Wyre Forest CCG: CVD Primary Care Intelligence Pack

CVD: Primary Care Intelligence Packs NHS Wyre Forest 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 Wyre Forest CCG are: NHS Newark & Sherwood CCG NHS Eastern Cheshire CCG NHS North Somerset CCG NHS South Eastern Hampshire CCG NHS Hardwick CCG NHS South Cheshire CCG NHS North Derbyshire CCG NHS Nottingham North and East CCG NHS Warwickshire North CCG NHS South Lincolnshire 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 Hardwick CCG 20.2%

NHS Warwickshire North CCG 18.7% • prevalence of 18.4% in NHS Wyre Forest CCG NHS Wyre Forest CCG 18.4%

NHS Nottingham North and East CCG 17.6%

NHS South Lincolnshire CCG 17.5%

NHS Newark & Sherwood CCG 17.4%

NHS South Cheshire CCG 16.9%

NHS South Eastern Hampshire CCG 16.8% Note: It has been found that the proportion of patients recorded as smokers correlates well NHS North Somerset CCG 16.4% with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, NHS North Derbyshire CCG 16.3% http://bmjopen.bmj.com/content/4/7/e005217.abs tract

NHS Eastern Cheshire CCG 13.8% Definition: denominator of QOF clinical indicator SMOKE004 ( number of patients 15+ who are 0% 5% 10% 15% 20% 25% recorded as current smokers) divided by GP practice’s estimated number of patients 15+

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

GP Practice CCG

KIDDERMINSTER MEDICAL CENTRE M81010 25.8%

• 17,752 people who are recorded as NORTHUMBERLAND HOUSE SURGERY M81005 23.7% smokers in NHS Wyre Forest CCG • GP practice range: 8.4% to 25.8% KIDDERMINSTER HEALTH CENTRE M81065 23.2%

THE CHURCH STREET PRACTICE M81056 22.8%

YORK HOUSE MEDICAL CTR. M81040 19.7%

AYLMER LODGE COOKLEY PARTNERSHIP M81068 16.9%

STOURPORT HEALTH CENTRE M81073 16.2%

STANMORE HOUSE SURGERY M81015 15.9%

BEWDLEY MEDICAL CENTRE M81057 14.4%

WOLVERLEY SURGERY M81608 13.9% Note: This method is thought to be a reasonably robust method in estimating smoking prevalence CHADDESLEY SURGERY M81090 9.5% for the majority of GP practices. However, caution is advised for extreme estimates of HAGLEY SURGERY M81027 8.4% smoking prevalence and those with high 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 Wyre Forest CCG 0.61

• the ratio of those diagnosed with hypertension versus those expected NHS South Worcestershire CCG 0.60 to have hypertension is 0.61. This compares to 0.59 for England • this suggests that 61% of people with hypertension have been diagnosed NHS Redditch And Bromsgrove CCG 0.60

NHS Herefordshire CCG 0.59

England 0.59 Note: this slide shows Hypertension prevalence 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 Hardwick CCG 0.63

NHS Warwickshire North CCG 0.62

NHS Wyre Forest CCG 0.61

NHS North Somerset CCG 0.61

NHS North Derbyshire CCG 0.61

NHS South Cheshire CCG 0.61

NHS South Lincolnshire CCG 0.61

NHS South Eastern Hampshire CCG 0.60

NHS Newark & Sherwood CCG 0.60

NHS Eastern Cheshire CCG 0.59

NHS Nottingham North and East CCG 0.58

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

18 CVD: Primary Care Intelligence Packs Hypertension observed prevalence compared with expected prevalence by GP practice

GP practice CCG

KIDDERMINSTER MEDICAL CENTRE M81010 0.70

THE CHURCH STREET PRACTICE M81056 0.65 • it is estimated that there are 12,452 people with undiagnosed STOURPORT HEALTH CENTRE M81073 0.64 hypertension in NHS Wyre Forest CCG BEWDLEY MEDICAL CENTRE M81057 0.63 • GP practice range of observed to expected hypertension prevalence YORK HOUSE MEDICAL CTR. M81040 0.62 0.51 to 0.7

AYLMER LODGE COOKLEY PARTNERSHIP M81068 0.60

STANMORE HOUSE SURGERY M81015 0.60

WOLVERLEY SURGERY M81608 0.59

KIDDERMINSTER HEALTH CENTRE M81065 0.58

CHADDESLEY SURGERY M81090 0.55

HAGLEY SURGERY M81027 0.52

NORTHUMBERLAND HOUSE SURGERY M81005 0.51

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

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

NHS South Worcestershire CCG 85.2%

• 20,014 people with hypertension (diagnosed)* in NHS Wyre Forest NHS Redditch And Bromsgrove CCG 81.9% CCG • 16,249 (81.2%) people whose blood pressure is <= 150/90 • 581 (2.9%) people who are excepted NHS Wyre Forest CCG 81.2% from optimal control • 3,184 (15.9%) additional people whose blood pressure is not <= 150/90

NHS Herefordshire CCG 80.7%

England 79.6%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% *Using QOF clinical indicator HYP006 denominator plus exceptions

20 CVD: Primary Care Intelligence Packs Percentage of patients with hypertension whose last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less by CCG Comparison with demographically similar CCGs

NHS South Lincolnshire CCG 83.8%

NHS Warwickshire North CCG 82.3%

NHS Wyre Forest CCG 81.2%

NHS Nottingham North and East CCG 81.1%

NHS Hardwick CCG 81.0%

NHS North Derbyshire CCG 80.8%

NHS South Eastern Hampshire CCG 80.6%

NHS South Cheshire CCG 80.3%

NHS Newark & Sherwood CCG 80.2%

NHS North Somerset CCG 79.8%

NHS Eastern Cheshire CCG 79.8%

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

NORTHUMBERLAND HOUSE SURGERY M81005 411

HAGLEY SURGERY M81027 241 • in total, including exceptions, there are 3,765 people whose blood

BEWDLEY MEDICAL CENTRE M81057 701 pressure is not <= 150/90 • GP practice range: 14.6% to 23.8%

KIDDERMINSTER HEALTH CENTRE M81065 216

STANMORE HOUSE SURGERY M81015 279

THE CHURCH STREET PRACTICE M81056 542

KIDDERMINSTER MEDICAL CENTRE M81010 227

CHADDESLEY SURGERY M81090 91

WOLVERLEY SURGERY M81608 91

STOURPORT HEALTH CENTRE M81073 265

YORK HOUSE MEDICAL CTR. M81040 357

AYLMER LODGE COOKLEY PARTNERSHIP M81068 344

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 Redditch And Bromsgrove CCG 64.8%

• 84 people with a new diagnosis* of hypertension with a CVD risk of 20% NHS Wyre Forest CCG 58.3% or higher in NHS Wyre Forest CCG • 49 (58.3%) people who are currently treated with statins • 34 (40.5%) people who are exempted NHS Herefordshire CCG 57.6% from treatment with statins • 1 (1.2%) additional people who are not currently treated with statins

NHS South Worcestershire CCG 55.1%

England 66.5%

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

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

NHS Warwickshire North CCG 80.8%

NHS South Eastern Hampshire CCG 77.7%

NHS Hardwick CCG 74.5%

NHS Newark & Sherwood CCG 70.9%

NHS Nottingham North and East CCG 67.2%

NHS Eastern Cheshire CCG 62.9%

NHS South Lincolnshire CCG 61.8%

NHS South Cheshire CCG 60.8%

NHS North Derbyshire CCG 58.8%

NHS Wyre Forest CCG 58.3%

NHS North Somerset CCG 53.9%

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

STANMORE HOUSE SURGERY M81015 3

STOURPORT HEALTH CENTRE M81073 4 • in total, including exceptions, there are 35 people who are not treated

KIDDERMINSTER HEALTH CENTRE M81065 5 with statins • GP practice range: 0.0% to 75.0%

KIDDERMINSTER MEDICAL CENTRE M81010 1

AYLMER LODGE COOKLEY PARTNERSHIP M81068 7

YORK HOUSE MEDICAL CTR. M81040 6

THE CHURCH STREET PRACTICE M81056 3

BEWDLEY MEDICAL CENTRE M81057 5

NORTHUMBERLAND HOUSE SURGERY M81005 1

HAGLEY SURGERY M81027

CHADDESLEY SURGERY M81090

WOLVERLEY SURGERY M81608

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 South Worcestershire CCG 0.71

• the ratio of those diagnosed with atrial fibrillation versus those expected to NHS Wyre Forest CCG 0.71 have atrial fibrillation is 0.71. This compares to 0.7 for England • this suggests that 71% of people with atrial fibrillation have been diagnosed. NHS Redditch And Bromsgrove CCG 0.69

NHS Herefordshire CCG 0.69

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 England 0.70 estimates were developed by applying age-sex 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 South Cheshire CCG 0.80

NHS North Somerset CCG 0.80

NHS North Derbyshire CCG 0.77

NHS Newark & Sherwood CCG 0.75

NHS Eastern Cheshire CCG 0.75

NHS South Eastern Hampshire CCG 0.74

NHS South Lincolnshire CCG 0.73

NHS Hardwick CCG 0.73

NHS Wyre Forest CCG 0.71

NHS Nottingham North and East CCG 0.65

NHS Warwickshire North CCG 0.65

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

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

GP practice CCG

NORTHUMBERLAND HOUSE SURGERY M81005 0.7

STANMORE HOUSE SURGERY M81015 0.7 • it is estimated that there are 3,632 people with undiagnosed atrial

HAGLEY SURGERY M81027 0.7 fibrillation in NHS Wyre Forest CCG • GP practice range of observed to

YORK HOUSE MEDICAL CTR. M81040 0.7 expected atrial fibrillation prevalence 0.4 to 0.7

THE CHURCH STREET PRACTICE M81056 0.7

BEWDLEY MEDICAL CENTRE M81057 0.7

AYLMER LODGE COOKLEY PARTNERSHIP M81068 0.7

STOURPORT HEALTH CENTRE M81073 0.7

CHADDESLEY SURGERY M81090 0.7

WOLVERLEY SURGERY M81608 0.5

KIDDERMINSTER MEDICAL CENTRE M81010 0.4

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

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

NHS Herefordshire CCG 80.8% • 2,152 people with atrial fibrillation* with a CHA2DS2-VASc score >= 2 in NHS Wyre Forest CCG NHS South Worcestershire CCG 78.9% • 1,667 (77.5%) people treated with anti-coagulation therapy • 311 (14.5%) people who are exceptions NHS Wyre Forest CCG 77.5% • 174 (8.1%) additional people with a recorded CHA2DS2-VASc score >= 2 who are not treated

NHS Redditch And Bromsgrove CCG 75.6%

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 South Lincolnshire CCG 83.4%

NHS Hardwick CCG 82.6%

NHS North Derbyshire CCG 82.0%

NHS Newark & Sherwood CCG 80.8%

NHS North Somerset CCG 77.8%

NHS Eastern Cheshire CCG 77.7%

NHS Warwickshire North CCG 77.5%

NHS Wyre Forest CCG 77.5%

NHS South Cheshire CCG 77.3%

NHS South Eastern Hampshire CCG 76.2%

NHS Nottingham North and East CCG 74.8%

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

STANMORE HOUSE SURGERY M81015 62

AYLMER LODGE COOKLEY PARTNERSHIP M81068 68 • in total, including exceptions, there are 485 people with a recorded

NORTHUMBERLAND HOUSE SURGERY M81005 44 CHA2DS2-VASc score >= 2 who are not treated

CHADDESLEY SURGERY M81090 16 • GP practice range: 13.2% to 35.4%

THE CHURCH STREET PRACTICE M81056 61

KIDDERMINSTER HEALTH CENTRE M81065 18

STOURPORT HEALTH CENTRE M81073 42

BEWDLEY MEDICAL CENTRE M81057 70

HAGLEY SURGERY M81027 27

KIDDERMINSTER MEDICAL CENTRE M81010 24

YORK HOUSE MEDICAL CTR. M81040 48

WOLVERLEY SURGERY M81608 5

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

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

STANMORE HOUSE SURGERY 32

CHADDESLEY SURGERY 6 • using the GP cluster method of calculating potential gains, if each AYLMER LODGE COOKLEY PARTNERSHIP 21 practice was to achieve as well as the

KIDDERMINSTER HEALTH CENTRE 6 upper quartile of its national cluster, then an additional 127 people would

NORTHUMBERLAND HOUSE SURGERY 12 be treated

THE CHURCH STREET PRACTICE 16

STOURPORT HEALTH CENTRE 10

HAGLEY SURGERY 6

KIDDERMINSTER MEDICAL CENTRE 5

BEWDLEY MEDICAL CENTRE 11

YORK HOUSE MEDICAL CTR. 2

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

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

Below 150/90 Not below 150/90 Exceptions reported

NHS South Worcestershire CCG 88.3% • 3,031 people with a history of stroke or TIA* in NHS Wyre Forest CCG • 2,593 (85.5%) people whose blood NHS Redditch And Bromsgrove CCG 86.4% pressure is <= 150 / 90 • 102 (3.4%) people who are exceptions • 336 (11.1%) additional people whose NHS Wyre Forest CCG 85.5% blood pressure is not <= 150 / 90

NHS Herefordshire CCG 84.1%

England 83.8%

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

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

NHS South Lincolnshire CCG 86.5%

NHS Wyre Forest CCG 85.5%

NHS Hardwick CCG 85.3%

NHS Warwickshire North CCG 85.1%

NHS Nottingham North and East CCG 85.0%

NHS North Somerset CCG 85.0%

NHS South Eastern Hampshire CCG 84.7%

NHS North Derbyshire CCG 84.1%

NHS South Cheshire CCG 84.0%

NHS Newark & Sherwood CCG 83.9%

NHS Eastern Cheshire CCG 82.5%

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

NORTHUMBERLAND HOUSE SURGERY M81005 58

THE CHURCH STREET PRACTICE M81056 64 • in total, including exceptions, there are 438 people whose blood pressure

HAGLEY SURGERY M81027 32 is not <= 150 / 90 • GP practice range: 6.3% to 19.5%

KIDDERMINSTER HEALTH CENTRE M81065 26

STANMORE HOUSE SURGERY M81015 38

BEWDLEY MEDICAL CENTRE M81057 71

WOLVERLEY SURGERY M81608 8

STOURPORT HEALTH CENTRE M81073 40

KIDDERMINSTER MEDICAL CENTRE M81010 26

YORK HOUSE MEDICAL CTR. M81040 38

AYLMER LODGE COOKLEY PARTNERSHIP M81068 33

CHADDESLEY SURGERY M81090 4

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 Wyre Forest CCG 93.3% • 2,628 people with a stroke shown to be non-haemorrhagic* in NHS Wyre Forest CCG NHS Redditch And Bromsgrove CCG 93.2% • 2,451 (93.3%) people who are taking an anti-platetet agent or anti- coagulant • 106 (4%) people who are exceptions NHS South Worcestershire CCG 92.1% • 71 (2.7%) additional people with no treatment

NHS Herefordshire CCG 91.3%

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 South Lincolnshire CCG 94.0%

NHS Wyre Forest CCG 93.3%

NHS Newark & Sherwood CCG 93.0%

NHS Nottingham North and East CCG 92.9%

NHS Hardwick CCG 92.8%

NHS North Derbyshire CCG 92.8%

NHS Warwickshire North CCG 92.4%

NHS South Eastern Hampshire CCG 91.5%

NHS North Somerset CCG 91.4%

NHS Eastern Cheshire CCG 89.3%

NHS South Cheshire CCG 88.9%

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

39 CVD: Primary Care Intelligence Packs Percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who do not have a record in the preceding 12 months that an anti-platelet agent, or an anti-coagulant is being taken by GP practice

No treatment Exceptions reported

AYLMER LODGE COOKLEY PARTNERSHIP M81068 27

HAGLEY SURGERY M81027 15 • in total, including exceptions, there are 177 people who are not taking an

STANMORE HOUSE SURGERY M81015 18 anti-platelet agent or anti-coagulant • GP practice range: 4.2% to 9.7%

STOURPORT HEALTH CENTRE M81073 18

YORK HOUSE MEDICAL CTR. M81040 22

THE CHURCH STREET PRACTICE M81056 21

WOLVERLEY SURGERY M81608 3

KIDDERMINSTER HEALTH CENTRE M81065 8

KIDDERMINSTER MEDICAL CENTRE M81010 9

NORTHUMBERLAND HOUSE SURGERY M81005 13

BEWDLEY MEDICAL CENTRE M81057 21

CHADDESLEY SURGERY M81090 2

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 Redditch And Bromsgrove CCG 0.83 • 0.80 ratio of observed to expected diabetes prevalence in NHS Wyre Forest CCG, compared to 0.77 in NHS Wyre Forest CCG 0.80 England • this suggests 80% of people have been diagnosed

NHS South Worcestershire CCG 0.79

NHS Herefordshire CCG 0.69

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 Hardwick CCG 0.94

NHS South Lincolnshire CCG 0.84

NHS Warwickshire North CCG 0.84

NHS Wyre Forest CCG 0.80

NHS South Eastern Hampshire CCG 0.80

NHS Newark & Sherwood CCG 0.80

NHS South Cheshire CCG 0.80

NHS North Derbyshire CCG 0.78

NHS Nottingham North and East CCG 0.78

NHS Eastern Cheshire CCG 0.72

NHS North Somerset CCG 0.71

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

STOURPORT HEALTH CENTRE M81073 8.6%

KIDDERMINSTER MEDICAL CENTRE M81010 8.4% • GP practice range of observed diabetes 5.1% to 8.6%

YORK HOUSE MEDICAL CTR. M81040 8.2% • there are an estimated 1,768 people with undiagnosed diabetes in NHS

AYLMER LODGE COOKLEY PARTNERSHIP M81068 8.2% Wyre Forest CCG

KIDDERMINSTER HEALTH CENTRE M81065 8.1%

BEWDLEY MEDICAL CENTRE M81057 7.9%

THE CHURCH STREET PRACTICE M81056 7.8%

NORTHUMBERLAND HOUSE SURGERY M81005 7.4%

WOLVERLEY SURGERY M81608 7.4%

STANMORE HOUSE SURGERY M81015 7.1%

CHADDESLEY SURGERY M81090 5.3% Note: The estimated number of undiagnosed HAGLEY SURGERY M81027 5.1% people with diabetes has been calculated by multiplying the estimated prevalence rate to the 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 2015/16 QOF list size and subtracting the number of people on the diabetes register.

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

Diabetes prevalence Undiagnosed diabetes prevalence Expected non-diabetic hyperglycaemia prevalence

• the estimated total prevalence of NHS Herefordshire CCG 6.6% 3.0% 12.4% diabetes in NHS Wyre Forest CCG is 9.5% (diagnosed and undiagnosed)

• in addition, there are an estimated NHS Wyre Forest CCG 7.7% 1.9% 12.2% 12.2% of people in NHS Wyre Forest CCG who are at increased risk of developing diabetes (i.e. with non- NHS South Worcestershire CCG 6.9% 1.9% 11.8% diabetic hyperglycaemia)

• this means that 21.7% of the population in NHS Wyre Forest CCG NHS Redditch And Bromsgrove CCG 6.9% 1.4% 11.3% are estimated to have diabetes, or at high risk of developing of diabetes

Note: Prevalence estimates of non-diabetic hyperglycaemia were developed using Health Survey for England (HSE) data. Five years of England 6.5% 1.9% 11.2% HSE data were combined, 2009- 2013. The estimates take into account the age, ethnic group and estimated body mass index of the population. 0% 5% 10% 15% 20% 25% 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 South Worcestershire CCG 61.3% • data on care processes and treatment targets are taken from the National Diabetes Audit (NDA) NHS Herefordshire CCG 61.0% • overall practice participation in the 2015/16 audit was 81.4% in England

• in NHS Wyre Forest CCG, 10 out of NHS Wyre Forest CCG 60.5% 12 practices (83.3%) participated in the NDA. Data is not available for the remaining practices

NHS Redditch And Bromsgrove CCG 60.2%

• 60.5% of people with diabetes (of practices who participated in the audit) had the eight recommended care processes in NHS Wyre Forest 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

BEWDLEY MEDICAL CENTRE M81057 79.3% • achievement - 8 care processes: in STOURPORT HEALTH CENTRE M81073 71.9% practices who provided data via the NDA, between 12.8% and 79.3% of THE CHURCH STREET PRACTICE M81056 66.3% patients received all 8 care processes

YORK HOUSE MEDICAL CTR. M81040 66.2% • at least 2,545 people did not receive the eight care processes AYLMER LODGE COOKLEY PARTNERSHIP M81068 64.2%

KIDDERMINSTER MEDICAL CENTRE M81010 62.5%

WOLVERLEY SURGERY M81608 39.5%

CHADDESLEY SURGERY M81090 31.8%

STANMORE HOUSE SURGERY M81015 21.8%

HAGLEY SURGERY M81027 12.8%

KIDDERMINSTER HEALTH CENTRE M81065

NORTHUMBERLAND HOUSE SURGERY M81005

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 South Worcestershire CCG 45.4% • 41.8% of people with diabetes (of practices who participated in the audit) met the three treatment targets NHS Redditch And Bromsgrove CCG 42.8% in NHS Wyre Forest CCG, compared to 39.0% in England

NHS Wyre Forest CCG 41.8%

NHS Herefordshire CCG 36.2%

England 39.0%

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

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

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

CHADDESLEY SURGERY M81090 47.7% • achievement - 3 treatment targets: in AYLMER LODGE COOKLEY PARTNERSHIP M81068 45.4% practices who provided data via the NDA, between 30.0% and 47.7% of WOLVERLEY SURGERY M81608 44.1% patients achieved all 3 treatment targets THE CHURCH STREET PRACTICE M81056 44.1% • at least 3,480 people did not meet the three treatment targets BEWDLEY MEDICAL CENTRE M81057 43.6%

YORK HOUSE MEDICAL CTR. M81040 42.1%

STOURPORT HEALTH CENTRE M81073 40.8%

KIDDERMINSTER MEDICAL CENTRE M81010 40.2%

HAGLEY SURGERY M81027 37.2%

STANMORE HOUSE SURGERY M81015 30.0%

KIDDERMINSTER HEALTH CENTRE M81065

NORTHUMBERLAND HOUSE SURGERY M81005

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% -14% -16%

STANMORE HOUSE SURGERY 63

HAGLEY SURGERY 23 • using the GP cluster method of calculating potential gains, if each practice was to achieve as well as the KIDDERMINSTER MEDICAL CENTRE 60 upper quartile of its national cluster, then an additional 195 people would be treated STOURPORT HEALTH CENTRE 20

YORK HOUSE MEDICAL CTR. 17

WOLVERLEY SURGERY 2

BEWDLEY MEDICAL CENTRE 6

THE CHURCH STREET PRACTICE 4

AYLMER LODGE COOKLEY PARTNERSHIP

CHADDESLEY 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 Wyre Forest CCG 0.79

• the ratio of those diagnosed with chronic kidney disease versus those NHS South Worcestershire CCG 0.78 expected to have chronic kidney disease is 0.79. This compares to 0.68 for England • this suggests that 79% of people with NHS Redditch And Bromsgrove CCG 0.74 chronic kidney disease have been diagnosed

NHS Herefordshire CCG 0.66

Note: This slide compares the prevalence of CKD recorded in QOF in 2015/16 to the expected prevalence of CKD produced by the University of Southampton in 2011. A small number of CCGs England 0.68 have a ratio greater than 1. It is unlikely that all people with CKD will be diagnosed in any CCG and therefore a ratio greater than 1 suggests that 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 the figures are underestimating the true CKD Ratio prevalence in the area. These ratios should be taken as an indication of the comparative scale of undiagnosed CKD rather than absolute figures.

54 CVD: Primary Care Intelligence Packs Chronic kidney disease (CKD) observed prevalence (2015/16) compared with expected prevalence (2011) by CCG Comparison with demographically similar CCGs

NHS Warwickshire North CCG 1.05

NHS Nottingham North and East CCG 1.00

NHS South Lincolnshire CCG 0.93

NHS Hardwick CCG 0.84

NHS North Derbyshire CCG 0.84

NHS Newark & Sherwood CCG 0.82

NHS Wyre Forest CCG 0.79

NHS South Cheshire CCG 0.75

NHS North Somerset CCG 0.73

NHS South Eastern Hampshire CCG 0.64

NHS Eastern Cheshire CCG 0.62

0.0 0.2 0.4 0.6 0.8 1.0 1.2 Ratio

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

GP practice CCG

WOLVERLEY SURGERY M81608 7.8%

KIDDERMINSTER MEDICAL CENTRE M81010 7.6% • it is estimated that there are 1,421 people with undiagnosed chronic

STOURPORT HEALTH CENTRE M81073 7.3% kidney disease in NHS Wyre Forest CCG

BEWDLEY MEDICAL CENTRE M81057 7.1% • GP practice range of observed CKD: 4.0% to 7.8%

YORK HOUSE MEDICAL CTR. M81040 6.0%

HAGLEY SURGERY M81027 5.6%

STANMORE HOUSE SURGERY M81015 5.3%

KIDDERMINSTER HEALTH CENTRE M81065 5.2%

NORTHUMBERLAND HOUSE SURGERY M81005 4.5%

CHADDESLEY SURGERY M81090 4.5%

THE CHURCH STREET PRACTICE M81056 4.3% Note: CCG estimates for the estimated number of people with CKD are based on applying a proportion from a resident based AYLMER LODGE COOKLEY PARTNERSHIP M81068 4.0% population estimate to a GP registered population. The characteristics of registered 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% and resident populations may vary in some CCGs, and local interpretation is required.

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

NHS South Worcestershire CCG 76.5% • 5,286 people with CKD (diagnosed*) in NHS Wyre Forest CCG • 3,856 (72.9%) people whose blood NHS Redditch And Bromsgrove CCG 75.2% pressure is <= 140 /85 • 505 (9.6%) people who are exceptions • 925 (17.5%) additional people whose NHS Wyre Forest CCG 72.9% blood pressure is not <= 140 / 85

NHS Herefordshire CCG 72.5%

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

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

NHS South Lincolnshire CCG 77.4%

NHS North Somerset CCG 75.5%

NHS Warwickshire North CCG 75.5%

NHS South Eastern Hampshire CCG 75.2%

NHS South Cheshire CCG 75.0%

NHS Nottingham North and East CCG 74.0%

NHS Eastern Cheshire CCG 73.0%

NHS Wyre Forest CCG 72.9%

NHS Hardwick CCG 72.9%

NHS North Derbyshire CCG 72.9%

NHS Newark & Sherwood CCG 71.5%

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

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

Not below 140/85 Exceptions reported

THE SURGERY M81090 51

DR A J DE COTHI & PARTNERS M81005 170 • in total, including exceptions, there are 1,430 people whose blood

BEWDLEY MEDICAL CENTRE M81057 334 pressure is not <= 140 / 85 • GP practice range: 17.2% to 38.9%

YORK HOUSE MEDICAL CENTRE M81040 176

HAGLEY SURGERY M81027 89

ALYMER LODGE COOKLEY PARTNERSHIP M81068 111

STANMORE HOUSE SURGERY M81015 89

CHURCH STREET PRACTICE M81056 131

KIDDERMINSTER HEALTH CENTRE PRACTICE M81065 64

WOLVERLEY SURGERY M81608 38

DR M J GIBSON AND PARTNERS M81073 100

FOREST GLADES MEDICAL CTR M81010 77

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

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

THE SURGERY 27

DR A J DE COTHI & PARTNERS 73 • using the GP cluster method of calculating potential gains, if each BEWDLEY MEDICAL CENTRE 129 practice was to achieve as well as the

HAGLEY SURGERY 28 upper quartile of its national cluster, then an additional 364 people would

YORK HOUSE MEDICAL CENTRE 47 be treated

KIDDERMINSTER HEALTH CENTRE PRACTICE 13

ALYMER LODGE COOKLEY PARTNERSHIP 16

WOLVERLEY SURGERY 6

CHURCH STREET PRACTICE 15

STANMORE HOUSE SURGERY 8

FOREST GLADES MEDICAL CTR 1

DR M J GIBSON AND PARTNERS 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 Wyre Forest CCG 79.6% • 5,286 people with CKD (diagnosed*) in NHS Wyre Forest CCG • 4,206 (79.6%) people who have a NHS Herefordshire CCG 79.2% record of urine albumin:creatinine ratio test • 212 (4%) people who are exceptions • 868 (16.4%) additional people who NHS South Worcestershire CCG 76.7% have no record of urine albumin:creatinine ratio test

NHS Redditch And Bromsgrove CCG 76.5%

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

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

NHS Wyre Forest CCG 79.6%

NHS South Lincolnshire CCG 77.9%

NHS North Derbyshire CCG 77.8%

NHS Eastern Cheshire CCG 77.6%

NHS Warwickshire North CCG 76.8%

NHS Newark & Sherwood CCG 76.8%

NHS South Cheshire CCG 75.3%

NHS Nottingham North and East CCG 75.3%

NHS North Somerset CCG 74.8%

NHS Hardwick CCG 72.5%

NHS South Eastern Hampshire CCG 70.8%

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

HAGLEY SURGERY M81027 99

BEWDLEY MEDICAL CENTRE M81057 259 • in total, including exceptions, there are 1,080 people who have no record

YORK HOUSE MEDICAL CENTRE M81040 134 of urine albumin:creatinine ratio test • GP practice range: 12.8% to 30.3%

DR A J DE COTHI & PARTNERS M81005 103

STANMORE HOUSE SURGERY M81015 80

THE SURGERY M81090 23

KIDDERMINSTER HEALTH CENTRE PRACTICE M81065 51

ALYMER LODGE COOKLEY PARTNERSHIP M81068 72

CHURCH STREET PRACTICE M81056 93

DR M J GIBSON AND PARTNERS M81073 78

FOREST GLADES MEDICAL CTR M81010 65

WOLVERLEY SURGERY M81608 23

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 Wyre Forest CCG 1.10%

• prevalence of 1.1% in NHS Wyre Forest CCG compared to 0.76% in NHS Herefordshire CCG 1.01% England

NHS South Worcestershire CCG 0.93%

NHS Redditch And Bromsgrove CCG 0.92%

England 0.76%

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

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

NHS North Derbyshire CCG 1.11%

NHS Wyre Forest CCG 1.10%

NHS Hardwick CCG 1.04%

NHS South Lincolnshire CCG 1.01%

NHS South Cheshire CCG 0.98%

NHS Newark & Sherwood CCG 0.94%

NHS North Somerset CCG 0.88%

NHS South Eastern Hampshire CCG 0.83%

NHS Warwickshire North CCG 0.82%

NHS Eastern Cheshire CCG 0.79%

NHS Nottingham North and East CCG 0.63%

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

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

GP practice CCG

BEWDLEY MEDICAL CENTRE M81057 1.7%

KIDDERMINSTER MEDICAL CENTRE M81010 1.6% • 1,255 people with diagnosed heart failure in NHS Wyre Forest CCG

YORK HOUSE MEDICAL CTR. M81040 1.4% • GP practice range: 0.5% to 1.7%

WOLVERLEY SURGERY M81608 1.2%

STOURPORT HEALTH CENTRE M81073 1.1%

STANMORE HOUSE SURGERY M81015 1.1%

AYLMER LODGE COOKLEY PARTNERSHIP M81068 1.0%

KIDDERMINSTER HEALTH CENTRE M81065 1.0%

NORTHUMBERLAND HOUSE SURGERY M81005 0.7%

THE CHURCH STREET PRACTICE M81056 0.7%

CHADDESLEY SURGERY M81090 0.7%

HAGLEY SURGERY M81027 0.5%

0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6% 1.8%

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

NHS Redditch And Bromsgrove CCG 88.9% • 297 people with heart failure* with LVSD in NHS Wyre Forest CCG • 246 (82.8%) people treated with ACE- NHS South Worcestershire CCG 84.5% I or ARB • 46 (15.5%) people who are exceptions • 5 (1.7%) additional people who are NHS Wyre Forest CCG 82.8% not treated with ACE-I or ARB

NHS Herefordshire CCG 81.1%

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 Nottingham North and East CCG 89.5%

NHS Warwickshire North CCG 87.6%

NHS South Cheshire CCG 87.5%

NHS South Eastern Hampshire CCG 86.8%

NHS Newark & Sherwood CCG 84.6%

NHS Hardwick CCG 84.4%

NHS North Somerset CCG 84.2%

NHS Wyre Forest CCG 82.8%

NHS North Derbyshire CCG 82.3%

NHS Eastern Cheshire CCG 80.3%

NHS South Lincolnshire CCG 79.9%

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

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

No treatment Exceptions reported

CHADDESLEY SURGERY M81090 2

YORK HOUSE MEDICAL CTR. M81040 7 • in total, including exceptions, there are 51 people who are not treated

STOURPORT HEALTH CENTRE M81073 17 with ACE-I or ARB • GP practice range: 0.0% to 40.0%

THE CHURCH STREET PRACTICE M81056 12

STANMORE HOUSE SURGERY M81015 2

BEWDLEY MEDICAL CENTRE M81057 3

AYLMER LODGE COOKLEY PARTNERSHIP M81068 2

NORTHUMBERLAND HOUSE SURGERY M81005 1

KIDDERMINSTER HEALTH CENTRE M81065 1

KIDDERMINSTER MEDICAL CENTRE M81010 4

HAGLEY SURGERY M81027

WOLVERLEY SURGERY M81608

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 Redditch And Bromsgrove CCG 78.1% • 246 people with heart failure* with LVSD treated with ACE-I/ARB in NHS Wyre Forest CCG NHS South Worcestershire CCG 74.4% • 181 (73.6%) people treated with ACE- I/ARB and BB • 47 (19.1%) people who are exceptions NHS Wyre Forest CCG 73.6% • 18 (7.3%) additional people who are not treated with ACE-I/ARB and BB

NHS Herefordshire CCG 69.3%

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 Warwickshire North CCG 83.0%

NHS South Eastern Hampshire CCG 82.0%

NHS Hardwick CCG 80.8%

NHS North Somerset CCG 79.9%

NHS Newark & Sherwood CCG 78.9%

NHS North Derbyshire CCG 76.9%

NHS Nottingham North and East CCG 75.0%

NHS Wyre Forest CCG 73.6%

NHS Eastern Cheshire CCG 73.0%

NHS South Lincolnshire CCG 72.4%

NHS South Cheshire CCG 72.0%

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

CHADDESLEY SURGERY M81090 2

STANMORE HOUSE SURGERY M81015 4 • in total, including exceptions, there are 65 people who are not treated

WOLVERLEY SURGERY M81608 2 with ACE-I or ARB • GP practice range: 11.1% to 66.7%

HAGLEY SURGERY M81027 1

KIDDERMINSTER HEALTH CENTRE M81065 3

STOURPORT HEALTH CENTRE M81073 20

BEWDLEY MEDICAL CENTRE M81057 4

AYLMER LODGE COOKLEY PARTNERSHIP M81068 3

KIDDERMINSTER MEDICAL CENTRE M81010 9

THE CHURCH STREET PRACTICE M81056 11

YORK HOUSE MEDICAL CTR. M81040 5

NORTHUMBERLAND HOUSE SURGERY M81005 1

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 South Worcestershire CCG 91.5% • 4,339 people with coronary heart disease* in NHS Wyre Forest CCG • 3,880 (89.4%) people whose blood NHS Redditch And Bromsgrove CCG 91.0% pressure <= 150 / 90 • 137 (3.2%) people who are exceptions • 322 (7.4%) additional people whose NHS Wyre Forest CCG 89.4% blood pressure is not <= 150 / 90

NHS Herefordshire CCG 89.4%

England 88.2%

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

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

NHS South Lincolnshire CCG 91.0%

NHS Warwickshire North CCG 90.1%

NHS North Somerset CCG 89.6%

NHS South Eastern Hampshire CCG 89.5%

NHS Wyre Forest CCG 89.4%

NHS Hardwick CCG 89.2%

NHS North Derbyshire CCG 88.9%

NHS Eastern Cheshire CCG 88.5%

NHS South Cheshire CCG 88.5%

NHS Nottingham North and East CCG 88.3%

NHS Newark & Sherwood CCG 87.8%

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

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

Not below 150/90 Exceptions reported

HAGLEY SURGERY M81027 33

BEWDLEY MEDICAL CENTRE M81057 106 • in total, including exceptions, there are 459 people whose blood pressure

STANMORE HOUSE SURGERY M81015 37 is not <= 150 / 90 • GP practice range: 5.7% to 14.5%

THE CHURCH STREET PRACTICE M81056 73

AYLMER LODGE COOKLEY PARTNERSHIP M81068 57

NORTHUMBERLAND HOUSE SURGERY M81005 46

WOLVERLEY SURGERY M81608 11

CHADDESLEY SURGERY M81090 8

STOURPORT HEALTH CENTRE M81073 31

YORK HOUSE MEDICAL CTR. M81040 30

KIDDERMINSTER MEDICAL CENTRE M81010 15

KIDDERMINSTER HEALTH CENTRE M81065 12

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%

HAGLEY SURGERY 17

BEWDLEY MEDICAL CENTRE 43 • using the GP cluster method of calculating potential gains, if each THE CHURCH STREET PRACTICE 25 practice was to achieve as well as the

STANMORE HOUSE SURGERY 12 upper quartile of its national cluster, then an additional 123 people would

WOLVERLEY SURGERY 3 be treated

AYLMER LODGE COOKLEY PARTNERSHIP 13

NORTHUMBERLAND HOUSE SURGERY 10

CHADDESLEY SURGERY 1

STOURPORT HEALTH CENTRE

KIDDERMINSTER MEDICAL CENTRE

KIDDERMINSTER HEALTH CENTRE

YORK HOUSE MEDICAL CTR. Details of this methodology are available on slide 9. Click here to view them.

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

NHS Wyre Forest CCG 94.3% • 4,339 people with coronary heart disease* in NHS Wyre Forest CCG • 4,091 (94.3%) people who are taking NHS Redditch And Bromsgrove CCG 93.4% aspirin, an alternative anti-platelet therapy, or an anti-coagulant • 132 (3%) people who are exceptions • 116 (2.7%) additional people who are NHS South Worcestershire CCG 92.9% not taking aspirin, an alternative anti- platelet therapy, or an anti-coagulant

NHS Herefordshire 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 Wyre Forest CCG 94.3%

NHS Warwickshire North CCG 93.7%

NHS South Lincolnshire CCG 92.6%

NHS North Somerset CCG 92.3%

NHS Newark & Sherwood CCG 92.1%

NHS North Derbyshire CCG 92.1%

NHS Nottingham North and East CCG 91.8%

NHS Hardwick CCG 91.8%

NHS South Cheshire CCG 91.6%

NHS South Eastern Hampshire CCG 91.5%

NHS Eastern Cheshire CCG 91.2%

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

HAGLEY SURGERY M81027 20

THE CHURCH STREET PRACTICE M81056 44 • in total, including exceptions, there are 248 people are not taking aspirin,

STANMORE HOUSE SURGERY M81015 21 an alternative anti-platelet therapy, or an anti-coagulant

AYLMER LODGE COOKLEY PARTNERSHIP M81068 35 • GP practice range: 3.0% to 8.8%

KIDDERMINSTER MEDICAL CENTRE M81010 14

YORK HOUSE MEDICAL CTR. M81040 27

KIDDERMINSTER HEALTH CENTRE M81065 11

STOURPORT HEALTH CENTRE M81073 18

NORTHUMBERLAND HOUSE SURGERY M81005 19

WOLVERLEY SURGERY M81608 5

BEWDLEY MEDICAL CENTRE M81057 31

CHADDESLEY SURGERY M81090 3

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 Wyre Forest CCG England 800

700 • in NHS Wyre Forest CCG, the hospital admission rate for coronary heart disease in 2015/16 was 364.6 600 (410) 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 Wyre Forest CCG England 200

180 • in NHS Wyre Forest CCG, the hospital admission rate for stroke in 160 2015/16 was 182.8 (208) compared to 172.8 for England 140

120

100

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

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

NHS Wyre Forest CCG England

104.8% Angina 136.8% • The risk of a stroke was 55.5% higher and the risk of a heart attack was 66.7% 66.7% higher compared to people Heart Attack 108.6% without diabetes. The risk of a major amputation was 585% higher. 94.2% Heart failure 150.0%

55.5% Stroke 81.3%

585.0% Major amputation 445.8%

673.4% Minor amputation 753.5%

263.0% RRT 293.0%

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

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

NHS Wyre Forest CCG England 90

80 • in NHS Wyre Forest CCG, the early mortality rate for coronary heart 70 disease in 2013-15 was 35.7, compared to 40.6 for England

30 Age Age standardised (per rate 1000,000) 20

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

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

86 CVD: Primary Care Intelligence Packs Deaths from stroke, under 75s

NHS Wyre Forest CCG England 30

• in NHS Wyre Forest CCG, the early 25 mortality rate for stroke in 2013-15 was 15.5, compared to 13.6 for England

10 Age Age standardised (per rate 100,000)

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

• 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

• 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.

88 CVD: Primary Care Intelligence Packs About Public Health England

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Published June 2017 Gateway number 2017095