CVD: Primary Care Intelligence Packs NHS Merton 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 Merton CCG are: NHS Hounslow CCG NHS Ealing CCG NHS Sutton CCG NHS Hillingdon CCG NHS Richmond CCG NHS Wandsworth CCG NHS North & West Reading CCG NHS Kingston CCG NHS Waltham Forest CCG NHS Barnet 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 Sutton CCG 16.6% • prevalence of 15.5% in NHS Merton CCG NHS Wandsworth CCG 16.4%
NHS Hillingdon CCG 16.3%
NHS Hounslow CCG 16.2%
NHS Merton CCG 15.5%
NHS Ealing CCG 15.5%
NHS Kingston CCG 15.3% Note: It has been found that the proportion of patients recorded as smokers correlates well NHS North & West Reading CCG 15.0% with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, NHS Barnet CCG 14.9% http://bmjopen.bmj.com/content/4/7/e005217.abs tract
NHS Richmond CCG 12.7% 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
GP LED HEALTH CENTRE Y02968 22.2%
CRICKET GREEN MEDICAL PRACTICE H85038 21.1% COLLIERS WOOD SURGERY H85649 20.7% • 28,041 people who are recorded as THE MERTON MEDICAL PRACTICE H85634 19.9% smokers in NHS Merton CCG THE MITCHAM MEDICAL CENTRE. H85024 19.8% • GP practice range: 8.2% to 22.2% TAMWORTH HOUSE MEDICAL CENTRE. H85033 19.4%
RAVENSBURY PARK MEDICAL CENTRE H85110 19.4%
ROWANS SURGERY H85035 18.7%
MITCHAM FAMILY PRACTICE H85078 18.6%
FIGGES MARSH SURGERY H85090 18.2%
WIDE WAY MEDICAL CENTRE H85029 18.2%
MORDEN HALL MEDICAL CENTRE H85037 18.1%
JAMES O'RIORDAN MEDICAL CENTRE H85072 17.8%
STONECOT SURGERY H85076 15.4%
ALEXANDRA SURGERY H85656 14.5%
RIVERHOUSE MEDICAL PRACTICE H85092 14.2%
LAMBTON ROAD MEDICAL PRACTICE H85051 14.0%
GRAND DRIVE SURGERY H85101 13.8%
PRINCES ROAD SURGERY H85028 12.3%
THE NELSON MEDICAL PRACTICE H85020 12.0% Note: This method is thought to be a reasonably CENTRAL MEDICAL CENTRE H85070 11.9% robust method in estimating smoking prevalence THE VINEYARD HILL ROAD SURGERY H85112 8.6% for the majority of GP practices. However,
FRANCIS GROVE SURGERY H85026 8.6% caution is advised for extreme estimates of smoking prevalence and those with high WIMBLEDON VILLAGE PRACTICE H85027 8.2% numbers of smoking status not recorded and 0% 5% 10% 15% 20% 25% exceptions.
14 CVD: Primary Care Intelligence Packs Hypertension
15 CVD: Primary Care Intelligence Packs Hypertension
The Missing Millions On average, each CCG in England has 26,000 residents with The Global Burden of Disease undiagnosed hypertension – these individuals are unaware of Study confirmed high blood pressure as their increased cardiovascular risk and are untreated. a leading cause of premature death and disability What questions should we ask in our CCG? 1. for each indicator how wide is the variation in achievement and exception reporting? 2. how many people would benefit if all practices performed High blood pressure is common and costly as well as the best? • it affects around a quarter of all adults 3. how can we support practices who are average or below • the NHS costs of hypertension are around £2bn average to perform as well as the best in: • social costs are probably considerably higher • detection of hypertension • management of hypertension What do we know? • at least half of all heart attacks and strokes are caused by high blood pressure and it is a major risk What might help? factor for chronic kidney disease and cognitive decline • support practices to share audit data and systematically • treatment is very effective – every 10mmHg reduction identify gaps and opportunities for improved detection and in systolic blood pressure lowers risk of heart attack management of hypertension and stroke by 20% • work with practices and local authorities to maximise • despite this 4 out of 10 adults with hypertension, over uptake and follow up in the NHS Health Check 5 and a half million people in England, remain • support access to self-test BP stations in waiting rooms undiagnosed and to ambulatory blood pressure monitoring. • and even when the condition is identified, treatment is • commission community pharmacists to offer blood often suboptimal, with blood pressure poorly pressure measurement, diagnosis and management controlled in about 1 out of 3 individuals support, including support for adherence to medication
16 CVD: Primary Care Intelligence Packs Hypertension observed prevalence compared with expected prevalence by CCG Comparison with CCGs in the STP
NHS Croydon CCG 0.57
• the ratio of those diagnosed with NHS Sutton CCG 0.57 hypertension versus those expected to have hypertension is 0.53. This compares to 0.59 for England NHS Kingston CCG 0.54 • this suggests that 53% of people with hypertension have been diagnosed
NHS Merton CCG 0.53
NHS Richmond CCG 0.53
NHS Wandsworth CCG 0.49
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 North & West Reading CCG 0.59
NHS Hillingdon CCG 0.58
NHS Hounslow CCG 0.57
NHS Ealing CCG 0.57
NHS Sutton CCG 0.57
NHS Barnet CCG 0.57
NHS Waltham Forest CCG 0.56
NHS Kingston CCG 0.54
NHS Merton CCG 0.53
NHS Richmond CCG 0.53
NHS Wandsworth CCG 0.49
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
STONECOT SURGERY H85076 0.72 WIDE WAY MEDICAL CENTRE H85029 0.65 FIGGES MARSH SURGERY H85090 0.63 • it is estimated that there are 20,190 MITCHAM FAMILY PRACTICE H85078 0.62 people with undiagnosed RAVENSBURY PARK MEDICAL CENTRE H85110 0.61 hypertension in NHS Merton CCG COLLIERS WOOD SURGERY H85649 0.60 THE MITCHAM MEDICAL CENTRE. H85024 0.60 • GP practice range of observed to TAMWORTH HOUSE MEDICAL CENTRE. H85033 0.59 expected hypertension prevalence GRAND DRIVE SURGERY H85101 0.58 0.37 to 0.72 JAMES O'RIORDAN MEDICAL CENTRE H85072 0.56 ROWANS SURGERY H85035 0.55 CENTRAL MEDICAL CENTRE H85070 0.55 CRICKET GREEN MEDICAL PRACTICE H85038 0.54 ALEXANDRA SURGERY H85656 0.51 MORDEN HALL MEDICAL CENTRE H85037 0.49 LAMBTON ROAD MEDICAL PRACTICE H85051 0.48 PRINCES ROAD SURGERY H85028 0.45 THE NELSON MEDICAL PRACTICE H85020 0.45 FRANCIS GROVE SURGERY H85026 0.44 RIVERHOUSE MEDICAL PRACTICE H85092 0.43 GP LED HEALTH CENTRE Y02968 0.41 THE VINEYARD HILL ROAD SURGERY H85112 0.40 WIMBLEDON VILLAGE PRACTICE H85027 0.40 THE MERTON MEDICAL PRACTICE H85634 0.37 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 Richmond CCG 80.0%
• 23,654 people with hypertension NHS Kingston CCG 78.9% (diagnosed)* in NHS Merton CCG • 18,280 (77.3%) people whose blood pressure is <= 150/90 NHS Sutton CCG 78.6% • 774 (3.3%) people who are excepted from optimal control • 4,600 (19.4%) additional people NHS Croydon CCG 78.5% whose blood pressure is not <= 150/90
NHS Wandsworth CCG 78.1%
NHS Merton CCG 77.3%
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 Richmond CCG 80.0%
NHS North & West Reading CCG 79.8%
NHS Hillingdon CCG 79.7%
NHS Kingston CCG 78.9%
NHS Hounslow CCG 78.8%
NHS Ealing CCG 78.7%
NHS Sutton CCG 78.6%
NHS Wandsworth CCG 78.1%
NHS Barnet CCG 77.9%
NHS Waltham Forest CCG 77.7%
NHS Merton CCG 77.3%
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
RAVENSBURY PARK MEDICAL CENTRE H85110 256
COLLIERS WOOD SURGERY H85649 348 WIMBLEDON VILLAGE PRACTICE H85027 320 • in total, including exceptions, there CRICKET GREEN MEDICAL PRACTICE H85038 383 are 5,374 people whose blood ALEXANDRA SURGERY H85656 142 pressure is not <= 150/90 PRINCES ROAD SURGERY H85028 197 • GP practice range: 14.9% to 37.4% THE VINEYARD HILL ROAD SURGERY H85112 73
WIDE WAY MEDICAL CENTRE H85029 285
MITCHAM FAMILY PRACTICE H85078 118
THE MITCHAM MEDICAL CENTRE. H85024 284
FIGGES MARSH SURGERY H85090 218
GP LED HEALTH CENTRE Y02968 118
MORDEN HALL MEDICAL CENTRE H85037 350
TAMWORTH HOUSE MEDICAL CENTRE. H85033 273
FRANCIS GROVE SURGERY H85026 200
THE MERTON MEDICAL PRACTICE H85634 96
LAMBTON ROAD MEDICAL PRACTICE H85051 267
THE NELSON MEDICAL PRACTICE H85020 476
ROWANS SURGERY H85035 212
GRAND DRIVE SURGERY H85101 182
CENTRAL MEDICAL CENTRE H85070 153
RIVERHOUSE MEDICAL PRACTICE H85092 72
STONECOT SURGERY H85076 225
JAMES O'RIORDAN MEDICAL CENTRE H85072 126
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 Wandsworth CCG 76.5%
• 82 people with a new diagnosis* of NHS Sutton CCG 74.7% hypertension with a CVD risk of 20% or higher in NHS Merton CCG • 59 (72%) people who are currently NHS Merton CCG 72.0% treated with statins • 23 (28%) people who are exempted from treatment with statins NHS Croydon CCG 70.8% • 0 (0%) additional people who are not currently treated with statins
NHS Kingston CCG 69.6%
NHS Richmond CCG 66.2%
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 Hounslow CCG 78.4%
NHS Wandsworth CCG 76.5%
NHS Sutton CCG 74.7%
NHS Waltham Forest CCG 72.5%
NHS Merton CCG 72.0%
NHS Hillingdon CCG 71.6%
NHS Kingston CCG 69.6%
NHS Barnet CCG 69.2%
NHS Richmond CCG 66.2%
NHS North & West Reading CCG 54.0%
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
MITCHAM FAMILY PRACTICE H85078 2
FRANCIS GROVE SURGERY H85026 2 ROWANS SURGERY H85035 1 • in total, including exceptions, there MORDEN HALL MEDICAL CENTRE H85037 4 are 23 people who are not treated COLLIERS WOOD SURGERY H85649 1 with statins JAMES O'RIORDAN MEDICAL CENTRE H85072 2 • GP practice range: 0.0% to 100.0% CRICKET GREEN MEDICAL PRACTICE H85038 1
LAMBTON ROAD MEDICAL PRACTICE H85051 1
THE NELSON MEDICAL PRACTICE H85020 4
TAMWORTH HOUSE MEDICAL CENTRE. H85033 1
STONECOT SURGERY H85076 2
FIGGES MARSH SURGERY H85090 1
GRAND DRIVE SURGERY H85101 1
THE MITCHAM MEDICAL CENTRE. H85024
WIMBLEDON VILLAGE PRACTICE H85027
WIDE WAY MEDICAL CENTRE H85029
CENTRAL MEDICAL CENTRE H85070
RAVENSBURY PARK MEDICAL CENTRE H85110
THE VINEYARD HILL ROAD SURGERY H85112
THE MERTON MEDICAL PRACTICE H85634
ALEXANDRA SURGERY H85656
GP LED HEALTH CENTRE Y02968
RIVERHOUSE MEDICAL PRACTICE H85092
PRINCES ROAD SURGERY H85028
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 Richmond CCG 0.65
• the ratio of those diagnosed with atrial NHS Sutton CCG 0.63 fibrillation versus those expected to have atrial fibrillation is 0.58. This compares to 0.7 for England NHS Kingston CCG 0.60 • this suggests that 58% of people with atrial fibrillation have been diagnosed.
NHS Merton CCG 0.58
NHS Wandsworth CCG 0.57
NHS Croydon CCG 0.54
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 North & West Reading CCG 0.65
NHS Richmond CCG 0.65
NHS Hillingdon CCG 0.64
NHS Sutton CCG 0.63
NHS Barnet CCG 0.61
NHS Ealing CCG 0.61
NHS Kingston CCG 0.60
NHS Hounslow CCG 0.59
NHS Merton CCG 0.58
NHS Wandsworth CCG 0.57
NHS Waltham Forest CCG 0.51
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
STONECOT SURGERY H85076 0.8 WIMBLEDON VILLAGE PRACTICE H85027 0.7 CRICKET GREEN MEDICAL PRACTICE H85038 0.7 • it is estimated that there are 4,014 THE MERTON MEDICAL PRACTICE H85634 0.7 people with undiagnosed atrial THE NELSON MEDICAL PRACTICE H85020 0.6 fibrillation in NHS Merton CCG FRANCIS GROVE SURGERY H85026 0.6 TAMWORTH HOUSE MEDICAL CENTRE. H85033 0.6 • GP practice range of observed to MORDEN HALL MEDICAL CENTRE H85037 0.6 expected atrial fibrillation prevalence LAMBTON ROAD MEDICAL PRACTICE H85051 0.6 0.3 to 0.8 JAMES O'RIORDAN MEDICAL CENTRE H85072 0.6 GRAND DRIVE SURGERY H85101 0.6 RAVENSBURY PARK MEDICAL CENTRE H85110 0.6 THE MITCHAM MEDICAL CENTRE. H85024 0.5 WIDE WAY MEDICAL CENTRE H85029 0.5 ROWANS SURGERY H85035 0.5 MITCHAM FAMILY PRACTICE H85078 0.5 FIGGES MARSH SURGERY H85090 0.5 THE VINEYARD HILL ROAD SURGERY H85112 0.5 COLLIERS WOOD SURGERY H85649 0.5 PRINCES ROAD SURGERY H85028 0.4 CENTRAL MEDICAL CENTRE H85070 0.4 RIVERHOUSE MEDICAL PRACTICE H85092 0.4 GP LED HEALTH CENTRE Y02968 0.4 ALEXANDRA SURGERY H85656 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 Sutton CCG 82.3% • 1,852 people with atrial fibrillation* with a CHA2DS2-VASc score >= 2 in NHS Richmond CCG 77.3% NHS Merton CCG • 1,431 (77.3%) people treated with anti-coagulation therapy NHS Merton CCG 77.3% • 160 (8.6%) people who are exceptions • 261 (14.1%) additional people with a NHS Wandsworth CCG 75.1% recorded CHA2DS2-VASc score >= 2 who are not treated
NHS Croydon CCG 72.8%
NHS Kingston CCG 71.6%
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 Sutton CCG 82.3%
NHS North & West Reading CCG 78.1%
NHS Richmond CCG 77.3%
NHS Merton CCG 77.3%
NHS Hounslow CCG 76.9%
NHS Ealing CCG 75.9%
NHS Waltham Forest CCG 75.7%
NHS Wandsworth CCG 75.1%
NHS Barnet CCG 72.7%
NHS Hillingdon CCG 72.2%
NHS Kingston CCG 71.6%
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
ALEXANDRA SURGERY H85656 9
THE VINEYARD HILL ROAD SURGERY H85112 10 RIVERHOUSE MEDICAL PRACTICE H85092 7 • in total, including exceptions, there MITCHAM FAMILY PRACTICE H85078 9 are 421 people with a recorded PRINCES ROAD SURGERY H85028 14 CHA2DS2-VASc score >= 2 who are FIGGES MARSH SURGERY H85090 13 not treated CRICKET GREEN MEDICAL PRACTICE H85038 30 • GP practice range: 9.9% to 42.9% LAMBTON ROAD MEDICAL PRACTICE H85051 36
MORDEN HALL MEDICAL CENTRE H85037 34
THE NELSON MEDICAL PRACTICE H85020 67
WIDE WAY MEDICAL CENTRE H85029 15
TAMWORTH HOUSE MEDICAL CENTRE. H85033 20
WIMBLEDON VILLAGE PRACTICE H85027 38
THE MERTON MEDICAL PRACTICE H85634 9
STONECOT SURGERY H85076 33
GP LED HEALTH CENTRE Y02968 4
COLLIERS WOOD SURGERY H85649 11
THE MITCHAM MEDICAL CENTRE. H85024 10
GRAND DRIVE SURGERY H85101 15
CENTRAL MEDICAL CENTRE H85070 6
FRANCIS GROVE SURGERY H85026 11
RAVENSBURY PARK MEDICAL CENTRE H85110 5
ROWANS SURGERY H85035 8
JAMES O'RIORDAN MEDICAL CENTRE H85072 7
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
33 CVD: Primary Care Intelligence Packs In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage treated with anti-coagulation therapy by GP practice – opportunities compared to GP cluster
10% 5% 0% -5% -10% -15% -20% -25% -30%
ALEXANDRA SURGERY 6
THE VINEYARD HILL ROAD SURGERY 6
RIVERHOUSE MEDICAL PRACTICE 4 • using the GP cluster method of MITCHAM FAMILY PRACTICE 5 calculating potential gains, if each PRINCES ROAD SURGERY 7 practice was to achieve as well as the FIGGES MARSH SURGERY 6 upper quartile of its national cluster, then an additional 124 people would CRICKET GREEN MEDICAL PRACTICE 10 be treated LAMBTON ROAD MEDICAL PRACTICE 12
WIDE WAY MEDICAL CENTRE 6
TAMWORTH HOUSE MEDICAL CENTRE. 7
STONECOT SURGERY 9
GP LED HEALTH CENTRE 1
THE MITCHAM MEDICAL CENTRE. 2
GRAND DRIVE SURGERY 2
COLLIERS WOOD SURGERY 1
RAVENSBURY PARK MEDICAL CENTRE
CENTRAL MEDICAL CENTRE
FRANCIS GROVE SURGERY
ROWANS SURGERY
JAMES O'RIORDAN MEDICAL CENTRE Details of this methodology are available on slide 9. Click here to view them.
34 CVD: Primary Care Intelligence Packs Percentage of patients with a history of stroke whose last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less by CCG Comparison with CCGs in the STP
Below 150/90 Not below 150/90 Exceptions reported
NHS Richmond CCG 85.8% • 2,298 people with a history of stroke or TIA* in NHS Merton CCG NHS Sutton CCG 83.6% • 1,891 (82.3%) people whose blood pressure is <= 150 / 90 • 90 (3.9%) people who are exceptions NHS Croydon CCG 83.6% • 317 (13.8%) additional people whose blood pressure is not <= 150 / 90
NHS Kingston CCG 83.4%
NHS Wandsworth CCG 82.5%
NHS Merton CCG 82.3%
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 Richmond CCG 85.8%
NHS Hounslow CCG 84.6%
NHS North & West Reading CCG 84.1%
NHS Sutton CCG 83.6%
NHS Kingston CCG 83.4%
NHS Hillingdon CCG 83.3%
NHS Barnet CCG 83.0%
NHS Ealing CCG 82.9%
NHS Waltham Forest CCG 82.9%
NHS Wandsworth CCG 82.5%
NHS Merton CCG 82.3%
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
RAVENSBURY PARK MEDICAL CENTRE H85110 13
COLLIERS WOOD SURGERY H85649 30 WIDE WAY MEDICAL CENTRE H85029 21 • in total, including exceptions, there THE MERTON MEDICAL PRACTICE H85634 10 are 407 people whose blood pressure THE MITCHAM MEDICAL CENTRE. H85024 21 is not <= 150 / 90 PRINCES ROAD SURGERY H85028 18 • GP practice range: 0.0% to 29.5% WIMBLEDON VILLAGE PRACTICE H85027 31
FIGGES MARSH SURGERY H85090 13
CRICKET GREEN MEDICAL PRACTICE H85038 29
TAMWORTH HOUSE MEDICAL CENTRE. H85033 22
MITCHAM FAMILY PRACTICE H85078 8
MORDEN HALL MEDICAL CENTRE H85037 28
GP LED HEALTH CENTRE Y02968 9
GRAND DRIVE SURGERY H85101 16
RIVERHOUSE MEDICAL PRACTICE H85092 6
THE NELSON MEDICAL PRACTICE H85020 45
ROWANS SURGERY H85035 18
LAMBTON ROAD MEDICAL PRACTICE H85051 20
FRANCIS GROVE SURGERY H85026 12
ALEXANDRA SURGERY H85656 5
CENTRAL MEDICAL CENTRE H85070 7
STONECOT SURGERY H85076 20
JAMES O'RIORDAN MEDICAL CENTRE H85072 5
THE VINEYARD HILL ROAD SURGERY H85112
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 Merton CCG 92.8% • 1,383 people with a stroke shown to be non-haemorrhagic* in NHS Merton NHS Richmond CCG 91.8% CCG • 1,284 (92.8%) people who are taking an anti-platetet agent or anti- NHS Sutton CCG 91.5% coagulant • 81 (5.9%) people who are exceptions • 18 (1.3%) additional people with no NHS Croydon CCG 91.3% treatment
NHS Wandsworth CCG 90.3%
NHS Kingston CCG 89.6%
England 91.8%
0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator STIA007 denominator plus exceptions
38 CVD: Primary Care Intelligence Packs Percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record in the preceding 12 months that an anti-platelet agent, or an anti-coagulant is being taken by CCG Comparison with demographically similar CCGs Below 150/90 Not below 150/90 Exceptions reported
NHS Ealing CCG 93.0%
NHS Merton CCG 92.8%
NHS Hounslow CCG 91.8%
NHS Richmond CCG 91.8%
NHS Sutton CCG 91.5%
NHS North & West Reading CCG 91.2%
NHS Waltham Forest CCG 90.9%
NHS Hillingdon CCG 90.8%
NHS Wandsworth CCG 90.3%
NHS Kingston CCG 89.6%
NHS Barnet CCG 89.1%
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
GP LED HEALTH CENTRE Y02968 3
TAMWORTH HOUSE MEDICAL CENTRE. H85033 9 LAMBTON ROAD MEDICAL PRACTICE H85051 13 • in total, including exceptions, there WIDE WAY MEDICAL CENTRE H85029 7 are 99 people who are not taking an PRINCES ROAD SURGERY H85028 5 anti-platelet agent or anti-coagulant COLLIERS WOOD SURGERY H85649 8 • GP practice range: 0.0% to 16.7% JAMES O'RIORDAN MEDICAL CENTRE H85072 3
GRAND DRIVE SURGERY H85101 5
WIMBLEDON VILLAGE PRACTICE H85027 7
MITCHAM FAMILY PRACTICE H85078 3
STONECOT SURGERY H85076 7
MORDEN HALL MEDICAL CENTRE H85037 5
FIGGES MARSH SURGERY H85090 2
CRICKET GREEN MEDICAL PRACTICE H85038 4
CENTRAL MEDICAL CENTRE H85070 2
THE NELSON MEDICAL PRACTICE H85020 9
FRANCIS GROVE SURGERY H85026 3
RAVENSBURY PARK MEDICAL CENTRE H85110 1
ALEXANDRA SURGERY H85656 1
THE MITCHAM MEDICAL CENTRE. H85024 1
ROWANS SURGERY H85035 1
RIVERHOUSE MEDICAL PRACTICE H85092
THE VINEYARD HILL ROAD SURGERY H85112
THE MERTON MEDICAL PRACTICE H85634
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 Sutton CCG 0.81 • 0.74 ratio of observed to expected diabetes prevalence in NHS Merton NHS Kingston CCG 0.75 CCG, compared to 0.77 in England
NHS Merton CCG 0.74 • this suggests 74% of people have been diagnosed
NHS Croydon CCG 0.65
NHS Wandsworth CCG 0.62
NHS Richmond CCG 0.53
Note: This slide compares the prevalence of Diabetes recorded in QOF in 2015/16 to the expected prevalence of Diabetes in 2016 taken England 0.77 from the NCVIN diabetes prevalence model produced in 2015.
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
43 CVD: Primary Care Intelligence Packs Diabetes observed prevalence compared with expected prevalence by CCG Comparison with demographically similar CCGs
NHS Hillingdon CCG 0.81
NHS Sutton CCG 0.81
NHS Hounslow CCG 0.79
NHS Ealing CCG 0.76
NHS Kingston CCG 0.75
NHS Merton CCG 0.74
NHS Barnet CCG 0.71
NHS North & West Reading CCG 0.67
NHS Waltham Forest CCG 0.67
NHS Wandsworth CCG 0.62
NHS Richmond CCG 0.53
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
44 CVD: Primary Care Intelligence Packs Diabetes prevalence by GP practice
GP practice CCG
CENTRAL MEDICAL CENTRE H85070 12.2%
RAVENSBURY PARK MEDICAL CENTRE H85110 9.7% WIDE WAY MEDICAL CENTRE H85029 9.2% • GP practice range of observed MITCHAM FAMILY PRACTICE H85078 8.5% diabetes 2.2% to 12.2% TAMWORTH HOUSE MEDICAL CENTRE. H85033 8.4% • there are an estimated 3,620 people RIVERHOUSE MEDICAL PRACTICE H85092 8.3% with undiagnosed diabetes in NHS ROWANS SURGERY H85035 8.1% Merton CCG FIGGES MARSH SURGERY H85090 7.7%
STONECOT SURGERY H85076 7.6%
THE MITCHAM MEDICAL CENTRE. H85024 7.5%
CRICKET GREEN MEDICAL PRACTICE H85038 7.4%
ALEXANDRA SURGERY H85656 7.2%
MORDEN HALL MEDICAL CENTRE H85037 7.1%
COLLIERS WOOD SURGERY H85649 6.6%
JAMES O'RIORDAN MEDICAL CENTRE H85072 6.5%
GP LED HEALTH CENTRE Y02968 5.5%
THE NELSON MEDICAL PRACTICE H85020 4.6%
GRAND DRIVE SURGERY H85101 4.5%
LAMBTON ROAD MEDICAL PRACTICE H85051 3.7%
PRINCES ROAD SURGERY H85028 3.4%
THE MERTON MEDICAL PRACTICE H85634 3.1%
THE VINEYARD HILL ROAD SURGERY H85112 2.6%
FRANCIS GROVE SURGERY H85026 2.6% Note: The estimated number of undiagnosed people with diabetes has been calculated by WIMBLEDON VILLAGE PRACTICE H85027 2.2% multiplying the estimated prevalence rate to the 0% 2% 4% 6% 8% 10% 12% 14% 2015/16 QOF list size and subtracting the number of people on the diabetes register.
45 CVD: Primary Care Intelligence Packs Expected total prevalence of diabetes and non-diabetic hyperglycaemia
Diabetes prevalence Undiagnosed diabetes prevalence Expected non-diabetic hyperglycaemia prevalence
• the estimated total prevalence of NHS Croydon CCG 6.7% 3.6% 12.4% diabetes in NHS Merton CCG is 8.1% (diagnosed and undiagnosed) NHS Merton CCG 6.0% 2.1% 10.9% • in addition, there are an estimated 10.9% of people in NHS Merton CCG NHS Sutton CCG 6.3% 1.5% 11.1% who are at increased risk of developing diabetes (i.e. with non- diabetic hyperglycaemia) NHS Kingston CCG 4.9% 1.6% 9.6%
• this means that 18.9% of the NHS Richmond CCG 3.6% 3.2% 9.3% population in NHS Merton CCG are estimated to have diabetes, or at high risk of developing of diabetes NHS Wandsworth CCG 4.3% 2.7% 9.0%
Note: Prevalence estimates of non-diabetic hyperglycaemia were developed using Health Survey for England (HSE) data. Five years of England 6.5% 1.9% 11.2% HSE data were combined, 2009- 2013. The estimates take into account the age, ethnic group and estimated body mass index of the population. 0% 5% 10% 15% 20% 25% 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 Kingston CCG 47.2%
• data on care processes and treatment NHS Sutton CCG 40.5% targets are taken from the National Diabetes Audit (NDA) • overall practice participation in the NHS Croydon CCG 39.7% 2015/16 audit was 81.4% in England
• in NHS Merton CCG, 5 out of 24 NHS Merton CCG 32.0% practices (20.8%) participated in the NDA. Data is not available for the remaining practices NHS Wandsworth CCG 31.4%
• 32.0% of people with diabetes (of NHS Richmond CCG 26.4% practices who participated in the audit) had the eight recommended care processes in NHS Merton CCG, compared to 52.6% in England
England 52.6%
0% 10% 20% 30% 40% 50% 60%
47 CVD: Primary Care Intelligence Packs People with diabetes who had eight care processes by GP practice, 2015/16
GP practice Average of practices in the CCG who participated in the audit
CENTRAL MEDICAL CENTRE H85070 45.6% PRINCES ROAD SURGERY H85028 31.9% • achievement - 8 care processes: in GP LED HEALTH CENTRE Y02968 26.4% practices who provided data via the LAMBTON ROAD MEDICAL PRACTICE H85051 23.5% NDA, between 11.2% and 45.6% of FRANCIS GROVE SURGERY H85026 11.2% patients received all 8 care processes ALEXANDRA SURGERY H85656
COLLIERS WOOD SURGERY H85649 THE MERTON MEDICAL PRACTICE H85634 • at least 1,346 people did not receive THE VINEYARD HILL ROAD SURGERY H85112 the eight care processes RAVENSBURY PARK MEDICAL CENTRE H85110
GRAND DRIVE SURGERY H85101
RIVERHOUSE MEDICAL PRACTICE H85092
FIGGES MARSH SURGERY H85090
MITCHAM FAMILY PRACTICE H85078
STONECOT SURGERY H85076
JAMES O'RIORDAN MEDICAL CENTRE H85072
CRICKET GREEN MEDICAL PRACTICE H85038
MORDEN HALL MEDICAL CENTRE H85037
ROWANS SURGERY H85035
TAMWORTH HOUSE MEDICAL CENTRE. H85033
WIDE WAY MEDICAL CENTRE H85029
WIMBLEDON VILLAGE PRACTICE H85027
THE MITCHAM MEDICAL CENTRE. H85024
THE NELSON MEDICAL PRACTICE H85020
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 Sutton CCG 40.2%
• 39.3% of people with diabetes (of NHS Richmond CCG 39.8% practices who participated in the audit) met the three treatment targets in NHS Merton CCG, compared to 39.0% in England NHS Kingston CCG 39.6%
NHS Merton CCG 39.3%
NHS Wandsworth CCG 38.9%
NHS Croydon CCG 37.9%
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
FRANCIS GROVE SURGERY H85026 45.1% LAMBTON ROAD MEDICAL PRACTICE H85051 41.3% • achievement - 3 treatment targets: in GP LED HEALTH CENTRE Y02968 40.5% practices who provided data via the CENTRAL MEDICAL CENTRE H85070 36.9% NDA, between 36.0% and 45.1% of PRINCES ROAD SURGERY H85028 36.0% patients achieved all 3 treatment ALEXANDRA SURGERY H85656 targets COLLIERS WOOD SURGERY H85649 THE MERTON MEDICAL PRACTICE H85634 • at least 1,057 people did not meet the THE VINEYARD HILL ROAD SURGERY H85112 three treatment targets RAVENSBURY PARK MEDICAL CENTRE H85110
GRAND DRIVE SURGERY H85101
RIVERHOUSE MEDICAL PRACTICE H85092
FIGGES MARSH SURGERY H85090
MITCHAM FAMILY PRACTICE H85078
STONECOT SURGERY H85076
JAMES O'RIORDAN MEDICAL CENTRE H85072
CRICKET GREEN MEDICAL PRACTICE H85038
MORDEN HALL MEDICAL CENTRE H85037
ROWANS SURGERY H85035
TAMWORTH HOUSE MEDICAL CENTRE. H85033
WIDE WAY MEDICAL CENTRE H85029
WIMBLEDON VILLAGE PRACTICE H85027
THE MITCHAM MEDICAL CENTRE. H85024
THE NELSON MEDICAL PRACTICE H85020
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
4% 2% 0% -2% -4% -6% -8% -10% -12%
PRINCES ROAD SURGERY 18 • using the GP cluster method of calculating potential gains, if each practice was to achieve as well as the upper quartile of its national cluster, CENTRAL MEDICAL CENTRE 39 then an additional 71 people would be treated
GP LED HEALTH CENTRE 8
LAMBTON ROAD MEDICAL PRACTICE 5
FRANCIS GROVE 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 Sutton CCG 0.62
NHS Croydon CCG 0.61 • the ratio of those diagnosed with chronic kidney disease versus those expected to have chronic kidney NHS Merton CCG 0.60 disease is 0.6. This compares to 0.68 for England • this suggests that 60% of people with NHS Richmond CCG 0.42 chronic kidney disease have been diagnosed
NHS Kingston CCG 0.42
NHS Wandsworth CCG 0.42
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 North & West Reading CCG 0.67
NHS Sutton CCG 0.62
NHS Merton CCG 0.60
NHS Hounslow CCG 0.56
NHS Barnet CCG 0.53
NHS Waltham Forest CCG 0.52
NHS Hillingdon CCG 0.50
NHS Ealing CCG 0.43
NHS Richmond CCG 0.42
NHS Kingston CCG 0.42
NHS Wandsworth CCG 0.42
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 Ratio
55 CVD: Primary Care Intelligence Packs CKD prevalence by GP practice, 2015/16
GP practice CCG
STONECOT SURGERY H85076 7.2%
GRAND DRIVE SURGERY H85101 5.4% MITCHAM FAMILY PRACTICE H85078 4.8% • it is estimated that there are 3,420 ROWANS SURGERY H85035 4.6% people with undiagnosed chronic JAMES O'RIORDAN MEDICAL CENTRE H85072 4.2% kidney disease in NHS Merton CCG THE NELSON MEDICAL PRACTICE H85020 4.0% • GP practice range of observed CKD: TAMWORTH HOUSE MEDICAL CENTRE. H85033 3.5% 0.9% to 7.2% WIDE WAY MEDICAL CENTRE H85029 3.4%
CRICKET GREEN MEDICAL PRACTICE H85038 3.3%
CENTRAL MEDICAL CENTRE H85070 2.8%
RAVENSBURY PARK MEDICAL CENTRE H85110 2.8%
WIMBLEDON VILLAGE PRACTICE H85027 2.6%
FRANCIS GROVE SURGERY H85026 2.4%
THE MITCHAM MEDICAL CENTRE. H85024 2.1%
LAMBTON ROAD MEDICAL PRACTICE H85051 2.0%
THE VINEYARD HILL ROAD SURGERY H85112 1.9%
ALEXANDRA SURGERY H85656 1.9%
MORDEN HALL MEDICAL CENTRE H85037 1.7%
THE MERTON MEDICAL PRACTICE H85634 1.7%
RIVERHOUSE MEDICAL PRACTICE H85092 1.6%
COLLIERS WOOD SURGERY H85649 1.6% Note: CCG estimates for the estimated FIGGES MARSH SURGERY H85090 1.5% number of people with CKD are based on GP LED HEALTH CENTRE Y02968 1.1% applying a proportion from a resident based PRINCES ROAD SURGERY H85028 0.9% population estimate to a GP registered population. The characteristics of registered 0% 1% 2% 3% 4% 5% 6% 7% 8% 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 Merton CCG 78.3% • 5,046 people with CKD (diagnosed*) in NHS Merton CCG NHS Richmond CCG 76.2% • 3,950 (78.3%) people whose blood pressure is <= 140 /85 • 297 (5.9%) people who are NHS Sutton CCG 75.6% exceptions • 799 (15.8%) additional people whose blood pressure is not <= 140 / 85 NHS Croydon CCG 75.5%
NHS Wandsworth CCG 75.4%
NHS Kingston CCG 75.4%
*Using the QOF clinical indicator CKD002 England 74.4% denominator plus exceptions. Note: as the CKD002 indicator was removed from 0% 20% 40% 60% 80% 100% the QOF in 15/16 this is historic data taken from the 2014/15 QOF.
57 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding 12 months) is 140/85 mmHg or less by CCG, 2014/15 Comparison with demographically similar CCGs Below 140/85 Not below 140/85 Exceptions reported
NHS Merton CCG 78.3%
NHS Hillingdon CCG 77.1%
NHS North & West Reading CCG 76.6%
NHS Richmond CCG 76.2%
NHS Waltham Forest CCG 75.8%
NHS Ealing CCG 75.7%
NHS Sutton CCG 75.6%
NHS Wandsworth CCG 75.4%
NHS Kingston CCG 75.4%
NHS Hounslow CCG 74.9%
NHS Barnet CCG 74.2%
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
DR AYUB & PARTNERS H85649 54 SORNALINGHAM H85656 39 V SHARMA H85028 29 • in total, including exceptions, there J R JONES H85112 19 are 1,096 people whose blood J J JEPHCOTT H85072 51 pressure is not <= 140 / 85 WIMBLEDON VILLAGE PRACTICE H85027 78 • GP practice range: 13.6% to 42.2% T KEYAMO H85110 24 G P HOLLIER H85033 68 CENTRAL MEDICAL CENTRE H85070 44 FIGGES MARSH SURGERY H85090 19 FRANCIS GROVE SURGERY H85026 44 MERTON MEDICAL PRACTICE H85634 23 DR GIBBS & PARTNERS H85037 39 CRICKET GREEN MEDICAL PRACTICE H85038 53 THE MITCHAM MEDICAL CENTRE. H85024 34 THE NELSON MEDICAL PRACTICE H85020 128 GP LED HEALTH CENTRE Y02968 10 STONECOT SURGERY H85076 91 GRAHAM ROAD SURGERY H85078 21 ROWANS SURGERY H85035 59 M N BAIG H85092 7 DR M.N.PATEL & PARTNERS H85029 32 THE GRAND DRIVE SURGERY H85101 59 S J WOROPAY H85016 37 LAMBTON ROAD MEDICAL PRACTICE H85051 34
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%
SORNALINGHAM 24
V SHARMA 17
DR AYUB & PARTNERS 28 • using the GP cluster method of J R JONES 10 calculating potential gains, if each J J JEPHCOTT 26 practice was to achieve as well as the T KEYAMO 11 upper quartile of its national cluster, then an additional 220 people would G P HOLLIER 31 be treated WIMBLEDON VILLAGE PRACTICE 26
FIGGES MARSH SURGERY 7
CENTRAL MEDICAL CENTRE 10
ROWANS SURGERY 6
FRANCIS GROVE SURGERY 3
DR M.N.PATEL & PARTNERS 2
DR GIBBS & PARTNERS 2
M N BAIG 0
CRICKET GREEN MEDICAL PRACTICE 0
STONECOT SURGERY
THE GRAND DRIVE SURGERY
THE NELSON MEDICAL PRACTICE
LAMBTON ROAD MEDICAL PRACTICE 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 Wandsworth CCG 76.7% • 5,046 people with CKD (diagnosed*) in NHS Merton CCG NHS Merton CCG 74.4% • 3,752 (74.4%) people who have a record of urine albumin:creatinine ratio test NHS Croydon CCG 73.9% • 268 (5.3%) people who are exceptions • 1,026 (20.3%) additional people who NHS Sutton CCG 71.8% have no record of urine albumin:creatinine ratio test
NHS Richmond CCG 71.6%
NHS Kingston CCG 71.2%
*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 North & West Reading CCG 80.5%
NHS Hillingdon CCG 78.6%
NHS Wandsworth CCG 76.7%
NHS Barnet CCG 76.3%
NHS Ealing CCG 75.5%
NHS Waltham Forest CCG 74.7%
NHS Merton CCG 74.4%
NHS Hounslow CCG 74.1%
NHS Sutton CCG 71.8%
NHS Richmond CCG 71.6%
NHS Kingston CCG 71.2%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
62 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose notes do not have a record of a urine albumin: creatinine ratio test in the preceding 12 months by GP practice, 2014/15
Not recorded Exceptions reported
THE MITCHAM MEDICAL CENTRE. H85024 126 SORNALINGHAM H85656 47 DR AYUB & PARTNERS H85649 57 • in total, including exceptions, there CRICKET GREEN MEDICAL PRACTICE H85038 113 are 1,294 people who have no record J R JONES H85112 23 of urine albumin:creatinine ratio test V SHARMA H85028 29 • GP practice range: 7.5% to 74.1% J J JEPHCOTT H85072 50 M N BAIG H85092 13 T KEYAMO H85110 23 G P HOLLIER H85033 67 DR M.N.PATEL & PARTNERS H85029 55 THE NELSON MEDICAL PRACTICE H85020 193 DR GIBBS & PARTNERS H85037 49 CENTRAL MEDICAL CENTRE H85070 39 ROWANS SURGERY H85035 71 S J WOROPAY H85016 50 FIGGES MARSH SURGERY H85090 15 FRANCIS GROVE SURGERY H85026 36 GRAHAM ROAD SURGERY H85078 21 WIMBLEDON VILLAGE PRACTICE H85027 42 THE GRAND DRIVE SURGERY H85101 58 LAMBTON ROAD MEDICAL PRACTICE H85051 34 STONECOT SURGERY H85076 68 GP LED HEALTH CENTRE Y02968 7 MERTON MEDICAL PRACTICE H85634 8
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 Sutton CCG 0.54%
• prevalence of 0.48% in NHS Merton NHS Merton CCG 0.48% CCG compared to 0.76% in England
NHS Croydon CCG 0.47%
NHS Richmond CCG 0.46%
NHS Kingston CCG 0.45%
NHS Wandsworth CCG 0.32%
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 North & West Reading CCG 0.62%
NHS Sutton CCG 0.54%
NHS Hounslow CCG 0.51%
NHS Barnet CCG 0.51%
NHS Hillingdon CCG 0.49%
NHS Merton CCG 0.48%
NHS Waltham Forest CCG 0.46%
NHS Ealing CCG 0.46%
NHS Richmond CCG 0.46%
NHS Kingston CCG 0.45%
NHS Wandsworth CCG 0.32%
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
STONECOT SURGERY H85076 0.9%
MITCHAM FAMILY PRACTICE H85078 0.7% JAMES O'RIORDAN MEDICAL CENTRE H85072 0.7% • 1,055 people with diagnosed heart ROWANS SURGERY H85035 0.6% failure in NHS Merton CCG COLLIERS WOOD SURGERY H85649 0.6% • GP practice range: 0.3% to 0.9% CRICKET GREEN MEDICAL PRACTICE H85038 0.6%
TAMWORTH HOUSE MEDICAL CENTRE. H85033 0.6%
GRAND DRIVE SURGERY H85101 0.5%
THE MITCHAM MEDICAL CENTRE. H85024 0.5%
WIMBLEDON VILLAGE PRACTICE H85027 0.5%
CENTRAL MEDICAL CENTRE H85070 0.5%
WIDE WAY MEDICAL CENTRE H85029 0.5%
LAMBTON ROAD MEDICAL PRACTICE H85051 0.5%
PRINCES ROAD SURGERY H85028 0.4%
FIGGES MARSH SURGERY H85090 0.4%
THE NELSON MEDICAL PRACTICE H85020 0.4%
ALEXANDRA SURGERY H85656 0.4%
THE MERTON MEDICAL PRACTICE H85634 0.4%
MORDEN HALL MEDICAL CENTRE H85037 0.3%
THE VINEYARD HILL ROAD SURGERY H85112 0.3%
RAVENSBURY PARK MEDICAL CENTRE H85110 0.3%
GP LED HEALTH CENTRE Y02968 0.3%
FRANCIS GROVE SURGERY H85026 0.3%
RIVERHOUSE MEDICAL PRACTICE H85092 0.3%
0.0% 0.1% 0.2% 0.3% 0.4% 0.5% 0.6% 0.7% 0.8% 0.9% 1.0%
68 CVD: Primary Care Intelligence Packs Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who are treated with ACE-I / ARB by CCG Comparison with CCGs in the STP Treatment No treatment Exceptions reported
NHS Richmond CCG 90.8% • 291 people with heart failure* with LVSD in NHS Merton CCG NHS Kingston CCG 88.7% • 254 (87.3%) people treated with ACE- I or ARB • 37 (12.7%) people who are NHS Sutton CCG 88.1% exceptions • 0 (0%) additional people who are not treated with ACE-I or ARB NHS Merton CCG 87.3%
NHS Wandsworth CCG 86.3%
NHS Croydon CCG 85.7%
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 Richmond CCG 90.8%
NHS Waltham Forest CCG 88.7%
NHS Kingston CCG 88.7%
NHS Sutton CCG 88.1%
NHS Hillingdon CCG 87.6%
NHS Merton CCG 87.3%
NHS Wandsworth CCG 86.3%
NHS North & West Reading CCG 82.0%
NHS Barnet CCG 79.8%
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
JAMES O'RIORDAN MEDICAL CENTRE H85072 4
CRICKET GREEN MEDICAL PRACTICE H85038 2 RAVENSBURY PARK MEDICAL CENTRE H85110 1 • in total, including exceptions, there THE MERTON MEDICAL PRACTICE H85634 3 are 37 people who are not treated LAMBTON ROAD MEDICAL PRACTICE H85051 2 with ACE-I or ARB CENTRAL MEDICAL CENTRE H85070 1 • GP practice range: 0.0% to 66.7% GP LED HEALTH CENTRE Y02968 1
WIMBLEDON VILLAGE PRACTICE H85027 3
STONECOT SURGERY H85076 7
THE MITCHAM MEDICAL CENTRE. H85024 5
MORDEN HALL MEDICAL CENTRE H85037 4
MITCHAM FAMILY PRACTICE H85078 1
THE NELSON MEDICAL PRACTICE H85020 2
ROWANS SURGERY H85035 1
FRANCIS GROVE SURGERY H85026
PRINCES ROAD SURGERY H85028
WIDE WAY MEDICAL CENTRE H85029
TAMWORTH HOUSE MEDICAL CENTRE. H85033
FIGGES MARSH SURGERY H85090
RIVERHOUSE MEDICAL PRACTICE H85092
GRAND DRIVE SURGERY H85101
THE VINEYARD HILL ROAD SURGERY H85112
COLLIERS WOOD SURGERY H85649
ALEXANDRA SURGERY H85656
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 Croydon CCG 84.6% • 254 people with heart failure* with LVSD treated with ACE-I/ARB in NHS NHS Wandsworth CCG 82.2% Merton CCG • 203 (79.9%) people treated with ACE- I/ARB and BB NHS Merton CCG 79.9% • 36 (14.2%) people who are exceptions • 15 (5.9%) additional people who are NHS Richmond CCG 78.9% not treated with ACE-I/ARB and BB
NHS Sutton CCG 75.0%
NHS Kingston CCG 74.0%
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 North & West Reading CCG 85.0%
NHS Ealing CCG 83.6%
NHS Hounslow CCG 82.8%
NHS Wandsworth CCG 82.2%
NHS Merton CCG 79.9%
NHS Richmond CCG 78.9%
NHS Barnet CCG 76.4%
NHS Sutton CCG 75.0%
NHS Waltham Forest CCG 74.5%
NHS Kingston CCG 74.0%
NHS Hillingdon CCG 72.6%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
73 CVD: Primary Care Intelligence Packs Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who are not treated with ACE-I / ARB and BB by GP practice
No treatment Exceptions reported
WIMBLEDON VILLAGE PRACTICE H85027 9
MITCHAM FAMILY PRACTICE H85078 4 THE VINEYARD HILL ROAD SURGERY H85112 1 • in total, including exceptions, there MORDEN HALL MEDICAL CENTRE H85037 7 are 51 people who are not treated THE NELSON MEDICAL PRACTICE H85020 5 with ACE-I or ARB STONECOT SURGERY H85076 9 • GP practice range: 0.0% to 56.3% PRINCES ROAD SURGERY H85028 1
WIDE WAY MEDICAL CENTRE H85029 1
LAMBTON ROAD MEDICAL PRACTICE H85051 2
CENTRAL MEDICAL CENTRE H85070 1
FRANCIS GROVE SURGERY H85026 1
GRAND DRIVE SURGERY H85101 2
ROWANS SURGERY H85035 3
THE MITCHAM MEDICAL CENTRE. H85024 4
THE MERTON MEDICAL PRACTICE H85634 1
TAMWORTH HOUSE MEDICAL CENTRE. H85033
CRICKET GREEN MEDICAL PRACTICE H85038
JAMES O'RIORDAN MEDICAL CENTRE H85072
FIGGES MARSH SURGERY H85090
RIVERHOUSE MEDICAL PRACTICE H85092
RAVENSBURY PARK MEDICAL CENTRE H85110
COLLIERS WOOD SURGERY H85649
ALEXANDRA SURGERY H85656
GP LED HEALTH CENTRE Y02968
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 Richmond CCG 90.2% • 4,470 people with coronary heart disease* in NHS Merton CCG NHS Merton CCG 89.5% • 4,000 (89.5%) people whose blood pressure <= 150 / 90 • 148 (3.3%) people who are NHS Wandsworth CCG 89.0% exceptions • 322 (7.2%) additional people whose blood pressure is not <= 150 / 90 NHS Croydon CCG 88.9%
NHS Sutton CCG 87.9%
NHS Kingston CCG 87.7%
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 Richmond CCG 90.2%
NHS North & West Reading CCG 89.5%
NHS Merton CCG 89.5%
NHS Hillingdon CCG 89.1%
NHS Wandsworth CCG 89.0%
NHS Waltham Forest CCG 88.9%
NHS Ealing CCG 88.0%
NHS Sutton CCG 87.9%
NHS Barnet CCG 87.9%
NHS Hounslow CCG 87.9%
NHS Kingston CCG 87.7%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
76 CVD: Primary Care Intelligence Packs Percentage of patients with CHD whose blood pressure reading (measured in the preceding 12 months) is not 150/90 mmHg or less by GP practice
Not below 150/90 Exceptions reported
RAVENSBURY PARK MEDICAL CENTRE H85110 29
WIMBLEDON VILLAGE PRACTICE H85027 41 COLLIERS WOOD SURGERY H85649 24 • in total, including exceptions, there CRICKET GREEN MEDICAL PRACTICE H85038 33 are 470 people whose blood pressure GP LED HEALTH CENTRE Y02968 10 is not <= 150 / 90 THE MITCHAM MEDICAL CENTRE. H85024 29 • GP practice range: 5.0% to 27.1% FIGGES MARSH SURGERY H85090 15
MITCHAM FAMILY PRACTICE H85078 8
TAMWORTH HOUSE MEDICAL CENTRE. H85033 30
THE VINEYARD HILL ROAD SURGERY H85112 5
CENTRAL MEDICAL CENTRE H85070 21
THE MERTON MEDICAL PRACTICE H85634 7
WIDE WAY MEDICAL CENTRE H85029 16
FRANCIS GROVE SURGERY H85026 17
ROWANS SURGERY H85035 19
JAMES O'RIORDAN MEDICAL CENTRE H85072 15
THE NELSON MEDICAL PRACTICE H85020 46
STONECOT SURGERY H85076 25
LAMBTON ROAD MEDICAL PRACTICE H85051 20
PRINCES ROAD SURGERY H85028 10
MORDEN HALL MEDICAL CENTRE H85037 22
GRAND DRIVE SURGERY H85101 13
ALEXANDRA SURGERY H85656 8
RIVERHOUSE MEDICAL PRACTICE H85092 7
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
77 CVD: Primary Care Intelligence Packs Percentage of patients with CHD whose blood pressure reading (measured in the preceding 12 months) is not 150/90 mmHg or less by GP practice – opportunities compared to GP cluster
5% 0% -5% -10% -15% -20% -25%
RAVENSBURY PARK MEDICAL CENTRE 22
WIMBLEDON VILLAGE PRACTICE 22
GP LED HEALTH CENTRE 6 • using the GP cluster method of THE MITCHAM MEDICAL CENTRE. 16 calculating potential gains, if each COLLIERS WOOD SURGERY 10 practice was to achieve as well as the CRICKET GREEN MEDICAL PRACTICE 14 upper quartile of its national cluster, then an additional 147 people would FIGGES MARSH SURGERY 7 be treated MITCHAM FAMILY PRACTICE 4
TAMWORTH HOUSE MEDICAL CENTRE. 14
THE VINEYARD HILL ROAD SURGERY 2
CENTRAL MEDICAL CENTRE 4
FRANCIS GROVE SURGERY 2
STONECOT SURGERY 3
PRINCES ROAD SURGERY 1
GRAND DRIVE SURGERY 1
ALEXANDRA SURGERY
THE NELSON MEDICAL PRACTICE
LAMBTON ROAD MEDICAL PRACTICE
MORDEN HALL MEDICAL CENTRE
RIVERHOUSE MEDICAL PRACTICE 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 Wandsworth CCG 93.0% • 4,470 people with coronary heart disease* in NHS Merton CCG NHS Kingston CCG 92.9% • 4,152 (92.9%) people who are taking aspirin, an alternative anti-platelet therapy, or an anti-coagulant NHS Merton CCG 92.9% • 151 (3.4%) people who are exceptions • 167 (3.7%) additional people who are NHS Richmond CCG 92.4% not taking aspirin, an alternative anti- platelet therapy, or an anti-coagulant
NHS Croydon CCG 92.2%
NHS Sutton CCG 91.4%
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 North & West Reading CCG 93.0%
NHS Wandsworth CCG 93.0%
NHS Kingston CCG 92.9%
NHS Merton CCG 92.9%
NHS Ealing CCG 92.8%
NHS Richmond CCG 92.4%
NHS Waltham Forest CCG 92.0%
NHS Hounslow CCG 91.8%
NHS Sutton CCG 91.4%
NHS Barnet CCG 90.8%
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
WIMBLEDON VILLAGE PRACTICE H85027 36
THE VINEYARD HILL ROAD SURGERY H85112 7 FRANCIS GROVE SURGERY H85026 22 • in total, including exceptions, there MITCHAM FAMILY PRACTICE H85078 7 are 318 people are not taking aspirin, LAMBTON ROAD MEDICAL PRACTICE H85051 28 an alternative anti-platelet therapy, or GP LED HEALTH CENTRE Y02968 7 an anti-coagulant CENTRAL MEDICAL CENTRE H85070 20 • GP practice range: 0.0% to 16.1% STONECOT SURGERY H85076 28
COLLIERS WOOD SURGERY H85649 14
RAVENSBURY PARK MEDICAL CENTRE H85110 9
ROWANS SURGERY H85035 17
WIDE WAY MEDICAL CENTRE H85029 11
JAMES O'RIORDAN MEDICAL CENTRE H85072 11
PRINCES ROAD SURGERY H85028 8
THE MERTON MEDICAL PRACTICE H85634 4
GRAND DRIVE SURGERY H85101 11
THE NELSON MEDICAL PRACTICE H85020 30
CRICKET GREEN MEDICAL PRACTICE H85038 12
MORDEN HALL MEDICAL CENTRE H85037 15
FIGGES MARSH SURGERY H85090 5
TAMWORTH HOUSE MEDICAL CENTRE. H85033 8
ALEXANDRA SURGERY H85656 4
THE MITCHAM MEDICAL CENTRE. H85024 4
RIVERHOUSE MEDICAL PRACTICE H85092
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 Merton CCG England 800
700 • in NHS Merton CCG, the hospital admission rate for coronary heart disease in 2015/16 was 477.9 (677) 600 compared to 527.9 for England
500
400
300
Age Age standardised (per rate 100,000) 200
100
0 2002/032003/042004/052005/062006/072007/082008/092009/102010/112011/122012/132013/142014/152015/16 Source: Hospital Episode Statistics (HES), 2002/03 - 2015/16, Copyright © 2017, Re‐used with the permission of NHS Digital. All rights reserved
83 CVD: Primary Care Intelligence Packs Hospital admissions for stroke for all ages 2002/03 – 2015/16
NHS Merton CCG England 250
• in NHS Merton CCG, the hospital admission rate for stroke in 2015/16 200 was 189.9 (267) 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 Merton CCG England
150.2% Angina 136.8% • The risk of a stroke was 83% higher and the risk of a heart attack was 125.4% 125.4% higher compared to people Heart Attack 108.6% without diabetes. The risk of a major amputation was 665.3% higher. 132.7% Heart failure 150.0%
83.0% Stroke 81.3%
665.3% Major amputation 445.8%
905.9% Minor amputation 753.5%
315.9% RRT 293.0%
0% 100% 200% 300% 400% 500% 600% 700% 800% 900% 1000% 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 Merton CCG England 90
80 • in NHS Merton CCG, the early mortality rate for coronary heart 70 disease in 2013-15 was 36.8, compared to 40.6 for England
60
50
40
30 Age Age standardised (per rate 1000,000) 20
10
0 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11 2010-12 2011-13 2012-14 2013-15
Source: Office for National Statistics (ONS) mortality data 2002 - 2015
86 CVD: Primary Care Intelligence Packs Deaths from stroke, under 75s
NHS Merton CCG England 30
• in NHS Merton CCG, the early 25 mortality rate for stroke in 2013-15 was 13.6, compared to 13.6 for England
20
15
10 Age Age standardised (per rate 100,000)
5
0 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11 2010-12 2011-13 2012-14 2013-15
Source: Office for National Statistics (ONS) mortality data 2002 - 2015
87 CVD: Primary Care Intelligence Packs Appendix Data sources
• Quality and Outcomes Framework (QOF), 2015/16, Copyright © 2016, re-used with the permission of NHS Digital. All rights reserved
• Non-diabetic hyperglycaemia prevalence estimates, NCVIN, PHE: https://www.gov.uk/government/publications/nhs-diabetes- prevention-programme-non-diabetic-hyperglycaemia
• Diabetes prevalence estimates, NCVIN, PHE: https://www.gov.uk/government/publications/diabetes-prevalence-estimates-for- local-populations
• CKD Prevalence model, G.Aitken, University of Southampton , 2014 https://www.gov.uk/government/publications/ckd- prevalence-estimates-for-local-and-regional-populations
• Hypertension prevalence estimates for local CCG populations. Created using data from: QOF hypertension registers 2014/15 and; Undiagnosed hypertension estimates for adults 16 years and older. 2014. Department of Primary Care & Public Health, Imperial College London https://www.gov.uk/government/publications/hypertension-prevalence-estimates-for-local-populations
• NHS Stop smoking services Copyright © 2014, NHS Digital
• Norberg J, Bäckström S , Jansson J-H, Johansson L. Estimating the prevalence of atrial fibrillation in a general population using validated electronic health data. Clin Epidemiol 2013 ; 5 475 – 81.
• National Diabetes Audit, 2013/14 and 2015/16, Copyright © 2016, re-used with the permission of NHS Digital. All rights reserved
• Hospital Episode Statistics (HES), 2002/03 - 2015/16, Copyright © 2017, Re‐used with the permission of NHS Digital. All rights reserved
• Office for National Statistics (ONS) mortality data 2002 – 2015, Copyright © 2017, Re-used with the permission of the Office for National Statistics. All rights reserved
88 CVD: Primary Care Intelligence Packs About Public Health England
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Published June 2017 Gateway number 2017095
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