CVD: Primary Care Intelligence Packs NHS Hounslow 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 Hounslow CCG are: NHS Ealing CCG NHS Redbridge CCG NHS Hillingdon CCG NHS Merton CCG NHS Harrow CCG NHS Luton CCG NHS Slough CCG NHS Birmingham South and Central CCG NHS Waltham Forest CCG NHS Brent 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 Waltham Forest CCG 19.7%

NHS Luton CCG 19.2% • prevalence of 16.2% in NHS Hounslow CCG NHS Birmingham South and Central CCG 18.7%

NHS Slough CCG 17.6%

NHS Brent CCG 16.9%

NHS Hillingdon CCG 16.3%

NHS Hounslow CCG 16.2%

NHS Merton CCG 15.5% Note: It has been found that the proportion of patients recorded as smokers correlates well NHS Ealing CCG 15.5% with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, NHS Redbridge CCG 13.6% http://bmjopen.bmj.com/content/4/7/e005217.abs tract

NHS Harrow CCG 12.9% 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

GROVE VILLAGE MEDICAL CENTRE E85699 24.2% MOUNT MEDICAL CENTRE E85035 23.5% GREENBROOK MANOR E85732 23.0% PENTELOW PRACTICE E85115 22.1% BRENTFORD FAMILY PRACTICE E85735 21.8% ALBANY PRACTICE E85004 21.7% LITTLE PARK SURGERY E85736 21.0% • 40,074 people who are recorded as GREENBROOK BEDFONT E85697 20.8% CARLTON SURGERY E85024 20.5% smokers in NHS Hounslow CCG GREENBROOK ISLEWORTH E85744 20.1% QUEENS PARK MEDICAL PRACTICE E85734 19.6% • GP practice range: 6.7% to 24.2% ST DAVIDS PRACTICE E85056 19.6% CLIFFORD HOUSE MEDICAL CENTRE E85071 19.5% TWICKENHAM PARK MEDICAL CENTRE E85045 19.2% MANOR HOUSE PRACTICE E85700 19.2% THE PRACTICE HEART OF HOUNSLOW Y02671 19.0% COLE PARK SURGERY E85117 18.7% WILLOW PRACTICE E85600 18.7% BRENTFORD GROUP PRACTICE E85605 18.3% ISLEWORTH CENTRE FOR HEALTH E85686 18.3% GREENBROOK CHINCHILLA E85727 18.0% THE PRACTICE FELTHAM Y02672 17.8% DR SOOD'S PRACTICE E85018 17.6% REDWOOD PRACTICE E85113 17.2% CHISWICK FAMILY DRS PRACTICE E85625 16.9% KINGFISHER PRACTICE E85060 16.8% ST.MARGARETS PRACTICE E85007 16.4% FIRSTCARE PRACTICE E85062 16.3% SPRING GROVE MEDICAL PRACTICE E85750 15.7% GREENBROOK HESTON E85739 15.5% CHISWICK HEALTH PRACTICE E85030 15.4% BLUE WING FAMILY DOCTOR UNIT E85058 15.4% HATTON MEDICAL PRACTICE E85718 15.4% WELLESLEY ROAD PRACTICE E85692 15.3% CRANFORD MEDICAL CENTRE E85052 15.1% BATH ROAD SURGERY E85716 14.8% GILL MEDICAL PRACTICE E85708 14.6% HOLLY ROAD MEDICAL CENTRE E85658 14.6% CHESTNUT PRACTICE E85059 14.5% GREEN PRACTICE E85126 14.2% THORNBURY ROAD CENTRE FOR HEALTH E85001 13.9% WEST4 GPS E85040 13.9% JERSEY PRACTICE E85681 13.6% SKYWAYS MEDICAL CENTRE E85707 13.3% Note: This method is thought to be a reasonably GROVE PARK TERRACE SURGERY E85746 12.7% HOUNSLOW FAMILY PRACTICE E85713 12.4% robust method in estimating smoking prevalence GLEBE STREET SURGERY E85683 12.3% GROVE PARK SURGERY E85693 11.7% for the majority of GP practices. However, CROSSLANDS SURGERY E85114 10.7% HOUNSLOW MEDICAL CENTRE E85015 9.6% caution is advised for extreme estimates of NORTH HYDE MEDICAL PRACTICE E85755 8.1% THE 303 BATH ROAD SURGERY E85044 7.4% smoking prevalence and those with high CLIFFORD ROAD SURGERY E85696 6.7% 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 0.57. This compares to 0.59 for England • this suggests that 57% 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 Harrow CCG 0.59

NHS Hillingdon CCG 0.58

NHS Brent CCG 0.58

NHS Luton CCG 0.57

NHS Redbridge CCG 0.57

NHS Hounslow CCG 0.57

NHS Ealing CCG 0.57

NHS Slough CCG 0.56

NHS Waltham Forest CCG 0.56

NHS Birmingham South and Central CCG 0.56

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

THE 303 BATH ROAD SURGERY E85044 0.86 SKYWAYS MEDICAL CENTRE E85707 0.76 HOUNSLOW FAMILY PRACTICE E85713 0.72 SPRING GROVE MEDICAL PRACTICE E85750 0.70 GREENBROOK CHINCHILLA E85727 0.70 GROVE VILLAGE MEDICAL CENTRE E85699 0.69 HOUNSLOW MEDICAL CENTRE E85015 0.69 • it is estimated that there are 25,646 DR SOOD'S PRACTICE E85018 0.69 BATH ROAD SURGERY E85716 0.69 CLIFFORD HOUSE MEDICAL CENTRE E85071 0.68 people with undiagnosed TWICKENHAM PARK MEDICAL CENTRE E85045 0.66 CROSSLANDS SURGERY E85114 0.66 hypertension in NHS Hounslow CCG BLUE WING FAMILY DOCTOR UNIT E85058 0.65 GREEN PRACTICE E85126 0.65 GREENBROOK BEDFONT E85697 0.64 • GP practice range of observed to KINGFISHER PRACTICE E85060 0.63 NORTH HYDE MEDICAL PRACTICE E85755 0.63 expected hypertension prevalence MANOR HOUSE PRACTICE E85700 0.63 CHESTNUT PRACTICE E85059 0.63 0.35 to 0.86 CLIFFORD ROAD SURGERY E85696 0.63 QUEENS PARK MEDICAL PRACTICE E85734 0.63 ST DAVIDS PRACTICE E85056 0.62 WILLOW PRACTICE E85600 0.62 THORNBURY ROAD CENTRE FOR HEALTH E85001 0.62 JERSEY PRACTICE E85681 0.62 HOLLY ROAD MEDICAL CENTRE E85658 0.61 GREENBROOK HESTON E85739 0.61 BRENTFORD GROUP PRACTICE E85605 0.60 HATTON MEDICAL PRACTICE E85718 0.59 LITTLE PARK SURGERY E85736 0.58 CRANFORD MEDICAL CENTRE E85052 0.58 COLE PARK SURGERY E85117 0.57 CARLTON SURGERY E85024 0.57 ALBANY PRACTICE E85004 0.57 BRENTFORD FAMILY PRACTICE E85735 0.56 THE PRACTICE FELTHAM Y02672 0.56 REDWOOD PRACTICE E85113 0.55 GREENBROOK MANOR E85732 0.55 ISLEWORTH CENTRE FOR HEALTH E85686 0.55 ST.MARGARETS PRACTICE E85007 0.50 THE PRACTICE HEART OF HOUNSLOW Y02671 0.50 PENTELOW PRACTICE E85115 0.50 MOUNT MEDICAL CENTRE E85035 0.50 GILL MEDICAL PRACTICE E85708 0.47 GREENBROOK ISLEWORTH E85744 0.45 WEST4 GPS E85040 0.44 CHISWICK FAMILY DRS PRACTICE E85625 0.42 GLEBE STREET SURGERY E85683 0.41 CHISWICK HEALTH PRACTICE E85030 0.41 FIRSTCARE PRACTICE E85062 0.41 WELLESLEY ROAD PRACTICE E85692 0.41 GROVE PARK SURGERY E85693 0.37 GROVE PARK TERRACE SURGERY E85746 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% • 34,967 people with hypertension (diagnosed)* in NHS Hounslow CCG NHS Hillingdon CCG 79.7% • 27,549 (78.8%) people whose blood pressure is <= 150/90 • 1,261 (3.6%) people who are NHS Hounslow CCG 78.8% excepted from optimal control • 6,157 (17.6%) 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 Slough CCG 80.5%

NHS Harrow CCG 80.3%

NHS Birmingham South and Central CCG 80.2%

NHS Brent CCG 79.8%

NHS Hillingdon CCG 79.7%

NHS Hounslow CCG 78.8%

NHS Ealing CCG 78.7%

NHS Redbridge CCG 78.3%

NHS Waltham Forest CCG 77.7%

NHS Merton CCG 77.3%

NHS Luton 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

CROSSLANDS SURGERY E85114 333 THE PRACTICE FELTHAM Y02672 162 ST.MARGARETS PRACTICE E85007 315 CRANFORD MEDICAL CENTRE E85052 186 HATTON MEDICAL PRACTICE E85718 138 PENTELOW PRACTICE E85115 126 ST DAVIDS PRACTICE E85056 244 • in total, including exceptions, there MANOR HOUSE PRACTICE E85700 76 THE PRACTICE HEART OF HOUNSLOW Y02671 215 are 7,418 people whose blood SPRING GROVE MEDICAL PRACTICE E85750 223 GREEN PRACTICE E85126 256 pressure is not <= 150/90 GREENBROOK ISLEWORTH E85744 111 GREENBROOK MANOR E85732 65 THORNBURY ROAD CENTRE FOR HEALTH E85001 273 • GP practice range: 11.7% to 30.8% BLUE WING FAMILY DOCTOR UNIT E85058 272 THE 303 BATH ROAD SURGERY E85044 106 GREENBROOK HESTON E85739 152 ISLEWORTH CENTRE FOR HEALTH E85686 97 CHESTNUT PRACTICE E85059 253 CHISWICK HEALTH PRACTICE E85030 137 ALBANY PRACTICE E85004 195 FIRSTCARE PRACTICE E85062 148 CLIFFORD HOUSE MEDICAL CENTRE E85071 85 SKYWAYS MEDICAL CENTRE E85707 183 GROVE PARK SURGERY E85693 138 GROVE VILLAGE MEDICAL CENTRE E85699 164 JERSEY PRACTICE E85681 184 NORTH HYDE MEDICAL PRACTICE E85755 37 KINGFISHER PRACTICE E85060 173 QUEENS PARK MEDICAL PRACTICE E85734 113 BRENTFORD GROUP PRACTICE E85605 175 GREENBROOK CHINCHILLA E85727 70 GROVE PARK TERRACE SURGERY E85746 38 HOLLY ROAD MEDICAL CENTRE E85658 96 WEST4 GPS E85040 207 BRENTFORD FAMILY PRACTICE E85735 72 GREENBROOK BEDFONT E85697 124 GILL MEDICAL PRACTICE E85708 79 WELLESLEY ROAD PRACTICE E85692 95 MOUNT MEDICAL CENTRE E85035 95 BATH ROAD SURGERY E85716 185 DR SOOD'S PRACTICE E85018 55 CHISWICK FAMILY DRS PRACTICE E85625 51 CLIFFORD ROAD SURGERY E85696 142 COLE PARK SURGERY E85117 61 REDWOOD PRACTICE E85113 117 LITTLE PARK SURGERY E85736 107 CARLTON SURGERY E85024 95 HOUNSLOW MEDICAL CENTRE E85015 108 HOUNSLOW FAMILY PRACTICE E85713 78 WILLOW PRACTICE E85600 84 TWICKENHAM PARK MEDICAL CENTRE E85045 78 GLEBE STREET SURGERY E85683 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 Hammersmith And Fulham CCG 84.4%

NHS Ealing CCG 83.4% • 116 people with a new diagnosis* of hypertension with a CVD risk of 20% NHS Hounslow CCG 78.4% or higher in NHS Hounslow CCG • 91 (78.4%) people who are currently treated with statins NHS West London CCG 76.0% • 23 (19.8%) people who are exempted from treatment with statins NHS Central London (Westminster) CCG 73.4% • 2 (1.7%) 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 Slough CCG 80.0%

NHS Hounslow CCG 78.4%

NHS Luton CCG 76.9%

NHS Waltham Forest CCG 72.5%

NHS Merton CCG 72.0%

NHS Hillingdon CCG 71.6%

NHS Birmingham South and Central CCG 70.7%

NHS Brent CCG 70.1%

NHS Harrow CCG 65.4%

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 303 BATH ROAD SURGERY E85044 1 CHISWICK FAMILY DRS PRACTICE E85625 1 WELLESLEY ROAD PRACTICE E85692 1 CARLTON SURGERY E85024 3 WEST4 GPS E85040 2 GREENBROOK MANOR E85732 3 KINGFISHER PRACTICE E85060 1 • in total, including exceptions, there CROSSLANDS SURGERY E85114 1 SKYWAYS MEDICAL CENTRE E85707 1 are 25 people who are not treated BATH ROAD SURGERY E85716 1 THE PRACTICE FELTHAM Y02672 1 with statins GREEN PRACTICE E85126 3 THORNBURY ROAD CENTRE FOR HEALTH E85001 2 THE PRACTICE HEART OF HOUNSLOW Y02671 1 • GP practice range: 0.0% to 100.0% CHISWICK HEALTH PRACTICE E85030 1 BRENTFORD GROUP PRACTICE E85605 1 REDWOOD PRACTICE E85113 1 ALBANY PRACTICE E85004 ST.MARGARETS PRACTICE E85007 HOUNSLOW MEDICAL CENTRE E85015 DR SOOD'S PRACTICE E85018 MOUNT MEDICAL CENTRE E85035 TWICKENHAM PARK MEDICAL CENTRE E85045 CRANFORD MEDICAL CENTRE E85052 ST DAVIDS PRACTICE E85056 BLUE WING FAMILY DOCTOR UNIT E85058 CHESTNUT PRACTICE E85059 FIRSTCARE PRACTICE E85062 CLIFFORD HOUSE MEDICAL CENTRE E85071 PENTELOW PRACTICE E85115 COLE PARK SURGERY E85117 WILLOW PRACTICE E85600 HOLLY ROAD MEDICAL CENTRE E85658 JERSEY PRACTICE E85681 GLEBE STREET SURGERY E85683 ISLEWORTH CENTRE FOR HEALTH E85686 GROVE PARK SURGERY E85693 CLIFFORD ROAD SURGERY E85696 GREENBROOK BEDFONT E85697 GROVE VILLAGE MEDICAL CENTRE E85699 GILL MEDICAL PRACTICE E85708 HOUNSLOW FAMILY PRACTICE E85713 HATTON MEDICAL PRACTICE E85718 GREENBROOK CHINCHILLA E85727 QUEENS PARK MEDICAL PRACTICE E85734 BRENTFORD FAMILY PRACTICE E85735 GREENBROOK HESTON E85739 GREENBROOK ISLEWORTH E85744 GROVE PARK TERRACE SURGERY E85746 SPRING GROVE MEDICAL PRACTICE E85750 NORTH HYDE MEDICAL PRACTICE E85755 LITTLE PARK SURGERY E85736 MANOR HOUSE PRACTICE E85700 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 0.59. This compares to 0.7 for England • this suggests that 59% 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 Hillingdon CCG 0.64

NHS Ealing CCG 0.61

NHS Birmingham South and Central CCG 0.60

NHS Hounslow CCG 0.59

NHS Harrow CCG 0.58

NHS Luton CCG 0.58

NHS Merton CCG 0.58

NHS Slough CCG 0.55

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

PENTELOW PRACTICE E85115 1.1 CARLTON SURGERY E85024 0.9 WEST4 GPS E85040 0.9 TWICKENHAM PARK MEDICAL CENTRE E85045 0.9 MOUNT MEDICAL CENTRE E85035 0.8 BRENTFORD GROUP PRACTICE E85605 0.8 GROVE VILLAGE MEDICAL CENTRE E85699 0.8 • it is estimated that there are 4,949 THORNBURY ROAD CENTRE FOR HEALTH E85001 0.7 ST.MARGARETS PRACTICE E85007 0.7 KINGFISHER PRACTICE E85060 0.7 people with undiagnosed atrial REDWOOD PRACTICE E85113 0.7 COLE PARK SURGERY E85117 0.7 fibrillation in NHS Hounslow CCG WELLESLEY ROAD PRACTICE E85692 0.7 MANOR HOUSE PRACTICE E85700 0.7 • GP practice range of observed to ALBANY PRACTICE E85004 0.6 ST DAVIDS PRACTICE E85056 0.6 BLUE WING FAMILY DOCTOR UNIT E85058 0.6 expected atrial fibrillation prevalence CLIFFORD HOUSE MEDICAL CENTRE E85071 0.6 CROSSLANDS SURGERY E85114 0.6 0.3 to 1.1 WILLOW PRACTICE E85600 0.6 CHISWICK FAMILY DRS PRACTICE E85625 0.6 HOLLY ROAD MEDICAL CENTRE E85658 0.6 GLEBE STREET SURGERY E85683 0.6 ISLEWORTH CENTRE FOR HEALTH E85686 0.6 SKYWAYS MEDICAL CENTRE E85707 0.6 GREENBROOK CHINCHILLA E85727 0.6 GREENBROOK MANOR E85732 0.6 BRENTFORD FAMILY PRACTICE E85735 0.6 LITTLE PARK SURGERY E85736 0.6 GREENBROOK HESTON E85739 0.6 GROVE PARK TERRACE SURGERY E85746 0.6 DR SOOD'S PRACTICE E85018 0.5 CHISWICK HEALTH PRACTICE E85030 0.5 CRANFORD MEDICAL CENTRE E85052 0.5 GROVE PARK SURGERY E85693 0.5 GREENBROOK BEDFONT E85697 0.5 GILL MEDICAL PRACTICE E85708 0.5 HATTON MEDICAL PRACTICE E85718 0.5 GREENBROOK ISLEWORTH E85744 0.5 THE PRACTICE HEART OF HOUNSLOW Y02671 0.5 FIRSTCARE PRACTICE E85062 0.4 GREEN PRACTICE E85126 0.4 JERSEY PRACTICE E85681 0.4 HOUNSLOW FAMILY PRACTICE E85713 0.4 QUEENS PARK MEDICAL PRACTICE E85734 0.4 HOUNSLOW MEDICAL CENTRE E85015 0.3 THE 303 BATH ROAD SURGERY E85044 0.3 CHESTNUT PRACTICE E85059 0.3 CLIFFORD ROAD SURGERY E85696 0.3 BATH ROAD SURGERY E85716 0.3 SPRING GROVE MEDICAL PRACTICE E85750 0.3 THE PRACTICE FELTHAM Y02672 0.3 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% • 2,351 people with atrial fibrillation* NHS Hammersmith And Fulham CCG 76.4% with a CHA2DS2-VASc score >= 2 in NHS Hounslow CCG NHS Central London (Westminster) CCG 76.1% • 1,808 (76.9%) people treated with anti-coagulation therapy • 203 (8.6%) people who are NHS Ealing CCG 75.9% exceptions • 340 (14.5%) 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 Slough CCG 79.8%

NHS Luton CCG 78.1%

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 Birmingham South and Central CCG 74.1%

NHS Hillingdon CCG 72.2%

NHS Harrow CCG 69.0%

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

GREENBROOK HESTON E85739 16 HOLLY ROAD MEDICAL CENTRE E85658 18 CROSSLANDS SURGERY E85114 24 CLIFFORD HOUSE MEDICAL CENTRE E85071 11 REDWOOD PRACTICE E85113 24 JERSEY PRACTICE E85681 12 WELLESLEY ROAD PRACTICE E85692 16 • in total, including exceptions, there GILL MEDICAL PRACTICE E85708 10 GROVE VILLAGE MEDICAL CENTRE E85699 20 are 543 people with a recorded CLIFFORD ROAD SURGERY E85696 6 BRENTFORD GROUP PRACTICE E85605 29 CHA2DS2-VASc score >= 2 who are GREENBROOK BEDFONT E85697 12 SKYWAYS MEDICAL CENTRE E85707 15 CRANFORD MEDICAL CENTRE E85052 10 not treated CARLTON SURGERY E85024 21 HOUNSLOW FAMILY PRACTICE E85713 7 • GP practice range: 0.0% to 37.2% BATH ROAD SURGERY E85716 9 HATTON MEDICAL PRACTICE E85718 7 ST.MARGARETS PRACTICE E85007 15 GROVE PARK SURGERY E85693 16 GROVE PARK TERRACE SURGERY E85746 3 COLE PARK SURGERY E85117 7 THE 303 BATH ROAD SURGERY E85044 2 WEST4 GPS E85040 39 THORNBURY ROAD CENTRE FOR HEALTH E85001 23 THE PRACTICE FELTHAM Y02672 3 GLEBE STREET SURGERY E85683 7 BLUE WING FAMILY DOCTOR UNIT E85058 18 ST DAVIDS PRACTICE E85056 11 GREEN PRACTICE E85126 9 BRENTFORD FAMILY PRACTICE E85735 5 WILLOW PRACTICE E85600 9 GREENBROOK CHINCHILLA E85727 4 SPRING GROVE MEDICAL PRACTICE E85750 5 TWICKENHAM PARK MEDICAL CENTRE E85045 12 CHISWICK FAMILY DRS PRACTICE E85625 4 KINGFISHER PRACTICE E85060 12 FIRSTCARE PRACTICE E85062 4 GREENBROOK MANOR E85732 3 LITTLE PARK SURGERY E85736 7 CHESTNUT PRACTICE E85059 6 MOUNT MEDICAL CENTRE E85035 11 MANOR HOUSE PRACTICE E85700 4 ALBANY PRACTICE E85004 10 THE PRACTICE HEART OF HOUNSLOW Y02671 3 ISLEWORTH CENTRE FOR HEALTH E85686 3 PENTELOW PRACTICE E85115 8 DR SOOD'S PRACTICE E85018 2 QUEENS PARK MEDICAL PRACTICE E85734 3 CHISWICK HEALTH PRACTICE E85030 4 GREENBROOK ISLEWORTH E85744 2 HOUNSLOW MEDICAL CENTRE E85015 2 NORTH HYDE MEDICAL PRACTICE E85755 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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

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

GREENBROOK HESTON 9

HOLLY ROAD MEDICAL CENTRE 10

CROSSLANDS SURGERY 13 • using the GP cluster method of CLIFFORD HOUSE MEDICAL CENTRE 6 calculating potential gains, if each JERSEY PRACTICE 6 practice was to achieve as well as the REDWOOD PRACTICE 13 upper quartile of its national cluster, then an additional 186 people would GILL MEDICAL PRACTICE 5 be treated WELLESLEY ROAD PRACTICE 8

GROVE VILLAGE MEDICAL CENTRE 10

CLIFFORD ROAD SURGERY 3

ALBANY PRACTICE

THE PRACTICE HEART OF HOUNSLOW

QUEENS PARK MEDICAL PRACTICE

ISLEWORTH CENTRE FOR HEALTH

PENTELOW PRACTICE

DR SOOD'S PRACTICE

GREENBROOK ISLEWORTH

CHISWICK HEALTH PRACTICE

HOUNSLOW MEDICAL CENTRE

NORTH HYDE MEDICAL PRACTICE 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% • 3,120 people with a history of stroke NHS Hounslow CCG 84.6% or TIA* in NHS Hounslow CCG • 2,638 (84.6%) people whose blood NHS Brent CCG 84.2% pressure is <= 150 / 90 • 108 (3.5%) people who are exceptions NHS Hillingdon CCG 83.3% • 374 (12%) 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 Slough CCG 87.5%

NHS Birmingham South and Central CCG 85.0%

NHS Harrow CCG 84.8%

NHS Redbridge CCG 84.6%

NHS Hounslow CCG 84.6%

NHS Brent CCG 84.2%

NHS Hillingdon CCG 83.3%

NHS Ealing CCG 82.9%

NHS Waltham Forest CCG 82.9%

NHS Merton CCG 82.3%

NHS Luton CCG 80.0%

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

CRANFORD MEDICAL CENTRE E85052 17 PENTELOW PRACTICE E85115 10 THORNBURY ROAD CENTRE FOR HEALTH E85001 28 FIRSTCARE PRACTICE E85062 18 CHISWICK HEALTH PRACTICE E85030 17 JERSEY PRACTICE E85681 16 CROSSLANDS SURGERY E85114 21 • in total, including exceptions, there THE PRACTICE HEART OF HOUNSLOW Y02671 17 GROVE PARK SURGERY E85693 16 are 482 people whose blood pressure GREENBROOK HESTON E85739 14 HATTON MEDICAL PRACTICE E85718 9 is not <= 150 / 90 ST DAVIDS PRACTICE E85056 15 CHISWICK FAMILY DRS PRACTICE E85625 6 MANOR HOUSE PRACTICE E85700 4 • GP practice range: 0.0% to 30.4% SPRING GROVE MEDICAL PRACTICE E85750 17 CLIFFORD HOUSE MEDICAL CENTRE E85071 5 GREEN PRACTICE E85126 15 GROVE VILLAGE MEDICAL CENTRE E85699 15 GILL MEDICAL PRACTICE E85708 7 GREENBROOK ISLEWORTH E85744 6 WEST4 GPS E85040 21 KINGFISHER PRACTICE E85060 13 CHESTNUT PRACTICE E85059 11 GREENBROOK MANOR E85732 4 BLUE WING FAMILY DOCTOR UNIT E85058 13 GREENBROOK CHINCHILLA E85727 4 ST.MARGARETS PRACTICE E85007 15 DR SOOD'S PRACTICE E85018 3 QUEENS PARK MEDICAL PRACTICE E85734 5 SKYWAYS MEDICAL CENTRE E85707 10 TWICKENHAM PARK MEDICAL CENTRE E85045 11 ALBANY PRACTICE E85004 9 THE PRACTICE FELTHAM Y02672 3 BRENTFORD FAMILY PRACTICE E85735 4 CLIFFORD ROAD SURGERY E85696 3 WELLESLEY ROAD PRACTICE E85692 6 HOLLY ROAD MEDICAL CENTRE E85658 5 HOUNSLOW MEDICAL CENTRE E85015 7 HOUNSLOW FAMILY PRACTICE E85713 5 LITTLE PARK SURGERY E85736 7 ISLEWORTH CENTRE FOR HEALTH E85686 4 MOUNT MEDICAL CENTRE E85035 6 BATH ROAD SURGERY E85716 6 GROVE PARK TERRACE SURGERY E85746 1 COLE PARK SURGERY E85117 4 NORTH HYDE MEDICAL PRACTICE E85755 1 BRENTFORD GROUP PRACTICE E85605 7 CARLTON SURGERY E85024 6 GREENBROOK BEDFONT E85697 6 REDWOOD PRACTICE E85113 4 WILLOW PRACTICE E85600 4 GLEBE STREET SURGERY E85683 1 THE 303 BATH ROAD SURGERY E85044 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% • 1,860 people with a stroke shown to NHS Hounslow CCG 91.8% be non-haemorrhagic* in NHS Hounslow CCG NHS Central London (Westminster) CCG 90.8% • 1,708 (91.8%) people who are taking an anti-platetet agent or anti- coagulant NHS Hillingdon CCG 90.8% • 76 (4.1%) people who are exceptions • 76 (4.1%) additional people with no NHS Brent CCG 90.4% 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 Birmingham South and Central CCG 92.5%

NHS Hounslow CCG 91.8%

NHS Slough CCG 91.5%

NHS Redbridge CCG 91.0%

NHS Waltham Forest CCG 90.9%

NHS Hillingdon CCG 90.8%

NHS Luton CCG 90.8%

NHS Brent CCG 90.4%

NHS Harrow CCG 90.3%

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

GREEN PRACTICE E85126 9 GREENBROOK HESTON E85739 10 MOUNT MEDICAL CENTRE E85035 5 CRANFORD MEDICAL CENTRE E85052 7 CHISWICK HEALTH PRACTICE E85030 7 GREENBROOK BEDFONT E85697 6 SPRING GROVE MEDICAL PRACTICE E85750 7 • in total, including exceptions, there ST.MARGARETS PRACTICE E85007 10 PENTELOW PRACTICE E85115 3 are 152 people who are not taking an CHISWICK FAMILY DRS PRACTICE E85625 2 LITTLE PARK SURGERY E85736 6 anti-platelet agent or anti-coagulant COLE PARK SURGERY E85117 3 WELLESLEY ROAD PRACTICE E85692 4 GROVE PARK SURGERY E85693 6 • GP practice range: 0.0% to 22.5% THE PRACTICE HEART OF HOUNSLOW Y02671 3 BLUE WING FAMILY DOCTOR UNIT E85058 7 GROVE VILLAGE MEDICAL CENTRE E85699 6 GREENBROOK CHINCHILLA E85727 2 QUEENS PARK MEDICAL PRACTICE E85734 2 THE PRACTICE FELTHAM Y02672 1 KINGFISHER PRACTICE E85060 4 ISLEWORTH CENTRE FOR HEALTH E85686 2 CHESTNUT PRACTICE E85059 3 CARLTON SURGERY E85024 4 GREENBROOK ISLEWORTH E85744 2 THORNBURY ROAD CENTRE FOR HEALTH E85001 4 TWICKENHAM PARK MEDICAL CENTRE E85045 4 DR SOOD'S PRACTICE E85018 1 BRENTFORD FAMILY PRACTICE E85735 1 ALBANY PRACTICE E85004 3 HOUNSLOW MEDICAL CENTRE E85015 2 GILL MEDICAL PRACTICE E85708 1 ST DAVIDS PRACTICE E85056 3 FIRSTCARE PRACTICE E85062 2 GLEBE STREET SURGERY E85683 1 HOUNSLOW FAMILY PRACTICE E85713 1 BRENTFORD GROUP PRACTICE E85605 2 HOLLY ROAD MEDICAL CENTRE E85658 1 WEST4 GPS E85040 2 BATH ROAD SURGERY E85716 1 SKYWAYS MEDICAL CENTRE E85707 1 CROSSLANDS SURGERY E85114 1 THE 303 BATH ROAD SURGERY E85044 CLIFFORD HOUSE MEDICAL CENTRE E85071 REDWOOD PRACTICE E85113 WILLOW PRACTICE E85600 JERSEY PRACTICE E85681 CLIFFORD ROAD SURGERY E85696 MANOR HOUSE PRACTICE E85700 HATTON MEDICAL PRACTICE E85718 GREENBROOK MANOR E85732 GROVE PARK TERRACE SURGERY E85746 NORTH HYDE MEDICAL PRACTICE E85755 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

• 0.79 ratio of observed to expected NHS Hillingdon CCG 0.81 diabetes prevalence in NHS Hounslow CCG, compared to 0.77 in NHS Hounslow CCG 0.79 England • this suggests 79% 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 Harrow CCG 0.87

NHS Slough CCG 0.85

NHS Birmingham South and Central CCG 0.83

NHS Hillingdon CCG 0.81

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 Luton CCG 0.74

NHS Waltham Forest CCG 0.67

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

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

GP practice CCG

HOUNSLOW MEDICAL CENTRE E85015 14.9% NORTH HYDE MEDICAL PRACTICE E85755 13.4% THE 303 BATH ROAD SURGERY E85044 12.6% HOUNSLOW FAMILY PRACTICE E85713 12.3% SKYWAYS MEDICAL CENTRE E85707 10.3% BATH ROAD SURGERY E85716 10.1% GREENBROOK HESTON E85739 9.8% • GP practice range of observed CROSSLANDS SURGERY E85114 9.8% GREEN PRACTICE E85126 9.8% diabetes 2.8% to 14.9% CHESTNUT PRACTICE E85059 9.4% SPRING GROVE MEDICAL PRACTICE E85750 9.3% • there are an estimated 4,579 people GROVE VILLAGE MEDICAL CENTRE E85699 9.3% CRANFORD MEDICAL CENTRE E85052 9.2% COLE PARK SURGERY E85117 9.1% with undiagnosed diabetes in NHS JERSEY PRACTICE E85681 9.1% DR SOOD'S PRACTICE E85018 9.1% Hounslow CCG GREENBROOK CHINCHILLA E85727 9.1% TWICKENHAM PARK MEDICAL CENTRE E85045 9.0% BLUE WING FAMILY DOCTOR UNIT E85058 8.8% CLIFFORD ROAD SURGERY E85696 8.8% MANOR HOUSE PRACTICE E85700 8.4% GREENBROOK BEDFONT E85697 8.2% THORNBURY ROAD CENTRE FOR HEALTH E85001 8.1% WILLOW PRACTICE E85600 8.0% CLIFFORD HOUSE MEDICAL CENTRE E85071 7.9% CARLTON SURGERY E85024 7.9% MOUNT MEDICAL CENTRE E85035 7.6% QUEENS PARK MEDICAL PRACTICE E85734 7.6% PENTELOW PRACTICE E85115 7.5% LITTLE PARK SURGERY E85736 7.3% ST DAVIDS PRACTICE E85056 7.1% ISLEWORTH CENTRE FOR HEALTH E85686 6.8% REDWOOD PRACTICE E85113 6.8% GILL MEDICAL PRACTICE E85708 6.7% KINGFISHER PRACTICE E85060 6.7% HATTON MEDICAL PRACTICE E85718 6.3% ALBANY PRACTICE E85004 6.1% GREENBROOK MANOR E85732 5.9% FIRSTCARE PRACTICE E85062 5.9% BRENTFORD GROUP PRACTICE E85605 5.8% BRENTFORD FAMILY PRACTICE E85735 5.7% GREENBROOK ISLEWORTH E85744 5.3% HOLLY ROAD MEDICAL CENTRE E85658 5.2% THE PRACTICE HEART OF HOUNSLOW Y02671 5.0% THE PRACTICE FELTHAM Y02672 4.9% WEST4 GPS E85040 4.7% CHISWICK FAMILY DRS PRACTICE E85625 4.4% ST.MARGARETS PRACTICE E85007 4.3% GROVE PARK SURGERY E85693 4.0% GLEBE STREET SURGERY E85683 4.0% Note: The estimated number of undiagnosed CHISWICK HEALTH PRACTICE E85030 3.3% WELLESLEY ROAD PRACTICE E85692 3.0% people with diabetes has been calculated by GROVE PARK TERRACE SURGERY E85746 2.8% 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 Hounslow CCG is 9.2% (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% 11.2% of people in NHS Hounslow 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 20.4% of the NHS West London CCG 4.6% 3.7% 9.4% population in NHS Hounslow CCG are estimated to have diabetes, or at NHS Hammersmith And Fulham CCG 4.5% 2.9% 8.7% high 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 Hounslow CCG, 51 out of 52 NHS Hammersmith And Fulham CCG 47.1% practices (98.1%) participated in the NDA. Data is not available for the remaining practices NHS Hillingdon CCG 39.6%

NHS Brent CCG 36.8% • 59.5% of people with diabetes (of practices who participated in the audit) had the eight recommended NHS Harrow CCG 31.9% care processes in NHS Hounslow 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

WILLOW PRACTICE E85600 96.6% GREEN PRACTICE E85126 91.7% HOUNSLOW MEDICAL CENTRE E85015 88.5% REDWOOD PRACTICE E85113 87.5% KINGFISHER PRACTICE E85060 86.5% • achievement - 8 care processes: in GROVE PARK TERRACE SURGERY E85746 82.9% DR SOOD'S PRACTICE E85018 81.0% practices who provided data via the WELLESLEY ROAD PRACTICE E85692 79.2% MOUNT MEDICAL CENTRE E85035 78.9% BRENTFORD FAMILY PRACTICE E85735 78.0% NDA, between 3.5% and 96.6% of COLE PARK SURGERY E85117 77.5% THORNBURY ROAD CENTRE FOR HEALTH E85001 77.3% patients received all 8 care processes TWICKENHAM PARK MEDICAL CENTRE E85045 76.8% GLEBE STREET SURGERY E85683 73.0% CLIFFORD ROAD SURGERY E85696 72.5% GREENBROOK MANOR E85732 71.3% SKYWAYS MEDICAL CENTRE E85707 68.8% BATH ROAD SURGERY E85716 67.9% • at least 6,803 people did not receive HOUNSLOW FAMILY PRACTICE E85713 67.5% FIRSTCARE PRACTICE E85062 67.0% the eight care processes ISLEWORTH CENTRE FOR HEALTH E85686 65.2% GREENBROOK CHINCHILLA E85727 65.1% ST.MARGARETS PRACTICE E85007 62.9% JERSEY PRACTICE E85681 62.7% CHISWICK HEALTH PRACTICE E85030 62.0% HOLLY ROAD MEDICAL CENTRE E85658 61.8% CROSSLANDS SURGERY E85114 61.0% CHISWICK FAMILY DRS PRACTICE E85625 60.5% ALBANY PRACTICE E85004 60.4% GREENBROOK ISLEWORTH E85744 60.2% BRENTFORD GROUP PRACTICE E85605 60.1% QUEENS PARK MEDICAL PRACTICE E85734 58.0% CLIFFORD HOUSE MEDICAL CENTRE E85071 57.6% THE PRACTICE HEART OF HOUNSLOW Y02671 57.5% HATTON MEDICAL PRACTICE E85718 56.8% LITTLE PARK SURGERY E85736 56.3% THE 303 BATH ROAD SURGERY E85044 56.1% WEST4 GPS E85040 54.2% GROVE PARK SURGERY E85693 52.1% CHESTNUT PRACTICE E85059 50.9% THE PRACTICE FELTHAM Y02672 44.7% GREENBROOK HESTON E85739 44.4% GILL MEDICAL PRACTICE E85708 42.2% PENTELOW PRACTICE E85115 41.7% CARLTON SURGERY E85024 36.2% BLUE WING FAMILY DOCTOR UNIT E85058 31.8% ST DAVIDS PRACTICE E85056 25.8% MANOR HOUSE PRACTICE E85700 22.9% GREENBROOK BEDFONT E85697 19.8% CRANFORD MEDICAL CENTRE E85052 11.7% SPRING GROVE MEDICAL PRACTICE E85750 3.5% NORTH HYDE MEDICAL PRACTICE E85755 GROVE VILLAGE MEDICAL CENTRE E85699 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% • 38.6% of people with diabetes (of practices who participated in the audit) met the three treatment targets NHS Harrow CCG 40.4% in NHS Hounslow 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

GROVE PARK TERRACE SURGERY E85746 62.2% CARLTON SURGERY E85024 52.9% WILLOW PRACTICE E85600 48.8% TWICKENHAM PARK MEDICAL CENTRE E85045 47.0% WEST4 GPS E85040 46.7% • achievement - 3 treatment targets: in MOUNT MEDICAL CENTRE E85035 46.7% CLIFFORD ROAD SURGERY E85696 46.5% practices who provided data via the GILL MEDICAL PRACTICE E85708 46.4% HOUNSLOW FAMILY PRACTICE E85713 46.1% REDWOOD PRACTICE E85113 45.8% NDA, between 22.2% and 62.2% of THE 303 BATH ROAD SURGERY E85044 45.8% BRENTFORD FAMILY PRACTICE E85735 44.1% patients achieved all 3 treatment COLE PARK SURGERY E85117 44.1% GREENBROOK BEDFONT E85697 43.2% targets BATH ROAD SURGERY E85716 42.3% CHISWICK HEALTH PRACTICE E85030 42.3% HOLLY ROAD MEDICAL CENTRE E85658 42.3% GLEBE STREET SURGERY E85683 42.2% • at least 9,205 people did not meet the ST DAVIDS PRACTICE E85056 42.0% HOUNSLOW MEDICAL CENTRE E85015 41.6% three treatment targets THORNBURY ROAD CENTRE FOR HEALTH E85001 40.8% GREENBROOK CHINCHILLA E85727 40.8% DR SOOD'S PRACTICE E85018 40.0% BLUE WING FAMILY DOCTOR UNIT E85058 39.4% SPRING GROVE MEDICAL PRACTICE E85750 38.9% CLIFFORD HOUSE MEDICAL CENTRE E85071 38.2% CHISWICK FAMILY DRS PRACTICE E85625 37.7% BRENTFORD GROUP PRACTICE E85605 37.7% CHESTNUT PRACTICE E85059 37.6% KINGFISHER PRACTICE E85060 37.1% FIRSTCARE PRACTICE E85062 36.9% QUEENS PARK MEDICAL PRACTICE E85734 36.3% WELLESLEY ROAD PRACTICE E85692 35.8% ALBANY PRACTICE E85004 35.7% THE PRACTICE FELTHAM Y02672 35.5% GREENBROOK ISLEWORTH E85744 35.4% GREENBROOK MANOR E85732 34.5% CRANFORD MEDICAL CENTRE E85052 34.4% LITTLE PARK SURGERY E85736 34.1% ISLEWORTH CENTRE FOR HEALTH E85686 33.5% MANOR HOUSE PRACTICE E85700 32.8% HATTON MEDICAL PRACTICE E85718 32.6% ST.MARGARETS PRACTICE E85007 32.0% GREENBROOK HESTON E85739 32.0% THE PRACTICE HEART OF HOUNSLOW Y02671 31.7% JERSEY PRACTICE E85681 31.6% SKYWAYS MEDICAL CENTRE E85707 30.3% GROVE PARK SURGERY E85693 29.5% GREEN PRACTICE E85126 29.4% CROSSLANDS SURGERY E85114 26.0% PENTELOW PRACTICE E85115 22.2% NORTH HYDE MEDICAL PRACTICE E85755 GROVE VILLAGE MEDICAL CENTRE E85699 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

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

PENTELOW PRACTICE 42

CROSSLANDS SURGERY 94

GROVE PARK SURGERY 32 • using the GP cluster method of SKYWAYS MEDICAL CENTRE 51 calculating potential gains, if each GREEN PRACTICE 82 practice was to achieve as well as the ST.MARGARETS PRACTICE 38 upper quartile of its national cluster, then an additional 981 people would MANOR HOUSE PRACTICE 15 be treated JERSEY PRACTICE 58

THE PRACTICE HEART OF HOUNSLOW 60

GREENBROOK HESTON 43

THE 303 BATH ROAD SURGERY

REDWOOD PRACTICE

HOUNSLOW FAMILY PRACTICE

MOUNT MEDICAL CENTRE

CLIFFORD ROAD SURGERY

WEST4 GPS

GILL MEDICAL PRACTICE

WILLOW PRACTICE

CARLTON SURGERY

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

51 CVD: Primary Care Intelligence Packs Kidney

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

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

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

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

NHS 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 0.56. This compares to NHS Brent CCG 0.49 0.68 for England • this suggests that 56% 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 Birmingham South and Central CCG 0.76

NHS Slough CCG 0.60

NHS Merton CCG 0.60

NHS Hounslow CCG 0.56

NHS Waltham Forest CCG 0.52

NHS Redbridge CCG 0.50

NHS Hillingdon CCG 0.50

NHS Brent CCG 0.49

NHS Luton CCG 0.48

NHS Ealing CCG 0.43

NHS Harrow CCG 0.41

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

CLIFFORD HOUSE MEDICAL CENTRE E85071 9.7% MANOR HOUSE PRACTICE E85700 6.4% TWICKENHAM PARK MEDICAL CENTRE E85045 5.6% CARLTON SURGERY E85024 5.6% QUEENS PARK MEDICAL PRACTICE E85734 4.8% GREENBROOK MANOR E85732 4.5% ST DAVIDS PRACTICE E85056 4.4% • it is estimated that there are 4,925 THORNBURY ROAD CENTRE FOR HEALTH E85001 4.4% GREEN PRACTICE E85126 4.1% people with undiagnosed chronic SKYWAYS MEDICAL CENTRE E85707 4.0% BRENTFORD GROUP PRACTICE E85605 4.0% kidney disease in NHS Hounslow GROVE VILLAGE MEDICAL CENTRE E85699 3.8% PENTELOW PRACTICE E85115 3.8% ALBANY PRACTICE E85004 3.6% CCG HOUNSLOW FAMILY PRACTICE E85713 3.6% GREENBROOK BEDFONT E85697 3.6% • GP practice range of observed CKD: MOUNT MEDICAL CENTRE E85035 3.5% WILLOW PRACTICE E85600 3.5% 0.9% to 9.7% CROSSLANDS SURGERY E85114 3.2% BATH ROAD SURGERY E85716 3.2% HOUNSLOW MEDICAL CENTRE E85015 3.1% GREENBROOK HESTON E85739 3.0% KINGFISHER PRACTICE E85060 3.0% GILL MEDICAL PRACTICE E85708 3.0% DR SOOD'S PRACTICE E85018 2.9% HOLLY ROAD MEDICAL CENTRE E85658 2.7% CHISWICK FAMILY DRS PRACTICE E85625 2.6% GREENBROOK CHINCHILLA E85727 2.6% BRENTFORD FAMILY PRACTICE E85735 2.5% BLUE WING FAMILY DOCTOR UNIT E85058 2.4% NORTH HYDE MEDICAL PRACTICE E85755 2.4% REDWOOD PRACTICE E85113 2.4% JERSEY PRACTICE E85681 2.3% HATTON MEDICAL PRACTICE E85718 2.2% WELLESLEY ROAD PRACTICE E85692 2.1% THE 303 BATH ROAD SURGERY E85044 2.0% GLEBE STREET SURGERY E85683 2.0% CLIFFORD ROAD SURGERY E85696 2.0% COLE PARK SURGERY E85117 2.0% ST.MARGARETS PRACTICE E85007 1.8% ISLEWORTH CENTRE FOR HEALTH E85686 1.8% CHESTNUT PRACTICE E85059 1.8% SPRING GROVE MEDICAL PRACTICE E85750 1.7% WEST4 GPS E85040 1.7% GREENBROOK ISLEWORTH E85744 1.6% CRANFORD MEDICAL CENTRE E85052 1.5% GROVE PARK SURGERY E85693 1.4% Note: CCG estimates for the estimated GROVE PARK TERRACE SURGERY E85746 1.3% LITTLE PARK SURGERY E85736 1.2% number of people with CKD are based on FIRSTCARE PRACTICE E85062 1.0% CHISWICK HEALTH PRACTICE E85030 1.0% applying a proportion from a resident based THE PRACTICE FELTHAM Y02672 0.9% population estimate to a GP registered THE PRACTICE HEART OF HOUNSLOW Y02671 0.9% 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 Hillingdon CCG 77.1% • 6,533 people with CKD (diagnosed*) NHS Ealing CCG 75.7% in NHS Hounslow CCG • 4,896 (74.9%) people whose blood NHS Brent CCG 75.3% pressure is <= 140 /85 • 333 (5.1%) people who are exceptions NHS Harrow CCG 75.1% • 1,304 (20%) 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 Slough CCG 82.2%

NHS Merton CCG 78.3%

NHS Hillingdon CCG 77.1%

NHS Waltham Forest CCG 75.8%

NHS Ealing CCG 75.7%

NHS Redbridge CCG 75.7%

NHS Birmingham South and Central CCG 75.5%

NHS Brent CCG 75.3%

NHS Harrow CCG 75.1%

NHS Hounslow CCG 74.9%

NHS Luton CCG 69.9%

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

FIRSTCARE PRACTICE E85062 38 CHESTNUT PRACTICE E85059 54 SKYWAYS MEDICAL CENTRE E85707 46 QUEENS PARK MEDICAL PRACTICE E85734 76 CROSSLANDS SURGERY E85114 74 GREENBROOK HESTON E85739 51 PENTELOW PRACTICE E85115 34 • in total, including exceptions, there WELLESLEY ROAD PRACTICE E85692 43 HIBERNIA HOUSE SURGERY E85724 22 are 1,637 people whose blood ST.MARGARETS PRACTICE E85007 50 CLIFFORD HOUSE MEDICAL CENTRE E85071 56 JERSEY PRACTICE E85681 48 pressure is not <= 140 / 85 SPRING GROVE MEDICAL PRACTICE E85750 36 THE GREEN PRACTICE E85126 74 • GP practice range: 7.9% to 43.7% KINGFISHER PRACTICE E85060 50 THE PRACTICE HEART OF HOUNSLOW Y02671 24 NORTH HYDE MEDICAL PRACTICE E85755 10 HOLLY ROAD MEDICAL CENTRE E85658 35 GREENBROOK MANOR E85732 25 HOUNSLOW FAMILY PRACTICE E85713 35 CRANFORD MEDICAL CENTRE E85052 19 GROVE VILLAGE MEDICAL CENTRE E85699 40 ALBANY PRACTICE E85004 60 BRENTFORD GROUP PRACTICE E85605 60 DR SOOD'S PRACTICE E85018 13 THORNBURY ROAD CENTRE FOR HEALTH E85001 64 DR TAN E85735 14 CHISWICK HEALTH PRACTICE E85030 14 GREENBROOK BEDFONT E85697 35 THE 303 BATH ROAD SURGERY E85044 8 ST DAVIDS PRACTICE E85056 55 WEST4 GPS E85040 29 GROVE PARK SURGERY E85693 15 GREENBROOK ISLEWORTH E85744 16 GREENBROOK CHINCHILLA E85727 11 BLUE WING FAMILY DOCTOR UNIT E85058 30 MOUNT MEDICAL CENTRE E85035 26 COLE PARK SURGERY E85117 10 WILLOW PRACTICE E85600 20 LITTLE PARK SURGERY E85736 9 HOUNSLOW MEDICAL CENTRE DR KUMAR E85015 14 CARLTON SURGERY E85024 39 MANOR HOUSE PRACTICE E85700 16 GLEBE STREET SURGERY E85683 11 GILL MEDICAL PRACTICE E85708 15 THE PRACTICE FELTHAM Y02672 7 CHISWICK FAMILY DRS PRACTICE E85625 12 REDWOOD PRACTICE E85113 17 CLIFFORD ROAD SURGERY E85696 16 BATH ROAD SURGERY E85716 26 HATTON MEDICAL PRACTICE E85718 9 TWICKENHAM PARK MEDICAL CENTRE E85045 18 THE GROVE MEDICAL AT ISLEWORTH E85686 5 GROVE PARK TERRACE SURGERY E85746 3 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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

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

FIRSTCARE PRACTICE 24

CHESTNUT PRACTICE 34

SKYWAYS MEDICAL CENTRE 28 • using the GP cluster method of QUEENS PARK MEDICAL PRACTICE 46 calculating potential gains, if each CROSSLANDS SURGERY 43 practice was to achieve as well as the GREENBROOK HESTON 29 upper quartile of its national cluster, then an additional 614 people would WELLESLEY ROAD PRACTICE 24 be treated PENTELOW PRACTICE 19

JERSEY PRACTICE 26

ST.MARGARETS PRACTICE 27

MANOR HOUSE PRACTICE

CHISWICK FAMILY DRS PRACTICE

GLEBE STREET SURGERY

REDWOOD PRACTICE

CLIFFORD ROAD SURGERY

BATH ROAD SURGERY

HATTON MEDICAL PRACTICE

THE GROVE MEDICAL AT ISLEWORTH

TWICKENHAM PARK MEDICAL CENTRE

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

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

NHS Hillingdon CCG 78.6% • 6,533 people with CKD (diagnosed*) NHS Harrow CCG 76.0% in NHS Hounslow CCG • 4,838 (74.1%) people who have a NHS Ealing CCG 75.5% record of urine albumin:creatinine ratio test • 353 (5.4%) people who are NHS Brent CCG 74.4% exceptions • 1,342 (20.5%) 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 Slough CCG 82.9%

NHS Hillingdon CCG 78.6%

NHS Birmingham South and Central CCG 77.0%

NHS Harrow CCG 76.0%

NHS Ealing CCG 75.5%

NHS Waltham Forest CCG 74.7%

NHS Brent CCG 74.4%

NHS Merton CCG 74.4%

NHS Hounslow CCG 74.1%

NHS Luton CCG 67.2%

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

QUEENS PARK MEDICAL PRACTICE E85734 147 GREENBROOK BEDFONT E85697 90 ST.MARGARETS PRACTICE E85007 80 THE GREEN PRACTICE E85126 109 CHESTNUT PRACTICE E85059 56 CRANFORD MEDICAL CENTRE E85052 27 CLIFFORD HOUSE MEDICAL CENTRE E85071 67 • in total, including exceptions, there THE 303 BATH ROAD SURGERY E85044 14 GREENBROOK ISLEWORTH E85744 27 are 1,695 people who have no record KINGFISHER PRACTICE E85060 50 GREENBROOK HESTON E85739 43 GREENBROOK MANOR E85732 24 of urine albumin:creatinine ratio test THE PRACTICE HEART OF HOUNSLOW Y02671 22 SKYWAYS MEDICAL CENTRE E85707 33 • GP practice range: 6.6% to 75.8% FIRSTCARE PRACTICE E85062 25 SPRING GROVE MEDICAL PRACTICE E85750 30 CHISWICK HEALTH PRACTICE E85030 17 HOLLY ROAD MEDICAL CENTRE E85658 30 ALBANY PRACTICE E85004 58 HOUNSLOW FAMILY PRACTICE E85713 30 GROVE VILLAGE MEDICAL CENTRE E85699 34 GREENBROOK CHINCHILLA E85727 14 JERSEY PRACTICE E85681 33 WELLESLEY ROAD PRACTICE E85692 28 PENTELOW PRACTICE E85115 21 HIBERNIA HOUSE SURGERY E85724 14 MANOR HOUSE PRACTICE E85700 24 DR SOOD'S PRACTICE E85018 11 BATH ROAD SURGERY E85716 47 BRENTFORD GROUP PRACTICE E85605 48 LITTLE PARK SURGERY E85736 11 ST DAVIDS PRACTICE E85056 49 GILL MEDICAL PRACTICE E85708 20 GROVE PARK TERRACE SURGERY E85746 7 CROSSLANDS SURGERY E85114 36 REDWOOD PRACTICE E85113 23 CARLTON SURGERY E85024 45 GROVE PARK SURGERY E85693 13 BLUE WING FAMILY DOCTOR UNIT E85058 27 DR TAN E85735 10 HOUNSLOW MEDICAL CENTRE DR KUMAR E85015 15 WILLOW PRACTICE E85600 20 COLE PARK SURGERY E85117 9 CLIFFORD ROAD SURGERY E85696 20 HATTON MEDICAL PRACTICE E85718 13 TWICKENHAM PARK MEDICAL CENTRE E85045 25 THORNBURY ROAD CENTRE FOR HEALTH E85001 38 NORTH HYDE MEDICAL PRACTICE E85755 4 CHISWICK FAMILY DRS PRACTICE E85625 11 WEST4 GPS E85040 17 MOUNT MEDICAL CENTRE E85035 15 THE GROVE MEDICAL AT ISLEWORTH E85686 5 THE PRACTICE FELTHAM Y02672 4 GLEBE STREET SURGERY E85683 5 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 0.51% in NHS Hounslow CCG compared to 0.76% NHS Hounslow CCG 0.51% in England

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 Birmingham South and Central CCG 0.60%

NHS Harrow CCG 0.57%

NHS Slough CCG 0.56%

NHS Brent CCG 0.54%

NHS Hounslow CCG 0.51%

NHS Luton CCG 0.50%

NHS Hillingdon CCG 0.49%

NHS Merton CCG 0.48%

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%

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

GP practice CCG

KINGFISHER PRACTICE E85060 1.2% GROVE VILLAGE MEDICAL CENTRE E85699 1.1% BRENTFORD GROUP PRACTICE E85605 1.0% SKYWAYS MEDICAL CENTRE E85707 0.9% CLIFFORD HOUSE MEDICAL CENTRE E85071 0.9% PENTELOW PRACTICE E85115 0.8% HOUNSLOW FAMILY PRACTICE E85713 0.8% • 1,569 people with diagnosed heart HOLLY ROAD MEDICAL CENTRE E85658 0.8% COLE PARK SURGERY E85117 0.8% failure in NHS Hounslow CCG HOUNSLOW MEDICAL CENTRE E85015 0.7% WILLOW PRACTICE E85600 0.7% • GP practice range: 0.1% to 1.2% GREENBROOK MANOR E85732 0.7% GREENBROOK HESTON E85739 0.7% SPRING GROVE MEDICAL PRACTICE E85750 0.7% THORNBURY ROAD CENTRE FOR HEALTH E85001 0.7% TWICKENHAM PARK MEDICAL CENTRE E85045 0.7% BRENTFORD FAMILY PRACTICE E85735 0.7% ALBANY PRACTICE E85004 0.7% QUEENS PARK MEDICAL PRACTICE E85734 0.6% MOUNT MEDICAL CENTRE E85035 0.6% CHISWICK FAMILY DRS PRACTICE E85625 0.6% ST DAVIDS PRACTICE E85056 0.6% BLUE WING FAMILY DOCTOR UNIT E85058 0.6% GREEN PRACTICE E85126 0.6% CARLTON SURGERY E85024 0.6% GREENBROOK BEDFONT E85697 0.6% LITTLE PARK SURGERY E85736 0.5% MANOR HOUSE PRACTICE E85700 0.5% ST.MARGARETS PRACTICE E85007 0.5% THE 303 BATH ROAD SURGERY E85044 0.5% ISLEWORTH CENTRE FOR HEALTH E85686 0.5% WEST4 GPS E85040 0.4% BATH ROAD SURGERY E85716 0.4% REDWOOD PRACTICE E85113 0.4% JERSEY PRACTICE E85681 0.4% GREENBROOK ISLEWORTH E85744 0.4% DR SOOD'S PRACTICE E85018 0.4% GILL MEDICAL PRACTICE E85708 0.4% CROSSLANDS SURGERY E85114 0.4% CHISWICK HEALTH PRACTICE E85030 0.4% NORTH HYDE MEDICAL PRACTICE E85755 0.4% CHESTNUT PRACTICE E85059 0.3% WELLESLEY ROAD PRACTICE E85692 0.3% THE PRACTICE HEART OF HOUNSLOW Y02671 0.3% CRANFORD MEDICAL CENTRE E85052 0.3% CLIFFORD ROAD SURGERY E85696 0.3% GLEBE STREET SURGERY E85683 0.3% HATTON MEDICAL PRACTICE E85718 0.3% FIRSTCARE PRACTICE E85062 0.2% GREENBROOK CHINCHILLA E85727 0.2% GROVE PARK SURGERY E85693 0.2% THE PRACTICE FELTHAM Y02672 0.2% GROVE PARK TERRACE SURGERY E85746 0.1% 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4%

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

NHS Hounslow CCG 91.5% • 425 people with heart failure* with NHS Ealing CCG 91.5% LVSD in NHS Hounslow CCG • 389 (91.5%) people treated with ACE- NHS Brent CCG 88.4% I or ARB • 33 (7.8%) people who are exceptions • 3 (0.7%) additional people who are NHS Hillingdon CCG 87.6% 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 Hounslow CCG 91.5%

NHS Ealing CCG 91.5%

NHS Redbridge CCG 89.3%

NHS Waltham Forest CCG 88.7%

NHS Brent CCG 88.4%

NHS Hillingdon CCG 87.6%

NHS Merton CCG 87.3%

NHS Harrow CCG 86.0%

NHS Slough CCG 83.7%

NHS Birmingham South and Central CCG 83.4%

NHS Luton CCG 82.9%

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

MANOR HOUSE PRACTICE E85700 1 GREENBROOK BEDFONT E85697 3 WEST4 GPS E85040 2 GREENBROOK CHINCHILLA E85727 1 GREENBROOK ISLEWORTH E85744 2 GREEN PRACTICE E85126 2 WILLOW PRACTICE E85600 3 • in total, including exceptions, there THE PRACTICE HEART OF HOUNSLOW Y02671 3 GROVE VILLAGE MEDICAL CENTRE E85699 6 are 36 people who are not treated HOUNSLOW FAMILY PRACTICE E85713 1 SKYWAYS MEDICAL CENTRE E85707 2 with ACE-I or ARB GREENBROOK HESTON E85739 1 BATH ROAD SURGERY E85716 1 LITTLE PARK SURGERY E85736 1 • GP practice range: 0.0% to 50.0% THORNBURY ROAD CENTRE FOR HEALTH E85001 1 ALBANY PRACTICE E85004 1 CROSSLANDS SURGERY E85114 1 KINGFISHER PRACTICE E85060 1 ST.MARGARETS PRACTICE E85007 2 QUEENS PARK MEDICAL PRACTICE E85734 1 HOUNSLOW MEDICAL CENTRE E85015 DR SOOD'S PRACTICE E85018 CARLTON SURGERY E85024 CHISWICK HEALTH PRACTICE E85030 MOUNT MEDICAL CENTRE E85035 THE 303 BATH ROAD SURGERY E85044 TWICKENHAM PARK MEDICAL CENTRE E85045 CRANFORD MEDICAL CENTRE E85052 ST DAVIDS PRACTICE E85056 BLUE WING FAMILY DOCTOR UNIT E85058 CHESTNUT PRACTICE E85059 FIRSTCARE PRACTICE E85062 CLIFFORD HOUSE MEDICAL CENTRE E85071 REDWOOD PRACTICE E85113 PENTELOW PRACTICE E85115 COLE PARK SURGERY E85117 BRENTFORD GROUP PRACTICE E85605 CHISWICK FAMILY DRS PRACTICE E85625 HOLLY ROAD MEDICAL CENTRE E85658 JERSEY PRACTICE E85681 GLEBE STREET SURGERY E85683 ISLEWORTH CENTRE FOR HEALTH E85686 WELLESLEY ROAD PRACTICE E85692 GROVE PARK SURGERY E85693 CLIFFORD ROAD SURGERY E85696 GILL MEDICAL PRACTICE E85708 HATTON MEDICAL PRACTICE E85718 GREENBROOK MANOR E85732 BRENTFORD FAMILY PRACTICE E85735 GROVE PARK TERRACE SURGERY E85746 SPRING GROVE MEDICAL PRACTICE E85750 NORTH HYDE MEDICAL PRACTICE E85755 THE PRACTICE FELTHAM Y02672 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% • 389 people with heart failure* with NHS Hounslow CCG 82.8% LVSD treated with ACE-I/ARB in NHS Hounslow CCG NHS Brent CCG 82.5% • 322 (82.8%) people treated with ACE- I/ARB and BB • 48 (12.3%) people who are NHS Harrow CCG 77.4% exceptions • 19 (4.9%) additional people who are NHS Hammersmith And Fulham CCG 74.0% not 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 Ealing CCG 83.6%

NHS Hounslow CCG 82.8%

NHS Brent CCG 82.5%

NHS Merton CCG 79.9%

NHS Luton CCG 77.5%

NHS Harrow CCG 77.4%

NHS Slough CCG 75.2%

NHS Waltham Forest CCG 74.5%

NHS Redbridge CCG 73.5%

NHS Hillingdon CCG 72.6%

NHS Birmingham South and Central CCG 70.3%

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

GREENBROOK MANOR E85732 2 THE PRACTICE FELTHAM Y02672 2 SPRING GROVE MEDICAL PRACTICE E85750 3 WEST4 GPS E85040 3 GROVE PARK SURGERY E85693 1 CROSSLANDS SURGERY E85114 5 ALBANY PRACTICE E85004 4 • in total, including exceptions, there LITTLE PARK SURGERY E85736 3 ST.MARGARETS PRACTICE E85007 11 are 67 people who are not treated CHISWICK HEALTH PRACTICE E85030 2 REDWOOD PRACTICE E85113 1 with ACE-I or ARB GLEBE STREET SURGERY E85683 1 GREENBROOK HESTON E85739 2 GROVE PARK TERRACE SURGERY E85746 1 • GP practice range: 0.0% to 66.7% GILL MEDICAL PRACTICE E85708 1 QUEENS PARK MEDICAL PRACTICE E85734 5 HOUNSLOW FAMILY PRACTICE E85713 1 GROVE VILLAGE MEDICAL CENTRE E85699 5 KINGFISHER PRACTICE E85060 2 WILLOW PRACTICE E85600 2 THE PRACTICE HEART OF HOUNSLOW Y02671 2 TWICKENHAM PARK MEDICAL CENTRE E85045 1 BATH ROAD SURGERY E85716 1 BLUE WING FAMILY DOCTOR UNIT E85058 1 GREEN PRACTICE E85126 1 BRENTFORD GROUP PRACTICE E85605 2 THORNBURY ROAD CENTRE FOR HEALTH E85001 1 ST DAVIDS PRACTICE E85056 1 HOUNSLOW MEDICAL CENTRE E85015 DR SOOD'S PRACTICE E85018 CARLTON SURGERY E85024 MOUNT MEDICAL CENTRE E85035 THE 303 BATH ROAD SURGERY E85044 CRANFORD MEDICAL CENTRE E85052 CHESTNUT PRACTICE E85059 FIRSTCARE PRACTICE E85062 CLIFFORD HOUSE MEDICAL CENTRE E85071 PENTELOW PRACTICE E85115 COLE PARK SURGERY E85117 CHISWICK FAMILY DRS PRACTICE E85625 HOLLY ROAD MEDICAL CENTRE E85658 JERSEY PRACTICE E85681 ISLEWORTH CENTRE FOR HEALTH E85686 WELLESLEY ROAD PRACTICE E85692 CLIFFORD ROAD SURGERY E85696 GREENBROOK BEDFONT E85697 MANOR HOUSE PRACTICE E85700 SKYWAYS MEDICAL CENTRE E85707 HATTON MEDICAL PRACTICE E85718 GREENBROOK CHINCHILLA E85727 BRENTFORD FAMILY PRACTICE E85735 GREENBROOK ISLEWORTH E85744 NORTH HYDE MEDICAL PRACTICE E85755 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% • 7,104 people with coronary heart NHS Harrow CCG 89.5% disease* in NHS Hounslow CCG • 6,245 (87.9%) people whose blood NHS Hillingdon CCG 89.1% pressure <= 150 / 90 • 210 (3%) people who are exceptions • 649 (9.1%) additional people whose NHS Ealing CCG 88.0% 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 Slough CCG 91.1%

NHS Birmingham South and Central CCG 90.4%

NHS Redbridge CCG 90.1%

NHS Brent CCG 89.8%

NHS Merton CCG 89.5%

NHS Harrow CCG 89.5%

NHS Hillingdon CCG 89.1%

NHS Waltham Forest CCG 88.9%

NHS Ealing CCG 88.0%

NHS Hounslow CCG 87.9%

NHS Luton CCG 85.4%

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

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

Not below 150/90 Exceptions reported

ST.MARGARETS PRACTICE E85007 39 MANOR HOUSE PRACTICE E85700 9 CLIFFORD HOUSE MEDICAL CENTRE E85071 13 BLUE WING FAMILY DOCTOR UNIT E85058 43 HATTON MEDICAL PRACTICE E85718 20 PENTELOW PRACTICE E85115 16 GREENBROOK HESTON E85739 25 • in total, including exceptions, there THE PRACTICE HEART OF HOUNSLOW Y02671 25 ST DAVIDS PRACTICE E85056 31 are 859 people whose blood pressure CROSSLANDS SURGERY E85114 41 GREEN PRACTICE E85126 37 is not <= 150 / 90 CRANFORD MEDICAL CENTRE E85052 23 JERSEY PRACTICE E85681 28 HOLLY ROAD MEDICAL CENTRE E85658 24 • GP practice range: 3.8% to 20.5% SPRING GROVE MEDICAL PRACTICE E85750 31 CHISWICK HEALTH PRACTICE E85030 16 COLE PARK SURGERY E85117 13 CHESTNUT PRACTICE E85059 32 GREENBROOK MANOR E85732 5 THORNBURY ROAD CENTRE FOR HEALTH E85001 29 LITTLE PARK SURGERY E85736 18 GROVE PARK SURGERY E85693 16 NORTH HYDE MEDICAL PRACTICE E85755 5 ALBANY PRACTICE E85004 22 GROVE VILLAGE MEDICAL CENTRE E85699 18 SKYWAYS MEDICAL CENTRE E85707 25 ISLEWORTH CENTRE FOR HEALTH E85686 11 THE 303 BATH ROAD SURGERY E85044 9 GREENBROOK ISLEWORTH E85744 10 FIRSTCARE PRACTICE E85062 16 THE PRACTICE FELTHAM Y02672 7 HOUNSLOW FAMILY PRACTICE E85713 14 BATH ROAD SURGERY E85716 21 KINGFISHER PRACTICE E85060 14 MOUNT MEDICAL CENTRE E85035 16 QUEENS PARK MEDICAL PRACTICE E85734 8 WILLOW PRACTICE E85600 11 BRENTFORD GROUP PRACTICE E85605 14 GILL MEDICAL PRACTICE E85708 6 TWICKENHAM PARK MEDICAL CENTRE E85045 10 GLEBE STREET SURGERY E85683 5 GREENBROOK CHINCHILLA E85727 5 DR SOOD'S PRACTICE E85018 5 WEST4 GPS E85040 15 BRENTFORD FAMILY PRACTICE E85735 4 CHISWICK FAMILY DRS PRACTICE E85625 3 HOUNSLOW MEDICAL CENTRE E85015 14 GREENBROOK BEDFONT E85697 7 GROVE PARK TERRACE SURGERY E85746 2 WELLESLEY ROAD PRACTICE E85692 6 CLIFFORD ROAD SURGERY E85696 9 REDWOOD PRACTICE E85113 7 CARLTON SURGERY E85024 6 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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

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

ST.MARGARETS PRACTICE 27

MANOR HOUSE PRACTICE 6

CLIFFORD HOUSE MEDICAL CENTRE 8 • using the GP cluster method of BLUE WING FAMILY DOCTOR UNIT 28 calculating potential gains, if each HATTON MEDICAL PRACTICE 13 practice was to achieve as well as the PENTELOW PRACTICE 10 upper quartile of its national cluster, then an additional 407 people would THE PRACTICE HEART OF HOUNSLOW 16 be treated GREENBROOK HESTON 16

CROSSLANDS SURGERY 25

GREEN PRACTICE 22

TWICKENHAM PARK MEDICAL CENTRE 1

CHISWICK FAMILY DRS PRACTICE 0

HOUNSLOW MEDICAL CENTRE 0

CLIFFORD ROAD SURGERY

WELLESLEY ROAD PRACTICE

GREENBROOK BEDFONT

GROVE PARK TERRACE SURGERY

WEST4 GPS

REDWOOD PRACTICE

CARLTON 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% • 7,104 people with coronary heart NHS Brent CCG 93.3% disease* in NHS Hounslow CCG • 6,518 (91.8%) people who are taking NHS Ealing CCG 92.8% aspirin, an alternative anti-platelet therapy, or an anti-coagulant • 179 (2.5%) people who are NHS Harrow CCG 92.4% exceptions • 407 (5.7%) 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 Hillingdon CCG 93.5%

NHS Birmingham South and Central CCG 93.4%

NHS Brent CCG 93.3%

NHS Merton CCG 92.9%

NHS Ealing CCG 92.8%

NHS Redbridge CCG 92.7%

NHS Harrow CCG 92.4%

NHS Slough CCG 92.3%

NHS Waltham Forest CCG 92.0%

NHS Hounslow CCG 91.8%

NHS Luton CCG 89.7%

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

ST.MARGARETS PRACTICE E85007 41 CLIFFORD HOUSE MEDICAL CENTRE E85071 13 HOLLY ROAD MEDICAL CENTRE E85658 25 CHISWICK FAMILY DRS PRACTICE E85625 7 CHISWICK HEALTH PRACTICE E85030 16 GROVE PARK SURGERY E85693 17 GREENBROOK BEDFONT E85697 16 • in total, including exceptions, there SPRING GROVE MEDICAL PRACTICE E85750 28 ST DAVIDS PRACTICE E85056 23 are 586 people are not taking aspirin, DR SOOD'S PRACTICE E85018 9 CHESTNUT PRACTICE E85059 28 an alternative anti-platelet therapy, or BATH ROAD SURGERY E85716 25 LITTLE PARK SURGERY E85736 15 MANOR HOUSE PRACTICE E85700 5 an anti-coagulant CRANFORD MEDICAL CENTRE E85052 16 PENTELOW PRACTICE E85115 10 • GP practice range: 0.0% to 21.6% TWICKENHAM PARK MEDICAL CENTRE E85045 14 HOUNSLOW FAMILY PRACTICE E85713 13 QUEENS PARK MEDICAL PRACTICE E85734 8 GROVE PARK TERRACE SURGERY E85746 3 GILL MEDICAL PRACTICE E85708 7 GREEN PRACTICE E85126 19 KINGFISHER PRACTICE E85060 12 GREENBROOK ISLEWORTH E85744 7 GREENBROOK HESTON E85739 11 THE PRACTICE HEART OF HOUNSLOW Y02671 11 CROSSLANDS SURGERY E85114 19 GROVE VILLAGE MEDICAL CENTRE E85699 10 HOUNSLOW MEDICAL CENTRE E85015 16 COLE PARK SURGERY E85117 6 ALBANY PRACTICE E85004 11 FIRSTCARE PRACTICE E85062 9 GLEBE STREET SURGERY E85683 4 BLUE WING FAMILY DOCTOR UNIT E85058 14 ISLEWORTH CENTRE FOR HEALTH E85686 5 CLIFFORD ROAD SURGERY E85696 9 GREENBROOK CHINCHILLA E85727 4 WEST4 GPS E85040 11 CARLTON SURGERY E85024 8 BRENTFORD GROUP PRACTICE E85605 9 BRENTFORD FAMILY PRACTICE E85735 3 REDWOOD PRACTICE E85113 7 THORNBURY ROAD CENTRE FOR HEALTH E85001 8 WELLESLEY ROAD PRACTICE E85692 4 THE 303 BATH ROAD SURGERY E85044 3 WILLOW PRACTICE E85600 5 MOUNT MEDICAL CENTRE E85035 6 JERSEY PRACTICE E85681 6 GREENBROOK MANOR E85732 1 HATTON MEDICAL PRACTICE E85718 3 SKYWAYS MEDICAL CENTRE E85707 5 THE PRACTICE FELTHAM Y02672 1 NORTH HYDE MEDICAL PRACTICE E85755 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 Hounslow CCG England 1200

• in NHS Hounslow CCG, the hospital 1000 admission rate for coronary heart disease in 2015/16 was 811.5 (1,461) 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 Hounslow CCG England 250

• in NHS Hounslow CCG, the hospital admission rate for stroke in 2015/16 200 was 193.4 (333) 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 Hounslow CCG England

177.3% Angina 136.8% • The risk of a stroke was 90.2% higher and the risk of a heart attack was 162.2% 162.2% higher compared to people Heart Attack 108.6% without diabetes. The risk of a major amputation was 192.8% higher. 151.1% Heart failure 150.0%

90.2% Stroke 81.3%

192.8% Major amputation 445.8%

1584.0% Minor amputation 753.5%

294.4% RRT 293.0%

0% 200% 400% 600% 800% 1000% 1200% 1400% 1600% 1800% 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 Hounslow CCG England 100

90 • in NHS Hounslow CCG, the early mortality rate for coronary heart 80 disease in 2013-15 was 45.6, compared to 40.6 for England 70

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 Hounslow CCG England 35

• in NHS Hounslow CCG, the early 30 mortality rate for stroke in 2013-15 was 18.2, compared to 13.6 for England 25

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

Public Health England exists to protect and improve the nation’s health and wellbeing, and reduce health inequalities. We do this through world-class science, knowledge and intelligence, advocacy, partnerships and the delivery of specialist public health services. We are an executive agency of the Department of Health, and are a distinct delivery organisation with operational autonomy to advise and support government, local authorities and the NHS in a professionally independent manner.

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Published June 2017 Gateway number 2017095

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