CVD: Primary Care Intelligence Packs NHS Hambleton, Richmondshire and Whitby 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 Hambleton, Richmondshire and Whitby CCG are: NHS Herefordshire CCG NHS South Lincolnshire CCG NHS West Suffolk CCG NHS South Norfolk CCG NHS Shropshire CCG NHS South West Lincolnshire CCG NHS Stafford and Surrounds CCG NHS High Weald Lewes Havens CCG NHS Isle of Wight CCG NHS East Riding of Yorkshire 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 Isle of Wight CCG 18.5%
NHS West Suffolk CCG 17.5% • prevalence of 14% in NHS Hambleton, Richmondshire and NHS South Lincolnshire CCG 17.5% Whitby CCG
NHS Herefordshire CCG 17.1%
NHS South West Lincolnshire CCG 16.7%
NHS South Norfolk CCG 16.4%
NHS Shropshire CCG 15.3%
NHS East Riding of Yorkshire CCG 15.2% Note: It has been found that the proportion of patients recorded as smokers correlates well NHS High Weald Lewes Havens CCG 15.1% with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, NHS Stafford and Surrounds CCG 14.5% http://bmjopen.bmj.com/content/4/7/e005217.abs tract
NHS Hambleton, Richmondshire and Whitby CCG 14.0% Definition: denominator of QOF clinical indicator SMOKE004 ( number of patients 15+ who are 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% 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
HAREWOOD MEDICAL PRACTICE B82104 21.5%
CATTERICK VILLAGE SURGERY B82023 21.4%
WHITBY GROUP PRACTICE B82017 19.2% • 17,145 people who are recorded as
THE FRIARY SURGERY B82072 17.4% smokers in NHS Hambleton,
STAITHES SURGERY B82046 16.4% Richmondshire and Whitby CCG • GP practice range: 8.0% to 21.5% THIRSK DOCTORS SURGERY B82049 15.7%
MAYFORD HOUSE SURGERY B82075 15.4%
LAMBERT MEDICAL CENTRE B82042 14.2%
SCORTON MEDICAL CENTRE B82035 13.3%
GLEBE HOUSE SURGERY B82066 12.7%
MOWBRAY HOUSE SURGERY B82050 12.7%
LEYBURN MEDICAL PRACTICE B82078 12.6%
TOPCLIFFE SURGERY B82019 12.5%
QUAKERS LANE SURGERY B82034 11.9%
SLEIGHTS AND SANDSEND MEDICAL PRACTICE B82101 11.6%
GREAT AYTON SURGERY B82022 10.4%
ALDBROUGH ST JOHN SURGERY B82029 9.5%
STOKESLEY SURGERY B82044 9.4% Note: This method is thought to be a reasonably CENTRAL DALES PRACTICE B82045 9.2% robust method in estimating smoking prevalence REETH MEDICAL CENTRE B82622 8.9% for the majority of GP practices. However, EGTON SURGERY B82062 8.9% caution is advised for extreme estimates of smoking prevalence and those with high THE DANBY PRACTICE B82086 8.0% numbers of smoking status not recorded and 0% 5% 10% 15% 20% 25% exceptions.
14 CVD: Primary Care Intelligence Packs Hypertension
15 CVD: Primary Care Intelligence Packs Hypertension
The Missing Millions On average, each CCG in England has 26,000 residents with The Global Burden of Disease undiagnosed hypertension – these individuals are unaware of Study confirmed high blood pressure as their increased cardiovascular risk and are untreated. a leading cause of premature death and disability What questions should we ask in our CCG? 1. for each indicator how wide is the variation in achievement and exception reporting? 2. how many people would benefit if all practices performed High blood pressure is common and costly as well as the best? • it affects around a quarter of all adults 3. how can we support practices who are average or below • the NHS costs of hypertension are around £2bn average to perform as well as the best in: • social costs are probably considerably higher • detection of hypertension • management of hypertension What do we know? • at least half of all heart attacks and strokes are caused by high blood pressure and it is a major risk What might help? factor for chronic kidney disease and cognitive decline • support practices to share audit data and systematically • treatment is very effective – every 10mmHg reduction identify gaps and opportunities for improved detection and in systolic blood pressure lowers risk of heart attack management of hypertension and stroke by 20% • work with practices and local authorities to maximise • despite this 4 out of 10 adults with hypertension, over uptake and follow up in the NHS Health Check 5 and a half million people in England, remain • support access to self-test BP stations in waiting rooms undiagnosed and to ambulatory blood pressure monitoring. • and even when the condition is identified, treatment is • commission community pharmacists to offer blood often suboptimal, with blood pressure poorly pressure measurement, diagnosis and management controlled in about 1 out of 3 individuals support, including support for adherence to medication
16 CVD: Primary Care Intelligence Packs Hypertension observed prevalence compared with expected prevalence by CCG Comparison with CCGs in the STP
NHS Durham Dales, Easington And Sedgefield CCG 0.62
• the ratio of those diagnosed with NHS Hartlepool And Stockton-On-Tees CCG 0.61 hypertension versus those expected to have hypertension is 0.6. This compares to 0.59 for England NHS Darlington CCG 0.60 • this suggests that 60% of people with hypertension have been diagnosed
NHS Hambleton, Richmondshire And Whitby CCG 0.60
NHS North Durham CCG 0.60
NHS South Tees CCG 0.60
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 South West Lincolnshire CCG 0.62
NHS East Riding of Yorkshire CCG 0.62
NHS Isle of Wight CCG 0.61
NHS South Lincolnshire CCG 0.61
NHS Stafford and Surrounds CCG 0.60
NHS Hambleton, Richmondshire and Whitby CCG 0.60
NHS Shropshire CCG 0.60
NHS Herefordshire CCG 0.59
NHS South Norfolk CCG 0.59
NHS High Weald Lewes Havens CCG 0.59
NHS West Suffolk CCG 0.59
0% 10% 20% 30% 40% 50% 60% 70%
18 CVD: Primary Care Intelligence Packs Hypertension observed prevalence compared with expected prevalence by GP practice
GP practice CCG
LAMBERT MEDICAL CENTRE B82042 0.65
LEYBURN MEDICAL PRACTICE B82078 0.65 QUAKERS LANE SURGERY B82034 0.65 • it is estimated that there are 15,745 GLEBE HOUSE SURGERY B82066 0.63 people with undiagnosed SCORTON MEDICAL CENTRE B82035 0.63 hypertension in NHS Hambleton, TOPCLIFFE SURGERY B82019 0.62 Richmondshire and Whitby CCG MOWBRAY HOUSE SURGERY B82050 0.62 • GP practice range of observed to STAITHES SURGERY B82046 0.60 expected hypertension prevalence REETH MEDICAL CENTRE B82622 0.59 0.5 to 0.65 CATTERICK VILLAGE SURGERY B82023 0.59
THE FRIARY SURGERY B82072 0.58
SLEIGHTS AND SANDSEND MEDICAL PRACTICE B82101 0.57
EGTON SURGERY B82062 0.57
MAYFORD HOUSE SURGERY B82075 0.57
CENTRAL DALES PRACTICE B82045 0.56
HAREWOOD MEDICAL PRACTICE B82104 0.56
STOKESLEY SURGERY B82044 0.55
GREAT AYTON SURGERY B82022 0.54
ALDBROUGH ST JOHN SURGERY B82029 0.54
THE DANBY PRACTICE B82086 0.53
THIRSK DOCTORS SURGERY B82049 0.51
WHITBY GROUP PRACTICE B82017 0.50
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 Hambleton, Richmondshire And Whitby CCG 82.7%
• 23,540 people with hypertension NHS Darlington CCG 82.3% (diagnosed)* in NHS Hambleton, Richmondshire and Whitby CCG • 19,458 (82.7%) people whose blood NHS Hartlepool And Stockton-On-Tees CCG 82.2% pressure is <= 150/90 • 748 (3.2%) people who are excepted from optimal control NHS North Durham CCG 82.1% • 3,334 (14.2%) additional people whose blood pressure is not <= 150/90 NHS Durham Dales, Easington And Sedgefield CCG 81.4%
NHS South Tees CCG 80.0%
England 79.6%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% *Using QOF clinical indicator HYP006 denominator plus exceptions
20 CVD: Primary Care Intelligence Packs Percentage of patients with hypertension whose last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less by CCG Comparison with demographically similar CCGs
NHS South Lincolnshire CCG 83.8%
NHS Isle of Wight CCG 82.8%
NHS Hambleton, Richmondshire and Whitby CCG 82.7%
NHS South Norfolk CCG 82.4%
NHS South West Lincolnshire CCG 81.3%
NHS West Suffolk CCG 81.2%
NHS Herefordshire CCG 80.7%
NHS East Riding of Yorkshire CCG 79.4%
NHS Shropshire CCG 79.2%
NHS Stafford and Surrounds CCG 76.8%
NHS High Weald Lewes Havens CCG 75.4%
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
ALDBROUGH ST JOHN SURGERY B82029 124
STOKESLEY SURGERY B82044 352 SCORTON MEDICAL CENTRE B82035 143 • in total, including exceptions, there WHITBY GROUP PRACTICE B82017 493 are 4,082 people whose blood
THE FRIARY SURGERY B82072 194 pressure is not <= 150/90
CATTERICK VILLAGE SURGERY B82023 195 • GP practice range: 9.6% to 25.1%
EGTON SURGERY B82062 79
QUAKERS LANE SURGERY B82034 222
MOWBRAY HOUSE SURGERY B82050 607
LEYBURN MEDICAL PRACTICE B82078 204
GLEBE HOUSE SURGERY B82066 283
LAMBERT MEDICAL CENTRE B82042 219
THE DANBY PRACTICE B82086 56
REETH MEDICAL CENTRE B82622 46
HAREWOOD MEDICAL PRACTICE B82104 76
MAYFORD HOUSE SURGERY B82075 212
GREAT AYTON SURGERY B82022 125
SLEIGHTS AND SANDSEND MEDICAL PRACTICE B82101 140
TOPCLIFFE SURGERY B82019 57
CENTRAL DALES PRACTICE B82045 93
THIRSK DOCTORS SURGERY B82049 112
STAITHES SURGERY B82046 50
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 Darlington CCG 80.0%
• 88 people with a new diagnosis* of NHS Hartlepool And Stockton-On-Tees CCG 75.9% hypertension with a CVD risk of 20% or higher in NHS Hambleton, Richmondshire and Whitby CCG NHS South Tees CCG 74.5% • 63 (71.6%) people who are currently treated with statins • 24 (27.3%) people who are exempted NHS Durham Dales, Easington And Sedgefield CCG 72.9% from treatment with statins • 1 (1.1%) additional people who are not currently treated with statins NHS Hambleton, Richmondshire And Whitby CCG 71.6%
NHS North Durham CCG 71.2%
England 66.5%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% *Using the QOF clinical indicator CVD-PP001 denominator plus exceptions
23 CVD: Primary Care Intelligence Packs New diagnosis of hypertension who have been given a CVD risk assessment whose CVD risk exceeds 20% and treated with statins by CCG Comparison with demographically similar CCGs
NHS Hambleton, Richmondshire and Whitby CCG 71.6%
NHS South West Lincolnshire CCG 67.3%
NHS West Suffolk CCG 64.3%
NHS East Riding of Yorkshire CCG 64.0%
NHS High Weald Lewes Havens CCG 61.9%
NHS South Lincolnshire CCG 61.8%
NHS Herefordshire CCG 57.6%
NHS Shropshire CCG 57.5%
NHS Isle of Wight CCG 54.8%
NHS Stafford and Surrounds CCG 53.7%
NHS South Norfolk CCG 49.2%
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
LEYBURN MEDICAL PRACTICE B82078 2
ALDBROUGH ST JOHN SURGERY B82029 1 STAITHES SURGERY B82046 2 • in total, including exceptions, there EGTON SURGERY B82062 1 are 25 people who are not treated
GLEBE HOUSE SURGERY B82066 3 with statins
SLEIGHTS AND SANDSEND MEDICAL PRACTICE B82101 5 • GP practice range: 0.0% to 66.7%
WHITBY GROUP PRACTICE B82017 6
STOKESLEY SURGERY B82044 1
QUAKERS LANE SURGERY B82034 1
HAREWOOD MEDICAL PRACTICE B82104 1
MOWBRAY HOUSE SURGERY B82050 2
GREAT AYTON SURGERY B82022
CATTERICK VILLAGE SURGERY B82023
SCORTON MEDICAL CENTRE B82035
LAMBERT MEDICAL CENTRE B82042
CENTRAL DALES PRACTICE B82045
THIRSK DOCTORS SURGERY B82049
THE FRIARY SURGERY B82072
MAYFORD HOUSE SURGERY B82075
THE DANBY PRACTICE B82086
REETH MEDICAL CENTRE B82622
TOPCLIFFE SURGERY B82019
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 Hartlepool And Stockton-On-Tees CCG 0.78
• the ratio of those diagnosed with atrial NHS Hambleton, Richmondshire And Whitby CCG 0.76 fibrillation versus those expected to have atrial fibrillation is 0.76. This compares to 0.7 for England NHS Darlington CCG 0.73 • this suggests that 76% of people with atrial fibrillation have been diagnosed.
NHS Durham Dales, Easington And Sedgefield CCG 0.72
NHS South Tees CCG 0.72
NHS North Durham CCG 0.69
Note: This slide compares the prevalence of atrial fibrillation recorded in QOF in 2015/16 to the estimated prevalence of atrial fibrillation, taken from National Cardiovascular Intelligence Network estimates produced in 2017. The estimates were developed by applying age-sex England 0.70 specific prevalence rates as reported by Norberg et al (2013) to GP population estimates from 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 NHS Digital. Estimates reported are adjusted for age and sex of the local population.
28 CVD: Primary Care Intelligence Packs Atrial fibrillation observed prevalence compared to expected prevalence by CCG Comparison with demographically similar CCGs
NHS Hambleton, Richmondshire and Whitby CCG 0.76
NHS High Weald Lewes Havens CCG 0.74
NHS South West Lincolnshire CCG 0.73
NHS South Lincolnshire CCG 0.73
NHS Stafford and Surrounds CCG 0.72
NHS Shropshire CCG 0.72
NHS East Riding of Yorkshire CCG 0.71
NHS South Norfolk CCG 0.69
NHS Herefordshire CCG 0.69
NHS West Suffolk CCG 0.67
NHS Isle of Wight CCG 0.63
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8
29 CVD: Primary Care Intelligence Packs Atrial fibrillation observed prevalence compared with expected prevalence by GP practice
GP practice CCG
TOPCLIFFE SURGERY B82019 0.9
ALDBROUGH ST JOHN SURGERY B82029 0.9 STAITHES SURGERY B82046 0.9 • it is estimated that there are 4,788 WHITBY GROUP PRACTICE B82017 0.8 people with undiagnosed atrial QUAKERS LANE SURGERY B82034 0.8 fibrillation in NHS Hambleton, LAMBERT MEDICAL CENTRE B82042 0.8 Richmondshire and Whitby CCG THIRSK DOCTORS SURGERY B82049 0.8 • GP practice range of observed to MOWBRAY HOUSE SURGERY B82050 0.8 expected atrial fibrillation prevalence GLEBE HOUSE SURGERY B82066 0.8 0.6 to 0.9 SLEIGHTS AND SANDSEND MEDICAL PRACTICE B82101 0.8
REETH MEDICAL CENTRE B82622 0.8
GREAT AYTON SURGERY B82022 0.7
CATTERICK VILLAGE SURGERY B82023 0.7
STOKESLEY SURGERY B82044 0.7
EGTON SURGERY B82062 0.7
THE FRIARY SURGERY B82072 0.7
MAYFORD HOUSE SURGERY B82075 0.7
LEYBURN MEDICAL PRACTICE B82078 0.7
HAREWOOD MEDICAL PRACTICE B82104 0.7
SCORTON MEDICAL CENTRE B82035 0.6
CENTRAL DALES PRACTICE B82045 0.6
THE DANBY PRACTICE B82086 0.6
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Ratio
30 CVD: Primary Care Intelligence Packs In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage treated with anti-coagulation therapy by CCG Comparison with CCGs in the STP Optimal management No treatment Exceptions reported
NHS Hambleton, Richmondshire And Whitby CCG 83.7% • 2,994 people with atrial fibrillation* with a CHA2DS2-VASc score >= 2 in NHS Durham Dales, Easington And Sedgefield CCG 83.6% NHS Hambleton, Richmondshire and Whitby CCG • 2,506 (83.7%) people treated with NHS North Durham CCG 83.5% anti-coagulation therapy • 209 (7%) people who are exceptions • 279 (9.3%) additional people with a NHS South Tees CCG 81.9% recorded CHA2DS2-VASc score >= 2 who are not treated
NHS Darlington CCG 81.7%
NHS Hartlepool And Stockton-On-Tees CCG 76.6%
England 77.9%
0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator AF007 denominator plus exceptions
31 CVD: Primary Care Intelligence Packs In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage treated with anti-coagulation therapy by CCG Comparison with demographically similar CCGs Optimal management No treatment Exceptions reported
NHS Hambleton, Richmondshire and Whitby CCG 83.7%
NHS South Lincolnshire CCG 83.4%
NHS South West Lincolnshire CCG 82.3%
NHS Herefordshire CCG 80.8%
NHS Stafford and Surrounds CCG 78.2%
NHS High Weald Lewes Havens CCG 77.8%
NHS South Norfolk CCG 77.4%
NHS East Riding of Yorkshire CCG 76.6%
NHS Shropshire CCG 76.0%
NHS West Suffolk CCG 75.7%
NHS Isle of Wight CCG 73.5%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
32 CVD: Primary Care Intelligence Packs In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage treated with anti-coagulation therapy by GP practice
No treatment Exceptions reported
STAITHES SURGERY B82046 23
QUAKERS LANE SURGERY B82034 44 TOPCLIFFE SURGERY B82019 12 • in total, including exceptions, there WHITBY GROUP PRACTICE B82017 65 are 488 people with a recorded
THIRSK DOCTORS SURGERY B82049 32 CHA2DS2-VASc score >= 2 who are
SLEIGHTS AND SANDSEND MEDICAL PRACTICE B82101 26 not treated
MOWBRAY HOUSE SURGERY B82050 78 • GP practice range: 7.9% to 30.7%
EGTON SURGERY B82062 7
THE FRIARY SURGERY B82072 18
SCORTON MEDICAL CENTRE B82035 10
REETH MEDICAL CENTRE B82622 5
GLEBE HOUSE SURGERY B82066 32
GREAT AYTON SURGERY B82022 17
LAMBERT MEDICAL CENTRE B82042 26
LEYBURN MEDICAL PRACTICE B82078 18
CATTERICK VILLAGE SURGERY B82023 11
HAREWOOD MEDICAL PRACTICE B82104 4
STOKESLEY SURGERY B82044 25
ALDBROUGH ST JOHN SURGERY B82029 5
CENTRAL DALES PRACTICE B82045 8
MAYFORD HOUSE SURGERY B82075 19
THE DANBY PRACTICE B82086 3
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
33 CVD: Primary Care Intelligence Packs In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage treated with anti-coagulation therapy by GP practice – opportunities compared to GP cluster
10% 5% 0% -5% -10% -15% -20%
STAITHES SURGERY 12
QUAKERS LANE SURGERY 20
TOPCLIFFE SURGERY 4 • using the GP cluster method of THIRSK DOCTORS SURGERY 9 calculating potential gains, if each WHITBY GROUP PRACTICE 13 practice was to achieve as well as the SLEIGHTS AND SANDSEND MEDICAL PRACTICE 4 upper quartile of its national cluster, then an additional 66 people would be EGTON SURGERY 1 treated THE FRIARY SURGERY 1
MOWBRAY HOUSE SURGERY 2
SCORTON MEDICAL CENTRE
HAREWOOD MEDICAL PRACTICE
GLEBE HOUSE SURGERY
LEYBURN MEDICAL PRACTICE
CATTERICK VILLAGE SURGERY
LAMBERT MEDICAL CENTRE
STOKESLEY SURGERY
ALDBROUGH ST JOHN SURGERY
CENTRAL DALES PRACTICE
THE DANBY PRACTICE
MAYFORD HOUSE SURGERY Details of this methodology are available on slide 9. Click here to view them.
34 CVD: Primary Care Intelligence Packs Percentage of patients with a history of stroke whose last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less by CCG Comparison with CCGs in the STP
Below 150/90 Not below 150/90 Exceptions reported
NHS North Durham CCG 85.7% • 3,578 people with a history of stroke or TIA* in NHS Hambleton, NHS Darlington CCG 85.6% Richmondshire and Whitby CCG • 3,056 (85.4%) people whose blood pressure is <= 150 / 90 NHS Hambleton, Richmondshire And Whitby CCG 85.4% • 133 (3.7%) people who are exceptions • 389 (10.9%) additional people whose NHS Durham Dales, Easington And Sedgefield CCG 84.8% blood pressure is not <= 150 / 90
NHS Hartlepool And Stockton-On-Tees CCG 84.5%
NHS South Tees CCG 83.2%
England 83.8%
0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator STIA003 denominator plus exceptions
35 CVD: Primary Care Intelligence Packs Percentage of patients with a history of stroke whose last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less by CCG Comparison with demographically similar CCGs Below 150/90 Not below 150/90 Exceptions reported
NHS South Lincolnshire CCG 86.5%
NHS West Suffolk CCG 85.5%
NHS Hambleton, Richmondshire and Whitby CCG 85.4%
NHS South West Lincolnshire CCG 85.3%
NHS South Norfolk CCG 84.8%
NHS Shropshire CCG 84.7%
NHS Isle of Wight CCG 84.3%
NHS Herefordshire CCG 84.1%
NHS East Riding of Yorkshire CCG 82.9%
NHS High Weald Lewes Havens CCG 82.1%
NHS Stafford and Surrounds CCG 80.4%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
36 CVD: Primary Care Intelligence Packs Percentage of patients with a history of stroke whose last blood pressure reading (measured in the preceding 12 months) is not 150/90 mmHg or less by GP practice
No treatment Exceptions reported
SCORTON MEDICAL CENTRE B82035 25
WHITBY GROUP PRACTICE B82017 64 STOKESLEY SURGERY B82044 53 • in total, including exceptions, there THE FRIARY SURGERY B82072 23 are 522 people whose blood pressure
MOWBRAY HOUSE SURGERY B82050 105 is not <= 150 / 90
ALDBROUGH ST JOHN SURGERY B82029 13 • GP practice range: 2.4% to 23.6%
EGTON SURGERY B82062 11
HAREWOOD MEDICAL PRACTICE B82104 11
GLEBE HOUSE SURGERY B82066 31
CATTERICK VILLAGE SURGERY B82023 15
MAYFORD HOUSE SURGERY B82075 33
QUAKERS LANE SURGERY B82034 20
STAITHES SURGERY B82046 12
LEYBURN MEDICAL PRACTICE B82078 20
THIRSK DOCTORS SURGERY B82049 17
SLEIGHTS AND SANDSEND MEDICAL PRACTICE B82101 16
GREAT AYTON SURGERY B82022 14
LAMBERT MEDICAL CENTRE B82042 20
CENTRAL DALES PRACTICE B82045 12
THE DANBY PRACTICE B82086 4
TOPCLIFFE SURGERY B82019 2
REETH MEDICAL CENTRE B82622 1
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 Durham Dales, Easington And Sedgefield CCG 94.4% • 2,535 people with a stroke shown to be non-haemorrhagic* in NHS NHS Hambleton, Richmondshire And Whitby CCG 93.9% Hambleton, Richmondshire and Whitby CCG • 2,381 (93.9%) people who are taking NHS Hartlepool And Stockton-On-Tees CCG 93.7% an anti-platetet agent or anti- coagulant • 111 (4.4%) people who are NHS Darlington CCG 93.3% exceptions • 43 (1.7%) additional people with no treatment NHS South Tees CCG 92.9%
NHS North Durham CCG 92.5%
England 91.8%
0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator STIA007 denominator plus exceptions
38 CVD: Primary Care Intelligence Packs Percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record in the preceding 12 months that an anti-platelet agent, or an anti-coagulant is being taken by CCG Comparison with demographically similar CCGs Below 150/90 Not below 150/90 Exceptions reported
NHS South Lincolnshire CCG 94.0%
NHS Hambleton, Richmondshire and Whitby CCG 93.9%
NHS West Suffolk CCG 92.9%
NHS South West Lincolnshire CCG 92.5%
NHS High Weald Lewes Havens CCG 92.2%
NHS Isle of Wight CCG 91.7%
NHS East Riding of Yorkshire CCG 91.7%
NHS South Norfolk CCG 91.5%
NHS Herefordshire CCG 91.3%
NHS Stafford and Surrounds CCG 90.6%
NHS Shropshire CCG 90.2%
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
EGTON SURGERY B82062 11
CATTERICK VILLAGE SURGERY B82023 8 SCORTON MEDICAL CENTRE B82035 7 • in total, including exceptions, there GLEBE HOUSE SURGERY B82066 15 are 154 people who are not taking an
STAITHES SURGERY B82046 5 anti-platelet agent or anti-coagulant
HAREWOOD MEDICAL PRACTICE B82104 3 • GP practice range: 0.0% to 25.0%
MOWBRAY HOUSE SURGERY B82050 35
WHITBY GROUP PRACTICE B82017 13
THE FRIARY SURGERY B82072 5
LAMBERT MEDICAL CENTRE B82042 7
SLEIGHTS AND SANDSEND MEDICAL PRACTICE B82101 6
STOKESLEY SURGERY B82044 9
CENTRAL DALES PRACTICE B82045 4
QUAKERS LANE SURGERY B82034 5
LEYBURN MEDICAL PRACTICE B82078 5
TOPCLIFFE SURGERY B82019 1
ALDBROUGH ST JOHN SURGERY B82029 2
GREAT AYTON SURGERY B82022 4
THE DANBY PRACTICE B82086 1
THIRSK DOCTORS SURGERY B82049 3
MAYFORD HOUSE SURGERY B82075 5
REETH MEDICAL CENTRE B82622
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 North Durham CCG 0.86 • 0.66 ratio of observed to expected diabetes prevalence in NHS NHS Darlington CCG 0.84 Hambleton, Richmondshire and Whitby CCG, compared to 0.77 in England NHS Durham Dales, Easington And Sedgefield CCG 0.84 • this suggests 66% of people have been diagnosed
NHS Hartlepool And Stockton-On-Tees CCG 0.78
NHS South Tees CCG 0.76
NHS Hambleton, Richmondshire And Whitby 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 England 0.77 from the NCVIN diabetes prevalence model produced in 2015.
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
43 CVD: Primary Care Intelligence Packs Diabetes observed prevalence compared with expected prevalence by CCG Comparison with demographically similar CCGs
NHS South Lincolnshire CCG 0.84
NHS South West Lincolnshire CCG 0.83
NHS East Riding of Yorkshire CCG 0.82
NHS Stafford and Surrounds CCG 0.77
NHS West Suffolk CCG 0.73
NHS South Norfolk CCG 0.71
NHS Shropshire CCG 0.70
NHS Herefordshire CCG 0.69
NHS Isle of Wight CCG 0.67
NHS Hambleton, Richmondshire and Whitby CCG 0.66
NHS High Weald Lewes Havens CCG 0.64
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
STAITHES SURGERY B82046 8.4%
SLEIGHTS AND SANDSEND MEDICAL PRACTICE B82101 7.0% CATTERICK VILLAGE SURGERY B82023 6.7% • GP practice range of observed LAMBERT MEDICAL CENTRE B82042 6.5% diabetes 4.0% to 8.4%
GLEBE HOUSE SURGERY B82066 6.4% • there are an estimated 3,700 people
MAYFORD HOUSE SURGERY B82075 6.3% with undiagnosed diabetes in NHS
MOWBRAY HOUSE SURGERY B82050 6.2% Hambleton, Richmondshire and
LEYBURN MEDICAL PRACTICE B82078 6.1% Whitby CCG
THIRSK DOCTORS SURGERY B82049 6.1%
GREAT AYTON SURGERY B82022 6.0%
QUAKERS LANE SURGERY B82034 6.0%
ALDBROUGH ST JOHN SURGERY B82029 6.0%
TOPCLIFFE SURGERY B82019 5.9%
WHITBY GROUP PRACTICE B82017 5.9%
SCORTON MEDICAL CENTRE B82035 5.9%
REETH MEDICAL CENTRE B82622 5.7%
EGTON SURGERY B82062 5.6%
STOKESLEY SURGERY B82044 5.5%
HAREWOOD MEDICAL PRACTICE B82104 5.1%
CENTRAL DALES PRACTICE B82045 5.1%
THE FRIARY SURGERY B82072 5.0% Note: The estimated number of undiagnosed
THE DANBY PRACTICE B82086 4.0% people with diabetes has been calculated by 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
• the estimated total prevalence of NHS Hambleton, Richmondshire And Whitby CCG 6.0% 3.1% 12.6% diabetes in NHS Hambleton, Richmondshire and Whitby CCG is NHS Durham Dales, Easington And Sedgefield CCG 7.7% 1.5% 11.7% 9.1% (diagnosed and undiagnosed) • in addition, there are an estimated 12.6% of people in NHS Hambleton, NHS Darlington CCG 7.1% 1.4% 11.5% Richmondshire and Whitby CCG who are at increased risk of developing diabetes (i.e. with non-diabetic NHS South Tees CCG 6.7% 2.1% 11.2% hyperglycaemia) • this means that 21.7% of the NHS Hartlepool And Stockton-On-Tees CCG 6.4% 1.8% 11.0% population in NHS Hambleton, Richmondshire and Whitby CCG are estimated to have diabetes, or at high NHS North Durham CCG 6.8% 1.2% 11.1% risk of developing of diabetes
Note: Prevalence estimates of non-diabetic hyperglycaemia were developed using Health Survey for England (HSE) data. Five years of England 6.5% 1.9% 11.2% HSE data were combined, 2009- 2013. The estimates take into account the age, ethnic group and estimated body mass index of the population. 0% 5% 10% 15% 20% 25% These estimates were produced using the GP registered population.
46 CVD: Primary Care Intelligence Packs People with diabetes who had eight care processes by CCG 2015/16
NHS Darlington CCG 65.3%
• data on care processes and treatment NHS North Durham CCG 63.0% targets are taken from the National Diabetes Audit (NDA) • overall practice participation in the NHS Durham Dales, Easington And Sedgefield CCG 63.0% 2015/16 audit was 81.4% in England
• in NHS Hambleton, Richmondshire NHS Hambleton, Richmondshire And Whitby CCG 58.6% and Whitby CCG, 21 out of 22 practices (95.5%) participated in the NDA. Data is not available for the NHS Hartlepool And Stockton-On-Tees CCG 52.6% remaining practices
• 58.6% of people with diabetes (of NHS South Tees CCG 52.6% practices who participated in the audit) had the eight recommended care processes in NHS Hambleton, Richmondshire and Whitby CCG, compared to 52.6% in England
England 52.6%
0% 10% 20% 30% 40% 50% 60% 70%
47 CVD: Primary Care Intelligence Packs People with diabetes who had eight care processes by GP practice, 2015/16
GP practice Average of practices in the CCG who participated in the audit
ALDBROUGH ST JOHN SURGERY B82029 87.0% REETH MEDICAL CENTRE B82622 84.9% • achievement - 8 care processes: in CENTRAL DALES PRACTICE B82045 81.0% practices who provided data via the GLEBE HOUSE SURGERY B82066 80.6% NDA, between 13.3% and 87.0% of HAREWOOD MEDICAL PRACTICE B82104 76.5% patients received all 8 care processes CATTERICK VILLAGE SURGERY B82023 76.5%
EGTON SURGERY B82062 71.6% • at least 2,794 people did not receive WHITBY GROUP PRACTICE B82017 70.2% the eight care processes SLEIGHTS AND SANDSEND MEDICAL PRACTICE B82101 70.1%
THIRSK DOCTORS SURGERY B82049 68.6%
STAITHES SURGERY B82046 68.4%
TOPCLIFFE SURGERY B82019 66.4%
LEYBURN MEDICAL PRACTICE B82078 65.1%
MAYFORD HOUSE SURGERY B82075 65.1%
LAMBERT MEDICAL CENTRE B82042 59.2%
MOWBRAY HOUSE SURGERY B82050 47.2%
THE FRIARY SURGERY B82072 32.2%
THE DANBY PRACTICE B82086 27.6%
GREAT AYTON SURGERY B82022 20.2%
SCORTON MEDICAL CENTRE B82035 18.6%
STOKESLEY SURGERY B82044 13.3%
QUAKERS LANE SURGERY B82034
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 Hartlepool And Stockton-On-Tees CCG 41.0%
• 41.0% of people with diabetes (of NHS Hambleton, Richmondshire And Whitby CCG 41.0% practices who participated in the audit) met the three treatment targets in NHS Hambleton, Richmondshire and Whitby CCG, compared to 39.0% NHS South Tees CCG 39.7% in England
NHS North Durham CCG 37.1%
NHS Durham Dales, Easington And Sedgefield CCG 36.4%
NHS Darlington CCG 35.3%
England 39.0%
0% 5% 10% 15% 20% 25% 30% 35% 40% 45%
49 CVD: Primary Care Intelligence Packs People with diabetes who met all 3 treatment targets by GP practice, 2015/16
GP practice Average of practices in the CCG who participated in the audit
THIRSK DOCTORS SURGERY B82049 50.3% HAREWOOD MEDICAL PRACTICE B82104 48.7% • achievement - 3 treatment targets: in REETH MEDICAL CENTRE B82622 47.8% practices who provided data via the LAMBERT MEDICAL CENTRE B82042 47.2% NDA, between 27.5% and 50.3% of SCORTON MEDICAL CENTRE B82035 44.4% patients achieved all 3 treatment MOWBRAY HOUSE SURGERY B82050 43.9% targets CENTRAL DALES PRACTICE B82045 43.5% • at least 3,681 people did not meet the MAYFORD HOUSE SURGERY B82075 43.5% three treatment targets LEYBURN MEDICAL PRACTICE B82078 42.5%
GLEBE HOUSE SURGERY B82066 42.1%
STOKESLEY SURGERY B82044 42.0%
SLEIGHTS AND SANDSEND MEDICAL PRACTICE B82101 39.8%
CATTERICK VILLAGE SURGERY B82023 39.5%
EGTON SURGERY B82062 38.1%
STAITHES SURGERY B82046 37.4%
GREAT AYTON SURGERY B82022 36.2%
WHITBY GROUP PRACTICE B82017 33.4%
TOPCLIFFE SURGERY B82019 32.5%
THE DANBY PRACTICE B82086 31.9%
ALDBROUGH ST JOHN SURGERY B82029 30.7%
THE FRIARY SURGERY B82072 27.5%
QUAKERS LANE SURGERY B82034
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
50 CVD: Primary Care Intelligence Packs People with diabetes who met all 3 treatment targets by GP practice, 2015/16 - opportunities compared to GP cluster
10% 5% 0% -5% -10% -15% -20%
THE FRIARY SURGERY 42
ALDBROUGH ST JOHN SURGERY 22
THE DANBY PRACTICE 10 • using the GP cluster method of TOPCLIFFE SURGERY 17 calculating potential gains, if each WHITBY GROUP PRACTICE 68 practice was to achieve as well as the GREAT AYTON SURGERY 24 upper quartile of its national cluster, then an additional 282 people would STAITHES SURGERY 15 be treated EGTON SURGERY 8
CATTERICK VILLAGE SURGERY 19
SLEIGHTS AND SANDSEND MEDICAL PRACTICE 16
LEYBURN MEDICAL PRACTICE 8
GLEBE HOUSE SURGERY 10
CENTRAL DALES PRACTICE 3
SCORTON MEDICAL CENTRE 2
MAYFORD HOUSE SURGERY 3
MOWBRAY HOUSE SURGERY 3
REETH MEDICAL CENTRE
LAMBERT MEDICAL CENTRE
THIRSK DOCTORS SURGERY
HAREWOOD MEDICAL PRACTICE 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 Darlington CCG 0.72
NHS North Durham CCG 0.71 • the ratio of those diagnosed with chronic kidney disease versus those expected to have chronic kidney NHS Durham Dales, Easington And Sedgefield CCG 0.70 disease is 0.57. This compares to 0.68 for England • this suggests that 57% of people with NHS Hartlepool And Stockton-On-Tees CCG 0.64 chronic kidney disease have been diagnosed
NHS South Tees CCG 0.59
NHS Hambleton, Richmondshire And Whitby CCG 0.57
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 South West Lincolnshire CCG 0.98
NHS South Lincolnshire CCG 0.93
NHS Shropshire CCG 0.80
NHS East Riding of Yorkshire CCG 0.71
NHS Herefordshire CCG 0.66
NHS South Norfolk CCG 0.65
NHS High Weald Lewes Havens CCG 0.62
NHS Hambleton, Richmondshire and Whitby CCG 0.57
NHS Isle of Wight CCG 0.53
NHS Stafford and Surrounds CCG 0.52
NHS West Suffolk CCG 0.52
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
LAMBERT MEDICAL CENTRE B82042 7.0%
SLEIGHTS AND SANDSEND MEDICAL PRACTICE B82101 7.0% GLEBE HOUSE SURGERY B82066 5.8% • it is estimated that there are 3,613 MOWBRAY HOUSE SURGERY B82050 5.7% people with undiagnosed chronic
LEYBURN MEDICAL PRACTICE B82078 4.6% kidney disease in NHS Hambleton,
WHITBY GROUP PRACTICE B82017 4.5% Richmondshire and Whitby CCG
CATTERICK VILLAGE SURGERY B82023 4.4% • GP practice range of observed CKD:
MAYFORD HOUSE SURGERY B82075 4.0% 1.2% to 7.0%
STAITHES SURGERY B82046 4.0%
SCORTON MEDICAL CENTRE B82035 3.4%
THIRSK DOCTORS SURGERY B82049 3.2%
ALDBROUGH ST JOHN SURGERY B82029 3.1%
QUAKERS LANE SURGERY B82034 2.9%
STOKESLEY SURGERY B82044 2.8%
TOPCLIFFE SURGERY B82019 2.8%
REETH MEDICAL CENTRE B82622 2.6%
THE FRIARY SURGERY B82072 2.2%
CENTRAL DALES PRACTICE B82045 2.1%
HAREWOOD MEDICAL PRACTICE B82104 1.9% Note: CCG estimates for the estimated GREAT AYTON SURGERY B82022 1.5% number of people with CKD are based on EGTON SURGERY B82062 1.4% applying a proportion from a resident based THE DANBY PRACTICE B82086 1.2% population estimate to a GP registered population. The characteristics of registered 0% 1% 2% 3% 4% 5% 6% 7% 8% and resident populations may vary in some CCGs, and local interpretation is required.
56 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding 12 months) is 140/85 mmHg or less by CCG, 2014/15 Comparison with CCGs in the STP Below 140/85 Not below 140/85 Exceptions reported
NHS Hartlepool And Stockton-On-Tees CCG 78.1% • 4,679 people with CKD (diagnosed*) in NHS Hambleton, Richmondshire NHS North Durham CCG 76.2% and Whitby CCG • 3,519 (75.2%) people whose blood pressure is <= 140 /85 NHS Durham Dales, Easington And Sedgefield CCG 75.8% • 483 (10.3%) people who are exceptions • 677 (14.5%) additional people whose NHS Darlington CCG 75.4% blood pressure is not <= 140 / 85
NHS Hambleton, Richmondshire And Whitby CCG 75.2%
NHS South Tees CCG 73.9%
*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 South Lincolnshire CCG 77.4%
NHS Isle of Wight CCG 76.0%
NHS Hambleton, Richmondshire and Whitby CCG 75.2%
NHS West Suffolk CCG 74.8%
NHS South West Lincolnshire CCG 73.9%
NHS South Norfolk CCG 73.7%
NHS East Riding of Yorkshire CCG 72.7%
NHS Herefordshire CCG 72.5%
NHS Shropshire CCG 71.9%
NHS Stafford and Surrounds CCG 71.6%
NHS High Weald Lewes Havens CCG 71.5%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
58 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding 12 months) is not 140/85 mmHg or less by GP practice, 2014/15
Not below 140/85 Exceptions reported
EGTON SURGERY B82062 11
DR HODGSON M D AND PARTNERS B82029 39 WHITBY GROUP PRACTICE B82017 209 • in total, including exceptions, there THE FRIARY SURGERY B82072 34 are 1,160 people whose blood
GREAT AYTON SURGERY B82022 22 pressure is not <= 140 / 85
MOWBRAY HOUSE SURGERY B82050 299 • GP practice range: 9.6% to 45.8%
LEYBURN MEDICAL PRACTICE B82078 61
DR DOOTSON J C & PARTNERS B82035 25
QUAKER'S LANE SURGERY B82034 36
TOPCLIFFE SURGERY B82019 14
STOKESLEY SURGERY B82044 45
DR TRZECIAK AND PARTNERS B82049 36
MAYFORD HOUSE SURGERY B82075 60
GLEBE HOUSE SURGERY B82066 92
HAREWOOD MEDICAL PRACTICE B82104 16
SLEIGHTS AND SANDSEND MEDICAL PRACTICE B82101 50
CATTERICK VILLAGE SURGERY B82023 11
REETH MEDICAL CENTRE B82622 5
STAITHES SURGERY B82046 13
LAMBERT MEDICAL CENTRE B82042 71
THE DANBY PRACTICE B82086 3
CENTRAL DALES PRACTICE B82045 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
15% 10% 5% 0% -5% -10% -15% -20% -25% -30%
EGTON SURGERY 7
DR HODGSON M D AND PARTNERS 23
WHITBY GROUP PRACTICE 89 • using the GP cluster method of THE FRIARY SURGERY 16 calculating potential gains, if each GREAT AYTON SURGERY 10 practice was to achieve as well as the MOWBRAY HOUSE SURGERY 91 upper quartile of its national cluster, then an additional 283 people would LEYBURN MEDICAL PRACTICE 17 be treated DR DOOTSON J C & PARTNERS 6
TOPCLIFFE SURGERY 3
QUAKER'S LANE SURGERY 8
DR TRZECIAK AND PARTNERS 4
CATTERICK VILLAGE SURGERY 0
SLEIGHTS AND SANDSEND MEDICAL PRACTICE
MAYFORD HOUSE SURGERY
REETH MEDICAL CENTRE
STAITHES SURGERY
GLEBE HOUSE SURGERY
THE DANBY PRACTICE
LAMBERT MEDICAL CENTRE
CENTRAL DALES PRACTICE Details of this methodology are available on slide 9. Click here to view them.
60 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose notes have a record of a urine albumin: creatinine ratio test in the preceding 12 months by CCG, 2014/15 Comparison with CCGs in the STP Recorded Not recorded Exceptions reported
NHS Darlington CCG 80.6% • 4,679 people with CKD (diagnosed*) in NHS Hambleton, Richmondshire NHS North Durham CCG 80.1% and Whitby CCG • 3,663 (78.3%) people who have a record of urine albumin:creatinine NHS Hambleton, Richmondshire And Whitby CCG 78.3% ratio test • 157 (3.4%) people who are exceptions NHS Hartlepool And Stockton-On-Tees CCG 78.0% • 859 (18.4%) additional people who have no record of urine albumin:creatinine ratio test NHS Durham Dales, Easington And Sedgefield CCG 77.1%
NHS South Tees CCG 76.1%
*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 South West Lincolnshire CCG 83.9%
NHS Herefordshire CCG 79.2%
NHS Hambleton, Richmondshire and Whitby CCG 78.3%
NHS South Lincolnshire CCG 77.9%
NHS South Norfolk CCG 77.4%
NHS Shropshire CCG 75.6%
NHS Isle of Wight CCG 74.9%
NHS East Riding of Yorkshire CCG 74.7%
NHS High Weald Lewes Havens CCG 73.0%
NHS Stafford and Surrounds CCG 72.9%
NHS West Suffolk CCG 70.7%
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
MAYFORD HOUSE SURGERY B82075 147
WHITBY GROUP PRACTICE B82017 208 STOKESLEY SURGERY B82044 58 • in total, including exceptions, there THE FRIARY SURGERY B82072 24 are 1,016 people who have no record
GREAT AYTON SURGERY B82022 14 of urine albumin:creatinine ratio test
LEYBURN MEDICAL PRACTICE B82078 50 • GP practice range: 9.9% to 48.5%
STAITHES SURGERY B82046 16
LAMBERT MEDICAL CENTRE B82042 93
REETH MEDICAL CENTRE B82622 6
MOWBRAY HOUSE SURGERY B82050 186
DR TRZECIAK AND PARTNERS B82049 33
CATTERICK VILLAGE SURGERY B82023 12
EGTON SURGERY B82062 4
TOPCLIFFE SURGERY B82019 10
HAREWOOD MEDICAL PRACTICE B82104 11
DR DOOTSON J C & PARTNERS B82035 13
THE DANBY PRACTICE B82086 3
GLEBE HOUSE SURGERY B82066 60
QUAKER'S LANE SURGERY B82034 18
SLEIGHTS AND SANDSEND MEDICAL PRACTICE B82101 32
CENTRAL DALES PRACTICE B82045 9
DR HODGSON M D AND PARTNERS B82029 9
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 Darlington CCG 1.42%
• prevalence of 0.95% in NHS NHS Durham Dales, Easington And Sedgefield CCG 1.21% Hambleton, Richmondshire and Whitby CCG compared to 0.76% in England NHS Hambleton, Richmondshire And Whitby CCG 0.95%
NHS Hartlepool And Stockton-On-Tees CCG 0.90%
NHS North Durham CCG 0.89%
NHS South Tees CCG 0.82%
England 0.76%
0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6%
66 CVD: Primary Care Intelligence Packs Heart failure prevalence by CCG Comparison with demographically similar CCGs
NHS South West Lincolnshire CCG 1.08%
NHS Herefordshire CCG 1.01%
NHS South Lincolnshire CCG 1.01%
NHS Isle of Wight CCG 0.98%
NHS Hambleton, Richmondshire and Whitby CCG 0.95%
NHS East Riding of Yorkshire CCG 0.88%
NHS Shropshire CCG 0.84%
NHS West Suffolk CCG 0.83%
NHS South Norfolk CCG 0.82%
NHS Stafford and Surrounds CCG 0.77%
NHS High Weald Lewes Havens CCG 0.73%
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
SLEIGHTS AND SANDSEND MEDICAL PRACTICE B82101 2.0%
EGTON SURGERY B82062 1.7% STAITHES SURGERY B82046 1.5% • 1,364 people with diagnosed heart MOWBRAY HOUSE SURGERY B82050 1.5% failure in NHS Hambleton,
REETH MEDICAL CENTRE B82622 1.2% Richmondshire and Whitby CCG
WHITBY GROUP PRACTICE B82017 1.1% • GP practice range: 0.1% to 2.0%
THE DANBY PRACTICE B82086 1.0%
THE FRIARY SURGERY B82072 1.0%
QUAKERS LANE SURGERY B82034 0.9%
CATTERICK VILLAGE SURGERY B82023 0.9%
LEYBURN MEDICAL PRACTICE B82078 0.9%
LAMBERT MEDICAL CENTRE B82042 0.9%
STOKESLEY SURGERY B82044 0.9%
ALDBROUGH ST JOHN SURGERY B82029 0.8%
MAYFORD HOUSE SURGERY B82075 0.8%
SCORTON MEDICAL CENTRE B82035 0.8%
TOPCLIFFE SURGERY B82019 0.7%
CENTRAL DALES PRACTICE B82045 0.7%
GLEBE HOUSE SURGERY B82066 0.6%
GREAT AYTON SURGERY B82022 0.6%
THIRSK DOCTORS SURGERY B82049 0.6%
HAREWOOD MEDICAL PRACTICE B82104 0.1%
0.0% 0.5% 1.0% 1.5% 2.0% 2.5%
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 Hambleton, Richmondshire And Whitby CCG 89.3% • 569 people with heart failure* with LVSD in NHS Hambleton, NHS North Durham CCG 88.9% Richmondshire and Whitby CCG • 508 (89.3%) people treated with ACE- I or ARB NHS Hartlepool And Stockton-On-Tees CCG 88.1% • 60 (10.5%) people who are exceptions • 1 (0.2%) additional people who are NHS South Tees CCG 87.8% not treated with ACE-I or ARB
NHS Durham Dales, Easington And Sedgefield CCG 85.7%
NHS Darlington CCG 83.0%
England 84.7%
0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator HF003 denominator plus exceptions
69 CVD: Primary Care Intelligence Packs Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who are treated with ACE-I / ARB by CCG Comparison with demographically similar CCGs Treatment No treatment Exceptions reported
NHS Hambleton, Richmondshire and Whitby CCG 89.3%
NHS Isle of Wight CCG 87.9%
NHS South West Lincolnshire CCG 87.3%
NHS East Riding of Yorkshire CCG 87.0%
NHS South Norfolk CCG 85.9%
NHS Stafford and Surrounds CCG 84.3%
NHS Shropshire CCG 83.3%
NHS High Weald Lewes Havens CCG 82.7%
NHS Herefordshire CCG 81.1%
NHS South Lincolnshire CCG 79.9%
NHS West Suffolk CCG 79.7%
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
THE DANBY PRACTICE B82086 2
THE FRIARY SURGERY B82072 2 WHITBY GROUP PRACTICE B82017 6 • in total, including exceptions, there MAYFORD HOUSE SURGERY B82075 7 are 61 people who are not treated
LAMBERT MEDICAL CENTRE B82042 3 with ACE-I or ARB
SCORTON MEDICAL CENTRE B82035 2 • GP practice range: 0.0% to 28.6%
MOWBRAY HOUSE SURGERY B82050 28
QUAKERS LANE SURGERY B82034 1
SLEIGHTS AND SANDSEND MEDICAL PRACTICE B82101 2
ALDBROUGH ST JOHN SURGERY B82029 1
GLEBE HOUSE SURGERY B82066 2
CATTERICK VILLAGE SURGERY B82023 1
STOKESLEY SURGERY B82044 3
THIRSK DOCTORS SURGERY B82049 1
TOPCLIFFE SURGERY B82019
GREAT AYTON SURGERY B82022
CENTRAL DALES PRACTICE B82045
STAITHES SURGERY B82046
EGTON SURGERY B82062
LEYBURN MEDICAL PRACTICE B82078
HAREWOOD MEDICAL PRACTICE B82104
REETH MEDICAL CENTRE B82622
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 South Tees CCG 87.3% • 508 people with heart failure* with LVSD treated with ACE-I/ARB in NHS NHS Darlington CCG 86.5% Hambleton, Richmondshire and Whitby CCG • 413 (81.3%) people treated with ACE- NHS Durham Dales, Easington And Sedgefield CCG 83.9% I/ARB and BB • 72 (14.2%) people who are exceptions NHS Hambleton, Richmondshire And Whitby CCG 81.3% • 23 (4.5%) additional people who are not treated with ACE-I/ARB and BB
NHS North Durham CCG 76.2%
NHS Hartlepool And Stockton-On-Tees CCG 75.4%
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 East Riding of Yorkshire CCG 82.2%
NHS Hambleton, Richmondshire and Whitby CCG 81.3%
NHS South West Lincolnshire CCG 79.2%
NHS West Suffolk CCG 78.7%
NHS Stafford and Surrounds CCG 77.7%
NHS Shropshire CCG 74.0%
NHS High Weald Lewes Havens CCG 72.9%
NHS South Lincolnshire CCG 72.4%
NHS Isle of Wight CCG 69.3%
NHS Herefordshire CCG 69.3%
NHS South Norfolk CCG 68.8%
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
TOPCLIFFE SURGERY B82019 4
GREAT AYTON SURGERY B82022 3 STOKESLEY SURGERY B82044 10 • in total, including exceptions, there LEYBURN MEDICAL PRACTICE B82078 2 are 95 people who are not treated
SLEIGHTS AND SANDSEND MEDICAL PRACTICE B82101 4 with ACE-I or ARB
WHITBY GROUP PRACTICE B82017 7 • GP practice range: 0.0% to 28.6%
CENTRAL DALES PRACTICE B82045 2
MOWBRAY HOUSE SURGERY B82050 46
REETH MEDICAL CENTRE B82622 2
MAYFORD HOUSE SURGERY B82075 6
CATTERICK VILLAGE SURGERY B82023 2
QUAKERS LANE SURGERY B82034 1
THE FRIARY SURGERY B82072 1
ALDBROUGH ST JOHN SURGERY B82029 1
LAMBERT MEDICAL CENTRE B82042 2
GLEBE HOUSE SURGERY B82066 2
SCORTON MEDICAL CENTRE B82035
STAITHES SURGERY B82046
THIRSK DOCTORS SURGERY B82049
EGTON SURGERY B82062
THE DANBY PRACTICE B82086
HAREWOOD MEDICAL PRACTICE B82104
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 Hambleton, Richmondshire And Whitby CCG 91.0% • 6,055 people with coronary heart disease* in NHS Hambleton, NHS North Durham CCG 89.4% Richmondshire and Whitby CCG • 5,509 (91%) people whose blood pressure <= 150 / 90 NHS Durham Dales, Easington And Sedgefield CCG 89.3% • 146 (2.4%) people who are exceptions • 400 (6.6%) additional people whose NHS Hartlepool And Stockton-On-Tees CCG 89.0% blood pressure is not <= 150 / 90
NHS South Tees CCG 88.6%
NHS Darlington CCG 88.6%
England 88.2%
0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator CHD002 denominator plus exceptions
75 CVD: Primary Care Intelligence Packs Percentage of patients with CHD whose blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less by CCG Comparison with demographically similar CCGs Below 150/90 Not below 150/90 Exceptions reported
NHS South Lincolnshire CCG 91.0%
NHS Hambleton, Richmondshire and Whitby CCG 91.0%
NHS Herefordshire CCG 89.4%
NHS South West Lincolnshire CCG 89.3%
NHS South Norfolk CCG 88.6%
NHS Shropshire CCG 88.5%
NHS West Suffolk CCG 88.5%
NHS Isle of Wight CCG 87.6%
NHS East Riding of Yorkshire CCG 87.0%
NHS High Weald Lewes Havens CCG 86.0%
NHS Stafford and Surrounds CCG 83.8%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
76 CVD: Primary Care Intelligence Packs Percentage of patients with CHD whose blood pressure reading (measured in the preceding 12 months) is not 150/90 mmHg or less by GP practice
Not below 150/90 Exceptions reported
WHITBY GROUP PRACTICE B82017 106
EGTON SURGERY B82062 12 SCORTON MEDICAL CENTRE B82035 18 • in total, including exceptions, there HAREWOOD MEDICAL PRACTICE B82104 12 are 546 people whose blood pressure
STOKESLEY SURGERY B82044 47 is not <= 150 / 90
THE FRIARY SURGERY B82072 27 • GP practice range: 2.8% to 15.6%
MOWBRAY HOUSE SURGERY B82050 89
CATTERICK VILLAGE SURGERY B82023 24
STAITHES SURGERY B82046 13
GREAT AYTON SURGERY B82022 23
SLEIGHTS AND SANDSEND MEDICAL PRACTICE B82101 23
ALDBROUGH ST JOHN SURGERY B82029 9
GLEBE HOUSE SURGERY B82066 28
MAYFORD HOUSE SURGERY B82075 30
QUAKERS LANE SURGERY B82034 18
THE DANBY PRACTICE B82086 5
LEYBURN MEDICAL PRACTICE B82078 15
CENTRAL DALES PRACTICE B82045 12
REETH MEDICAL CENTRE B82622 4
LAMBERT MEDICAL CENTRE B82042 20
TOPCLIFFE SURGERY B82019 3
THIRSK DOCTORS SURGERY B82049 8
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
6% 4% 2% 0% -2% -4% -6% -8%
WHITBY GROUP PRACTICE 48
EGTON SURGERY 5
SCORTON MEDICAL CENTRE 7 • using the GP cluster method of HAREWOOD MEDICAL PRACTICE 4 calculating potential gains, if each STOKESLEY SURGERY 15 practice was to achieve as well as the CATTERICK VILLAGE SURGERY 8 upper quartile of its national cluster, then an additional 119 people would THE FRIARY SURGERY 8 be treated STAITHES SURGERY 3
GREAT AYTON SURGERY 4
MOWBRAY HOUSE SURGERY 13
QUAKERS LANE SURGERY 0
THE DANBY PRACTICE
LEYBURN MEDICAL PRACTICE
CENTRAL DALES PRACTICE
REETH MEDICAL CENTRE
GLEBE HOUSE SURGERY
MAYFORD HOUSE SURGERY
TOPCLIFFE SURGERY
LAMBERT MEDICAL CENTRE
THIRSK DOCTORS SURGERY Details of this methodology are available on slide 9. Click here to view them.
78 CVD: Primary Care Intelligence Packs Percentage of patients with CHD with a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken by CCG Comparison with CCGs in the STP Optimal management No treatment Exceptions reported
NHS Hambleton, Richmondshire And Whitby CCG 94.1% • 6,055 people with coronary heart disease* in NHS Hambleton, NHS Darlington CCG 93.3% Richmondshire and Whitby CCG • 5,695 (94.1%) people who are taking aspirin, an alternative anti-platelet NHS North Durham CCG 92.9% therapy, or an anti-coagulant • 216 (3.6%) people who are exceptions NHS South Tees CCG 92.5% • 144 (2.4%) additional people who are not taking aspirin, an alternative anti- platelet therapy, or an anti-coagulant NHS Durham Dales, Easington And Sedgefield CCG 92.5%
NHS Hartlepool And Stockton-On-Tees CCG 92.4%
England 91.8%
0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator CHD005 denominator plus exceptions
79 CVD: Primary Care Intelligence Packs Percentage of patients with CHD with a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken by CCG Comparison with demographically similar CCGs Optimal management No treatment Exceptions reported
NHS Hambleton, Richmondshire and Whitby CCG 94.1%
NHS West Suffolk CCG 93.0%
NHS South Lincolnshire CCG 92.6%
NHS Stafford and Surrounds CCG 92.3%
NHS South West Lincolnshire CCG 92.0%
NHS South Norfolk CCG 91.7%
NHS Isle of Wight CCG 91.6%
NHS Herefordshire CCG 91.4%
NHS High Weald Lewes Havens CCG 91.4%
NHS East Riding of Yorkshire CCG 90.6%
NHS Shropshire CCG 90.6%
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
EGTON SURGERY B82062 13
SCORTON MEDICAL CENTRE B82035 17 CATTERICK VILLAGE SURGERY B82023 24 • in total, including exceptions, there THE DANBY PRACTICE B82086 6 are 360 people are not taking aspirin,
HAREWOOD MEDICAL PRACTICE B82104 8 an alternative anti-platelet therapy, or
THIRSK DOCTORS SURGERY B82049 19 an anti-coagulant
WHITBY GROUP PRACTICE B82017 45 • GP practice range: 3.2% to 12.7%
REETH MEDICAL CENTRE B82622 4
SLEIGHTS AND SANDSEND MEDICAL PRACTICE B82101 18
GREAT AYTON SURGERY B82022 16
MOWBRAY HOUSE SURGERY B82050 52
GLEBE HOUSE SURGERY B82066 22
QUAKERS LANE SURGERY B82034 14
STAITHES SURGERY B82046 8
STOKESLEY SURGERY B82044 25
MAYFORD HOUSE SURGERY B82075 22
TOPCLIFFE SURGERY B82019 4
ALDBROUGH ST JOHN SURGERY B82029 6
LAMBERT MEDICAL CENTRE B82042 14
CENTRAL DALES PRACTICE B82045 7
THE FRIARY SURGERY B82072 9
LEYBURN MEDICAL PRACTICE B82078 7
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 Hambleton, Richmondshire and Whitby CCG England 800
700 • in NHS Hambleton, Richmondshire and Whitby CCG, the hospital admission rate for coronary heart 600 disease in 2015/16 was 379.5 (666) 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 Hambleton, Richmondshire and Whitby CCG England 250
• in NHS Hambleton, Richmondshire and Whitby CCG, the hospital 200 admission rate for stroke in 2015/16 was 170.3 (300) 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 Hambleton, Richmondshire and Whitby CCG England
144.8% Angina 136.8% • The risk of a stroke was 95.7% higher and the risk of a heart attack was 99.5% 99.5% higher compared to people Heart Attack 108.6% without diabetes. The risk of a major amputation was 767.7% higher. 157.7% Heart failure 150.0%
95.7% Stroke 81.3%
767.7% Major amputation 445.8%
769.0% Minor amputation 753.5%
270.3% RRT 293.0%
0% 100% 200% 300% 400% 500% 600% 700% 800% 900% 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 Hambleton, Richmondshire and Whitby CCG England 90
80 • in NHS Hambleton, Richmondshire and Whitby CCG, the early mortality 70 rate for coronary heart disease in 2013-15 was 34.8, compared to 40.6 for England 60
50
40
30 Age Age standardised (per rate 1000,000) 20
10
0 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11 2010-12 2011-13 2012-14 2013-15
Source: Office for National Statistics (ONS) mortality data 2002 - 2015
86 CVD: Primary Care Intelligence Packs Deaths from stroke, under 75s
NHS Hambleton, Richmondshire and Whitby CCG England 30
• in NHS Hambleton, Richmondshire 25 and Whitby CCG, the early mortality rate for stroke in 2013-15 was 9.9, 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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