CCG 86.5%

NHS Central London (Westminster) CCG 86.3%

NHS Hammersmith And Fulham CCG 83.9%

England 88.2%

0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator CHD002 denominator plus exceptions

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

NHS Redbridge CCG 90.1%

NHS Brent CCG 89.8%

NHS Merton CCG 89.5%

NHS Croydon CCG 88.9%

NHS Waltham Forest CCG 88.9%

NHS Ealing CCG 88.0%

NHS Hounslow CCG 87.9%

NHS Sandwell and West Birmingham CCG 87.0%

NHS Greenwich CCG 86.8%

NHS Lewisham CCG 86.2%

NHS Haringey CCG 85.7%

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

CRICKLEWOOD BROADWAY SURGERY E83654 16 PARK ROAD SURGERY E84624 14 THE SUNFLOWER MEDICAL CENTRE E84626 17 THE WILLESDEN MEDICAL CENTRE E84021 48 KILBURN PARK MEDICAL CENTRE E84042 21 ELLIS PRACTICE E84032 26 SMS MEDICAL PRACTICE Y01090 12 INTERGRATED HEALTH CIC E84685 35 • in total, including exceptions, there BUCKINGHAM RD SURGERY E84026 17 AKSYR MEDICAL PRACTICE E84030 22 GLADSTONE MEDICAL CENTRE E84036 29 are 796 people whose blood pressure THE CLARENCE MEDICAL CENTRE E84056 9 FORTY WILLOWS SURGERY E84002 21 PEEL PRECINCT SURGERY E84696 3 is not <= 150 / 90 PARK HOUSE MEDICAL CENTRE E84023 11 THE LAW MEDICAL GROUP PRACTICE E84006 40 BURNLEY PRACTICE Y00206 10 • GP practice range: 0.0% to 27.1% FREUCHEN MEDICAL CENTRE E84074 13 THE LONSDALE MEDICAL CENTRE E84025 23 HAZELDENE MEDICAL CENTRE E84066 8 KINGS EDGE MEDICAL CENTRE E84699 10 BRENTFIELD MEDICAL CENTRE E84031 21 ACTON LANE SURGERY E84645 8 HARNESS HARLESDEN PRACTICE E84029 9 THE SURGERY E84635 9 THE STONEBRIDGE PRACTICE E84028 9 PEARL MEDICAL PRACTICE E84701 7 CHURCH LANE SURGERY E84067 12 THE VILLAGE MEDICAL CENTRE E84708 5 SUDBURY & ALPERTON MEDICAL CENTRE E84017 27 BRAMPTON HEALTH CENTRE E84049 8 THE TUDOR HOUSE MEDICAL CENTRE E84684 8 CHALKHILL FAMILY PRACTICE E84033 10 OXGATE GARDENS SURGERY E84076 15 STAVERTON SURGERY E84080 13 WILLOW TREE FAMILY DOCTORS E84706 5 CHURCH END MEDICAL CENTRE E84013 11 KINGSBURY HEALTH AND WELLBEING E84078 21 BLESSING MEDICAL CENTRE E84667 2 HARNESS WEMBLEY PRACTICE Y02692 5 CREST MEDICAL CENTRE E84690 6 THE FRYENT WAY SURGERY E84048 19 LANCELOT MEDICAL CENTRE E84063 6 UXENDON CRESCENT SURGERY E84007 16 WALM LANE SURGERY E84086 6 ST ANDREWS MEDICAL CENTRE E84011 5 PRESTON ROAD SURGERY E84620 10 THE WINDMILL MEDICAL PRACTICE E84012 8 PREMIER MEDICAL CENTRE E84003 12 STANLEY CORNER MEDICAL CENTRE E84051 10 WEMBLEY PARK DRIVE MEDICAL CENTRE E84709 12 THE SHELDON PRACTICE E84077 4 WILLOW TREE FAMILY DOCTORS E84015 16 CHAMBERLAYNE RD SURGERY E84705 2 THE BEECHCROFT MEDICAL CENTRE E84084 8 NEASDEN MEDICAL CENTRE E84665 10 LANFRANC MEDICAL CENTRE E84083 10 CHICHELE ROAD SURGERY E84674 4 ST.GEORGES MEDICAL CENTRE E84704 3 ROUNDWOOD PARK MEDICAL CENTRE E84656 4 THE STAG - HOLLYROOD PRACTICE E84020 5 ALPERTON MEDICAL CENTRE E84638 6 THE EAGLE EYE E84669 2 HILLTOP MEDICAL PRACTICE E84637 1 PRESTON MEDICAL CENTRE E84678 1 WILLESDEN GREEN SURGERY E84702 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

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

CRICKLEWOOD BROADWAY SURGERY 12

PARK ROAD SURGERY 11

THE SUNFLOWER MEDICAL CENTRE 12 • using the GP cluster method of THE WILLESDEN MEDICAL CENTRE 32 calculating potential gains, if each KILBURN PARK MEDICAL CENTRE 14 practice was to achieve as well as the ELLIS PRACTICE 16 upper quartile of its national cluster, then an additional 312 people would SMS MEDICAL PRACTICE 7 be treated INTERGRATED HEALTH CIC 21

BUCKINGHAM RD SURGERY 10

AKSYR MEDICAL PRACTICE 13

LANFRANC MEDICAL CENTRE

CHICHELE ROAD SURGERY

THE STAG - HOLLYROOD PRACTICE

ST.GEORGES MEDICAL CENTRE

ROUNDWOOD PARK MEDICAL CENTRE

THE EAGLE EYE

ALPERTON MEDICAL CENTRE

HILLTOP MEDICAL PRACTICE

PRESTON MEDICAL CENTRE

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

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

NHS Hillingdon CCG 93.5% • 7,803 people with coronary heart NHS Brent CCG 93.3% disease* in NHS Brent CCG • 7,284 (93.3%) people who are taking NHS Ealing CCG 92.8% aspirin, an alternative anti-platelet therapy, or an anti-coagulant • 284 (3.6%) people who are NHS Harrow CCG 92.4% exceptions • 235 (3%) additional people who are NHS Hounslow CCG 91.8% not taking aspirin, an alternative anti- platelet therapy, or an anti-coagulant

NHS Central London (Westminster) CCG 89.1%

NHS West London CCG 88.4%

NHS Hammersmith And Fulham CCG 87.9%

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 Brent CCG 93.3%

NHS Merton CCG 92.9%

NHS Ealing CCG 92.8%

NHS Redbridge CCG 92.7%

NHS Croydon CCG 92.2%

NHS Waltham Forest CCG 92.0%

NHS Lewisham CCG 91.9%

NHS Hounslow CCG 91.8%

NHS Greenwich CCG 91.4%

NHS Haringey CCG 91.4%

NHS Sandwell and West Birmingham CCG 90.7%

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

PARK ROAD SURGERY E84624 11 HARNESS HARLESDEN PRACTICE E84029 13 THE CLARENCE MEDICAL CENTRE E84056 10 ACTON LANE SURGERY E84645 10 INTERGRATED HEALTH CIC E84685 29 FORTY WILLOWS SURGERY E84002 17 OXGATE GARDENS SURGERY E84076 17 WALM LANE SURGERY E84086 9 • in total, including exceptions, there BURNLEY PRACTICE Y00206 8 GLADSTONE MEDICAL CENTRE E84036 20 THE LAW MEDICAL GROUP PRACTICE E84006 30 are 519 people are not taking aspirin, THE TUDOR HOUSE MEDICAL CENTRE E84684 8 WILLOW TREE FAMILY DOCTORS E84015 25 WILLOW TREE FAMILY DOCTORS E84706 5 an alternative anti-platelet therapy, or CRICKLEWOOD BROADWAY SURGERY E83654 5 WEMBLEY PARK DRIVE MEDICAL CENTRE E84709 15 AKSYR MEDICAL PRACTICE E84030 12 an anti-coagulant BUCKINGHAM RD SURGERY E84026 9 THE BEECHCROFT MEDICAL CENTRE E84084 11 • GP practice range: 0.0% to 20.4% CHALKHILL FAMILY PRACTICE E84033 8 THE SURGERY E84635 6 ELLIS PRACTICE E84032 12 BRENTFIELD MEDICAL CENTRE E84031 13 STAVERTON SURGERY E84080 10 CHURCH END MEDICAL CENTRE E84013 9 THE LONSDALE MEDICAL CENTRE E84025 13 ST ANDREWS MEDICAL CENTRE E84011 5 FREUCHEN MEDICAL CENTRE E84074 7 SUDBURY & ALPERTON MEDICAL CENTRE E84017 17 UXENDON CRESCENT SURGERY E84007 14 KINGS EDGE MEDICAL CENTRE E84699 5 KILBURN PARK MEDICAL CENTRE E84042 7 THE FRYENT WAY SURGERY E84048 15 THE SUNFLOWER MEDICAL CENTRE E84626 4 KINGSBURY HEALTH AND WELLBEING E84078 14 SMS MEDICAL PRACTICE Y01090 4 THE WINDMILL MEDICAL PRACTICE E84012 6 NEASDEN MEDICAL CENTRE E84665 9 CHICHELE ROAD SURGERY E84674 4 CREST MEDICAL CENTRE E84690 4 LANFRANC MEDICAL CENTRE E84083 9 THE SHELDON PRACTICE E84077 3 THE STAG - HOLLYROOD PRACTICE E84020 5 STANLEY CORNER MEDICAL CENTRE E84051 7 THE VILLAGE MEDICAL CENTRE E84708 2 THE WILLESDEN MEDICAL CENTRE E84021 10 THE STONEBRIDGE PRACTICE E84028 3 ROUNDWOOD PARK MEDICAL CENTRE E84656 3 CHURCH LANE SURGERY E84067 4 PRESTON ROAD SURGERY E84620 5 HARNESS WEMBLEY PRACTICE Y02692 2 CHAMBERLAYNE RD SURGERY E84705 1 PREMIER MEDICAL CENTRE E84003 5 PARK HOUSE MEDICAL CENTRE E84023 2 ALPERTON MEDICAL CENTRE E84638 3 HAZELDENE MEDICAL CENTRE E84066 1 PEARL MEDICAL PRACTICE E84701 1 BRAMPTON HEALTH CENTRE E84049 1 LANCELOT MEDICAL CENTRE E84063 1 PRESTON MEDICAL CENTRE E84678 1 HILLTOP MEDICAL PRACTICE E84637 BLESSING MEDICAL CENTRE E84667 THE EAGLE EYE E84669 PEEL PRECINCT SURGERY E84696 WILLESDEN GREEN SURGERY E84702 ST.GEORGES MEDICAL CENTRE E84704 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 Brent CCG England 1200

• in NHS Brent CCG, the hospital 1000 admission rate for coronary heart disease in 2015/16 was 489.5 (1,067) compared to 527.9 for England

800

600

400 Age Age standardised (per rate 100,000)

200

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 Brent CCG England 250

• in NHS Brent CCG, the hospital admission rate for stroke in 2015/16 200 was 181.4 (377) 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 Brent CCG England

155.6% Angina 136.8% • The risk of a stroke was 88.5% higher and the risk of a heart attack was 122.7% 122.7% higher compared to people Heart Attack 108.6% without diabetes. The risk of a major amputation was 159.7% higher. 164.6% Heart failure 150.0%

88.5% Stroke 81.3%

159.7% Major amputation 445.8%

305.4% Minor amputation 753.5%

301.3% 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 Brent CCG England 90

80 • in NHS Brent CCG, the early mortality rate for coronary heart disease in 70 2013-15 was 51.7, 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 Brent CCG England 30

• in NHS Brent CCG, the early mortality 25 rate for stroke in 2013-15 was 21.1, 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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