CVD: Primary Care Intelligence Packs NHS North Norfolk 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 North Norfolk CCG are: NHS Eastbourne, Hailsham and Seaford CCG NHS Isle of Wight CCG NHS Fylde & Wyre CCG NHS South Lincolnshire CCG NHS Hambleton, Richmondshire and Whitby CCG NHS Eastern Cheshire CCG NHS West Norfolk CCG NHS Stafford and Surrounds CCG NHS North Derbyshire CCG NHS Wyre Forest 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 West Norfolk CCG 19.2%

NHS Isle of Wight CCG 18.5% • prevalence of 15.6% in NHS North Norfolk CCG NHS Wyre Forest CCG 18.4%

NHS Fylde & Wyre CCG 17.7%

NHS South Lincolnshire CCG 17.5%

NHS North Derbyshire CCG 16.3%

NHS Eastbourne, Hailsham and Seaford CCG 16.2%

NHS North Norfolk CCG 15.6% Note: It has been found that the proportion of patients recorded as smokers correlates well NHS Stafford and Surrounds CCG 14.5% with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, NHS Hambleton, Richmondshire and Whitby CCG 14.0% http://bmjopen.bmj.com/content/4/7/e005217.abs tract

NHS Eastern Cheshire CCG 13.8% 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

WELLS HEALTH CENTRE D82038 20.0%

PASTON SURGERY D82066 19.0% • 23,122 people who are recorded as BIRCHWOOD MEDICAL PRACTICE D82059 18.9% smokers in NHS North Norfolk CCG STALHAM STAITHE SURGERY D82009 18.2% • GP practice range: 11.3% to 20.0%

MUNDESLEY MEDICAL CENTRE D82053 17.9%

REEPHAM & AYLSHAM MEDICAL PRACTICE D82030 17.8%

FAKENHAM MEDICAL PRACTICE D82054 17.6%

CROMER GROUP PRACTICE D82004 17.2%

BRUNDALL MEDICAL PARTNERSHIP D82032 14.4%

HOLT MEDICAL PRACTICE D82001 14.3%

MARKET SURGERY D82016 14.3%

DRAYTON & ST FAITHS MEDICAL PRACTICE D82029 14.1%

SHERINGHAM MEDICAL PRACTICE D82005 14.0%

HOVETON & WROXHAM MEDICAL CENTRE D82025 13.9%

LUDHAM AND STALHAM GREEN SURGERIES D82028 13.9%

COLTISHALL MEDICAL PRACTICE D82062 13.7% Note: This method is thought to be a reasonably

ACLE MEDICAL PARTNERSHIP D82104 13.7% robust method in estimating smoking prevalence for the majority of GP practices. However, ALDBOROUGH SURGERY D82628 13.2% caution is advised for extreme estimates of

BLOFIELD SURGERY D82080 11.3% smoking prevalence and those with high numbers of smoking status not recorded and 0% 5% 10% 15% 20% 25% 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 West Norfolk CCG 0.62

• the ratio of those diagnosed with NHS Great Yarmouth And Waveney CCG 0.60 hypertension versus those expected to have hypertension is 0.6. This compares to 0.59 for England • this suggests that 60% of people with NHS North Norfolk CCG 0.60 hypertension have been diagnosed

NHS South Norfolk CCG 0.59

NHS Norwich CCG 0.55

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 Fylde & Wyre CCG 0.62

NHS West Norfolk CCG 0.62

NHS Wyre Forest CCG 0.61

NHS North Derbyshire CCG 0.61

NHS Eastbourne, Hailsham and Seaford CCG 0.61

NHS Isle of Wight CCG 0.61

NHS South Lincolnshire CCG 0.61

NHS North Norfolk CCG 0.60

NHS Stafford and Surrounds CCG 0.60

NHS Hambleton, Richmondshire and Whitby CCG 0.60

NHS Eastern Cheshire CCG 0.59

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

STALHAM STAITHE SURGERY D82009 0.68

BLOFIELD SURGERY D82080 0.64

PASTON SURGERY D82066 0.63 • it is estimated that there are 19,949 people with undiagnosed HOVETON & WROXHAM MEDICAL CENTRE D82025 0.61 hypertension in NHS North Norfolk MUNDESLEY MEDICAL CENTRE D82053 0.61 CCG ALDBOROUGH SURGERY D82628 0.59 • GP practice range of observed to COLTISHALL MEDICAL PRACTICE D82062 0.58 expected hypertension prevalence SHERINGHAM MEDICAL PRACTICE D82005 0.58 0.46 to 0.68

BRUNDALL MEDICAL PARTNERSHIP D82032 0.57

CROMER GROUP PRACTICE D82004 0.56

BIRCHWOOD MEDICAL PRACTICE D82059 0.56

REEPHAM & AYLSHAM MEDICAL PRACTICE D82030 0.55

LUDHAM AND STALHAM GREEN SURGERIES D82028 0.55

ACLE MEDICAL PARTNERSHIP D82104 0.52

FAKENHAM MEDICAL PRACTICE D82054 0.51

DRAYTON & ST FAITHS MEDICAL PRACTICE D82029 0.50

MARKET SURGERY D82016 0.49

WELLS HEALTH CENTRE D82038 0.46

HOLT MEDICAL PRACTICE D82001 0.46

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 South Norfolk CCG 82.4%

• 30,422 people with hypertension NHS North Norfolk CCG 82.1% (diagnosed)* in NHS North Norfolk CCG • 24,970 (82.1%) people whose blood pressure is <= 150/90 NHS Norwich CCG 81.5% • 1,185 (3.9%) people who are excepted from optimal control • 4,267 (14%) additional people whose NHS West Norfolk CCG 81.1% blood pressure is not <= 150/90

NHS Great Yarmouth And Waveney CCG 76.9%

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 South Lincolnshire CCG 83.8%

NHS Isle of Wight CCG 82.8%

NHS Hambleton, Richmondshire and Whitby CCG 82.7%

NHS North Norfolk CCG 82.1%

NHS Fylde & Wyre CCG 81.4%

NHS Wyre Forest CCG 81.2%

NHS West Norfolk CCG 81.1%

NHS North Derbyshire CCG 80.8%

NHS Eastern Cheshire CCG 79.8%

NHS Eastbourne, Hailsham and Seaford CCG 77.3%

NHS Stafford and Surrounds CCG 76.8%

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

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

No treatment Exceptions reported

ACLE MEDICAL PARTNERSHIP D82104 500

ALDBOROUGH SURGERY D82628 185 • in total, including exceptions, there BRUNDALL MEDICAL PARTNERSHIP D82032 346 are 5,452 people whose blood MARKET SURGERY D82016 327 pressure is not <= 150/90 CROMER GROUP PRACTICE D82004 540 • GP practice range: 9.4% to 34.3%

PASTON SURGERY D82066 257

HOVETON & WROXHAM MEDICAL CENTRE D82025 347

FAKENHAM MEDICAL PRACTICE D82054 423

HOLT MEDICAL PRACTICE D82001 415

BLOFIELD SURGERY D82080 188

LUDHAM AND STALHAM GREEN SURGERIES D82028 183

COLTISHALL MEDICAL PRACTICE D82062 227

DRAYTON & ST FAITHS MEDICAL PRACTICE D82029 411

MUNDESLEY MEDICAL CENTRE D82053 185

STALHAM STAITHE SURGERY D82009 226

BIRCHWOOD MEDICAL PRACTICE D82059 261

REEPHAM & AYLSHAM MEDICAL PRACTICE D82030 158

SHERINGHAM MEDICAL PRACTICE D82005 227

WELLS HEALTH CENTRE D82038 46

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 West Norfolk CCG 68.5%

• 122 people with a new diagnosis* of NHS Norwich CCG 64.2% hypertension with a CVD risk of 20% or higher in NHS North Norfolk CCG • 70 (57.4%) people who are currently treated with statins NHS Great Yarmouth And Waveney CCG 62.1% • 51 (41.8%) people who are exempted from treatment with statins • 1 (0.8%) additional people who are NHS North Norfolk CCG 57.4% not currently treated with statins

NHS South Norfolk CCG 49.2%

England 66.5%

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

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

NHS Hambleton, Richmondshire and Whitby CCG 71.6%

NHS West Norfolk CCG 68.5%

NHS Fylde & Wyre CCG 64.5%

NHS Eastern Cheshire CCG 62.9%

NHS South Lincolnshire CCG 61.8%

NHS North Derbyshire CCG 58.8%

NHS Wyre Forest CCG 58.3%

NHS North Norfolk CCG 57.4%

NHS Eastbourne, Hailsham and Seaford CCG 54.9%

NHS Isle of Wight CCG 54.8%

NHS Stafford and Surrounds CCG 53.7%

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

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

No treatment Exceptions reported

MUNDESLEY MEDICAL CENTRE D82053 6

COLTISHALL MEDICAL PRACTICE D82062 5 • in total, including exceptions, there PASTON SURGERY D82066 3 are 52 people who are not treated STALHAM STAITHE SURGERY D82009 2 with statins LUDHAM AND STALHAM GREEN SURGERIES D82028 2 • GP practice range: 0.0% to 85.7%

BLOFIELD SURGERY D82080 4

MARKET SURGERY D82016 8

ACLE MEDICAL PARTNERSHIP D82104 5

CROMER GROUP PRACTICE D82004 3

FAKENHAM MEDICAL PRACTICE D82054 4

SHERINGHAM MEDICAL PRACTICE D82005 2

HOVETON & WROXHAM MEDICAL CENTRE D82025 1

BIRCHWOOD MEDICAL PRACTICE D82059 6

DRAYTON & ST FAITHS MEDICAL PRACTICE D82029 1

HOLT MEDICAL PRACTICE D82001

REEPHAM & AYLSHAM MEDICAL PRACTICE D82030

BRUNDALL MEDICAL PARTNERSHIP D82032

WELLS HEALTH CENTRE D82038

ALDBOROUGH SURGERY D82628

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 West Norfolk CCG 0.79

• the ratio of those diagnosed with atrial NHS North Norfolk CCG 0.74 fibrillation versus those expected to have atrial fibrillation is 0.74. This compares to 0.7 for England • this suggests that 74% of people with NHS South Norfolk CCG 0.69 atrial fibrillation have been diagnosed.

NHS Great Yarmouth And Waveney CCG 0.66

NHS Norwich CCG 0.65

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 0.9 NHS Digital. Estimates reported are adjusted for age and sex of the local population.

28 CVD: Primary Care Intelligence Packs Atrial fibrillation observed prevalence compared to expected prevalence by CCG Comparison with demographically similar CCGs

NHS Eastbourne, Hailsham and Seaford CCG 0.84

NHS West Norfolk CCG 0.79

NHS North Derbyshire CCG 0.77

NHS Hambleton, Richmondshire and Whitby CCG 0.76

NHS Eastern Cheshire CCG 0.75

NHS North Norfolk CCG 0.74

NHS South Lincolnshire CCG 0.73

NHS Fylde & Wyre CCG 0.72

NHS Stafford and Surrounds CCG 0.72

NHS Wyre Forest CCG 0.71

NHS Isle of Wight CCG 0.63

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

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

GP practice CCG

BLOFIELD SURGERY D82080 0.9

CROMER GROUP PRACTICE D82004 0.8

SHERINGHAM MEDICAL PRACTICE D82005 0.8 • it is estimated that there are 6,713 people with undiagnosed atrial HOVETON & WROXHAM MEDICAL CENTRE D82025 0.8 fibrillation in NHS North Norfolk CCG LUDHAM AND STALHAM GREEN SURGERIES D82028 0.8 • GP practice range of observed to MUNDESLEY MEDICAL CENTRE D82053 0.8 expected atrial fibrillation prevalence FAKENHAM MEDICAL PRACTICE D82054 0.8 0.6 to 0.9 COLTISHALL MEDICAL PRACTICE D82062 0.8

PASTON SURGERY D82066 0.8

ALDBOROUGH SURGERY D82628 0.8

HOLT MEDICAL PRACTICE D82001 0.7

MARKET SURGERY D82016 0.7

DRAYTON & ST FAITHS MEDICAL PRACTICE D82029 0.7

REEPHAM & AYLSHAM MEDICAL PRACTICE D82030 0.7

BRUNDALL MEDICAL PARTNERSHIP D82032 0.7

WELLS HEALTH CENTRE D82038 0.7

BIRCHWOOD MEDICAL PRACTICE D82059 0.7

ACLE MEDICAL PARTNERSHIP D82104 0.7

STALHAM STAITHE SURGERY D82009 0.6

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Ratio

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

NHS Norwich CCG 78.7% • 4,129 people with atrial fibrillation* with a CHA2DS2-VASc score >= 2 in NHS North Norfolk CCG NHS South Norfolk CCG 77.4% • 3,079 (74.6%) people treated with anti-coagulation therapy • 535 (13%) people who are exceptions NHS West Norfolk CCG 74.8% • 515 (12.5%) additional people with a recorded CHA2DS2-VASc score >= 2 who are not treated NHS North Norfolk CCG 74.6%

NHS Great Yarmouth And Waveney CCG 71.3%

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 Hambleton, Richmondshire and Whitby CCG 83.7%

NHS South Lincolnshire CCG 83.4%

NHS North Derbyshire CCG 82.0%

NHS Stafford and Surrounds CCG 78.2%

NHS Eastbourne, Hailsham and Seaford CCG 78.1%

NHS Eastern Cheshire CCG 77.7%

NHS Wyre Forest CCG 77.5%

NHS Fylde & Wyre CCG 76.5%

NHS West Norfolk CCG 74.8%

NHS North Norfolk CCG 74.6%

NHS Isle of Wight CCG 73.5%

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

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

No treatment Exceptions reported

CROMER GROUP PRACTICE D82004 140

MUNDESLEY MEDICAL CENTRE D82053 55 • in total, including exceptions, there MARKET SURGERY D82016 58 are 1,050 people with a recorded FAKENHAM MEDICAL PRACTICE D82054 115 CHA2DS2-VASc score >= 2 who are SHERINGHAM MEDICAL PRACTICE D82005 95 not treated

HOVETON & WROXHAM MEDICAL CENTRE D82025 72 • GP practice range: 10.8% to 35.2%

ACLE MEDICAL PARTNERSHIP D82104 49

REEPHAM & AYLSHAM MEDICAL PRACTICE D82030 40

LUDHAM AND STALHAM GREEN SURGERIES D82028 42

BRUNDALL MEDICAL PARTNERSHIP D82032 40

HOLT MEDICAL PRACTICE D82001 80

PASTON SURGERY D82066 46

ALDBOROUGH SURGERY D82628 18

DRAYTON & ST FAITHS MEDICAL PRACTICE D82029 63

WELLS HEALTH CENTRE D82038 17

COLTISHALL MEDICAL PRACTICE D82062 34

BLOFIELD SURGERY D82080 25

BIRCHWOOD MEDICAL PRACTICE D82059 44

STALHAM STAITHE SURGERY D82009 17

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

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

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

CROMER GROUP PRACTICE 65

MARKET SURGERY 30 MUNDESLEY MEDICAL CENTRE 24 • using the GP cluster method of FAKENHAM MEDICAL PRACTICE 46 calculating potential gains, if each

ACLE MEDICAL PARTNERSHIP 18 practice was to achieve as well as the upper quartile of its national cluster, SHERINGHAM MEDICAL PRACTICE 31 then an additional 334 people would BRUNDALL MEDICAL PARTNERSHIP 15 be treated REEPHAM & AYLSHAM MEDICAL PRACTICE 14

HOVETON & WROXHAM MEDICAL CENTRE 23

ALDBOROUGH SURGERY 6

LUDHAM AND STALHAM GREEN SURGERIES 10

COLTISHALL MEDICAL PRACTICE 9

HOLT MEDICAL PRACTICE 17

PASTON SURGERY 10

DRAYTON & ST FAITHS MEDICAL PRACTICE 11

BLOFIELD SURGERY 4

WELLS HEALTH CENTRE 2

BIRCHWOOD MEDICAL PRACTICE

STALHAM STAITHE 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 South Norfolk CCG 84.8% • 4,575 people with a history of stroke or TIA* in NHS North Norfolk CCG • 3,850 (84.2%) people whose blood NHS West Norfolk CCG 84.8% pressure is <= 150 / 90 • 205 (4.5%) people who are exceptions NHS North Norfolk CCG 84.2% • 520 (11.4%) additional people whose blood pressure is not <= 150 / 90

NHS Norwich CCG 83.4%

NHS Great Yarmouth And Waveney CCG 81.4%

England 83.8%

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

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

NHS South Lincolnshire CCG 86.5%

NHS Fylde & Wyre CCG 86.0%

NHS Wyre Forest CCG 85.5%

NHS Hambleton, Richmondshire and Whitby CCG 85.4%

NHS West Norfolk CCG 84.8%

NHS Isle of Wight CCG 84.3%

NHS North Norfolk CCG 84.2%

NHS North Derbyshire CCG 84.1%

NHS Eastbourne, Hailsham and Seaford CCG 82.6%

NHS Eastern Cheshire CCG 82.5%

NHS Stafford and Surrounds CCG 80.4%

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

ALDBOROUGH SURGERY D82628 23

ACLE MEDICAL PARTNERSHIP D82104 48 • in total, including exceptions, there MARKET SURGERY D82016 50 are 725 people whose blood pressure BRUNDALL MEDICAL PARTNERSHIP D82032 40 is not <= 150 / 90 CROMER GROUP PRACTICE D82004 86 • GP practice range: 6.5% to 29.1%

HOLT MEDICAL PRACTICE D82001 67

LUDHAM AND STALHAM GREEN SURGERIES D82028 28

BLOFIELD SURGERY D82080 30

FAKENHAM MEDICAL PRACTICE D82054 62

BIRCHWOOD MEDICAL PRACTICE D82059 37

DRAYTON & ST FAITHS MEDICAL PRACTICE D82029 54

HOVETON & WROXHAM MEDICAL CENTRE D82025 40

STALHAM STAITHE SURGERY D82009 25

MUNDESLEY MEDICAL CENTRE D82053 24

REEPHAM & AYLSHAM MEDICAL PRACTICE D82030 22

COLTISHALL MEDICAL PRACTICE D82062 23

PASTON SURGERY D82066 22

SHERINGHAM MEDICAL PRACTICE D82005 37

WELLS HEALTH CENTRE D82038 7

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 Norwich CCG 92.7% • 3,210 people with a stroke shown to be non-haemorrhagic* in NHS North Norfolk CCG NHS West Norfolk CCG 92.3% • 2,933 (91.4%) people who are taking an anti-platetet agent or anti- coagulant NHS South Norfolk CCG 91.5% • 182 (5.7%) people who are exceptions • 95 (3%) additional people with no NHS North Norfolk CCG 91.4% treatment

NHS Great Yarmouth And Waveney CCG 90.6%

England 91.8%

0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator STIA007 denominator plus exceptions

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

NHS South Lincolnshire CCG 94.0%

NHS Hambleton, Richmondshire and Whitby CCG 93.9%

NHS Wyre Forest CCG 93.3%

NHS North Derbyshire CCG 92.8%

NHS West Norfolk CCG 92.3%

NHS Eastbourne, Hailsham and Seaford CCG 92.1%

NHS Isle of Wight CCG 91.7%

NHS North Norfolk CCG 91.4%

NHS Stafford and Surrounds CCG 90.6%

NHS Fylde & Wyre CCG 90.1%

NHS Eastern Cheshire CCG 89.3%

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

MUNDESLEY MEDICAL CENTRE D82053 27

ACLE MEDICAL PARTNERSHIP D82104 19 • in total, including exceptions, there DRAYTON & ST FAITHS MEDICAL PRACTICE D82029 33 are 277 people who are not taking an COLTISHALL MEDICAL PRACTICE D82062 14 anti-platelet agent or anti-coagulant WELLS HEALTH CENTRE D82038 9 • GP practice range: 4.2% to 18.9%

HOVETON & WROXHAM MEDICAL CENTRE D82025 29

MARKET SURGERY D82016 17

HOLT MEDICAL PRACTICE D82001 19

LUDHAM AND STALHAM GREEN SURGERIES D82028 8

BRUNDALL MEDICAL PARTNERSHIP D82032 9

CROMER GROUP PRACTICE D82004 19

REEPHAM & AYLSHAM MEDICAL PRACTICE D82030 8

STALHAM STAITHE SURGERY D82009 9

BLOFIELD SURGERY D82080 8

FAKENHAM MEDICAL PRACTICE D82054 15

SHERINGHAM MEDICAL PRACTICE D82005 14

ALDBOROUGH SURGERY D82628 3

BIRCHWOOD MEDICAL PRACTICE D82059 10

PASTON SURGERY D82066 7

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 West Norfolk CCG 0.82 • 0.68 ratio of observed to expected diabetes prevalence in NHS North

NHS Great Yarmouth And Waveney CCG 0.79 Norfolk CCG, compared to 0.77 in England

• this suggests 68% of people have NHS South Norfolk CCG 0.71 been diagnosed

NHS North Norfolk CCG 0.68

NHS Norwich CCG 0.67

Note: This slide compares the prevalence of Diabetes recorded in QOF in 2015/16 to the expected prevalence of Diabetes in 2016 taken England 0.77 from the NCVIN diabetes prevalence model produced in 2015.

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

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

NHS South Lincolnshire CCG 0.84

NHS West Norfolk CCG 0.82

NHS Wyre Forest CCG 0.80

NHS North Derbyshire CCG 0.78

NHS Stafford and Surrounds CCG 0.77

NHS Fylde & Wyre CCG 0.75

NHS Eastern Cheshire CCG 0.72

NHS North Norfolk CCG 0.68

NHS Eastbourne, Hailsham and Seaford CCG 0.67

NHS Isle of Wight CCG 0.67

NHS Hambleton, Richmondshire and Whitby CCG 0.66

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

MUNDESLEY MEDICAL CENTRE D82053 8.8%

STALHAM STAITHE SURGERY D82009 8.5% • GP practice range of observed LUDHAM AND STALHAM GREEN SURGERIES D82028 8.4% diabetes 5.2% to 8.8% SHERINGHAM MEDICAL PRACTICE D82005 8.2% • there are an estimated 4,822 people PASTON SURGERY D82066 8.1% with undiagnosed diabetes in NHS

CROMER GROUP PRACTICE D82004 7.6% North Norfolk CCG

BIRCHWOOD MEDICAL PRACTICE D82059 7.6%

HOVETON & WROXHAM MEDICAL CENTRE D82025 7.4%

FAKENHAM MEDICAL PRACTICE D82054 7.3%

WELLS HEALTH CENTRE D82038 6.7%

BLOFIELD SURGERY D82080 6.6%

HOLT MEDICAL PRACTICE D82001 6.6%

MARKET SURGERY D82016 6.5%

BRUNDALL MEDICAL PARTNERSHIP D82032 6.4%

ALDBOROUGH SURGERY D82628 6.3%

COLTISHALL MEDICAL PRACTICE D82062 6.2%

ACLE MEDICAL PARTNERSHIP D82104 6.2%

DRAYTON & ST FAITHS MEDICAL PRACTICE D82029 5.8% Note: The estimated number of undiagnosed REEPHAM & AYLSHAM MEDICAL PRACTICE D82030 5.2% people with diabetes has been calculated by multiplying the estimated prevalence rate to the 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 2015/16 QOF list size and subtracting the number of people on the diabetes register.

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

Diabetes prevalence Undiagnosed diabetes prevalence Expected non-diabetic hyperglycaemia prevalence

• the estimated total prevalence of NHS North Norfolk CCG 7.0% 3.3% 13.6% diabetes in NHS North Norfolk CCG is 10.3% (diagnosed and undiagnosed) NHS West Norfolk CCG 8.2% 1.8% 12.8% • in addition, there are an estimated 13.6% of people in NHS North Norfolk CCG who are at increased risk of NHS Great Yarmouth And Waveney CCG 7.7% 2.1% 12.2% developing diabetes (i.e. with non- diabetic hyperglycaemia)

NHS South Norfolk CCG 6.3% 2.6% 12.1% • this means that 24.0% of the population in NHS North Norfolk CCG are estimated to have diabetes, or at NHS Norwich CCG 5.0% 2.4% 10.3% high risk of developing of diabetes

Note: Prevalence estimates of non-diabetic hyperglycaemia were developed using Health Survey for England (HSE) data. Five years of England 6.5% 1.9% 11.2% HSE data were combined, 2009- 2013. The estimates take into account the age, ethnic group and estimated body mass index of the population. 0% 5% 10% 15% 20% 25% 30% These estimates were produced using the GP registered population.

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

NHS North Norfolk CCG 63.6%

• data on care processes and treatment targets are taken from the National NHS South Norfolk CCG 62.3% Diabetes Audit (NDA) • overall practice participation in the 2015/16 audit was 81.4% in England NHS Norwich CCG 58.0% • in NHS North Norfolk CCG, 17 out of 19 practices (89.5%) participated in the NDA. Data is not available for the NHS West Norfolk CCG 47.4% remaining practices

NHS Great Yarmouth And Waveney CCG 46.4% • 63.6% of people with diabetes (of practices who participated in the audit) had the eight recommended care processes in NHS North Norfolk 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

BIRCHWOOD MEDICAL PRACTICE D82059 80.5%

SHERINGHAM MEDICAL PRACTICE D82005 79.7% • achievement - 8 care processes: in

CROMER GROUP PRACTICE D82004 74.9% practices who provided data via the NDA, between 46.7% and 80.5% of FAKENHAM MEDICAL PRACTICE D82054 74.1% patients received all 8 care processes HOVETON & WROXHAM MEDICAL CENTRE D82025 65.9%

LUDHAM AND STALHAM GREEN SURGERIES D82028 64.7% • at least 3,374 people did not receive MARKET SURGERY D82016 64.3% the eight care processes MUNDESLEY MEDICAL CENTRE D82053 63.9%

ACLE MEDICAL PARTNERSHIP D82104 61.8%

BRUNDALL MEDICAL PARTNERSHIP D82032 61.5%

HOLT MEDICAL PRACTICE D82001 58.3%

PASTON SURGERY D82066 54.8%

WELLS HEALTH CENTRE D82038 51.7%

ALDBOROUGH SURGERY D82628 50.9%

STALHAM STAITHE SURGERY D82009 49.4%

COLTISHALL MEDICAL PRACTICE D82062 46.8%

DRAYTON & ST FAITHS MEDICAL PRACTICE D82029 46.7%

BLOFIELD SURGERY D82080

REEPHAM & AYLSHAM MEDICAL PRACTICE D82030

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

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

NHS West Norfolk CCG 37.1%

• 32.4% of people with diabetes (of practices who participated in the NHS Great Yarmouth And Waveney CCG 33.6% audit) met the three treatment targets in NHS North Norfolk CCG, compared to 39.0% in England

NHS South Norfolk CCG 32.4%

NHS North Norfolk CCG 32.4%

NHS Norwich CCG 32.3%

England 39.0%

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

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

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

WELLS HEALTH CENTRE D82038 52.5%

PASTON SURGERY D82066 44.8% • achievement - 3 treatment targets: in

SHERINGHAM MEDICAL PRACTICE D82005 38.1% practices who provided data via the NDA, between 21.8% and 52.5% of HOVETON & WROXHAM MEDICAL CENTRE D82025 36.2% patients achieved all 3 treatment COLTISHALL MEDICAL PRACTICE D82062 35.7% targets STALHAM STAITHE SURGERY D82009 35.5% • at least 5,673 people did not meet the ALDBOROUGH SURGERY D82628 33.6% three treatment targets BIRCHWOOD MEDICAL PRACTICE D82059 33.4%

LUDHAM AND STALHAM GREEN SURGERIES D82028 33.0%

FAKENHAM MEDICAL PRACTICE D82054 32.6%

HOLT MEDICAL PRACTICE D82001 30.9%

MARKET SURGERY D82016 30.2%

MUNDESLEY MEDICAL CENTRE D82053 29.5%

CROMER GROUP PRACTICE D82004 28.8%

DRAYTON & ST FAITHS MEDICAL PRACTICE D82029 25.6%

BRUNDALL MEDICAL PARTNERSHIP D82032 25.2%

ACLE MEDICAL PARTNERSHIP D82104 21.8%

BLOFIELD SURGERY D82080

REEPHAM & AYLSHAM MEDICAL PRACTICE D82030

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%

ACLE MEDICAL PARTNERSHIP 96

BRUNDALL MEDICAL PARTNERSHIP 76

DRAYTON & ST FAITHS MEDICAL PRACTICE 130 • using the GP cluster method of calculating potential gains, if each CROMER GROUP PRACTICE 111 practice was to achieve as well as the MARKET SURGERY 65 upper quartile of its national cluster,

MUNDESLEY MEDICAL CENTRE 56 then an additional 1,015 people would be treated HOLT MEDICAL PRACTICE 100

ALDBOROUGH SURGERY 15

FAKENHAM MEDICAL PRACTICE 90

LUDHAM AND STALHAM GREEN SURGERIES 39

BIRCHWOOD MEDICAL PRACTICE 73

COLTISHALL MEDICAL PRACTICE 40

STALHAM STAITHE SURGERY 47

HOVETON & WROXHAM MEDICAL CENTRE 39

SHERINGHAM MEDICAL PRACTICE 37

PASTON SURGERY

WELLS HEALTH CENTRE Details of this methodology are available on slide 9. Click here to view them.

51 CVD: Primary Care Intelligence Packs Kidney

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

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

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

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

NHS Great Yarmouth And Waveney CCG 0.71

• the ratio of those diagnosed with NHS North Norfolk CCG 0.70 chronic kidney disease versus those expected to have chronic kidney disease is 0.7. This compares to 0.68 NHS West Norfolk CCG 0.66 for England • this suggests that 70% of people with chronic kidney disease have been diagnosed NHS South Norfolk CCG 0.65

NHS Norwich CCG 0.58

Note: This slide compares the prevalence of CKD recorded in QOF in 2015/16 to the expected prevalence of CKD produced by the University of Southampton in 2011. A small number of CCGs England 0.68 have a ratio greater than 1. It is unlikely that all people with CKD will be diagnosed in any CCG and therefore a ratio greater than 1 suggests that 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 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 South Lincolnshire CCG 0.93

NHS Fylde & Wyre CCG 0.85

NHS North Derbyshire CCG 0.84

NHS Wyre Forest CCG 0.79

NHS Eastbourne, Hailsham and Seaford CCG 0.75

NHS North Norfolk CCG 0.70

NHS West Norfolk CCG 0.66

NHS Eastern Cheshire CCG 0.62

NHS Hambleton, Richmondshire and Whitby CCG 0.57

NHS Isle of Wight CCG 0.53

NHS Stafford and Surrounds CCG 0.52

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Ratio

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

GP practice CCG

COLTISHALL MEDICAL PRACTICE D82062 11.2%

MUNDESLEY MEDICAL CENTRE D82053 10.6% • it is estimated that there are 3,722 SHERINGHAM MEDICAL PRACTICE D82005 8.9% people with undiagnosed chronic LUDHAM AND STALHAM GREEN SURGERIES D82028 8.0% kidney disease in NHS North Norfolk STALHAM STAITHE SURGERY D82009 7.9% CCG

HOVETON & WROXHAM MEDICAL CENTRE D82025 7.8% • GP practice range of observed CKD: 3.0% to 11.2% ALDBOROUGH SURGERY D82628 7.8%

WELLS HEALTH CENTRE D82038 6.7%

PASTON SURGERY D82066 6.1%

ACLE MEDICAL PARTNERSHIP D82104 5.8%

HOLT MEDICAL PRACTICE D82001 5.4%

BLOFIELD SURGERY D82080 5.4%

CROMER GROUP PRACTICE D82004 5.4%

BIRCHWOOD MEDICAL PRACTICE D82059 5.0%

REEPHAM & AYLSHAM MEDICAL PRACTICE D82030 4.7%

FAKENHAM MEDICAL PRACTICE D82054 4.4%

MARKET SURGERY D82016 3.9% Note: CCG estimates for the estimated number of people with CKD are based on DRAYTON & ST FAITHS MEDICAL PRACTICE D82029 3.6% applying a proportion from a resident based BRUNDALL MEDICAL PARTNERSHIP D82032 3.0% population estimate to a GP registered population. The characteristics of registered 0% 2% 4% 6% 8% 10% 12% and resident populations may vary in some CCGs, and local interpretation is required.

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

NHS South Norfolk CCG 73.7% • 8,765 people with CKD (diagnosed*) in NHS North Norfolk CCG • 6,271 (71.5%) people whose blood NHS West Norfolk CCG 72.5% pressure is <= 140 /85 • 988 (11.3%) people who are exceptions NHS Great Yarmouth And Waveney CCG 71.8% • 1,506 (17.2%) additional people whose blood pressure is not <= 140 / 85 NHS North Norfolk CCG 71.5%

NHS Norwich CCG 71.5%

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

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

NHS South Lincolnshire CCG 77.4%

NHS Isle of Wight CCG 76.0%

NHS Hambleton, Richmondshire and Whitby CCG 75.2%

NHS Fylde & Wyre CCG 74.9%

NHS Eastbourne, Hailsham and Seaford CCG 74.7%

NHS Eastern Cheshire CCG 73.0%

NHS Wyre Forest CCG 72.9%

NHS North Derbyshire CCG 72.9%

NHS West Norfolk CCG 72.5%

NHS Stafford and Surrounds CCG 71.6%

NHS North Norfolk CCG 71.5%

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

ACLE MEDICAL PARTNERSHIP D82104 202

DR A LENNOX AND PARTNERS D82004 255 • in total, including exceptions, there DR P J R HARSTON & PARTNERS D82032 84 are 2,494 people whose blood DR FLEMING & PARTNERS D82628 71 pressure is not <= 140 / 85 DR M GASKIN & PARTNERS D82080 96 • GP practice range: 5.5% to 43.5%

DR L HUNTER & PARTNERS D82025 182

DALRYMPLE & PARTNERS D82029 159

ELSBY & PARTNERS D82016 88

DR D BENNETT AND PARTNERS D82054 166

COLTISHALL MEDICAL PRACTICE D82062 222

DR D J H HOOD & PARTNERS D82009 143

DR P EVERDEN AND PARTNERS D82059 123

DR A C BROOKS & PARTNERS D82001 168

LUDHAM AND STALHAM GREEN SURGERIES D82028 94

DR A HALLATT & PARTNERS D82053 117

DR P W SAMPSON & PARTNERS D82005 166

REEPHAM & AYLSHAM MEDICAL PRACTICE D82030 77

DR R J YOUNG & PARTNERS D82066 72

DR G C MCANSH D82038 9

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

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

ACLE MEDICAL PARTNERSHIP 102

DR P J R HARSTON & PARTNERS 44 DR A LENNOX AND PARTNERS 118 • using the GP cluster method of DR FLEMING & PARTNERS 34 calculating potential gains, if each

DR M GASKIN & PARTNERS 45 practice was to achieve as well as the upper quartile of its national cluster, ELSBY & PARTNERS 32 then an additional 736 people would DR L HUNTER & PARTNERS 60 be treated COLTISHALL MEDICAL PRACTICE 73

DR D J H HOOD & PARTNERS 48

DALRYMPLE & PARTNERS 46

DR D BENNETT AND PARTNERS 40

DR P EVERDEN AND PARTNERS 21

DR A C BROOKS & PARTNERS 24

LUDHAM AND STALHAM GREEN SURGERIES 13

DR A HALLATT & PARTNERS 14

DR P W SAMPSON & PARTNERS 19

REEPHAM & AYLSHAM MEDICAL PRACTICE 1

DR R J YOUNG & PARTNERS

DR G C MCANSH 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 West Norfolk CCG 77.7% • 8,765 people with CKD (diagnosed*) in NHS North Norfolk CCG • 6,249 (71.3%) people who have a NHS South Norfolk CCG 77.4% record of urine albumin:creatinine ratio test • 641 (7.3%) people who are NHS Great Yarmouth And Waveney CCG 75.9% exceptions • 1,875 (21.4%) additional people who have no record of urine NHS Norwich CCG 74.8% albumin:creatinine ratio test

NHS North Norfolk CCG 71.3%

*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 Wyre Forest CCG 79.6%

NHS Hambleton, Richmondshire and Whitby CCG 78.3%

NHS South Lincolnshire CCG 77.9%

NHS North Derbyshire CCG 77.8%

NHS West Norfolk CCG 77.7%

NHS Eastern Cheshire CCG 77.6%

NHS Fylde & Wyre CCG 76.4%

NHS Isle of Wight CCG 74.9%

NHS Eastbourne, Hailsham and Seaford CCG 74.9%

NHS Stafford and Surrounds CCG 72.9%

NHS North Norfolk CCG 71.3%

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

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

Not recorded Exceptions reported

DR P J R HARSTON & PARTNERS D82032 168

DALRYMPLE & PARTNERS D82029 311 • in total, including exceptions, there DR D J H HOOD & PARTNERS D82009 189 are 2,516 people who have no record DR P EVERDEN AND PARTNERS D82059 155 of urine albumin:creatinine ratio test DR P W SAMPSON & PARTNERS D82005 227 • GP practice range: 12.7% to 76.7%

COLTISHALL MEDICAL PRACTICE D82062 231

ACLE MEDICAL PARTNERSHIP D82104 131

DR A LENNOX AND PARTNERS D82004 179

DR M GASKIN & PARTNERS D82080 75

DR FLEMING & PARTNERS D82628 50

ELSBY & PARTNERS D82016 76

DR D BENNETT AND PARTNERS D82054 143

DR L HUNTER & PARTNERS D82025 139

LUDHAM AND STALHAM GREEN SURGERIES D82028 90

DR A HALLATT & PARTNERS D82053 97

DR R J YOUNG & PARTNERS D82066 67

DR A C BROOKS & PARTNERS D82001 118

DR G C MCANSH D82038 25

REEPHAM & AYLSHAM MEDICAL PRACTICE D82030 45

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

63 CVD: Primary Care Intelligence Packs Heart

64 CVD: Primary Care Intelligence Packs Management of Heart Disease

Premature death and disability in people with What questions should we ask in our CCG? CHD can be reduced significantly by systematic 1. for each indicator how wide is the variation in evidence based management in primary care achievement and exception reporting? 2. how many people would benefit if all practices performed as well as the best? 3. how can we support practices who are Coronary Heart Disease is one of the principal causes of average and below average to perform as premature death and disability. The key elements of management for well as the best in: an individual who has already had a heart attack or angina are • more systematic delivery of evidence symptom control and secondary prevention of further cardiovascular based care for people with CHD events and premature mortality. There is robust evidence to support the • improved detection and management use of anti-platelet treatment, statins, beta-blockers and angiotensin of heart failure converting enzyme inhibitors or angiotensin receptor blockers. There is also robust evidence to support good control of blood pressure. Each of these interventions is incentivised in QOF but variation in achievement What might help and exception reporting at practice level shows that there is often 1. roll out of GRASP-Heart Failure audit tool considerable potential for improving management and outcomes. that identifies people with heart failure who are undiagnosed or under treated 2. education for health professionals to Heart failure is a common and an important complication of promote evidence based management of coronary heart disease and other conditions. Appropriate treatment CHD and high quality measurement of including up-titration of ace inhibitors and beta blockers in heart failure blood pressure due to LVSD can significantly improve symptom control and quality of 3. ensure access to rapid access diagnostic life, and improve outcomes for patients. Despite this, around a quarter clinics and specialist support for of people with heart failure are undetected and untreated. And amongst management of angina and heart failure those who are diagnosed, there is significant variation in the quality of 4. ensure access to cardiac rehab for care. individuals with CHD and heart failure

65 CVD: Primary Care Intelligence Packs Heart failure prevalence by CCG Comparison with CCGs in the STP

NHS North Norfolk CCG 1.05%

• prevalence of 1.05% in NHS North NHS West Norfolk CCG 0.93% Norfolk CCG compared to 0.76% in England

NHS Great Yarmouth And Waveney CCG 0.91%

NHS South Norfolk CCG 0.82%

NHS Norwich CCG 0.75%

England 0.76%

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

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

NHS Fylde & Wyre CCG 1.49%

NHS Eastbourne, Hailsham and Seaford CCG 1.13%

NHS North Derbyshire CCG 1.11%

NHS Wyre Forest CCG 1.10%

NHS North Norfolk CCG 1.05%

NHS South Lincolnshire CCG 1.01%

NHS Isle of Wight CCG 0.98%

NHS Hambleton, Richmondshire and Whitby CCG 0.95%

NHS West Norfolk CCG 0.93%

NHS Eastern Cheshire CCG 0.79%

NHS Stafford and Surrounds CCG 0.77%

0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6%

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

GP practice CCG

MUNDESLEY MEDICAL CENTRE D82053 2.8%

WELLS HEALTH CENTRE D82038 1.5% • 1,804 people with diagnosed heart BLOFIELD SURGERY D82080 1.5% failure in NHS North Norfolk CCG SHERINGHAM MEDICAL PRACTICE D82005 1.5% • GP practice range: 0.5% to 2.8% FAKENHAM MEDICAL PRACTICE D82054 1.3%

HOVETON & WROXHAM MEDICAL CENTRE D82025 1.2%

CROMER GROUP PRACTICE D82004 1.2%

PASTON SURGERY D82066 1.2%

BIRCHWOOD MEDICAL PRACTICE D82059 1.2%

LUDHAM AND STALHAM GREEN SURGERIES D82028 1.2%

COLTISHALL MEDICAL PRACTICE D82062 0.9%

MARKET SURGERY D82016 0.9%

STALHAM STAITHE SURGERY D82009 0.9%

ACLE MEDICAL PARTNERSHIP D82104 0.9%

REEPHAM & AYLSHAM MEDICAL PRACTICE D82030 0.8%

HOLT MEDICAL PRACTICE D82001 0.7%

BRUNDALL MEDICAL PARTNERSHIP D82032 0.6%

ALDBOROUGH SURGERY D82628 0.5%

DRAYTON & ST FAITHS MEDICAL PRACTICE D82029 0.5%

0.0% 0.5% 1.0% 1.5% 2.0% 2.5% 3.0%

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

NHS South Norfolk CCG 85.9% • 301 people with heart failure* with LVSD in NHS North Norfolk CCG • 247 (82.1%) people treated with ACE- NHS Great Yarmouth And Waveney CCG 85.6% I or ARB • 52 (17.3%) people who are exceptions NHS North Norfolk CCG 82.1% • 2 (0.7%) additional people who are not treated with ACE-I or ARB

NHS West Norfolk CCG 81.9%

NHS Norwich CCG 81.7%

England 84.7%

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

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

NHS Hambleton, Richmondshire and Whitby CCG 89.3%

NHS Isle of Wight CCG 87.9%

NHS Fylde & Wyre CCG 86.9%

NHS Stafford and Surrounds CCG 84.3%

NHS Eastbourne, Hailsham and Seaford CCG 83.4%

NHS Wyre Forest CCG 82.8%

NHS North Derbyshire CCG 82.3%

NHS North Norfolk CCG 82.1%

NHS West Norfolk CCG 81.9%

NHS Eastern Cheshire CCG 80.3%

NHS South Lincolnshire CCG 79.9%

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

BRUNDALL MEDICAL PARTNERSHIP D82032 4

MARKET SURGERY D82016 4 • in total, including exceptions, there FAKENHAM MEDICAL PRACTICE D82054 4 are 54 people who are not treated STALHAM STAITHE SURGERY D82009 5 with ACE-I or ARB COLTISHALL MEDICAL PRACTICE D82062 3 • GP practice range: 0.0% to 50.0%

DRAYTON & ST FAITHS MEDICAL PRACTICE D82029 2

LUDHAM AND STALHAM GREEN SURGERIES D82028 5

BIRCHWOOD MEDICAL PRACTICE D82059 1

ALDBOROUGH SURGERY D82628 1

CROMER GROUP PRACTICE D82004 6

MUNDESLEY MEDICAL CENTRE D82053 5

HOLT MEDICAL PRACTICE D82001 2

BLOFIELD SURGERY D82080 2

HOVETON & WROXHAM MEDICAL CENTRE D82025 4

WELLS HEALTH CENTRE D82038 1

SHERINGHAM MEDICAL PRACTICE D82005 4

PASTON SURGERY D82066 1

REEPHAM & AYLSHAM MEDICAL PRACTICE D82030

ACLE MEDICAL PARTNERSHIP D82104

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 Great Yarmouth And Waveney CCG 74.1% • 247 people with heart failure* with LVSD treated with ACE-I/ARB in NHS North Norfolk CCG NHS West Norfolk CCG 73.3% • 152 (61.5%) people treated with ACE- I/ARB and BB • 72 (29.1%) people who are NHS South Norfolk CCG 68.8% exceptions • 23 (9.3%) additional people who are not treated with ACE-I/ARB and BB NHS Norwich CCG 66.6%

NHS North Norfolk CCG 61.5%

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 Fylde & Wyre CCG 84.9%

NHS Hambleton, Richmondshire and Whitby CCG 81.3%

NHS Stafford and Surrounds CCG 77.7%

NHS North Derbyshire CCG 76.9%

NHS Eastbourne, Hailsham and Seaford CCG 74.9%

NHS Wyre Forest CCG 73.6%

NHS West Norfolk CCG 73.3%

NHS Eastern Cheshire CCG 73.0%

NHS South Lincolnshire CCG 72.4%

NHS Isle of Wight CCG 69.3%

NHS North Norfolk CCG 61.5%

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

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

No treatment Exceptions reported

MARKET SURGERY D82016 4

HOLT MEDICAL PRACTICE D82001 6 • in total, including exceptions, there STALHAM STAITHE SURGERY D82009 8 are 95 people who are not treated SHERINGHAM MEDICAL PRACTICE D82005 17 with ACE-I or ARB COLTISHALL MEDICAL PRACTICE D82062 5 • GP practice range: 0.0% to 57.1%

ACLE MEDICAL PARTNERSHIP D82104 1

ALDBOROUGH SURGERY D82628 2

PASTON SURGERY D82066 6

REEPHAM & AYLSHAM MEDICAL PRACTICE D82030 4

WELLS HEALTH CENTRE D82038 3

LUDHAM AND STALHAM GREEN SURGERIES D82028 8

HOVETON & WROXHAM MEDICAL CENTRE D82025 10

CROMER GROUP PRACTICE D82004 9

BLOFIELD SURGERY D82080 4

MUNDESLEY MEDICAL CENTRE D82053 6

DRAYTON & ST FAITHS MEDICAL PRACTICE D82029 1

FAKENHAM MEDICAL PRACTICE D82054 1

BRUNDALL MEDICAL PARTNERSHIP D82032

BIRCHWOOD MEDICAL PRACTICE D82059

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

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

NHS West Norfolk CCG 89.3% • 7,688 people with coronary heart disease* in NHS North Norfolk CCG • 6,788 (88.3%) people whose blood NHS South Norfolk CCG 88.6% pressure <= 150 / 90 • 375 (4.9%) people who are exceptions NHS North Norfolk CCG 88.3% • 525 (6.8%) additional people whose blood pressure is not <= 150 / 90

NHS Norwich CCG 88.1%

NHS Great Yarmouth And Waveney CCG 84.5%

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 South Lincolnshire CCG 91.0%

NHS Hambleton, Richmondshire and Whitby CCG 91.0%

NHS Wyre Forest CCG 89.4%

NHS West Norfolk CCG 89.3%

NHS North Derbyshire CCG 88.9%

NHS Fylde & Wyre CCG 88.8%

NHS Eastern Cheshire CCG 88.5%

NHS North Norfolk CCG 88.3%

NHS Isle of Wight CCG 87.6%

NHS Eastbourne, Hailsham and Seaford CCG 86.5%

NHS Stafford and Surrounds CCG 83.8%

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

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

Not below 150/90 Exceptions reported

ACLE MEDICAL PARTNERSHIP D82104 97

ALDBOROUGH SURGERY D82628 29 • in total, including exceptions, there BRUNDALL MEDICAL PARTNERSHIP D82032 44 are 900 people whose blood pressure CROMER GROUP PRACTICE D82004 106 is not <= 150 / 90 DRAYTON & ST FAITHS MEDICAL PRACTICE D82029 81 • GP practice range: 5.3% to 26.6%

FAKENHAM MEDICAL PRACTICE D82054 96

PASTON SURGERY D82066 38

LUDHAM AND STALHAM GREEN SURGERIES D82028 34

HOVETON & WROXHAM MEDICAL CENTRE D82025 50

STALHAM STAITHE SURGERY D82009 36

MARKET SURGERY D82016 34

MUNDESLEY MEDICAL CENTRE D82053 40

BLOFIELD SURGERY D82080 23

HOLT MEDICAL PRACTICE D82001 58

REEPHAM & AYLSHAM MEDICAL PRACTICE D82030 30

COLTISHALL MEDICAL PRACTICE D82062 21

BIRCHWOOD MEDICAL PRACTICE D82059 35

SHERINGHAM MEDICAL PRACTICE D82005 41

WELLS HEALTH CENTRE D82038 7

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

77 CVD: Primary Care Intelligence Packs Percentage of patients with CHD whose blood pressure reading (measured in the preceding 12 months) is not 150/90 mmHg or less by GP practice – opportunities compared to GP cluster

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

ACLE MEDICAL PARTNERSHIP 66

ALDBOROUGH SURGERY 20 BRUNDALL MEDICAL PARTNERSHIP 24 • using the GP cluster method of CROMER GROUP PRACTICE 49 calculating potential gains, if each

FAKENHAM MEDICAL PRACTICE 32 practice was to achieve as well as the upper quartile of its national cluster, DRAYTON & ST FAITHS MEDICAL PRACTICE 24 then an additional 288 people would STALHAM STAITHE SURGERY 12 be treated PASTON SURGERY 11

MARKET SURGERY 10

LUDHAM AND STALHAM GREEN SURGERIES 8

HOVETON & WROXHAM MEDICAL CENTRE 11

BLOFIELD SURGERY 6

MUNDESLEY MEDICAL CENTRE 7

HOLT MEDICAL PRACTICE 6

REEPHAM & AYLSHAM MEDICAL PRACTICE 2

COLTISHALL MEDICAL PRACTICE 1

SHERINGHAM MEDICAL PRACTICE

BIRCHWOOD MEDICAL PRACTICE

WELLS HEALTH CENTRE Details of this methodology are available on slide 9. Click here to view them.

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

NHS South Norfolk CCG 91.7% • 7,688 people with coronary heart disease* in NHS North Norfolk CCG • 7,016 (91.3%) people who are taking NHS North Norfolk CCG 91.3% aspirin, an alternative anti-platelet therapy, or an anti-coagulant • 430 (5.6%) people who are NHS West Norfolk CCG 91.1% exceptions • 242 (3.1%) additional people who are not taking aspirin, an alternative anti- NHS Norwich CCG 90.6% platelet therapy, or an anti-coagulant

NHS Great Yarmouth And Waveney CCG 90.0%

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 Wyre Forest CCG 94.3%

NHS Hambleton, Richmondshire and Whitby CCG 94.1%

NHS South Lincolnshire CCG 92.6%

NHS Eastbourne, Hailsham and Seaford CCG 92.4%

NHS Stafford and Surrounds CCG 92.3%

NHS North Derbyshire CCG 92.1%

NHS Isle of Wight CCG 91.6%

NHS Fylde & Wyre CCG 91.5%

NHS North Norfolk CCG 91.3%

NHS Eastern Cheshire CCG 91.2%

NHS West Norfolk CCG 91.1%

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

MARKET SURGERY D82016 40

REEPHAM & AYLSHAM MEDICAL PRACTICE D82030 37 • in total, including exceptions, there FAKENHAM MEDICAL PRACTICE D82054 82 are 672 people are not taking aspirin, DRAYTON & ST FAITHS MEDICAL PRACTICE D82029 66 an alternative anti-platelet therapy, or HOVETON & WROXHAM MEDICAL CENTRE D82025 49 an anti-coagulant

HOLT MEDICAL PRACTICE D82001 64 • GP practice range: 3.8% to 11.7%

BRUNDALL MEDICAL PARTNERSHIP D82032 26

CROMER GROUP PRACTICE D82004 60

ACLE MEDICAL PARTNERSHIP D82104 31

MUNDESLEY MEDICAL CENTRE D82053 34

ALDBOROUGH SURGERY D82628 10

BIRCHWOOD MEDICAL PRACTICE D82059 34

SHERINGHAM MEDICAL PRACTICE D82005 39

COLTISHALL MEDICAL PRACTICE D82062 19

PASTON SURGERY D82066 22

BLOFIELD SURGERY D82080 16

LUDHAM AND STALHAM GREEN SURGERIES D82028 19

STALHAM STAITHE SURGERY D82009 19

WELLS HEALTH CENTRE D82038 5

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

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

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

NHS North Norfolk CCG England 800

700 • in NHS North Norfolk CCG, the hospital admission rate for coronary heart disease in 2015/16 was 434.8 600 (991) compared to 527.9 for England

500

400

300

Age Age standardised (per rate 100,000) 200

100

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

83 CVD: Primary Care Intelligence Packs Hospital admissions for stroke for all ages 2002/03 – 2015/16

NHS North Norfolk CCG England 300

• in NHS North Norfolk CCG, the 250 hospital admission rate for stroke in 2015/16 was 218.5 (528) compared to 172.8 for England

200

150

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

50

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

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

NHS North Norfolk CCG England

141.3% Angina 136.8% • The risk of a stroke was 83.8% higher and the risk of a heart attack was 115.0% 115% higher compared to people Heart Attack 108.6% without diabetes. The risk of a major amputation was 460.9% higher. 132.6% Heart failure 150.0%

83.8% Stroke 81.3%

460.9% Major amputation 445.8%

509.3% Minor amputation 753.5%

356.7% RRT 293.0%

0% 100% 200% 300% 400% 500% 600% 700% 800% Note: This slide uses data from the National Diabetes Audit (NDA)

85 CVD: Primary Care Intelligence Packs Deaths from coronary heart disease, under 75s

NHS North Norfolk CCG England 90

80 • in NHS North Norfolk CCG, the early mortality rate for coronary heart 70 disease in 2013-15 was 29.8, 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 North Norfolk CCG England 30

• in NHS North Norfolk CCG, the early 25 mortality rate for stroke in 2013-15 was 11.3, compared to 13.6 for England

20

15

10 Age Age standardised (per rate 100,000)

5

0 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11 2010-12 2011-13 2012-14 2013-15

Source: Office for National Statistics (ONS) mortality data 2002 - 2015

87 CVD: Primary Care Intelligence Packs Appendix Data sources

• Quality and Outcomes Framework (QOF), 2015/16, Copyright © 2016, re-used with the permission of NHS Digital. All rights reserved

• Non-diabetic hyperglycaemia prevalence estimates, NCVIN, PHE: https://www.gov.uk/government/publications/nhs-diabetes- prevention-programme-non-diabetic-hyperglycaemia

• Diabetes prevalence estimates, NCVIN, PHE: https://www.gov.uk/government/publications/diabetes-prevalence-estimates-for- local-populations

• CKD Prevalence model, G.Aitken, University of Southampton , 2014 https://www.gov.uk/government/publications/ckd- prevalence-estimates-for-local-and-regional-populations

• Hypertension prevalence estimates for local CCG populations. Created using data from: QOF hypertension registers 2014/15 and; Undiagnosed hypertension estimates for adults 16 years and older. 2014. Department of Primary Care & Public Health, Imperial College London https://www.gov.uk/government/publications/hypertension-prevalence-estimates-for-local-populations

• NHS Stop smoking services Copyright © 2014, NHS Digital

• Norberg J, Bäckström S , Jansson J-H, Johansson L. Estimating the prevalence of atrial fibrillation in a general population using validated electronic health data. Clin Epidemiol 2013 ; 5 475 – 81.

• National Diabetes Audit, 2013/14 and 2015/16, Copyright © 2016, re-used with the permission of NHS Digital. All rights reserved

• Hospital Episode Statistics (HES), 2002/03 - 2015/16, Copyright © 2017, Re‐used with the permission of NHS Digital. All rights reserved

• Office for National Statistics (ONS) mortality data 2002 – 2015, Copyright © 2017, Re-used with the permission of the Office for National Statistics. All rights reserved

88 CVD: Primary Care Intelligence Packs About Public Health England

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© Crown copyright 2017 You may re-use this information (excluding logos) free of charge in any format or medium, under the terms of the Open Government Licence v3.0. To view this licence, visit OGL or email [email protected]. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.

Published June 2017 Gateway number 2017095

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