CVD: Primary Care Intelligence Packs NHS Oxfordshire 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 Oxfordshire CCG are: NHS Cambridgeshire and Peterborough CCG NHS Nene CCG NHS Gloucestershire CCG NHS Southern Derbyshire CCG NHS Northern, Eastern and Western Devon CCG NHS Somerset CCG NHS Herts Valleys CCG NHS East and North Hertfordshire CCG NHS Kernow CCG NHS Bedfordshire 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 Nene CCG 19.3%

NHS Kernow CCG 18.0% • prevalence of 14.7% in NHS Oxfordshire CCG NHS Somerset CCG 17.7%

NHS Southern Derbyshire CCG 17.6%

NHS Cambridgeshire and Peterborough CCG 17.5%

NHS Northern, Eastern and Western Devon CCG 17.0%

NHS Bedfordshire CCG 16.8%

NHS Gloucestershire CCG 15.9% Note: It has been found that the proportion of patients recorded as smokers correlates well NHS East and North Hertfordshire CCG 15.8% with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, NHS Herts Valleys CCG 14.8% http://bmjopen.bmj.com/content/4/7/e005217.abs tract

NHS Oxfordshire CCG 14.7% 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

LUTHER STREET MEDICAL PRACTICE K84066 94.7% THE LEYS HEALTH CENTRE K84031 29.8% BANBURY HEALTH CENTRE Y02754 29.7% WOOD FARM HEALTH CENTRE K84620 24.1% WOODLANDS SURGERY K84062 20.8% WEST BAR SURGERY K84028 20.1% TEMPLE COWLEY HEALTH CENTRE K84007 20.0% WINDRUSH SURGERY K84024 19.3% HOLLOW WAY MEDICAL CENTRE K84048 19.2% • 88,042 people who are recorded as HORSEFAIR SURGERY K84040 19.2% BARTLEMAS SURGERY K84032 18.9% BICESTER HEALTH CENTRE K84052 18.9% smokers in NHS Oxfordshire CCG DONNINGTON MEDICAL PARTNERSHIP K84004 18.8% BROADSHIRES HEALTH CENTRE K84075 18.6% DIDCOT HEALTH CENTRE PRACTICE K84002 18.2% • GP practice range: 6.1% to 94.7% ST. BARTHOLEMEW'S MEDICAL CENTRE K84013 18.0% BERINSFIELD HEALTH CENTRE K84023 17.8% MONTGOMERY HOUSE SURGERY K84038 17.6% COWLEY ROAD MEDICAL PRACTICE K84063 17.5% VICTORIA HOUSE SURGERY K84073 17.1% MALTHOUSE SURGERY K84027 16.7% SOUTH OXFORD HEALTH CENTRE K84617 16.1% BURY KNOWLE HEALTH CENTRE K84009 16.1% HIGHTOWN SURGERY K84059 15.7% WOODLANDS MEDICAL CENTRE K84043 15.5% DEER PARK MEDICAL CENTRE K84622 15.5% NUFFIELD HEALTH CENTRE K84072 15.4% THE KEY MEDICAL PRACTICE K84082 15.3% GOSFORD HILL MEDICAL CENTRE K84045 15.2% WINDRUSH MEDICAL PRACTICE K84017 15.2% CHURCH STREET PRACTICE K84033 14.9% OAK TREE HEALTH CENTRE K84624 14.6% NEWBURY STREET PRACTICE K84019 14.4% ST. CLEMENT'S SURGERY K84060 14.3% THE ABINGDON SURGERY K84054 14.3% CHIPPING NORTON HEALTH CENTRE K84030 14.2% LANGFORD MEDICAL PRACTICE K84613 14.1% MARSTON MEDICAL CENTRE K84076 14.1% CHALGROVE & WATLINGTON SURGERIES K84008 14.1% WALLINGFORD MEDICAL PRACTICE K84037 14.0% BAMPTON SURGERY K84010 13.9% BURFORD SURGERY K84047 13.9% NORTH BICESTER SURGERY K84621 13.6% THE RYCOTE PRACTICE K84050 13.6% WHITE HORSE MEDICAL PRACTICE K84051 13.5% MORLAND HOUSE SURGERY K84014 13.4% MARCHAM RD FAMILY HEALTH CENTRE K84041 13.0% MANOR SURGERY K84044 12.6% COGGES SURGERY K84618 12.5% DEDDINGTON HEALTH CENTRE K84055 12.1% KENNINGTON HEALTH CENTRE K84005 12.1% SIBFORD SURGERY K84065 12.1% THE CHARLBURY MEDICAL CENTRE K84610 12.0% EYNSHAM MEDICAL GROUP K84006 12.0% BOTLEY MEDICAL CENTRE K84025 11.8% MILL STREAM SURGERY K84036 11.4% THE BELL SURGERY K84035 11.4% WOODSTOCK SURGERY K84042 11.4% THE HART SURGERY K84001 11.4% ISLIP SURGERY K84003 11.3% WYCHWOOD SURGERY K84046 11.3% SONNING COMMON HEALTH CTR K84020 11.1% JERICHO HEALTH CENTRE (KEARLEY/CHIVERS) K84026 11.1% BLOXHAM SURGERY K84058 11.0% Note: This method is thought to be a reasonably 28 BEAUMONT STREET K84080 10.7% GORING & WOODCOTE MEDICAL PRACTICE K84071 10.1% robust method in estimating smoking prevalence SUMMERTOWN HEALTH CENTRE K84011 10.1% CROPREDY SURGERY K84056 9.9% LONG FURLONG MEDICAL CENTRE K84079 9.5% for the majority of GP practices. However, 27 BEAUMONT STREET K84049 9.2% CLIFTON HAMPDEN SURGERY K84034 9.0% caution is advised for extreme estimates of NETTLEBED SURGERY K84015 8.6% 19 BEAUMONT STREET SURGERY K84016 8.5% BANBURY ROAD MEDICAL CENTRE K84021 7.5% smoking prevalence and those with high JERICHO HEALTH CENTRE K84078 6.4% 9 KING EDWARD STREET K84605 6.1% numbers of smoking status not recorded and 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 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 North & West Reading CCG 0.59

NHS Aylesbury Vale CCG 0.59 • the ratio of those diagnosed with hypertension versus those expected to have hypertension is 0.57. This NHS Wokingham CCG 0.58 compares to 0.59 for England • this suggests that 57% of people with hypertension have been diagnosed NHS Chiltern CCG 0.58

NHS Oxfordshire CCG 0.57

NHS Newbury And District CCG 0.57

NHS South Reading CCG 0.54

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 Somerset CCG 0.60

NHS Nene CCG 0.60

NHS Northern, Eastern and Western Devon CCG 0.59

NHS Bedfordshire CCG 0.59

NHS Southern Derbyshire CCG 0.59

NHS Kernow CCG 0.58

NHS East and North Hertfordshire CCG 0.58

NHS Gloucestershire CCG 0.58

NHS Herts Valleys CCG 0.57

NHS Oxfordshire CCG 0.57

NHS Cambridgeshire and Peterborough CCG 0.56

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

NUFFIELD HEALTH CENTRE K84072 0.79 CROPREDY SURGERY K84056 0.67 EYNSHAM MEDICAL GROUP K84006 0.64 GOSFORD HILL MEDICAL CENTRE K84045 0.64 MALTHOUSE SURGERY K84027 0.63 KENNINGTON HEALTH CENTRE K84005 0.63 MARCHAM RD FAMILY HEALTH CENTRE K84041 0.61 BERINSFIELD HEALTH CENTRE K84023 0.61 WOOD FARM HEALTH CENTRE K84620 0.60 DEER PARK MEDICAL CENTRE K84622 0.60 • it is estimated that there are 65,430 COGGES SURGERY K84618 0.60 WYCHWOOD SURGERY K84046 0.60 CHURCH STREET PRACTICE K84033 0.59 MONTGOMERY HOUSE SURGERY K84038 0.59 people with undiagnosed THE KEY MEDICAL PRACTICE K84082 0.58 NETTLEBED SURGERY K84015 0.58 MORLAND HOUSE SURGERY K84014 0.58 hypertension in NHS Oxfordshire DIDCOT HEALTH CENTRE PRACTICE K84002 0.58 BAMPTON SURGERY K84010 0.57 CHIPPING NORTON HEALTH CENTRE K84030 0.57 CCG LANGFORD MEDICAL PRACTICE K84613 0.56 WHITE HORSE MEDICAL PRACTICE K84051 0.56 WOODLANDS SURGERY K84062 0.56 WOODLANDS MEDICAL CENTRE K84043 0.56 • GP practice range of observed to THE BELL SURGERY K84035 0.56 WINDRUSH MEDICAL PRACTICE K84017 0.56 THE LEYS HEALTH CENTRE K84031 0.56 expected hypertension prevalence ISLIP SURGERY K84003 0.56 DEDDINGTON HEALTH CENTRE K84055 0.55 BROADSHIRES HEALTH CENTRE K84075 0.55 0.24 to 0.79 CHALGROVE & WATLINGTON SURGERIES K84008 0.55 WALLINGFORD MEDICAL PRACTICE K84037 0.55 BICESTER HEALTH CENTRE K84052 0.55 BURFORD SURGERY K84047 0.55 GORING & WOODCOTE MEDICAL PRACTICE K84071 0.55 TEMPLE COWLEY HEALTH CENTRE K84007 0.55 ST. CLEMENT'S SURGERY K84060 0.54 THE ABINGDON SURGERY K84054 0.54 OAK TREE HEALTH CENTRE K84624 0.54 SONNING COMMON HEALTH CTR K84020 0.54 MILL STREAM SURGERY K84036 0.53 THE CHARLBURY MEDICAL CENTRE K84610 0.53 CLIFTON HAMPDEN SURGERY K84034 0.53 VICTORIA HOUSE SURGERY K84073 0.53 WOODSTOCK SURGERY K84042 0.52 MANOR SURGERY K84044 0.52 HOLLOW WAY MEDICAL CENTRE K84048 0.52 HORSEFAIR SURGERY K84040 0.52 THE RYCOTE PRACTICE K84050 0.52 LONG FURLONG MEDICAL CENTRE K84079 0.51 WEST BAR SURGERY K84028 0.51 NEWBURY STREET PRACTICE K84019 0.51 HIGHTOWN SURGERY K84059 0.51 DONNINGTON MEDICAL PARTNERSHIP K84004 0.51 SUMMERTOWN HEALTH CENTRE K84011 0.51 WINDRUSH SURGERY K84024 0.50 BARTLEMAS SURGERY K84032 0.49 BURY KNOWLE HEALTH CENTRE K84009 0.49 BLOXHAM SURGERY K84058 0.48 SIBFORD SURGERY K84065 0.48 NORTH BICESTER SURGERY K84621 0.47 SOUTH OXFORD HEALTH CENTRE K84617 0.47 THE HART SURGERY K84001 0.46 BOTLEY MEDICAL CENTRE K84025 0.46 BANBURY ROAD MEDICAL CENTRE K84021 0.43 28 BEAUMONT STREET K84080 0.41 JERICHO HEALTH CENTRE (KEARLEY/CHIVERS) K84026 0.40 MARSTON MEDICAL CENTRE K84076 0.39 BANBURY HEALTH CENTRE Y02754 0.39 19 BEAUMONT STREET SURGERY K84016 0.37 ST. BARTHOLEMEW'S MEDICAL CENTRE K84013 0.36 COWLEY ROAD MEDICAL PRACTICE K84063 0.36 JERICHO HEALTH CENTRE K84078 0.32 27 BEAUMONT STREET K84049 0.29 9 KING EDWARD STREET K84605 0.24 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 Newbury And District CCG 81.8%

NHS Wokingham CCG 80.3% • 87,506 people with hypertension (diagnosed)* in NHS Oxfordshire CCG NHS Chiltern CCG 80.0% • 69,856 (79.8%) people whose blood pressure is <= 150/90 • 3,996 (4.6%) people who are NHS North & West Reading CCG 79.8% excepted from optimal control • 13,654 (15.6%) additional people NHS Oxfordshire CCG 79.8% whose blood pressure is not <= 150/90

NHS South Reading CCG 78.8%

NHS Aylesbury Vale CCG 78.5%

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 Nene CCG 80.9%

NHS Southern Derbyshire CCG 80.6%

NHS Herts Valleys CCG 80.1%

NHS Gloucestershire CCG 80.1%

NHS Bedfordshire CCG 79.9%

NHS Oxfordshire CCG 79.8%

NHS Kernow CCG 79.7%

NHS East and North Hertfordshire CCG 79.6%

NHS Northern, Eastern and Western Devon CCG 79.4%

NHS Cambridgeshire and Peterborough CCG 78.2%

NHS Somerset CCG 74.8%

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

LUTHER STREET MEDICAL PRACTICE K84066 5 COWLEY ROAD MEDICAL PRACTICE K84063 151 WEST BAR SURGERY K84028 653 ST. BARTHOLEMEW'S MEDICAL CENTRE K84013 234 WOODLANDS SURGERY K84062 214 DONNINGTON MEDICAL PARTNERSHIP K84004 535 NEWBURY STREET PRACTICE K84019 591 CROPREDY SURGERY K84056 182 OAK TREE HEALTH CENTRE K84624 222 MALTHOUSE SURGERY K84027 810 • in total, including exceptions, there BARTLEMAS SURGERY K84032 243 NORTH BICESTER SURGERY K84621 83 MARSTON MEDICAL CENTRE K84076 108 are 17,650 people whose blood MONTGOMERY HOUSE SURGERY K84038 459 DEER PARK MEDICAL CENTRE K84622 128 TEMPLE COWLEY HEALTH CENTRE K84007 273 pressure is not <= 150/90 VICTORIA HOUSE SURGERY K84073 188 WINDRUSH SURGERY K84024 228 MANOR SURGERY K84044 405 • GP practice range: 10.8% to 38.5% BURY KNOWLE HEALTH CENTRE K84009 294 WALLINGFORD MEDICAL PRACTICE K84037 495 CHALGROVE & WATLINGTON SURGERIES K84008 224 ST. CLEMENT'S SURGERY K84060 115 CHIPPING NORTON HEALTH CENTRE K84030 481 GORING & WOODCOTE MEDICAL PRACTICE K84071 315 SIBFORD SURGERY K84065 71 28 BEAUMONT STREET K84080 72 HIGHTOWN SURGERY K84059 274 CHURCH STREET PRACTICE K84033 423 LANGFORD MEDICAL PRACTICE K84613 181 EYNSHAM MEDICAL GROUP K84006 508 THE ABINGDON SURGERY K84054 351 THE HART SURGERY K84001 243 JERICHO HEALTH CENTRE K84078 61 HORSEFAIR SURGERY K84040 490 KENNINGTON HEALTH CENTRE K84005 224 SOUTH OXFORD HEALTH CENTRE K84617 70 NUFFIELD HEALTH CENTRE K84072 449 SUMMERTOWN HEALTH CENTRE K84011 276 BOTLEY MEDICAL CENTRE K84025 218 WHITE HORSE MEDICAL PRACTICE K84051 416 JERICHO HEALTH CENTRE (KEARLEY/CHIVERS) K84026 169 BANBURY HEALTH CENTRE Y02754 56 WOODSTOCK SURGERY K84042 251 CLIFTON HAMPDEN SURGERY K84034 84 27 BEAUMONT STREET K84049 61 DEDDINGTON HEALTH CENTRE K84055 258 THE LEYS HEALTH CENTRE K84031 233 9 KING EDWARD STREET K84605 30 THE CHARLBURY MEDICAL CENTRE K84610 133 MARCHAM RD FAMILY HEALTH CENTRE K84041 319 19 BEAUMONT STREET SURGERY K84016 142 THE BELL SURGERY K84035 218 BURFORD SURGERY K84047 169 THE KEY MEDICAL PRACTICE K84082 299 HOLLOW WAY MEDICAL CENTRE K84048 158 SONNING COMMON HEALTH CTR K84020 210 MORLAND HOUSE SURGERY K84014 246 WYCHWOOD SURGERY K84046 159 DIDCOT HEALTH CENTRE PRACTICE K84002 340 BAMPTON SURGERY K84010 195 BICESTER HEALTH CENTRE K84052 233 ISLIP SURGERY K84003 124 COGGES SURGERY K84618 118 MILL STREAM SURGERY K84036 94 BLOXHAM SURGERY K84058 128 WOOD FARM HEALTH CENTRE K84620 26 BERINSFIELD HEALTH CENTRE K84023 106 BANBURY ROAD MEDICAL CENTRE K84021 81 WINDRUSH MEDICAL PRACTICE K84017 267 GOSFORD HILL MEDICAL CENTRE K84045 147 BROADSHIRES HEALTH CENTRE K84075 117 LONG FURLONG MEDICAL CENTRE K84079 103 THE RYCOTE PRACTICE K84050 173 NETTLEBED SURGERY K84015 69 WOODLANDS MEDICAL CENTRE K84043 171 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 Chiltern CCG 65.9%

NHS Newbury And District CCG 65.3% • 409 people with a new diagnosis* of hypertension with a CVD risk of 20% or higher in NHS Oxfordshire CCG NHS Aylesbury Vale CCG 64.9% • 245 (59.9%) people who are currently treated with statins • 151 (36.9%) people who are NHS Oxfordshire CCG 59.9% exempted from treatment with statins • 13 (3.2%) additional people who are NHS South Reading CCG 54.5% not currently treated with statins

NHS North & West Reading CCG 54.0%

NHS Wokingham CCG 50.0%

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 Nene CCG 69.5%

NHS Bedfordshire CCG 67.6%

NHS East and North Hertfordshire CCG 65.4%

NHS Gloucestershire CCG 65.1%

NHS Northern, Eastern and Western Devon CCG 64.0%

NHS Kernow CCG 62.0%

NHS Southern Derbyshire CCG 61.5%

NHS Cambridgeshire and Peterborough CCG 61.2%

NHS Herts Valleys CCG 60.5%

NHS Oxfordshire CCG 59.9%

NHS Somerset CCG 55.1%

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

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

No treatment Exceptions reported

CROPREDY SURGERY K84056 4 THE CHARLBURY MEDICAL CENTRE K84610 1 WOOD FARM HEALTH CENTRE K84620 1 HORSEFAIR SURGERY K84040 6 ST. BARTHOLEMEW'S MEDICAL CENTRE K84013 3 27 BEAUMONT STREET K84049 3 DEER PARK MEDICAL CENTRE K84622 3 NEWBURY STREET PRACTICE K84019 4 WINDRUSH SURGERY K84024 2 BOTLEY MEDICAL CENTRE K84025 2 • in total, including exceptions, there MILL STREAM SURGERY K84036 2 CHALGROVE & WATLINGTON SURGERIES K84008 3 SONNING COMMON HEALTH CTR K84020 3 are 164 people who are not treated CHURCH STREET PRACTICE K84033 3 DEDDINGTON HEALTH CENTRE K84055 7 MORLAND HOUSE SURGERY K84014 4 with statins WOODLANDS MEDICAL CENTRE K84043 4 WALLINGFORD MEDICAL PRACTICE K84037 9 DONNINGTON MEDICAL PARTNERSHIP K84004 9 • GP practice range: 0.0% to 100.0% KENNINGTON HEALTH CENTRE K84005 3 BAMPTON SURGERY K84010 2 WOODSTOCK SURGERY K84042 2 WHITE HORSE MEDICAL PRACTICE K84051 4 BLOXHAM SURGERY K84058 3 WOODLANDS SURGERY K84062 1 COWLEY ROAD MEDICAL PRACTICE K84063 1 NUFFIELD HEALTH CENTRE K84072 3 9 KING EDWARD STREET K84605 1 NORTH BICESTER SURGERY K84621 1 OAK TREE HEALTH CENTRE K84624 1 MONTGOMERY HOUSE SURGERY K84038 6 THE RYCOTE PRACTICE K84050 5 BURY KNOWLE HEALTH CENTRE K84009 4 CHIPPING NORTON HEALTH CENTRE K84030 7 MARSTON MEDICAL CENTRE K84076 3 WEST BAR SURGERY K84028 2 LANGFORD MEDICAL PRACTICE K84613 2 19 BEAUMONT STREET SURGERY K84016 3 THE ABINGDON SURGERY K84054 3 JERICHO HEALTH CENTRE (KEARLEY/CHIVERS) K84026 4 TEMPLE COWLEY HEALTH CENTRE K84007 1 SUMMERTOWN HEALTH CENTRE K84011 1 MANOR SURGERY K84044 1 HIGHTOWN SURGERY K84059 1 BROADSHIRES HEALTH CENTRE K84075 2 DIDCOT HEALTH CENTRE PRACTICE K84002 4 THE LEYS HEALTH CENTRE K84031 5 BICESTER HEALTH CENTRE K84052 2 BURFORD SURGERY K84047 1 LONG FURLONG MEDICAL CENTRE K84079 1 THE KEY MEDICAL PRACTICE K84082 3 SOUTH OXFORD HEALTH CENTRE K84617 1 THE BELL SURGERY K84035 1 HOLLOW WAY MEDICAL CENTRE K84048 2 COGGES SURGERY K84618 1 EYNSHAM MEDICAL GROUP K84006 1 MALTHOUSE SURGERY K84027 1 VICTORIA HOUSE SURGERY K84073 1 THE HART SURGERY K84001 ISLIP SURGERY K84003 NETTLEBED SURGERY K84015 WINDRUSH MEDICAL PRACTICE K84017 BANBURY ROAD MEDICAL CENTRE K84021 BERINSFIELD HEALTH CENTRE K84023 BARTLEMAS SURGERY K84032 CLIFTON HAMPDEN SURGERY K84034 MARCHAM RD FAMILY HEALTH CENTRE K84041 GOSFORD HILL MEDICAL CENTRE K84045 WYCHWOOD SURGERY K84046 ST. CLEMENT'S SURGERY K84060 SIBFORD SURGERY K84065 GORING & WOODCOTE MEDICAL PRACTICE K84071 JERICHO HEALTH CENTRE K84078 28 BEAUMONT STREET K84080 BANBURY HEALTH CENTRE Y02754 LUTHER STREET MEDICAL PRACTICE K84066 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 Aylesbury Vale CCG 0.76

NHS Chiltern CCG 0.72 • the ratio of those diagnosed with atrial fibrillation versus those expected to have atrial fibrillation is 0.69. This NHS Oxfordshire CCG 0.69 compares to 0.7 for England • this suggests that 69% of people with atrial fibrillation have been diagnosed. NHS Newbury And District CCG 0.68

NHS Wokingham CCG 0.66

NHS North & West Reading CCG 0.65

NHS South Reading CCG 0.60 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 Somerset CCG 0.78

NHS Gloucestershire CCG 0.74

NHS Northern, Eastern and Western Devon CCG 0.73

NHS Kernow CCG 0.72

NHS Nene CCG 0.70

NHS Herts Valleys CCG 0.70

NHS Oxfordshire CCG 0.69

NHS Southern Derbyshire CCG 0.69

NHS East and North Hertfordshire CCG 0.68

NHS Bedfordshire CCG 0.68

NHS Cambridgeshire and Peterborough CCG 0.67

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

NORTH BICESTER SURGERY K84621 3.1 NETTLEBED SURGERY K84015 0.9 KENNINGTON HEALTH CENTRE K84005 0.8 BAMPTON SURGERY K84010 0.8 SUMMERTOWN HEALTH CENTRE K84011 0.8 BERINSFIELD HEALTH CENTRE K84023 0.8 CLIFTON HAMPDEN SURGERY K84034 0.8 THE BELL SURGERY K84035 0.8 WOODSTOCK SURGERY K84042 0.8 BURFORD SURGERY K84047 0.8 • it is estimated that there are 17,199 GORING & WOODCOTE MEDICAL PRACTICE K84071 0.8 NUFFIELD HEALTH CENTRE K84072 0.8 THE KEY MEDICAL PRACTICE K84082 0.8 people with undiagnosed atrial LANGFORD MEDICAL PRACTICE K84613 0.8 SOUTH OXFORD HEALTH CENTRE K84617 0.8 DONNINGTON MEDICAL PARTNERSHIP K84004 0.7 EYNSHAM MEDICAL GROUP K84006 0.7 fibrillation in NHS Oxfordshire CCG TEMPLE COWLEY HEALTH CENTRE K84007 0.7 CHALGROVE & WATLINGTON SURGERIES K84008 0.7 ST. BARTHOLEMEW'S MEDICAL CENTRE K84013 0.7 • GP practice range of observed to MORLAND HOUSE SURGERY K84014 0.7 NEWBURY STREET PRACTICE K84019 0.7 SONNING COMMON HEALTH CTR K84020 0.7 expected atrial fibrillation prevalence BANBURY ROAD MEDICAL CENTRE K84021 0.7 BOTLEY MEDICAL CENTRE K84025 0.7 MALTHOUSE SURGERY K84027 0.7 CHIPPING NORTON HEALTH CENTRE K84030 0.7 0.5 to 3.1 MILL STREAM SURGERY K84036 0.7 WALLINGFORD MEDICAL PRACTICE K84037 0.7 MONTGOMERY HOUSE SURGERY K84038 0.7 MARCHAM RD FAMILY HEALTH CENTRE K84041 0.7 WOODLANDS MEDICAL CENTRE K84043 0.7 GOSFORD HILL MEDICAL CENTRE K84045 0.7 WYCHWOOD SURGERY K84046 0.7 HOLLOW WAY MEDICAL CENTRE K84048 0.7 WHITE HORSE MEDICAL PRACTICE K84051 0.7 BICESTER HEALTH CENTRE K84052 0.7 THE ABINGDON SURGERY K84054 0.7 DEDDINGTON HEALTH CENTRE K84055 0.7 HIGHTOWN SURGERY K84059 0.7 SIBFORD SURGERY K84065 0.7 BROADSHIRES HEALTH CENTRE K84075 0.7 THE CHARLBURY MEDICAL CENTRE K84610 0.7 COGGES SURGERY K84618 0.7 THE HART SURGERY K84001 0.6 DIDCOT HEALTH CENTRE PRACTICE K84002 0.6 ISLIP SURGERY K84003 0.6 BURY KNOWLE HEALTH CENTRE K84009 0.6 19 BEAUMONT STREET SURGERY K84016 0.6 WINDRUSH MEDICAL PRACTICE K84017 0.6 WINDRUSH SURGERY K84024 0.6 JERICHO HEALTH CENTRE (KEARLEY/CHIVERS) K84026 0.6 WEST BAR SURGERY K84028 0.6 THE LEYS HEALTH CENTRE K84031 0.6 BARTLEMAS SURGERY K84032 0.6 CHURCH STREET PRACTICE K84033 0.6 HORSEFAIR SURGERY K84040 0.6 MANOR SURGERY K84044 0.6 THE RYCOTE PRACTICE K84050 0.6 CROPREDY SURGERY K84056 0.6 BLOXHAM SURGERY K84058 0.6 WOODLANDS SURGERY K84062 0.6 COWLEY ROAD MEDICAL PRACTICE K84063 0.6 VICTORIA HOUSE SURGERY K84073 0.6 JERICHO HEALTH CENTRE K84078 0.6 28 BEAUMONT STREET K84080 0.6 DEER PARK MEDICAL CENTRE K84622 0.6 OAK TREE HEALTH CENTRE K84624 0.6 27 BEAUMONT STREET K84049 0.5 ST. CLEMENT'S SURGERY K84060 0.5 MARSTON MEDICAL CENTRE K84076 0.5 LONG FURLONG MEDICAL CENTRE K84079 0.5 9 KING EDWARD STREET K84605 0.5 BANBURY HEALTH CENTRE Y02754 0.5 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 Chiltern CCG 84.9% • 9,561 people with atrial fibrillation* NHS Aylesbury Vale CCG 80.1% with a CHA2DS2-VASc score >= 2 in NHS Oxfordshire CCG • 7,317 (76.5%) people treated with NHS Wokingham CCG 79.1% anti-coagulation therapy • 1,153 (12.1%) people who are exceptions NHS Newbury And District CCG 79.0% • 1,091 (11.4%) additional people with a recorded CHA2DS2-VASc score >= NHS South Reading CCG 78.7% 2 who are not treated

NHS North & West Reading CCG 78.1%

NHS Oxfordshire CCG 76.5%

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 Gloucestershire CCG 82.0%

NHS Nene CCG 81.8%

NHS Northern, Eastern and Western Devon CCG 80.3%

NHS Kernow CCG 80.2%

NHS Somerset CCG 79.5%

NHS Herts Valleys CCG 78.7%

NHS East and North Hertfordshire CCG 78.7%

NHS Bedfordshire CCG 77.8%

NHS Oxfordshire CCG 76.5%

NHS Southern Derbyshire CCG 76.0%

NHS Cambridgeshire and Peterborough CCG 75.7%

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

ST. CLEMENT'S SURGERY K84060 13 27 BEAUMONT STREET K84049 17 SOUTH OXFORD HEALTH CENTRE K84617 16 HIGHTOWN SURGERY K84059 51 ST. BARTHOLEMEW'S MEDICAL CENTRE K84013 25 BOTLEY MEDICAL CENTRE K84025 54 NORTH BICESTER SURGERY K84621 10 NUFFIELD HEALTH CENTRE K84072 81 WEST BAR SURGERY K84028 69 BURY KNOWLE HEALTH CENTRE K84009 32 • in total, including exceptions, there WINDRUSH SURGERY K84024 31 OAK TREE HEALTH CENTRE K84624 15 TEMPLE COWLEY HEALTH CENTRE K84007 38 are 2,244 people with a recorded 28 BEAUMONT STREET K84080 10 COWLEY ROAD MEDICAL PRACTICE K84063 13 THE ABINGDON SURGERY K84054 55 CHA2DS2-VASc score >= 2 who are THE BELL SURGERY K84035 55 SUMMERTOWN HEALTH CENTRE K84011 53 WALLINGFORD MEDICAL PRACTICE K84037 78 not treated BLOXHAM SURGERY K84058 29 CHIPPING NORTON HEALTH CENTRE K84030 73 THE CHARLBURY MEDICAL CENTRE K84610 24 • GP practice range: 10.9% to 56.5% DEER PARK MEDICAL CENTRE K84622 11 CHURCH STREET PRACTICE K84033 55 DIDCOT HEALTH CENTRE PRACTICE K84002 49 WOODLANDS MEDICAL CENTRE K84043 45 DONNINGTON MEDICAL PARTNERSHIP K84004 43 MONTGOMERY HOUSE SURGERY K84038 49 BURFORD SURGERY K84047 35 BANBURY HEALTH CENTRE Y02754 4 BARTLEMAS SURGERY K84032 18 WOODLANDS SURGERY K84062 12 HOLLOW WAY MEDICAL CENTRE K84048 22 MANOR SURGERY K84044 43 GORING & WOODCOTE MEDICAL PRACTICE K84071 47 CHALGROVE & WATLINGTON SURGERIES K84008 24 NEWBURY STREET PRACTICE K84019 56 THE LEYS HEALTH CENTRE K84031 23 THE HART SURGERY K84001 32 19 BEAUMONT STREET SURGERY K84016 20 KENNINGTON HEALTH CENTRE K84005 34 WHITE HORSE MEDICAL PRACTICE K84051 54 WOODSTOCK SURGERY K84042 46 JERICHO HEALTH CENTRE (KEARLEY/CHIVERS) K84026 19 COGGES SURGERY K84618 15 HORSEFAIR SURGERY K84040 50 CLIFTON HAMPDEN SURGERY K84034 12 SONNING COMMON HEALTH CTR K84020 35 BERINSFIELD HEALTH CENTRE K84023 22 9 KING EDWARD STREET K84605 3 WOOD FARM HEALTH CENTRE K84620 2 THE KEY MEDICAL PRACTICE K84082 45 LANGFORD MEDICAL PRACTICE K84613 12 BAMPTON SURGERY K84010 34 VICTORIA HOUSE SURGERY K84073 13 NETTLEBED SURGERY K84015 16 JERICHO HEALTH CENTRE K84078 6 THE RYCOTE PRACTICE K84050 33 BICESTER HEALTH CENTRE K84052 30 DEDDINGTON HEALTH CENTRE K84055 30 MALTHOUSE SURGERY K84027 59 MARCHAM RD FAMILY HEALTH CENTRE K84041 35 SIBFORD SURGERY K84065 8 GOSFORD HILL MEDICAL CENTRE K84045 20 MARSTON MEDICAL CENTRE K84076 7 EYNSHAM MEDICAL GROUP K84006 44 ISLIP SURGERY K84003 14 CROPREDY SURGERY K84056 8 BANBURY ROAD MEDICAL CENTRE K84021 9 LONG FURLONG MEDICAL CENTRE K84079 9 WINDRUSH MEDICAL PRACTICE K84017 30 MORLAND HOUSE SURGERY K84014 25 WYCHWOOD SURGERY K84046 16 BROADSHIRES HEALTH CENTRE K84075 9 MILL STREAM SURGERY K84036 10 LUTHER STREET MEDICAL PRACTICE K84066 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% 0% -10% -20% -30% -40% -50%

ST. CLEMENT'S SURGERY 9

27 BEAUMONT STREET 11

SOUTH OXFORD HEALTH CENTRE 10 • using the GP cluster method of BOTLEY MEDICAL CENTRE 31 calculating potential gains, if each NORTH BICESTER SURGERY 6 practice was to achieve as well as the HIGHTOWN SURGERY 27 upper quartile of its national cluster, then an additional 676 people would ST. BARTHOLEMEW'S MEDICAL CENTRE 13 be treated OAK TREE HEALTH CENTRE 8

WINDRUSH SURGERY 16

NUFFIELD HEALTH CENTRE 39

LONG FURLONG MEDICAL CENTRE 0

MALTHOUSE SURGERY 0

BANBURY ROAD MEDICAL CENTRE

GOSFORD HILL MEDICAL CENTRE

WYCHWOOD SURGERY

EYNSHAM MEDICAL GROUP

WINDRUSH MEDICAL PRACTICE

MORLAND HOUSE SURGERY

MILL STREAM SURGERY

BROADSHIRES HEALTH 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 Chiltern CCG 86.1% • 11,963 people with a history of stroke NHS South Reading CCG 85.2% or TIA* in NHS Oxfordshire CCG • 10,034 (83.9%) people whose blood pressure is <= 150 / 90 NHS Newbury And District CCG 84.7% • 581 (4.9%) people who are exceptions • 1,348 (11.3%) additional people NHS North & West Reading CCG 84.1% whose blood pressure is not <= 150 / 90 NHS Aylesbury Vale CCG 84.0%

NHS Oxfordshire CCG 83.9%

NHS Wokingham CCG 82.8%

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 Herts Valleys CCG 85.1%

NHS Gloucestershire CCG 84.2%

NHS Oxfordshire CCG 83.9%

NHS Nene CCG 83.8%

NHS Bedfordshire CCG 83.4%

NHS East and North Hertfordshire CCG 83.4%

NHS Northern, Eastern and Western Devon CCG 83.4%

NHS Southern Derbyshire CCG 83.1%

NHS Kernow CCG 82.6%

NHS Cambridgeshire and Peterborough CCG 81.7%

NHS Somerset CCG 77.5%

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

ST. BARTHOLEMEW'S MEDICAL CENTRE K84013 26 LUTHER STREET MEDICAL PRACTICE K84066 2 COWLEY ROAD MEDICAL PRACTICE K84063 15 DEER PARK MEDICAL CENTRE K84622 17 VICTORIA HOUSE SURGERY K84073 25 NORTH BICESTER SURGERY K84621 13 SIBFORD SURGERY K84065 13 WOODLANDS SURGERY K84062 20 NEWBURY STREET PRACTICE K84019 71 WEST BAR SURGERY K84028 71 • in total, including exceptions, there CROPREDY SURGERY K84056 16 28 BEAUMONT STREET K84080 7 WINDRUSH SURGERY K84024 30 are 1,929 people whose blood HIGHTOWN SURGERY K84059 40 KENNINGTON HEALTH CENTRE K84005 36 BARTLEMAS SURGERY K84032 28 pressure is not <= 150 / 90 27 BEAUMONT STREET K84049 10 DONNINGTON MEDICAL PARTNERSHIP K84004 46 MONTGOMERY HOUSE SURGERY K84038 49 • GP practice range: 0.0% to 29.9% MANOR SURGERY K84044 46 THE HART SURGERY K84001 28 GORING & WOODCOTE MEDICAL PRACTICE K84071 41 MALTHOUSE SURGERY K84027 103 HORSEFAIR SURGERY K84040 62 SUMMERTOWN HEALTH CENTRE K84011 38 CHALGROVE & WATLINGTON SURGERIES K84008 19 BURFORD SURGERY K84047 26 EYNSHAM MEDICAL GROUP K84006 57 HOLLOW WAY MEDICAL CENTRE K84048 25 MARCHAM RD FAMILY HEALTH CENTRE K84041 44 WHITE HORSE MEDICAL PRACTICE K84051 46 THE LEYS HEALTH CENTRE K84031 29 CHIPPING NORTON HEALTH CENTRE K84030 52 MORLAND HOUSE SURGERY K84014 29 CHURCH STREET PRACTICE K84033 53 DIDCOT HEALTH CENTRE PRACTICE K84002 49 NUFFIELD HEALTH CENTRE K84072 42 DEDDINGTON HEALTH CENTRE K84055 27 SOUTH OXFORD HEALTH CENTRE K84617 7 THE BELL SURGERY K84035 31 TEMPLE COWLEY HEALTH CENTRE K84007 22 JERICHO HEALTH CENTRE (KEARLEY/CHIVERS) K84026 19 BURY KNOWLE HEALTH CENTRE K84009 22 LANGFORD MEDICAL PRACTICE K84613 14 WOODSTOCK SURGERY K84042 32 MARSTON MEDICAL CENTRE K84076 8 ST. CLEMENT'S SURGERY K84060 7 WALLINGFORD MEDICAL PRACTICE K84037 44 19 BEAUMONT STREET SURGERY K84016 21 BROADSHIRES HEALTH CENTRE K84075 16 BAMPTON SURGERY K84010 26 BOTLEY MEDICAL CENTRE K84025 21 THE KEY MEDICAL PRACTICE K84082 42 OAK TREE HEALTH CENTRE K84624 10 MILL STREAM SURGERY K84036 12 THE ABINGDON SURGERY K84054 30 SONNING COMMON HEALTH CTR K84020 17 WYCHWOOD SURGERY K84046 13 BLOXHAM SURGERY K84058 12 THE CHARLBURY MEDICAL CENTRE K84610 10 BERINSFIELD HEALTH CENTRE K84023 16 LONG FURLONG MEDICAL CENTRE K84079 9 CLIFTON HAMPDEN SURGERY K84034 5 ISLIP SURGERY K84003 11 BANBURY ROAD MEDICAL CENTRE K84021 8 GOSFORD HILL MEDICAL CENTRE K84045 13 BICESTER HEALTH CENTRE K84052 17 WOODLANDS MEDICAL CENTRE K84043 17 THE RYCOTE PRACTICE K84050 15 BANBURY HEALTH CENTRE Y02754 3 WINDRUSH MEDICAL PRACTICE K84017 17 NETTLEBED SURGERY K84015 5 COGGES SURGERY K84618 5 9 KING EDWARD STREET K84605 1 JERICHO HEALTH CENTRE K84078 WOOD FARM HEALTH CENTRE K84620 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 Wokingham CCG 92.4% • 7,611 people with a stroke shown to NHS Chiltern CCG 92.3% be non-haemorrhagic* in NHS Oxfordshire CCG • 6,869 (90.3%) people who are taking NHS Newbury And District CCG 92.2% an anti-platetet agent or anti- coagulant • 498 (6.5%) people who are NHS South Reading CCG 91.4% exceptions • 244 (3.2%) additional people with no NHS North & West Reading CCG 91.2% treatment

NHS Aylesbury Vale CCG 91.1%

NHS Oxfordshire CCG 90.3%

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 Nene CCG 93.2%

NHS Northern, Eastern and Western Devon CCG 93.0%

NHS Kernow CCG 92.3%

NHS Bedfordshire CCG 92.2%

NHS East and North Hertfordshire CCG 91.9%

NHS Gloucestershire CCG 91.7%

NHS Herts Valleys CCG 91.4%

NHS Southern Derbyshire CCG 91.3%

NHS Oxfordshire CCG 90.3%

NHS Cambridgeshire and Peterborough CCG 89.8%

NHS Somerset 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

LUTHER STREET MEDICAL PRACTICE K84066 1 BANBURY HEALTH CENTRE Y02754 7 ST. CLEMENT'S SURGERY K84060 6 HOLLOW WAY MEDICAL CENTRE K84048 13 BERINSFIELD HEALTH CENTRE K84023 16 OAK TREE HEALTH CENTRE K84624 9 THE BELL SURGERY K84035 17 NORTH BICESTER SURGERY K84621 5 SONNING COMMON HEALTH CTR K84020 14 WEST BAR SURGERY K84028 41 • in total, including exceptions, there EYNSHAM MEDICAL GROUP K84006 29 TEMPLE COWLEY HEALTH CENTRE K84007 14 GORING & WOODCOTE MEDICAL PRACTICE K84071 18 are 742 people who are not taking an THE RYCOTE PRACTICE K84050 17 ST. BARTHOLEMEW'S MEDICAL CENTRE K84013 7 NEWBURY STREET PRACTICE K84019 27 anti-platelet agent or anti-coagulant JERICHO HEALTH CENTRE (KEARLEY/CHIVERS) K84026 11 THE HART SURGERY K84001 11 MANOR SURGERY K84044 16 • GP practice range: 0.0% to 50.0% DEER PARK MEDICAL CENTRE K84622 5 LANGFORD MEDICAL PRACTICE K84613 6 BURFORD SURGERY K84047 10 COWLEY ROAD MEDICAL PRACTICE K84063 3 BOTLEY MEDICAL CENTRE K84025 10 MALTHOUSE SURGERY K84027 38 DEDDINGTON HEALTH CENTRE K84055 12 CHALGROVE & WATLINGTON SURGERIES K84008 8 MONTGOMERY HOUSE SURGERY K84038 14 CROPREDY SURGERY K84056 5 LONG FURLONG MEDICAL CENTRE K84079 4 BROADSHIRES HEALTH CENTRE K84075 7 HORSEFAIR SURGERY K84040 19 THE ABINGDON SURGERY K84054 19 28 BEAUMONT STREET K84080 2 BLOXHAM SURGERY K84058 8 WOODLANDS MEDICAL CENTRE K84043 14 CHIPPING NORTON HEALTH CENTRE K84030 20 NUFFIELD HEALTH CENTRE K84072 16 MARSTON MEDICAL CENTRE K84076 3 NETTLEBED SURGERY K84015 7 JERICHO HEALTH CENTRE K84078 2 CHURCH STREET PRACTICE K84033 18 DONNINGTON MEDICAL PARTNERSHIP K84004 11 THE LEYS HEALTH CENTRE K84031 7 WHITE HORSE MEDICAL PRACTICE K84051 14 KENNINGTON HEALTH CENTRE K84005 10 SUMMERTOWN HEALTH CENTRE K84011 10 ISLIP SURGERY K84003 5 BURY KNOWLE HEALTH CENTRE K84009 7 WOODSTOCK SURGERY K84042 11 COGGES SURGERY K84618 4 MARCHAM RD FAMILY HEALTH CENTRE K84041 13 WINDRUSH SURGERY K84024 5 DIDCOT HEALTH CENTRE PRACTICE K84002 17 BAMPTON SURGERY K84010 7 HIGHTOWN SURGERY K84059 7 BICESTER HEALTH CENTRE K84052 9 WALLINGFORD MEDICAL PRACTICE K84037 13 27 BEAUMONT STREET K84049 2 MORLAND HOUSE SURGERY K84014 9 19 BEAUMONT STREET SURGERY K84016 5 WINDRUSH MEDICAL PRACTICE K84017 8 MILL STREAM SURGERY K84036 3 CLIFTON HAMPDEN SURGERY K84034 2 THE KEY MEDICAL PRACTICE K84082 11 WYCHWOOD SURGERY K84046 4 BARTLEMAS SURGERY K84032 4 VICTORIA HOUSE SURGERY K84073 2 WOODLANDS SURGERY K84062 2 SOUTH OXFORD HEALTH CENTRE K84617 1 GOSFORD HILL MEDICAL CENTRE K84045 5 THE CHARLBURY MEDICAL CENTRE K84610 2 SIBFORD SURGERY K84065 1 BANBURY ROAD MEDICAL CENTRE K84021 2 9 KING EDWARD STREET K84605 WOOD FARM HEALTH CENTRE K84620 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 Aylesbury Vale CCG 0.78

• 0.69 ratio of observed to expected NHS Chiltern CCG 0.72 diabetes prevalence in NHS Oxfordshire CCG, compared to 0.77 in England NHS Oxfordshire CCG 0.69 • this suggests 69% of people have been diagnosed NHS South Reading CCG 0.68

NHS North & West Reading CCG 0.67

NHS Newbury And District CCG 0.66

NHS Wokingham CCG 0.66

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

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

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

NHS Southern Derbyshire CCG 0.81

NHS Bedfordshire CCG 0.79

NHS Nene CCG 0.78

NHS Gloucestershire CCG 0.77

NHS Cambridgeshire and Peterborough CCG 0.77

NHS Northern, Eastern and Western Devon CCG 0.75

NHS Somerset CCG 0.74

NHS East and North Hertfordshire CCG 0.73

NHS Oxfordshire CCG 0.69

NHS Herts Valleys CCG 0.68

NHS Kernow CCG 0.65

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

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

GP practice CCG

BERINSFIELD HEALTH CENTRE K84023 8.1% WINDRUSH SURGERY K84024 7.2% THE LEYS HEALTH CENTRE K84031 6.9% BARTLEMAS SURGERY K84032 6.9% GOSFORD HILL MEDICAL CENTRE K84045 6.9% WOOD FARM HEALTH CENTRE K84620 6.6% WEST BAR SURGERY K84028 6.6% TEMPLE COWLEY HEALTH CENTRE K84007 6.5% DONNINGTON MEDICAL PARTNERSHIP K84004 6.5% MONTGOMERY HOUSE SURGERY K84038 6.3% • GP practice range of observed NUFFIELD HEALTH CENTRE K84072 6.3% THE KEY MEDICAL PRACTICE K84082 6.1% WOODLANDS SURGERY K84062 6.1% diabetes 1.2% to 8.1% MALTHOUSE SURGERY K84027 6.0% WOODLANDS MEDICAL CENTRE K84043 6.0% CHURCH STREET PRACTICE K84033 6.0% • there are an estimated 13,079 people HOLLOW WAY MEDICAL CENTRE K84048 5.9% HORSEFAIR SURGERY K84040 5.8% HIGHTOWN SURGERY K84059 5.8% with undiagnosed diabetes in NHS EYNSHAM MEDICAL GROUP K84006 5.7% BURFORD SURGERY K84047 5.7% BAMPTON SURGERY K84010 5.6% CHALGROVE & WATLINGTON SURGERIES K84008 5.6% Oxfordshire CCG KENNINGTON HEALTH CENTRE K84005 5.6% CROPREDY SURGERY K84056 5.6% WOODSTOCK SURGERY K84042 5.5% DIDCOT HEALTH CENTRE PRACTICE K84002 5.5% WHITE HORSE MEDICAL PRACTICE K84051 5.5% BICESTER HEALTH CENTRE K84052 5.5% NEWBURY STREET PRACTICE K84019 5.4% DEER PARK MEDICAL CENTRE K84622 5.3% CHIPPING NORTON HEALTH CENTRE K84030 5.2% MARCHAM RD FAMILY HEALTH CENTRE K84041 5.2% CLIFTON HAMPDEN SURGERY K84034 5.1% THE CHARLBURY MEDICAL CENTRE K84610 5.1% VICTORIA HOUSE SURGERY K84073 5.1% WINDRUSH MEDICAL PRACTICE K84017 5.1% THE RYCOTE PRACTICE K84050 5.1% DEDDINGTON HEALTH CENTRE K84055 5.1% MILL STREAM SURGERY K84036 5.0% GORING & WOODCOTE MEDICAL PRACTICE K84071 4.9% BLOXHAM SURGERY K84058 4.9% BROADSHIRES HEALTH CENTRE K84075 4.9% WYCHWOOD SURGERY K84046 4.9% ST. CLEMENT'S SURGERY K84060 4.8% MORLAND HOUSE SURGERY K84014 4.8% SIBFORD SURGERY K84065 4.7% WALLINGFORD MEDICAL PRACTICE K84037 4.7% MANOR SURGERY K84044 4.7% SONNING COMMON HEALTH CTR K84020 4.7% MARSTON MEDICAL CENTRE K84076 4.6% NORTH BICESTER SURGERY K84621 4.5% BOTLEY MEDICAL CENTRE K84025 4.5% ISLIP SURGERY K84003 4.5% THE ABINGDON SURGERY K84054 4.4% THE BELL SURGERY K84035 4.3% LANGFORD MEDICAL PRACTICE K84613 4.2% OAK TREE HEALTH CENTRE K84624 4.2% COGGES SURGERY K84618 4.2% NETTLEBED SURGERY K84015 4.1% BURY KNOWLE HEALTH CENTRE K84009 4.1% THE HART SURGERY K84001 4.1% COWLEY ROAD MEDICAL PRACTICE K84063 3.8% LUTHER STREET MEDICAL PRACTICE K84066 3.7% LONG FURLONG MEDICAL CENTRE K84079 3.6% SOUTH OXFORD HEALTH CENTRE K84617 3.3% JERICHO HEALTH CENTRE (KEARLEY/CHIVERS) K84026 3.2% SUMMERTOWN HEALTH CENTRE K84011 3.1% BANBURY HEALTH CENTRE Y02754 2.8% 28 BEAUMONT STREET K84080 2.8% 27 BEAUMONT STREET K84049 2.6% BANBURY ROAD MEDICAL CENTRE K84021 2.5% Note: The estimated number of undiagnosed ST. BARTHOLEMEW'S MEDICAL CENTRE K84013 2.0% 19 BEAUMONT STREET SURGERY K84016 1.9% people with diabetes has been calculated by JERICHO HEALTH CENTRE K84078 1.5% 9 KING EDWARD STREET K84605 1.2% multiplying the estimated prevalence rate to the 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 2015/16 QOF list size and subtracting the number of people on the diabetes register.

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

Diabetes prevalence Undiagnosed diabetes prevalence Expected non-diabetic hyperglycaemia prevalence

NHS Chiltern CCG 5.9% 2.3% 11.9% • the estimated total prevalence of diabetes in NHS Oxfordshire CCG is 7.2% (diagnosed and undiagnosed) NHS Aylesbury Vale CCG 6.0% 1.7% 11.1% • in addition, there are an estimated NHS North & West Reading CCG 5.0% 2.5% 10.6% 10.3% of people in NHS Oxfordshire CCG who are at increased risk of developing diabetes (i.e. with non- NHS Wokingham CCG 4.7% 2.4% 10.8% diabetic hyperglycaemia)

NHS Newbury And District CCG 4.9% 2.5% 10.4% • this means that 17.5% of the population in NHS Oxfordshire CCG NHS Oxfordshire CCG 4.9% 2.2% 10.3% are estimated to have diabetes, or at high risk of developing of diabetes

NHS South Reading CCG 4.7% 2.2% 8.9%

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

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

NHS North & West Reading CCG 71.0%

• data on care processes and treatment NHS Wokingham CCG 62.8% targets are taken from the National Diabetes Audit (NDA)

NHS South Reading CCG 54.9% • overall practice participation in the 2015/16 audit was 81.4% in England

NHS Aylesbury Vale CCG 54.3% • in NHS Oxfordshire CCG, 68 out of 75 practices (90.7%) participated in the NDA. Data is not available for the NHS Newbury And District CCG 54.2% remaining practices

NHS Oxfordshire CCG 49.5% • 49.5% of people with diabetes (of practices who participated in the NHS Chiltern CCG 43.2% audit) had the eight recommended care processes in NHS Oxfordshire CCG, compared to 52.6% in England

England 52.6%

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

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

LANGFORD MEDICAL PRACTICE K84613 75.2% GORING & WOODCOTE MEDICAL PRACTICE K84071 75.1% MARCHAM RD FAMILY HEALTH CENTRE K84041 73.3% WOODSTOCK SURGERY K84042 71.7% ISLIP SURGERY K84003 71.7% MORLAND HOUSE SURGERY K84014 69.6% DEDDINGTON HEALTH CENTRE K84055 68.2% • achievement - 8 care processes: in CROPREDY SURGERY K84056 67.9% BANBURY ROAD MEDICAL CENTRE K84021 67.5% WYCHWOOD SURGERY K84046 66.8% practices who provided data via the THE KEY MEDICAL PRACTICE K84082 65.1% THE RYCOTE PRACTICE K84050 65.1% BURFORD SURGERY K84047 63.8% THE ABINGDON SURGERY K84054 62.4% NDA, between 11.4% and 75.2% of WALLINGFORD MEDICAL PRACTICE K84037 61.9% BOTLEY MEDICAL CENTRE K84025 61.5% MONTGOMERY HOUSE SURGERY K84038 61.5% patients received all 8 care processes NETTLEBED SURGERY K84015 61.4% CHIPPING NORTON HEALTH CENTRE K84030 61.2% WINDRUSH SURGERY K84024 61.0% WHITE HORSE MEDICAL PRACTICE K84051 60.2% CLIFTON HAMPDEN SURGERY K84034 60.0% SUMMERTOWN HEALTH CENTRE K84011 59.4% WOODLANDS SURGERY K84062 55.8% EYNSHAM MEDICAL GROUP K84006 55.3% • at least 13,009 people did not receive TEMPLE COWLEY HEALTH CENTRE K84007 55.0% OAK TREE HEALTH CENTRE K84624 54.3% JERICHO HEALTH CENTRE (KEARLEY/CHIVERS) K84026 53.7% the eight care processes WINDRUSH MEDICAL PRACTICE K84017 53.1% HOLLOW WAY MEDICAL CENTRE K84048 53.1% MALTHOUSE SURGERY K84027 50.6% HIGHTOWN SURGERY K84059 50.5% BANBURY HEALTH CENTRE Y02754 50.0% CHALGROVE & WATLINGTON SURGERIES K84008 49.6% ST. BARTHOLEMEW'S MEDICAL CENTRE K84013 48.6% COGGES SURGERY K84618 48.2% DONNINGTON MEDICAL PARTNERSHIP K84004 48.2% MANOR SURGERY K84044 47.7% NORTH BICESTER SURGERY K84621 45.5% NUFFIELD HEALTH CENTRE K84072 45.5% WEST BAR SURGERY K84028 45.3% THE LEYS HEALTH CENTRE K84031 44.0% CHURCH STREET PRACTICE K84033 43.8% BLOXHAM SURGERY K84058 42.8% COWLEY ROAD MEDICAL PRACTICE K84063 41.8% VICTORIA HOUSE SURGERY K84073 41.5% THE BELL SURGERY K84035 41.0% BERINSFIELD HEALTH CENTRE K84023 40.7% 27 BEAUMONT STREET K84049 37.2% BURY KNOWLE HEALTH CENTRE K84009 36.2% KENNINGTON HEALTH CENTRE K84005 35.3% GOSFORD HILL MEDICAL CENTRE K84045 34.5% ST. CLEMENT'S SURGERY K84060 34.0% 28 BEAUMONT STREET K84080 32.8% 19 BEAUMONT STREET SURGERY K84016 30.8% 9 KING EDWARD STREET K84605 30.8% SONNING COMMON HEALTH CTR K84020 30.5% LONG FURLONG MEDICAL CENTRE K84079 29.8% WOODLANDS MEDICAL CENTRE K84043 29.1% DIDCOT HEALTH CENTRE PRACTICE K84002 29.0% BROADSHIRES HEALTH CENTRE K84075 24.1% THE HART SURGERY K84001 23.6% BARTLEMAS SURGERY K84032 22.7% BAMPTON SURGERY K84010 22.3% BICESTER HEALTH CENTRE K84052 18.2% JERICHO HEALTH CENTRE K84078 11.4% DEER PARK MEDICAL CENTRE K84622 WOOD FARM HEALTH CENTRE K84620 SOUTH OXFORD HEALTH CENTRE K84617 THE CHARLBURY MEDICAL CENTRE K84610 MARSTON MEDICAL CENTRE K84076 LUTHER STREET MEDICAL PRACTICE K84066 SIBFORD SURGERY K84065 HORSEFAIR SURGERY K84040 MILL STREAM SURGERY K84036 NEWBURY STREET PRACTICE K84019 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 Chiltern CCG 44.2%

• 38.7% of people with diabetes (of NHS Aylesbury Vale CCG 43.9% practices who participated in the audit) met the three treatment targets in NHS Oxfordshire CCG, compared NHS Oxfordshire CCG 38.7% to 39.0% in England

NHS Wokingham CCG 37.8%

NHS North & West Reading CCG 37.5%

NHS South Reading CCG 37.1%

NHS Newbury And District CCG 34.0%

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

9 KING EDWARD STREET K84605 62.0% BANBURY ROAD MEDICAL CENTRE K84021 55.9% BLOXHAM SURGERY K84058 54.8% WOODSTOCK SURGERY K84042 53.2% BICESTER HEALTH CENTRE K84052 50.4% HOLLOW WAY MEDICAL CENTRE K84048 48.4% MARCHAM RD FAMILY HEALTH CENTRE K84041 48.4% • achievement - 3 treatment targets: in WOODLANDS MEDICAL CENTRE K84043 46.0% KENNINGTON HEALTH CENTRE K84005 45.8% 28 BEAUMONT STREET K84080 45.2% practices who provided data via the LANGFORD MEDICAL PRACTICE K84613 45.1% THE KEY MEDICAL PRACTICE K84082 44.4% WINDRUSH MEDICAL PRACTICE K84017 44.3% SUMMERTOWN HEALTH CENTRE K84011 44.2% NDA, between 27.1% and 62.0% of THE ABINGDON SURGERY K84054 43.7% DEDDINGTON HEALTH CENTRE K84055 43.0% OAK TREE HEALTH CENTRE K84624 42.9% patients achieved all 3 treatment BAMPTON SURGERY K84010 42.5% COGGES SURGERY K84618 42.2% ST. CLEMENT'S SURGERY K84060 41.8% targets THE LEYS HEALTH CENTRE K84031 40.9% VICTORIA HOUSE SURGERY K84073 40.6% WHITE HORSE MEDICAL PRACTICE K84051 40.4% CHURCH STREET PRACTICE K84033 39.9% GOSFORD HILL MEDICAL CENTRE K84045 39.8% • at least 14,200 people did not meet ISLIP SURGERY K84003 39.5% NETTLEBED SURGERY K84015 39.5% DIDCOT HEALTH CENTRE PRACTICE K84002 39.3% the three treatment targets WYCHWOOD SURGERY K84046 39.1% BROADSHIRES HEALTH CENTRE K84075 38.9% NUFFIELD HEALTH CENTRE K84072 38.9% BURY KNOWLE HEALTH CENTRE K84009 38.8% THE RYCOTE PRACTICE K84050 38.5% 27 BEAUMONT STREET K84049 38.3% MANOR SURGERY K84044 38.1% THE BELL SURGERY K84035 37.9% 19 BEAUMONT STREET SURGERY K84016 37.8% EYNSHAM MEDICAL GROUP K84006 37.7% MONTGOMERY HOUSE SURGERY K84038 37.5% BOTLEY MEDICAL CENTRE K84025 37.4% BANBURY HEALTH CENTRE Y02754 37.4% LONG FURLONG MEDICAL CENTRE K84079 37.2% MORLAND HOUSE SURGERY K84014 36.8% WEST BAR SURGERY K84028 36.5% SONNING COMMON HEALTH CTR K84020 36.4% GORING & WOODCOTE MEDICAL PRACTICE K84071 36.3% CLIFTON HAMPDEN SURGERY K84034 35.7% BERINSFIELD HEALTH CENTRE K84023 35.3% MALTHOUSE SURGERY K84027 34.9% BURFORD SURGERY K84047 34.7% NORTH BICESTER SURGERY K84621 34.5% JERICHO HEALTH CENTRE K84078 34.2% DONNINGTON MEDICAL PARTNERSHIP K84004 33.7% CHIPPING NORTON HEALTH CENTRE K84030 33.6% CROPREDY SURGERY K84056 33.6% JERICHO HEALTH CENTRE (KEARLEY/CHIVERS) K84026 32.5% WINDRUSH SURGERY K84024 31.9% CHALGROVE & WATLINGTON SURGERIES K84008 31.9% THE HART SURGERY K84001 30.9% COWLEY ROAD MEDICAL PRACTICE K84063 30.0% WALLINGFORD MEDICAL PRACTICE K84037 29.8% ST. BARTHOLEMEW'S MEDICAL CENTRE K84013 29.3% BARTLEMAS SURGERY K84032 28.9% TEMPLE COWLEY HEALTH CENTRE K84007 28.5% HIGHTOWN SURGERY K84059 28.4% WOODLANDS SURGERY K84062 27.1% DEER PARK MEDICAL CENTRE K84622 WOOD FARM HEALTH CENTRE K84620 SOUTH OXFORD HEALTH CENTRE K84617 THE CHARLBURY MEDICAL CENTRE K84610 MARSTON MEDICAL CENTRE K84076 LUTHER STREET MEDICAL PRACTICE K84066 SIBFORD SURGERY K84065 HORSEFAIR SURGERY K84040 MILL STREAM SURGERY K84036 NEWBURY STREET PRACTICE K84019 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

50 CVD: Primary Care Intelligence Packs People with diabetes who met all 3 treatment targets by GP practice, 2015/16 - opportunities compared to GP cluster

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

TEMPLE COWLEY HEALTH CENTRE 70

WOODLANDS SURGERY 49

HIGHTOWN SURGERY 70 • using the GP cluster method of THE HART SURGERY 42 calculating potential gains, if each CHALGROVE & WATLINGTON SURGERIES 41 practice was to achieve as well as the WINDRUSH SURGERY 58 upper quartile of its national cluster, then an additional 1,445 people would ST. BARTHOLEMEW'S MEDICAL CENTRE 40 be treated BARTLEMAS SURGERY 60

WALLINGFORD MEDICAL PRACTICE 71

COWLEY ROAD MEDICAL PRACTICE 25

KENNINGTON HEALTH CENTRE

28 BEAUMONT STREET

LANGFORD MEDICAL PRACTICE

HOLLOW WAY MEDICAL CENTRE

MARCHAM RD FAMILY HEALTH CENTRE

BICESTER HEALTH CENTRE

BLOXHAM SURGERY

WOODSTOCK SURGERY

BANBURY ROAD MEDICAL CENTRE

9 KING EDWARD STREET 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 South Reading CCG 0.73

NHS North & West Reading CCG 0.67 • the ratio of those diagnosed with chronic kidney disease versus those

NHS Wokingham CCG 0.63 expected to have chronic kidney disease is 0.59. This compares to 0.68 for England NHS Newbury And District CCG 0.61 • this suggests that 59% of people with chronic kidney disease have been diagnosed NHS Oxfordshire CCG 0.59

NHS Aylesbury Vale CCG 0.52

NHS Chiltern CCG 0.51

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 Gloucestershire CCG 0.98

NHS Southern Derbyshire CCG 0.81

NHS Kernow CCG 0.72

NHS Northern, Eastern and Western Devon CCG 0.67

NHS Nene CCG 0.67

NHS Somerset CCG 0.64

NHS Bedfordshire CCG 0.59

NHS Oxfordshire CCG 0.59

NHS Herts Valleys CCG 0.56

NHS East and North Hertfordshire CCG 0.55

NHS Cambridgeshire and Peterborough CCG 0.51

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

NETTLEBED SURGERY K84015 7.7% EYNSHAM MEDICAL GROUP K84006 6.9% KENNINGTON HEALTH CENTRE K84005 6.2% THE KEY MEDICAL PRACTICE K84082 6.0% WOODSTOCK SURGERY K84042 5.9% MARCHAM RD FAMILY HEALTH CENTRE K84041 5.2% SIBFORD SURGERY K84065 5.1% DONNINGTON MEDICAL PARTNERSHIP K84004 5.0% WOODLANDS MEDICAL CENTRE K84043 4.9% GORING & WOODCOTE MEDICAL PRACTICE K84071 4.9% • it is estimated that there are 14,025 MORLAND HOUSE SURGERY K84014 4.8% BLOXHAM SURGERY K84058 4.8% MONTGOMERY HOUSE SURGERY K84038 4.7% people with undiagnosed chronic HORSEFAIR SURGERY K84040 4.7% WYCHWOOD SURGERY K84046 4.7% MALTHOUSE SURGERY K84027 4.7% kidney disease in NHS Oxfordshire CHALGROVE & WATLINGTON SURGERIES K84008 4.6% WINDRUSH SURGERY K84024 4.5% CHIPPING NORTON HEALTH CENTRE K84030 4.4% CCG HOLLOW WAY MEDICAL CENTRE K84048 4.3% THE BELL SURGERY K84035 4.3% OAK TREE HEALTH CENTRE K84624 4.3% • GP practice range of observed CKD: BAMPTON SURGERY K84010 4.2% COGGES SURGERY K84618 4.2% DIDCOT HEALTH CENTRE PRACTICE K84002 4.1% SONNING COMMON HEALTH CTR K84020 4.1% 0.0% to 7.7% DEER PARK MEDICAL CENTRE K84622 4.1% BICESTER HEALTH CENTRE K84052 4.0% BERINSFIELD HEALTH CENTRE K84023 3.9% NEWBURY STREET PRACTICE K84019 3.9% SUMMERTOWN HEALTH CENTRE K84011 3.7% THE ABINGDON SURGERY K84054 3.7% CHURCH STREET PRACTICE K84033 3.7% WALLINGFORD MEDICAL PRACTICE K84037 3.6% CLIFTON HAMPDEN SURGERY K84034 3.5% NUFFIELD HEALTH CENTRE K84072 3.5% BOTLEY MEDICAL CENTRE K84025 3.5% WINDRUSH MEDICAL PRACTICE K84017 3.4% WOODLANDS SURGERY K84062 3.4% WHITE HORSE MEDICAL PRACTICE K84051 3.3% CROPREDY SURGERY K84056 3.3% BURFORD SURGERY K84047 3.2% HIGHTOWN SURGERY K84059 3.2% LANGFORD MEDICAL PRACTICE K84613 3.1% THE LEYS HEALTH CENTRE K84031 3.1% LONG FURLONG MEDICAL CENTRE K84079 3.0% NORTH BICESTER SURGERY K84621 3.0% ISLIP SURGERY K84003 2.9% THE RYCOTE PRACTICE K84050 2.8% DEDDINGTON HEALTH CENTRE K84055 2.7% SOUTH OXFORD HEALTH CENTRE K84617 2.6% THE CHARLBURY MEDICAL CENTRE K84610 2.5% VICTORIA HOUSE SURGERY K84073 2.5% MANOR SURGERY K84044 2.5% BURY KNOWLE HEALTH CENTRE K84009 2.4% BROADSHIRES HEALTH CENTRE K84075 2.4% JERICHO HEALTH CENTRE (KEARLEY/CHIVERS) K84026 2.4% BARTLEMAS SURGERY K84032 2.4% WEST BAR SURGERY K84028 2.3% GOSFORD HILL MEDICAL CENTRE K84045 2.1% THE HART SURGERY K84001 1.9% MARSTON MEDICAL CENTRE K84076 1.7% 19 BEAUMONT STREET SURGERY K84016 1.7% TEMPLE COWLEY HEALTH CENTRE K84007 1.7% BANBURY ROAD MEDICAL CENTRE K84021 1.6% WOOD FARM HEALTH CENTRE K84620 1.6% 28 BEAUMONT STREET K84080 1.6% Note: CCG estimates for the estimated ST. CLEMENT'S SURGERY K84060 1.3% 27 BEAUMONT STREET K84049 1.2% COWLEY ROAD MEDICAL PRACTICE K84063 1.0% number of people with CKD are based on MILL STREAM SURGERY K84036 0.9% BANBURY HEALTH CENTRE Y02754 0.8% applying a proportion from a resident based 9 KING EDWARD STREET K84605 0.7% ST. BARTHOLEMEW'S MEDICAL CENTRE K84013 0.6% JERICHO HEALTH CENTRE K84078 0.6% population estimate to a GP registered LUTHER STREET MEDICAL PRACTICE K84066 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 Aylesbury Vale CCG 78.0% • 19,571 people with CKD (diagnosed*) NHS North & West Reading CCG 76.6% in NHS Oxfordshire CCG • 14,583 (74.5%) people whose blood pressure is <= 140 /85 NHS Chiltern CCG 75.9% • 1,678 (8.6%) people who are exceptions • 3,310 (16.9%) additional people NHS Wokingham CCG 75.5% whose blood pressure is not <= 140 / 85 NHS South Reading CCG 75.1%

NHS Oxfordshire CCG 74.5%

NHS Newbury And District CCG 73.6%

*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 Nene CCG 75.5%

NHS Herts Valleys CCG 75.4%

NHS Oxfordshire CCG 74.5%

NHS Gloucestershire CCG 74.4%

NHS East and North Hertfordshire CCG 73.7%

NHS Southern Derbyshire CCG 72.7%

NHS Kernow CCG 72.5%

NHS Cambridgeshire and Peterborough CCG 71.5%

NHS Northern, Eastern and Western Devon CCG 71.1%

NHS Bedfordshire CCG 71.0%

NHS Somerset CCG 67.3%

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

BARTLEMAS SURGERY K84032 78 MANOR SURGERY K84044 114 WHITE HOUSE SURGERY K84039 130 WOODLANDS SURGERY K84062 53 MONTGOMERY HOUSE SURGERY K84038 185 GORING AND WOODCOTE MEDICAL PRACTICE K84071 133 EYNSHAM MEDICAL GROUP K84006 277 OAK TREE HEALTH CENTRE K84624 106 VICTORIA HOUSE SURGERY K84073 52 TEMPLE COWLEY HEALTH CENTRE K84007 28 • in total, including exceptions, there MARSTON MEDICAL CENTRE K84076 24 THE HART SURGERY K84001 56 WOOD FARM HEALTH CENTRE K84620 4 are 4,988 people whose blood CLIFTON HAMPDEN SURGERY K84034 32 DEER PARK MEDICAL CENTRE K84622 41 THE WYCHWOOD SURGERY K84046 73 CROPREDY SURGERY K84056 28 pressure is not <= 140 / 85 THE MALTHOUSE SURGERY K84027 199 WINDRUSH SURGERY K84024 86 MILL STREAM SURGERY K84036 11 • GP practice range: 10.7% to 46.2% DONNINGTON MEDICAL PARTNERSHIP K84004 187 JERICHO HEALTH CENTRE BOGDANOR K84078 12 COWLEY ROAD MEDICAL PRACTICE K84063 19 ST BARTHOLOMEWS MEDICAL CENTRE K84013 35 THE BELL SURGERY K84035 89 28 BEAUMONT STREET SURGERY K84080 12 THE LEYS HEALTH CENTRE K84031 49 DEDDINGTON HEALTH CENTRE K84055 56 SONNING COMMON HEALTH CTR K84020 80 27 BEAUMONT STREET K84049 24 HIGHTOWN SURGERY K84059 75 WHITE HORSE MEDICAL PRACTICE K84051 99 19 BEAUMONT STREET K84016 52 WOODSTOCK SURGERY K84042 111 KENNINGTON HEALTH CENTRE K84005 87 WEST BAR SURGERY K84028 75 LANGFORD MEDICAL PRACTICE K84613 58 SIBFORD SURGERY K84065 30 CHALGROVE & WATLINGTON SURGERIES K84008 75 HORSE FAIR SURGERY K84040 103 BURY KNOWLE HEALTH CENTRE K84009 86 DIDCOT HEALTH CENTRE PRACTICE K84002 137 CHIPPING NORTON HEALTH CENTRE K84030 39 WALLINGFORD MEDICAL PRACTICE K84037 110 NUFFIELD HEALTH CENTRE K84072 79 JERICHO HEALTH CENTRE (KEARLEY) K84026 47 GROVE MEDICAL CENTRE K84074 26 THE RYCOTE PRACTICE K84050 54 THE ABINGDON SURGERY K84054 86 LONG FURLONG MEDICAL CENTRE K84079 39 BANBURY ROAD MEDICAL CENTRE K84021 24 NORTH BICESTER SURGERY K84621 20 SOUTH OXFORD HEALTH CENTRE K84617 18 BERINSFIELD HEALTH CENTRE K84023 18 CHURCH STREET PRACTICE K84033 84 SUMMERTOWN HEALTH CENTRE K84011 93 BOTLEY MEDICAL CENTRE K84025 45 BURFORD SURGERY K84047 32 DR PANDHER & EVANS AND PARTNERS K84082 74 BANBURY HEALTH CENTRE Y02754 6 MORLAND HOUSE SURGERY K84014 81 BROADSHIRES HEALTH CENTRE K84075 33 NEWBURY STREET PRACTICE K84019 75 EXETER SURGERY K84022 47 WINDRUSH MEDICAL PRACTICE K84017 77 THE HEALTH CENTRE K84052 73 GOSFORD HILL MEDICAL CENTRE K84045 18 HOLLOW WAY MEDICAL CENTRE K84048 55 ISLIP SURGERY K84003 27 COGGES SURGERY K84618 39 BLOXHAM SURGERY K84058 52 NETTLEBED SURGERY K84015 36 BAMPTON SURGERY K84010 51 KING EDWARD STREET SURGERY K84605 2 MARCHAM RD FAMILY HEALTH CENTRE K84041 78 THE CHARLBURY MEDICAL CENTRE K84610 18 ST CLEMENTS SURGERY K84060 5 WOODLANDS MEDICAL CENTRE K84043 58 FERN HILL PRACTICE K84077 8 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%

BARTLEMAS SURGERY 43

MANOR SURGERY 58

WOODLANDS SURGERY 29 • using the GP cluster method of OAK TREE HEALTH CENTRE 59 calculating potential gains, if each VICTORIA HOUSE SURGERY 27 practice was to achieve as well as the TEMPLE COWLEY HEALTH CENTRE 14 upper quartile of its national cluster, then an additional 1,142 people would MARSTON MEDICAL CENTRE 12 be treated WOOD FARM HEALTH CENTRE 2

MONTGOMERY HOUSE SURGERY 82

THE HART SURGERY 26

BROADSHIRES HEALTH CENTRE

NETTLEBED SURGERY

CHURCH STREET PRACTICE

ST CLEMENTS SURGERY

NEWBURY STREET PRACTICE

GOSFORD HILL MEDICAL CENTRE

THE CHARLBURY MEDICAL CENTRE

BAMPTON SURGERY

MARCHAM RD FAMILY HEALTH CENTRE

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

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

NHS North & West Reading CCG 80.5% • 19,582 people with CKD (diagnosed*) NHS Aylesbury Vale CCG 77.2% in NHS Oxfordshire CCG • 15,040 (76.8%) people who have a record of urine albumin:creatinine NHS Newbury And District CCG 77.0% ratio test • 1,294 (6.6%) people who are exceptions NHS Oxfordshire CCG 76.8% • 3,248 (16.6%) additional people who have no record of urine NHS Wokingham CCG 75.6% albumin:creatinine ratio test

NHS South Reading CCG 75.5%

NHS Chiltern CCG 73.9%

*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 Southern Derbyshire CCG 78.6%

NHS Herts Valleys CCG 77.1%

NHS Kernow CCG 77.0%

NHS Oxfordshire CCG 76.8%

NHS Northern, Eastern and Western Devon CCG 75.8%

NHS Nene CCG 75.3%

NHS Bedfordshire CCG 74.6%

NHS East and North Hertfordshire CCG 74.4%

NHS Gloucestershire CCG 74.1%

NHS Cambridgeshire and Peterborough CCG 73.7%

NHS Somerset CCG 61.5%

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 BELL SURGERY K84035 137 TEMPLE COWLEY HEALTH CENTRE K84007 34 BARTLEMAS SURGERY K84032 69 OAK TREE HEALTH CENTRE K84624 116 MANOR SURGERY K84044 108 LONG FURLONG MEDICAL CENTRE K84079 70 WEST BAR SURGERY K84028 107 CROPREDY SURGERY K84056 31 THE ABINGDON SURGERY K84054 136 HORSE FAIR SURGERY K84040 142 • in total, including exceptions, there THE HART SURGERY K84001 54 COWLEY ROAD MEDICAL PRACTICE K84063 20 THE LEYS HEALTH CENTRE K84031 52 are 4,542 people who have no record BAMPTON SURGERY K84010 85 MONTGOMERY HOUSE SURGERY K84038 145 KENNINGTON HEALTH CENTRE K84005 95 ST BARTHOLOMEWS MEDICAL CENTRE K84013 33 of urine albumin:creatinine ratio test CHIPPING NORTON HEALTH CENTRE K84030 46 THE MALTHOUSE SURGERY K84027 175 BANBURY ROAD MEDICAL CENTRE K84021 30 • GP practice range: 0.0% to 44.6% WHITE HOUSE SURGERY K84039 90 HIGHTOWN SURGERY K84059 71 BURY KNOWLE HEALTH CENTRE K84009 92 JERICHO HEALTH CENTRE (KEARLEY) K84026 53 JERICHO HEALTH CENTRE BOGDANOR K84078 10 SONNING COMMON HEALTH CTR K84020 71 MARCHAM RD FAMILY HEALTH CENTRE K84041 125 MORLAND HOUSE SURGERY K84014 99 DEER PARK MEDICAL CENTRE K84622 31 WHITE HORSE MEDICAL PRACTICE K84051 87 WINDRUSH SURGERY K84024 66 NUFFIELD HEALTH CENTRE K84072 79 EYNSHAM MEDICAL GROUP K84006 179 MARSTON MEDICAL CENTRE K84076 16 HOLLOW WAY MEDICAL CENTRE K84048 66 DEDDINGTON HEALTH CENTRE K84055 45 GORING AND WOODCOTE MEDICAL PRACTICE K84071 83 WOODLANDS SURGERY K84062 32 BROADSHIRES HEALTH CENTRE K84075 36 19 BEAUMONT STREET K84016 41 VICTORIA HOUSE SURGERY K84073 31 NEWBURY STREET PRACTICE K84019 80 DONNINGTON MEDICAL PARTNERSHIP K84004 129 THE RYCOTE PRACTICE K84050 52 DIDCOT HEALTH CENTRE PRACTICE K84002 119 CHALGROVE & WATLINGTON SURGERIES K84008 62 THE WYCHWOOD SURGERY K84046 47 ST CLEMENTS SURGERY K84060 7 NORTH BICESTER SURGERY K84621 19 WINDRUSH MEDICAL PRACTICE K84017 74 WALLINGFORD MEDICAL PRACTICE K84037 87 GROVE MEDICAL CENTRE K84074 21 DR PANDHER & EVANS AND PARTNERS K84082 65 27 BEAUMONT STREET K84049 15 THE HEALTH CENTRE K84052 65 WOODSTOCK SURGERY K84042 72 SUMMERTOWN HEALTH CENTRE K84011 77 BLOXHAM SURGERY K84058 48 SIBFORD SURGERY K84065 20 NETTLEBED SURGERY K84015 34 THE CHARLBURY MEDICAL CENTRE K84610 19 GOSFORD HILL MEDICAL CENTRE K84045 14 CHURCH STREET PRACTICE K84033 60 WOODLANDS MEDICAL CENTRE K84043 62 FERN HILL PRACTICE K84077 12 MILL STREAM SURGERY K84036 5 BERINSFIELD HEALTH CENTRE K84023 12 BANBURY HEALTH CENTRE Y02754 4 BURFORD SURGERY K84047 21 COGGES SURGERY K84618 28 ISLIP SURGERY K84003 19 CLIFTON HAMPDEN SURGERY K84034 12 28 BEAUMONT STREET SURGERY K84080 5 LANGFORD MEDICAL PRACTICE K84613 27 BOTLEY MEDICAL CENTRE K84025 25 EXETER SURGERY K84022 27 SOUTH OXFORD HEALTH CENTRE K84617 8 WOOD FARM HEALTH CENTRE K84620 1 KING EDWARD STREET SURGERY K84605 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 Aylesbury Vale CCG 0.67%

NHS Oxfordshire CCG 0.63% • prevalence of 0.63% in NHS Oxfordshire CCG compared to 0.76% in England NHS North & West Reading CCG 0.62%

NHS Newbury And District CCG 0.59%

NHS Wokingham CCG 0.56%

NHS Chiltern CCG 0.56%

NHS South Reading CCG 0.41%

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 Kernow CCG 1.03%

NHS Southern Derbyshire CCG 0.92%

NHS Somerset CCG 0.89%

NHS Northern, Eastern and Western Devon CCG 0.88%

NHS Gloucestershire CCG 0.77%

NHS Nene CCG 0.77%

NHS Bedfordshire CCG 0.66%

NHS Oxfordshire CCG 0.63%

NHS East and North Hertfordshire CCG 0.62%

NHS Cambridgeshire and Peterborough CCG 0.61%

NHS Herts Valleys CCG 0.59%

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

KENNINGTON HEALTH CENTRE K84005 1.4% HORSEFAIR SURGERY K84040 1.2% EYNSHAM MEDICAL GROUP K84006 1.1% NUFFIELD HEALTH CENTRE K84072 1.1% MONTGOMERY HOUSE SURGERY K84038 1.1% NETTLEBED SURGERY K84015 1.0% WALLINGFORD MEDICAL PRACTICE K84037 1.0% THE KEY MEDICAL PRACTICE K84082 1.0% BERINSFIELD HEALTH CENTRE K84023 1.0% SONNING COMMON HEALTH CTR K84020 0.9% • 4,524 people with diagnosed heart CHIPPING NORTON HEALTH CENTRE K84030 0.9% SOUTH OXFORD HEALTH CENTRE K84617 0.9% CHURCH STREET PRACTICE K84033 0.9% failure in NHS Oxfordshire CCG BOTLEY MEDICAL CENTRE K84025 0.8% WOODSTOCK SURGERY K84042 0.8% MILL STREAM SURGERY K84036 0.8% • GP practice range: 0.1% to 1.4% MALTHOUSE SURGERY K84027 0.8% GORING & WOODCOTE MEDICAL PRACTICE K84071 0.8% THE BELL SURGERY K84035 0.7% ISLIP SURGERY K84003 0.7% BROADSHIRES HEALTH CENTRE K84075 0.7% THE LEYS HEALTH CENTRE K84031 0.7% WHITE HORSE MEDICAL PRACTICE K84051 0.7% NEWBURY STREET PRACTICE K84019 0.7% CLIFTON HAMPDEN SURGERY K84034 0.7% BAMPTON SURGERY K84010 0.7% WINDRUSH SURGERY K84024 0.6% HIGHTOWN SURGERY K84059 0.6% GOSFORD HILL MEDICAL CENTRE K84045 0.6% DEDDINGTON HEALTH CENTRE K84055 0.6% TEMPLE COWLEY HEALTH CENTRE K84007 0.6% WINDRUSH MEDICAL PRACTICE K84017 0.6% DEER PARK MEDICAL CENTRE K84622 0.6% MORLAND HOUSE SURGERY K84014 0.6% BICESTER HEALTH CENTRE K84052 0.6% DONNINGTON MEDICAL PARTNERSHIP K84004 0.6% THE ABINGDON SURGERY K84054 0.6% HOLLOW WAY MEDICAL CENTRE K84048 0.6% MANOR SURGERY K84044 0.6% THE RYCOTE PRACTICE K84050 0.6% BURFORD SURGERY K84047 0.6% SUMMERTOWN HEALTH CENTRE K84011 0.6% MARCHAM RD FAMILY HEALTH CENTRE K84041 0.6% WOODLANDS MEDICAL CENTRE K84043 0.5% BLOXHAM SURGERY K84058 0.5% DIDCOT HEALTH CENTRE PRACTICE K84002 0.5% SIBFORD SURGERY K84065 0.5% WOOD FARM HEALTH CENTRE K84620 0.5% BURY KNOWLE HEALTH CENTRE K84009 0.5% WEST BAR SURGERY K84028 0.5% CHALGROVE & WATLINGTON SURGERIES K84008 0.5% 28 BEAUMONT STREET K84080 0.5% WYCHWOOD SURGERY K84046 0.5% THE CHARLBURY MEDICAL CENTRE K84610 0.5% WOODLANDS SURGERY K84062 0.5% BARTLEMAS SURGERY K84032 0.5% CROPREDY SURGERY K84056 0.5% COGGES SURGERY K84618 0.5% THE HART SURGERY K84001 0.4% COWLEY ROAD MEDICAL PRACTICE K84063 0.4% JERICHO HEALTH CENTRE (KEARLEY/CHIVERS) K84026 0.4% 19 BEAUMONT STREET SURGERY K84016 0.4% ST. CLEMENT'S SURGERY K84060 0.4% OAK TREE HEALTH CENTRE K84624 0.3% VICTORIA HOUSE SURGERY K84073 0.3% LANGFORD MEDICAL PRACTICE K84613 0.3% LUTHER STREET MEDICAL PRACTICE K84066 0.3% MARSTON MEDICAL CENTRE K84076 0.3% NORTH BICESTER SURGERY K84621 0.3% BANBURY ROAD MEDICAL CENTRE K84021 0.2% LONG FURLONG MEDICAL CENTRE K84079 0.2% BANBURY HEALTH CENTRE Y02754 0.2% JERICHO HEALTH CENTRE K84078 0.2% 27 BEAUMONT STREET K84049 0.2% ST. BARTHOLEMEW'S MEDICAL CENTRE K84013 0.2% 9 KING EDWARD STREET K84605 0.1% 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6%

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 Aylesbury Vale CCG 88.9% • 1,448 people with heart failure* with NHS Chiltern CCG 87.7% LVSD in NHS Oxfordshire CCG • 1,200 (82.9%) people treated with ACE-I or ARB NHS Wokingham CCG 85.7% • 243 (16.8%) people who are exceptions • 5 (0.3%) additional people who are NHS Newbury And District CCG 84.3% not treated with ACE-I or ARB

NHS Oxfordshire CCG 82.9%

NHS North & West Reading CCG 82.0%

NHS South Reading CCG 80.8%

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 East and North Hertfordshire CCG 87.4%

NHS Gloucestershire CCG 85.4%

NHS Nene CCG 84.1%

NHS Herts Valleys CCG 83.3%

NHS Oxfordshire CCG 82.9%

NHS Northern, Eastern and Western Devon CCG 82.6%

NHS Bedfordshire CCG 82.3%

NHS Kernow CCG 81.0%

NHS Southern Derbyshire CCG 80.8%

NHS Somerset CCG 80.1%

NHS Cambridgeshire and Peterborough CCG 80.1%

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

CLIFTON HAMPDEN SURGERY K84034 2 THE HART SURGERY K84001 1 NETTLEBED SURGERY K84015 7 CHALGROVE & WATLINGTON SURGERIES K84008 4 BANBURY ROAD MEDICAL CENTRE K84021 3 CHIPPING NORTON HEALTH CENTRE K84030 4 SONNING COMMON HEALTH CTR K84020 7 CROPREDY SURGERY K84056 1 COWLEY ROAD MEDICAL PRACTICE K84063 1 SIBFORD SURGERY K84065 1 • in total, including exceptions, there OAK TREE HEALTH CENTRE K84624 2 MILL STREAM SURGERY K84036 6 WOODLANDS SURGERY K84062 5 are 248 people who are not treated CHURCH STREET PRACTICE K84033 10 THE RYCOTE PRACTICE K84050 2 JERICHO HEALTH CENTRE (KEARLEY/CHIVERS) K84026 5 with ACE-I or ARB KENNINGTON HEALTH CENTRE K84005 3 SUMMERTOWN HEALTH CENTRE K84011 3 BOTLEY MEDICAL CENTRE K84025 4 • GP practice range: 0.0% to 66.7% 19 BEAUMONT STREET SURGERY K84016 4 THE LEYS HEALTH CENTRE K84031 4 THE BELL SURGERY K84035 3 WOODSTOCK SURGERY K84042 2 NUFFIELD HEALTH CENTRE K84072 12 WEST BAR SURGERY K84028 7 NEWBURY STREET PRACTICE K84019 4 HORSEFAIR SURGERY K84040 29 MANOR SURGERY K84044 6 WHITE HORSE MEDICAL PRACTICE K84051 6 EYNSHAM MEDICAL GROUP K84006 7 LANGFORD MEDICAL PRACTICE K84613 2 WOOD FARM HEALTH CENTRE K84620 1 GOSFORD HILL MEDICAL CENTRE K84045 4 HIGHTOWN SURGERY K84059 6 THE KEY MEDICAL PRACTICE K84082 10 TEMPLE COWLEY HEALTH CENTRE K84007 1 BROADSHIRES HEALTH CENTRE K84075 6 DIDCOT HEALTH CENTRE PRACTICE K84002 7 DEDDINGTON HEALTH CENTRE K84055 3 WINDRUSH MEDICAL PRACTICE K84017 8 THE ABINGDON SURGERY K84054 3 DONNINGTON MEDICAL PARTNERSHIP K84004 5 MALTHOUSE SURGERY K84027 7 BAMPTON SURGERY K84010 5 COGGES SURGERY K84618 2 ISLIP SURGERY K84003 2 VICTORIA HOUSE SURGERY K84073 2 WALLINGFORD MEDICAL PRACTICE K84037 3 MONTGOMERY HOUSE SURGERY K84038 2 MARCHAM RD FAMILY HEALTH CENTRE K84041 2 MORLAND HOUSE SURGERY K84014 3 GORING & WOODCOTE MEDICAL PRACTICE K84071 1 HOLLOW WAY MEDICAL CENTRE K84048 2 BICESTER HEALTH CENTRE K84052 3 BURFORD SURGERY K84047 1 BURY KNOWLE HEALTH CENTRE K84009 2 ST. BARTHOLEMEW'S MEDICAL CENTRE K84013 BERINSFIELD HEALTH CENTRE K84023 WINDRUSH SURGERY K84024 BARTLEMAS SURGERY K84032 WOODLANDS MEDICAL CENTRE K84043 WYCHWOOD SURGERY K84046 27 BEAUMONT STREET K84049 BLOXHAM SURGERY K84058 ST. CLEMENT'S SURGERY K84060 MARSTON MEDICAL CENTRE K84076 JERICHO HEALTH CENTRE K84078 LONG FURLONG MEDICAL CENTRE K84079 28 BEAUMONT STREET K84080 9 KING EDWARD STREET K84605 THE CHARLBURY MEDICAL CENTRE K84610 SOUTH OXFORD HEALTH CENTRE K84617 NORTH BICESTER SURGERY K84621 DEER PARK MEDICAL CENTRE K84622 BANBURY HEALTH CENTRE Y02754 LUTHER STREET MEDICAL PRACTICE K84066 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 North & West Reading CCG 85.0% • 1,201 people with heart failure* with NHS Wokingham CCG 82.2% LVSD treated with ACE-I/ARB in NHS Oxfordshire CCG • 854 (71.1%) people treated with ACE- NHS Newbury And District CCG 79.6% I/ARB and BB • 255 (21.2%) people who are exceptions NHS Chiltern CCG 77.3% • 92 (7.7%) additional people who are not treated with ACE-I/ARB and BB NHS South Reading CCG 74.2%

NHS Aylesbury Vale CCG 74.1%

NHS Oxfordshire CCG 71.1%

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 Bedfordshire CCG 79.4%

NHS Nene CCG 78.7%

NHS Herts Valleys CCG 78.1%

NHS East and North Hertfordshire CCG 76.8%

NHS Gloucestershire CCG 75.9%

NHS Kernow CCG 73.4%

NHS Somerset CCG 72.5%

NHS Southern Derbyshire CCG 72.2%

NHS Northern, Eastern and Western Devon CCG 71.9%

NHS Oxfordshire CCG 71.1%

NHS Cambridgeshire and Peterborough CCG 69.4%

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

CROPREDY SURGERY K84056 2 SUMMERTOWN HEALTH CENTRE K84011 5 MARSTON MEDICAL CENTRE K84076 4 BOTLEY MEDICAL CENTRE K84025 6 27 BEAUMONT STREET K84049 1 BLOXHAM SURGERY K84058 2 VICTORIA HOUSE SURGERY K84073 8 COGGES SURGERY K84618 7 WHITE HORSE MEDICAL PRACTICE K84051 11 MALTHOUSE SURGERY K84027 20 • in total, including exceptions, there GOSFORD HILL MEDICAL CENTRE K84045 7 DEDDINGTON HEALTH CENTRE K84055 7 NETTLEBED SURGERY K84015 4 are 347 people who are not treated THE RYCOTE PRACTICE K84050 2 LONG FURLONG MEDICAL CENTRE K84079 4 NUFFIELD HEALTH CENTRE K84072 15 with ACE-I or ARB WINDRUSH MEDICAL PRACTICE K84017 19 SOUTH OXFORD HEALTH CENTRE K84617 6 EYNSHAM MEDICAL GROUP K84006 10 • GP practice range: 0.0% to 66.7% HORSEFAIR SURGERY K84040 41 MORLAND HOUSE SURGERY K84014 11 MANOR SURGERY K84044 8 ST. BARTHOLEMEW'S MEDICAL CENTRE K84013 2 19 BEAUMONT STREET SURGERY K84016 4 THE LEYS HEALTH CENTRE K84031 4 WOODSTOCK SURGERY K84042 2 WOODLANDS SURGERY K84062 4 BAMPTON SURGERY K84010 11 BURY KNOWLE HEALTH CENTRE K84009 12 SONNING COMMON HEALTH CTR K84020 4 BROADSHIRES HEALTH CENTRE K84075 9 NEWBURY STREET PRACTICE K84019 4 DONNINGTON MEDICAL PARTNERSHIP K84004 9 KENNINGTON HEALTH CENTRE K84005 2 WOODLANDS MEDICAL CENTRE K84043 2 LANGFORD MEDICAL PRACTICE K84613 2 WOOD FARM HEALTH CENTRE K84620 1 BICESTER HEALTH CENTRE K84052 11 HIGHTOWN SURGERY K84059 7 JERICHO HEALTH CENTRE (KEARLEY/CHIVERS) K84026 3 THE KEY MEDICAL PRACTICE K84082 11 MONTGOMERY HOUSE SURGERY K84038 4 WEST BAR SURGERY K84028 5 TEMPLE COWLEY HEALTH CENTRE K84007 1 ST. CLEMENT'S SURGERY K84060 1 WALLINGFORD MEDICAL PRACTICE K84037 5 CHALGROVE & WATLINGTON SURGERIES K84008 1 MARCHAM RD FAMILY HEALTH CENTRE K84041 3 HOLLOW WAY MEDICAL CENTRE K84048 4 DIDCOT HEALTH CENTRE PRACTICE K84002 6 MILL STREAM SURGERY K84036 2 BARTLEMAS SURGERY K84032 1 BERINSFIELD HEALTH CENTRE K84023 1 CHURCH STREET PRACTICE K84033 3 BURFORD SURGERY K84047 2 DEER PARK MEDICAL CENTRE K84622 1 THE ABINGDON SURGERY K84054 2 GORING & WOODCOTE MEDICAL PRACTICE K84071 1 THE HART SURGERY K84001 ISLIP SURGERY K84003 BANBURY ROAD MEDICAL CENTRE K84021 WINDRUSH SURGERY K84024 CHIPPING NORTON HEALTH CENTRE K84030 CLIFTON HAMPDEN SURGERY K84034 THE BELL SURGERY K84035 WYCHWOOD SURGERY K84046 COWLEY ROAD MEDICAL PRACTICE K84063 SIBFORD SURGERY K84065 JERICHO HEALTH CENTRE K84078 28 BEAUMONT STREET K84080 9 KING EDWARD STREET K84605 THE CHARLBURY MEDICAL CENTRE K84610 NORTH BICESTER SURGERY K84621 OAK TREE HEALTH CENTRE K84624 BANBURY HEALTH CENTRE Y02754 LUTHER STREET MEDICAL PRACTICE K84066 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 Chiltern CCG 90.0% • 17,759 people with coronary heart NHS Newbury And District CCG 89.6% disease* in NHS Oxfordshire CCG • 15,716 (88.5%) people whose blood pressure <= 150 / 90 NHS North & West Reading CCG 89.5% • 746 (4.2%) people who are exceptions • 1,297 (7.3%) additional people whose NHS South Reading CCG 89.4% blood pressure is not <= 150 / 90

NHS Wokingham CCG 88.7%

NHS Oxfordshire CCG 88.5%

NHS Aylesbury Vale CCG 87.2%

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 Herts Valleys CCG 89.5%

NHS Nene CCG 88.9%

NHS Kernow CCG 88.5%

NHS Oxfordshire CCG 88.5%

NHS East and North Hertfordshire CCG 88.3%

NHS Gloucestershire CCG 88.2%

NHS Bedfordshire CCG 87.9%

NHS Northern, Eastern and Western Devon CCG 87.6%

NHS Southern Derbyshire CCG 87.6%

NHS Cambridgeshire and Peterborough CCG 86.2%

NHS Somerset CCG 82.4%

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

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

Not below 150/90 Exceptions reported

LUTHER STREET MEDICAL PRACTICE K84066 3 CROPREDY SURGERY K84056 23 NEWBURY STREET PRACTICE K84019 94 DONNINGTON MEDICAL PARTNERSHIP K84004 72 MALTHOUSE SURGERY K84027 120 MONTGOMERY HOUSE SURGERY K84038 76 COWLEY ROAD MEDICAL PRACTICE K84063 20 NORTH BICESTER SURGERY K84621 12 BARTLEMAS SURGERY K84032 30 WINDRUSH SURGERY K84024 39 • in total, including exceptions, there WEST BAR SURGERY K84028 89 CHALGROVE & WATLINGTON SURGERIES K84008 36 ST. BARTHOLEMEW'S MEDICAL CENTRE K84013 20 are 2,043 people whose blood MANOR SURGERY K84044 58 TEMPLE COWLEY HEALTH CENTRE K84007 42 DEER PARK MEDICAL CENTRE K84622 12 pressure is not <= 150 / 90 28 BEAUMONT STREET K84080 10 EYNSHAM MEDICAL GROUP K84006 58 SOUTH OXFORD HEALTH CENTRE K84617 7 • GP practice range: 3.7% to 33.3% MARCHAM RD FAMILY HEALTH CENTRE K84041 50 WOODLANDS SURGERY K84062 20 SIBFORD SURGERY K84065 13 MARSTON MEDICAL CENTRE K84076 14 HIGHTOWN SURGERY K84059 43 BURFORD SURGERY K84047 22 OAK TREE HEALTH CENTRE K84624 14 JERICHO HEALTH CENTRE K84078 6 GORING & WOODCOTE MEDICAL PRACTICE K84071 37 THE LEYS HEALTH CENTRE K84031 30 BERINSFIELD HEALTH CENTRE K84023 20 WALLINGFORD MEDICAL PRACTICE K84037 53 WHITE HORSE MEDICAL PRACTICE K84051 46 THE BELL SURGERY K84035 28 CHIPPING NORTON HEALTH CENTRE K84030 47 DIDCOT HEALTH CENTRE PRACTICE K84002 43 VICTORIA HOUSE SURGERY K84073 15 CHURCH STREET PRACTICE K84033 45 BANBURY HEALTH CENTRE Y02754 6 BURY KNOWLE HEALTH CENTRE K84009 26 BOTLEY MEDICAL CENTRE K84025 27 BAMPTON SURGERY K84010 33 THE HART SURGERY K84001 21 NUFFIELD HEALTH CENTRE K84072 39 KENNINGTON HEALTH CENTRE K84005 24 CLIFTON HAMPDEN SURGERY K84034 8 ST. CLEMENT'S SURGERY K84060 11 JERICHO HEALTH CENTRE (KEARLEY/CHIVERS) K84026 16 THE CHARLBURY MEDICAL CENTRE K84610 13 LANGFORD MEDICAL PRACTICE K84613 15 ISLIP SURGERY K84003 14 HORSEFAIR SURGERY K84040 48 COGGES SURGERY K84618 11 WYCHWOOD SURGERY K84046 15 SUMMERTOWN HEALTH CENTRE K84011 20 9 KING EDWARD STREET K84605 2 WINDRUSH MEDICAL PRACTICE K84017 35 BLOXHAM SURGERY K84058 16 THE KEY MEDICAL PRACTICE K84082 26 DEDDINGTON HEALTH CENTRE K84055 22 HOLLOW WAY MEDICAL CENTRE K84048 14 MORLAND HOUSE SURGERY K84014 20 SONNING COMMON HEALTH CTR K84020 21 THE RYCOTE PRACTICE K84050 26 BROADSHIRES HEALTH CENTRE K84075 11 LONG FURLONG MEDICAL CENTRE K84079 10 19 BEAUMONT STREET SURGERY K84016 9 WOODSTOCK SURGERY K84042 23 27 BEAUMONT STREET K84049 5 THE ABINGDON SURGERY K84054 20 BICESTER HEALTH CENTRE K84052 18 WOODLANDS MEDICAL CENTRE K84043 20 MILL STREAM SURGERY K84036 9 BANBURY ROAD MEDICAL CENTRE K84021 6 GOSFORD HILL MEDICAL CENTRE K84045 10 NETTLEBED SURGERY K84015 5 WOOD FARM HEALTH CENTRE K84620 1 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%

CROPREDY SURGERY 16

DONNINGTON MEDICAL PARTNERSHIP 42

NEWBURY STREET PRACTICE 54 • using the GP cluster method of NORTH BICESTER SURGERY 8 calculating potential gains, if each ST. BARTHOLEMEW'S MEDICAL CENTRE 13 practice was to achieve as well as the MONTGOMERY HOUSE SURGERY 42 upper quartile of its national cluster, then an additional 678 people would WINDRUSH SURGERY 23 be treated COWLEY ROAD MEDICAL PRACTICE 11

MALTHOUSE SURGERY 61

CHALGROVE & WATLINGTON SURGERIES 21

BROADSHIRES HEALTH CENTRE

MILL STREAM SURGERY

BANBURY ROAD MEDICAL CENTRE

WOODSTOCK SURGERY

THE ABINGDON SURGERY

WOOD FARM HEALTH CENTRE

BICESTER HEALTH CENTRE

WOODLANDS MEDICAL CENTRE

NETTLEBED SURGERY

GOSFORD HILL MEDICAL CENTRE Details of this methodology are available on slide 9. Click here to view them.

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

NHS South Reading CCG 93.3% • 17,759 people with coronary heart NHS Chiltern CCG 93.1% disease* in NHS Oxfordshire CCG • 16,357 (92.1%) people who are taking aspirin, an alternative anti- NHS North & West Reading CCG 93.0% platelet therapy, or an anti-coagulant • 774 (4.4%) people who are exceptions NHS Wokingham CCG 93.0% • 628 (3.5%) additional people who are not taking aspirin, an alternative anti- NHS Newbury And District CCG 92.6% platelet therapy, or an anti-coagulant

NHS Oxfordshire CCG 92.1%

NHS Aylesbury Vale CCG 91.7%

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 Herts Valleys CCG 93.3%

NHS Kernow CCG 92.6%

NHS Nene CCG 92.6%

NHS East and North Hertfordshire CCG 92.2%

NHS Oxfordshire CCG 92.1%

NHS Northern, Eastern and Western Devon CCG 92.0%

NHS Gloucestershire CCG 91.5%

NHS Bedfordshire CCG 91.2%

NHS Southern Derbyshire CCG 90.6%

NHS Cambridgeshire and Peterborough CCG 90.5%

NHS Somerset CCG 88.9%

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

LUTHER STREET MEDICAL PRACTICE K84066 5 ST. CLEMENT'S SURGERY K84060 34 NORTH BICESTER SURGERY K84621 13 9 KING EDWARD STREET K84605 4 DEER PARK MEDICAL CENTRE K84622 12 SONNING COMMON HEALTH CTR K84020 37 BANBURY HEALTH CENTRE Y02754 7 NEWBURY STREET PRACTICE K84019 56 VICTORIA HOUSE SURGERY K84073 16 MALTHOUSE SURGERY K84027 73 • in total, including exceptions, there THE BELL SURGERY K84035 27 ST. BARTHOLEMEW'S MEDICAL CENTRE K84013 13 CHIPPING NORTON HEALTH CENTRE K84030 44 are 1,402 people are not taking MANOR SURGERY K84044 36 DEDDINGTON HEALTH CENTRE K84055 29 HIGHTOWN SURGERY K84059 34 aspirin, an alternative anti-platelet EYNSHAM MEDICAL GROUP K84006 41 TEMPLE COWLEY HEALTH CENTRE K84007 25 SUMMERTOWN HEALTH CENTRE K84011 24 therapy, or an anti-coagulant BARTLEMAS SURGERY K84032 16 HORSEFAIR SURGERY K84040 53 GORING & WOODCOTE MEDICAL PRACTICE K84071 28 • GP practice range: 0.5% to 55.6% COWLEY ROAD MEDICAL PRACTICE K84063 10 WEST BAR SURGERY K84028 46 19 BEAUMONT STREET SURGERY K84016 12 CHURCH STREET PRACTICE K84033 36 THE HART SURGERY K84001 18 CROPREDY SURGERY K84056 9 THE CHARLBURY MEDICAL CENTRE K84610 12 DONNINGTON MEDICAL PARTNERSHIP K84004 30 JERICHO HEALTH CENTRE (KEARLEY/CHIVERS) K84026 14 BURY KNOWLE HEALTH CENTRE K84009 20 WINDRUSH SURGERY K84024 18 CHALGROVE & WATLINGTON SURGERIES K84008 17 SOUTH OXFORD HEALTH CENTRE K84617 4 NUFFIELD HEALTH CENTRE K84072 31 BURFORD SURGERY K84047 13 WHITE HORSE MEDICAL PRACTICE K84051 30 BLOXHAM SURGERY K84058 15 MONTGOMERY HOUSE SURGERY K84038 29 CLIFTON HAMPDEN SURGERY K84034 6 OAK TREE HEALTH CENTRE K84624 8 THE RYCOTE PRACTICE K84050 25 BOTLEY MEDICAL CENTRE K84025 18 KENNINGTON HEALTH CENTRE K84005 17 DIDCOT HEALTH CENTRE PRACTICE K84002 26 BROADSHIRES HEALTH CENTRE K84075 10 MORLAND HOUSE SURGERY K84014 17 WOODLANDS MEDICAL CENTRE K84043 23 BERINSFIELD HEALTH CENTRE K84023 11 BAMPTON SURGERY K84010 20 COGGES SURGERY K84618 8 MARCHAM RD FAMILY HEALTH CENTRE K84041 22 HOLLOW WAY MEDICAL CENTRE K84048 11 NETTLEBED SURGERY K84015 7 THE ABINGDON SURGERY K84054 18 WYCHWOOD SURGERY K84046 10 WALLINGFORD MEDICAL PRACTICE K84037 25 LANGFORD MEDICAL PRACTICE K84613 9 WINDRUSH MEDICAL PRACTICE K84017 23 BICESTER HEALTH CENTRE K84052 16 SIBFORD SURGERY K84065 5 MARSTON MEDICAL CENTRE K84076 5 LONG FURLONG MEDICAL CENTRE K84079 7 THE KEY MEDICAL PRACTICE K84082 15 ISLIP SURGERY K84003 7 THE LEYS HEALTH CENTRE K84031 11 28 BEAUMONT STREET K84080 3 WOOD FARM HEALTH CENTRE K84620 1 WOODSTOCK SURGERY K84042 13 WOODLANDS SURGERY K84062 5 MILL STREAM SURGERY K84036 4 JERICHO HEALTH CENTRE K84078 1 BANBURY ROAD MEDICAL CENTRE K84021 2 27 BEAUMONT STREET K84049 1 GOSFORD HILL MEDICAL CENTRE K84045 1 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 Oxfordshire CCG England 800

700 • in NHS Oxfordshire CCG, the hospital admission rate for coronary heart disease in 2015/16 was 353.5 (2,109) 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 Oxfordshire CCG England 250

• in NHS Oxfordshire CCG, the hospital admission rate for stroke in 2015/16 200 was 145.5 (881) 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 Oxfordshire CCG England

166.8% Angina 136.8% • The risk of a stroke was 82.3% higher and the risk of a heart attack was 127.1% 127.1% higher compared to people Heart Attack 108.6% without diabetes. The risk of a major amputation was 303.7% higher. 170.7% Heart failure 150.0%

82.3% Stroke 81.3%

303.7% Major amputation 445.8%

656.6% Minor amputation 753.5%

425.7% RRT 293.0%

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

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

NHS Oxfordshire CCG England 90

80 • in NHS Oxfordshire CCG, the early mortality rate for coronary heart 70 disease in 2013-15 was 28.4, 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 Oxfordshire CCG England 30

• in NHS Oxfordshire CCG, the early 25 mortality rate for stroke in 2013-15 was 10.3, compared to 13.6 for England

20

15

10 Age Age standardised (per rate 100,000)

5

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

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

87 CVD: Primary Care Intelligence Packs Appendix Data sources

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

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

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

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

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

• NHS Stop smoking services Copyright © 2014, NHS Digital

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

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

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

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

88 CVD: Primary Care Intelligence Packs About Public Health England

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Published June 2017 Gateway number 2017095

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