CVD: Primary Care Intelligence Packs NHS Somerset 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 Somerset CCG are: NHS Kernow CCG NHS Gloucestershire CCG NHS Wiltshire CCG NHS West Hampshire CCG NHS Cumbria CCG NHS Ipswich and East Suffolk CCG NHS Coastal West Sussex CCG NHS South Worcestershire CCG NHS East Riding of Yorkshire CCG NHS Southern Derbyshire 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 Kernow CCG 18.0%
NHS Somerset CCG 17.7% • prevalence of 17.7% in NHS Somerset CCG NHS Southern Derbyshire CCG 17.6%
NHS Cumbria CCG 17.1%
NHS Ipswich and East Suffolk CCG 16.8%
NHS Coastal West Sussex CCG 16.8%
NHS South Worcestershire CCG 16.7%
NHS Gloucestershire CCG 15.9% Note: It has been found that the proportion of patients recorded as smokers correlates well NHS Wiltshire CCG 15.3% with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, NHS East Riding of Yorkshire CCG 15.2% http://bmjopen.bmj.com/content/4/7/e005217.abs tract
NHS West Hampshire 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
NHS YEOVIL HEALTH CENTRE Y02778 34.1% REDGATE MEDICAL CENTRE L85051 28.8% VICTORIA GATE SURGERY L85616 28.6% VICTORIA PARK MEDICAL CENTRE L85612 27.2% LYNGFORD PARK L85062 25.7% CRANLEIGH GARDENS MEDICAL CENTRE L85025 24.9% OAKLANDS SURGERY, YEOVIL L85064 24.9% TAUNTON ROAD MEDICAL CENTRE L85042 24.4% EAST QUAY MEDICAL CENTRE L85035 23.1% • 83,603 people who are recorded as GLASTONBURY HEALTH CENTRE L85047 22.9% THE BLACKBROOK SURGERY L85014 21.7% DUNSTER SURGERY L85065 21.6% smokers in NHS Somerset CCG SOMERSET BRIDGE MEDICAL CENTRE L85607 21.5% TAWSTOCK MEDICAL CENTRE, CHARD L85619 21.3% GROVE HOUSE SURGERY L85053 20.8% • GP practice range: 9.8% to 34.1% HIGHBRIDGE MEDICAL CENTRE L85010 20.7% PARK MEDICAL PRACTICE L85043 20.3% FROME MEDICAL CENTRE L85008 20.1% ST JAMES MEDICAL CENTRE L85023 19.7% THE MEADOWS SURGERY L85061 19.5% PENN HILL SURGERY, YEOVIL L85017 19.3% RYALLS PARK MEDICAL CENTRE, YEOVIL L85048 18.8% HARLEY HOUSE SURGERY L85019 18.6% WINCANTON HEALTH CENTRE L85027 18.6% CROWN MEDICAL CENTRE L85006 18.6% ESSEX HOUSE MEDICAL CENTRE, CHARD L85030 18.3% BURNHAM MEDICAL CENTRE L85016 18.3% LUSON L85050 18.1% WEST SOMERSET HEALTHCARE L85009 17.9% L85060 (VINE SURGERY) L85060 17.6% WARWICK HOUSE MEDICAL PRACTICE L85052 17.0% FRENCH WEIR HEALTH CENTRE L85001 17.0% IRNHAM LODGE SURGERY L85041 17.0% PRESTON GROVE MEDICAL CENTRE, YEOVIL L85015 17.0% SPRINGMEAD SURGERY, CHARD L85028 16.9% MENDIP COUNTRY PRACTICE L85046 16.9% HENDFORD LODGE MEDICAL CENTRE, YEOVIL L85022 16.7% GLASTONBURY SURGERY L85039 16.5% MILLBROOK SURGERY, CASTLE CARY L85040 16.5% L85029 (VINE SURGERY) L85029 16.2% WEST ONE SURGERY L85620 16.0% WELLINGTON MEDICAL CENTRE L85012 15.9% ABBEY MANOR MEDICAL PRACTICE Y00189 15.8% BUTTERCROSS HEALTH CENTRE L85005 15.7% CREWKERNE HEALTH CENTRE, CREWKERNE L85004 15.6% HAMDON MEDICAL CENTRE, STOKE-SUB-HAMDON L85026 15.4% WESTLAKE SURGERY L85045 15.4% CHURCH STREET SURGERY, MARTOCK L85007 15.4% WELLS CITY PRACTICE L85034 15.3% CANNINGTON HEALTH CENTRE L85018 15.2% SUMMERVALE SURGERY L85054 14.9% ILCHESTER SURGERY, ILCHESTER L85066 14.8% QUANTOCK VALE SURGERY L85036 14.5% WELLS HEALTH CENTRE L85002 14.3% EXMOOR MEDICAL CENTRE L85003 14.2% WESTLAKE (S) Y01163 14.2% NORTH PETHERTON SURGERY L85056 14.1% LANGPORT SURGERY L85033 14.0% BRUTON SURGERY L85032 13.7% QUANTOCK MEDICAL CENTRE L85013 13.4% POLDEN MEDICAL PRACTICE L85024 13.3% CREECH L85609 13.2% Note: This method is thought to be a reasonably BECKINGTON FAMILY PRACTICE L85020 12.6% CHEDDAR MEDICAL CENTRE L85011 12.5% PORLOCK MEDICAL CENTRE L85608 12.4% robust method in estimating smoking prevalence MILBORNE PORT SURGERY L85031 12.2% NORTH CURRY L85037 12.2% for the majority of GP practices. However, LISTER HOUSE PARTNERSHIP L85038 12.0% COLLEGE WAY SURGERY L85021 11.2% AXBRIDGE SURGERY L85055 11.1% caution is advised for extreme estimates of QUEEN CAMEL MEDICAL CENTRE L85044 11.0% CHURCH VIEW SURGERY, ILLMINSTER L85624 10.8% smoking prevalence and those with high OAKHILL SURGERY L85611 10.7% BRENT AREA MEDICAL CENTRE L85601 9.8% numbers of smoking status not recorded and 0% 5% 10% 15% 20% 25% 30% 35% 40% 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 Somerset CCG 0.60 • the ratio of those diagnosed with hypertension versus those expected to have hypertension is 0.6. This compares to 0.59 for England • this suggests that 60% of people with hypertension have been diagnosed
England 0.59
Note: this slide shows Hypertension prevalence estimates created using data from QOF hypertension registers 2014/15 and Undiagnosed hypertension estimates for adults 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 16 years and older. 2014. Department of Primary Ratio Care & Public Health, Imperial College London
17 CVD: Primary Care Intelligence Packs Hypertension observed prevalence compared with expected prevalence by CCG Comparison with demographically similar CCGs
NHS East Riding of Yorkshire CCG 0.62
NHS South Worcestershire CCG 0.60
NHS Somerset CCG 0.60
NHS Wiltshire CCG 0.60
NHS Coastal West Sussex CCG 0.60
NHS Cumbria CCG 0.59
NHS West Hampshire CCG 0.59
NHS Southern Derbyshire CCG 0.59
NHS Ipswich and East Suffolk CCG 0.59
NHS Kernow CCG 0.58
NHS Gloucestershire CCG 0.58
0% 10% 20% 30% 40% 50% 60% 70%
18 CVD: Primary Care Intelligence Packs Hypertension observed prevalence compared with expected prevalence by GP practice
GP practice CCG
DUNSTER SURGERY L85065 0.91 WEST ONE SURGERY L85620 0.77 CHURCH VIEW SURGERY, ILLMINSTER L85624 0.75 ILCHESTER SURGERY, ILCHESTER L85066 0.74 LISTER HOUSE PARTNERSHIP L85038 0.73 ABBEY MANOR MEDICAL PRACTICE Y00189 0.73 SUMMERVALE SURGERY L85054 0.71 HENDFORD LODGE MEDICAL CENTRE, YEOVIL L85022 0.69 BUTTERCROSS HEALTH CENTRE L85005 0.69 CREWKERNE HEALTH CENTRE, CREWKERNE L85004 0.66 • it is estimated that there are 60,075 ESSEX HOUSE MEDICAL CENTRE, CHARD L85030 0.64 HAMDON MEDICAL CENTRE, STOKE-SUB-HAMDON L85026 0.63 QUANTOCK VALE SURGERY L85036 0.63 people with undiagnosed MENDIP COUNTRY PRACTICE L85046 0.63 LANGPORT SURGERY L85033 0.63 GROVE HOUSE SURGERY L85053 0.62 WESTLAKE (S) Y01163 0.62 hypertension in NHS Somerset CCG L85060 (VINE SURGERY) L85060 0.62 WARWICK HOUSE MEDICAL PRACTICE L85052 0.61 BECKINGTON FAMILY PRACTICE L85020 0.61 • GP practice range of observed to THE MEADOWS SURGERY L85061 0.61 WELLS HEALTH CENTRE L85002 0.61 GLASTONBURY SURGERY L85039 0.61 expected hypertension prevalence CHURCH STREET SURGERY, MARTOCK L85007 0.61 CANNINGTON HEALTH CENTRE L85018 0.60 FROME MEDICAL CENTRE L85008 0.60 PENN HILL SURGERY, YEOVIL L85017 0.60 0.41 to 0.91 LUSON L85050 0.60 TAWSTOCK MEDICAL CENTRE, CHARD L85619 0.59 BURNHAM MEDICAL CENTRE L85016 0.59 NORTH CURRY L85037 0.59 NORTH PETHERTON SURGERY L85056 0.59 BRUTON SURGERY L85032 0.59 IRNHAM LODGE SURGERY L85041 0.59 OAKLANDS SURGERY, YEOVIL L85064 0.59 MILLBROOK SURGERY, CASTLE CARY L85040 0.58 PORLOCK MEDICAL CENTRE L85608 0.58 HIGHBRIDGE MEDICAL CENTRE L85010 0.58 PRESTON GROVE MEDICAL CENTRE, YEOVIL L85015 0.58 OAKHILL SURGERY L85611 0.58 TAUNTON ROAD MEDICAL CENTRE L85042 0.58 SPRINGMEAD SURGERY, CHARD L85028 0.57 COLLEGE WAY SURGERY L85021 0.57 WESTLAKE SURGERY L85045 0.57 WEST SOMERSET HEALTHCARE L85009 0.57 WINCANTON HEALTH CENTRE L85027 0.56 QUEEN CAMEL MEDICAL CENTRE L85044 0.56 PARK MEDICAL PRACTICE L85043 0.56 REDGATE MEDICAL CENTRE L85051 0.56 RYALLS PARK MEDICAL CENTRE, YEOVIL L85048 0.56 L85029 (VINE SURGERY) L85029 0.56 POLDEN MEDICAL PRACTICE L85024 0.55 MILBORNE PORT SURGERY L85031 0.55 CHEDDAR MEDICAL CENTRE L85011 0.55 CRANLEIGH GARDENS MEDICAL CENTRE L85025 0.54 LYNGFORD PARK L85062 0.54 EXMOOR MEDICAL CENTRE L85003 0.54 FRENCH WEIR HEALTH CENTRE L85001 0.53 WELLINGTON MEDICAL CENTRE L85012 0.53 BRENT AREA MEDICAL CENTRE L85601 0.53 THE BLACKBROOK SURGERY L85014 0.53 EAST QUAY MEDICAL CENTRE L85035 0.52 HARLEY HOUSE SURGERY L85019 0.52 AXBRIDGE SURGERY L85055 0.51 CROWN MEDICAL CENTRE L85006 0.51 ST JAMES MEDICAL CENTRE L85023 0.51 QUANTOCK MEDICAL CENTRE L85013 0.50 SOMERSET BRIDGE MEDICAL CENTRE L85607 0.50 WELLS CITY PRACTICE L85034 0.49 VICTORIA PARK MEDICAL CENTRE L85612 0.48 CREECH L85609 0.47 GLASTONBURY HEALTH CENTRE L85047 0.44 NHS YEOVIL HEALTH CENTRE Y02778 0.43 VICTORIA GATE SURGERY L85616 0.41 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 Somerset CCG 74.8% • 90,979 people with hypertension (diagnosed)* in NHS Somerset CCG • 68,038 (74.8%) people whose blood pressure is <= 150/90 • 2,927 (3.2%) people who are excepted from optimal control • 20,014 (22%) additional people whose blood pressure is not <= 150/90
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 Worcestershire CCG 85.2%
NHS Cumbria CCG 80.9%
NHS Southern Derbyshire CCG 80.6%
NHS Gloucestershire CCG 80.1%
NHS Ipswich and East Suffolk CCG 80.0%
NHS Kernow CCG 79.7%
NHS Wiltshire CCG 79.6%
NHS East Riding of Yorkshire CCG 79.4%
NHS West Hampshire CCG 78.3%
NHS Coastal West Sussex CCG 76.1%
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
WEST ONE SURGERY L85620 212 SPRINGMEAD SURGERY, CHARD L85028 468 NHS YEOVIL HEALTH CENTRE Y02778 153 RYALLS PARK MEDICAL CENTRE, YEOVIL L85048 327 VICTORIA GATE SURGERY L85616 145 ABBEY MANOR MEDICAL PRACTICE Y00189 159 GLASTONBURY HEALTH CENTRE L85047 280 LISTER HOUSE PARTNERSHIP L85038 519 FROME MEDICAL CENTRE L85008 1637 • in total, including exceptions, there LANGPORT SURGERY L85033 828 SUMMERVALE SURGERY L85054 487 LUSON L85050 310 are 22,941 people whose blood PRESTON GROVE MEDICAL CENTRE, YEOVIL L85015 610 CREECH L85609 160 WINCANTON HEALTH CENTRE L85027 436 BURNHAM MEDICAL CENTRE L85016 1006 pressure is not <= 150/90 THE BLACKBROOK SURGERY L85014 414 TAWSTOCK MEDICAL CENTRE, CHARD L85619 270 FRENCH WEIR HEALTH CENTRE L85001 661 • GP practice range: 11.4% to 45.8% BUTTERCROSS HEALTH CENTRE L85005 293 QUEEN CAMEL MEDICAL CENTRE L85044 260 WELLS CITY PRACTICE L85034 305 HIGHBRIDGE MEDICAL CENTRE L85010 615 ST JAMES MEDICAL CENTRE L85023 465 GLASTONBURY SURGERY L85039 564 THE MEADOWS SURGERY L85061 158 HARLEY HOUSE SURGERY L85019 314 L85029 (VINE SURGERY) L85029 332 MILLBROOK SURGERY, CASTLE CARY L85040 212 PENN HILL SURGERY, YEOVIL L85017 422 WELLS HEALTH CENTRE L85002 565 WELLINGTON MEDICAL CENTRE L85012 592 COLLEGE WAY SURGERY L85021 531 WARWICK HOUSE MEDICAL PRACTICE L85052 310 HENDFORD LODGE MEDICAL CENTRE, YEOVIL L85022 520 PARK MEDICAL PRACTICE L85043 387 QUANTOCK VALE SURGERY L85036 212 WESTLAKE SURGERY L85045 81 CROWN MEDICAL CENTRE L85006 268 VICTORIA PARK MEDICAL CENTRE L85612 112 AXBRIDGE SURGERY L85055 254 HAMDON MEDICAL CENTRE, STOKE-SUB-HAMDON L85026 197 CHURCH STREET SURGERY, MARTOCK L85007 426 IRNHAM LODGE SURGERY L85041 279 CREWKERNE HEALTH CENTRE, CREWKERNE L85004 478 NORTH PETHERTON SURGERY L85056 185 BRUTON SURGERY L85032 162 POLDEN MEDICAL PRACTICE L85024 273 WEST SOMERSET HEALTHCARE L85009 372 NORTH CURRY L85037 127 GROVE HOUSE SURGERY L85053 209 LYNGFORD PARK L85062 148 MENDIP COUNTRY PRACTICE L85046 171 MILBORNE PORT SURGERY L85031 170 EXMOOR MEDICAL CENTRE L85003 142 CANNINGTON HEALTH CENTRE L85018 178 EAST QUAY MEDICAL CENTRE L85035 372 CRANLEIGH GARDENS MEDICAL CENTRE L85025 273 BECKINGTON FAMILY PRACTICE L85020 282 DUNSTER SURGERY L85065 134 OAKLANDS SURGERY, YEOVIL L85064 73 ILCHESTER SURGERY, ILCHESTER L85066 85 REDGATE MEDICAL CENTRE L85051 126 WESTLAKE (S) Y01163 45 TAUNTON ROAD MEDICAL CENTRE L85042 303 CHURCH VIEW SURGERY, ILLMINSTER L85624 84 OAKHILL SURGERY L85611 48 L85060 (VINE SURGERY) L85060 113 CHEDDAR MEDICAL CENTRE L85011 166 ESSEX HOUSE MEDICAL CENTRE, CHARD L85030 240 QUANTOCK MEDICAL CENTRE L85013 77 BRENT AREA MEDICAL CENTRE L85601 52 PORLOCK MEDICAL CENTRE L85608 50 SOMERSET BRIDGE MEDICAL CENTRE L85607 47 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 Somerset CCG 55.1% • 341 people with a new diagnosis* of hypertension with a CVD risk of 20% or higher in NHS Somerset CCG • 188 (55.1%) people who are currently treated with statins • 85 (24.9%) people who are exempted from treatment with statins • 68 (19.9%) additional people who are not currently treated with statins
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 Gloucestershire CCG 65.1%
NHS Cumbria CCG 64.0%
NHS East Riding of Yorkshire CCG 64.0%
NHS Ipswich and East Suffolk CCG 62.1%
NHS Kernow CCG 62.0%
NHS Southern Derbyshire CCG 61.5%
NHS Wiltshire CCG 59.7%
NHS Coastal West Sussex CCG 59.6%
NHS West Hampshire CCG 55.9%
NHS Somerset CCG 55.1%
NHS South Worcestershire CCG 55.1%
0% 10% 20% 30% 40% 50% 60% 70%
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
SPRINGMEAD SURGERY, CHARD L85028 1 QUANTOCK VALE SURGERY L85036 2 NORTH CURRY L85037 2 WESTLAKE SURGERY L85045 1 THE MEADOWS SURGERY L85061 1 PORLOCK MEDICAL CENTRE L85608 1 FRENCH WEIR HEALTH CENTRE L85001 12 HIGHBRIDGE MEDICAL CENTRE L85010 4 CHEDDAR MEDICAL CENTRE L85011 4 • in total, including exceptions, there MILBORNE PORT SURGERY L85031 3 SUMMERVALE SURGERY L85054 8 HENDFORD LODGE MEDICAL CENTRE, YEOVIL L85022 2 are 153 people who are not treated GLASTONBURY HEALTH CENTRE L85047 2 ILCHESTER SURGERY, ILCHESTER L85066 2 SOMERSET BRIDGE MEDICAL CENTRE L85607 2 WELLS HEALTH CENTRE L85002 5 with statins WELLINGTON MEDICAL CENTRE L85012 3 QUEEN CAMEL MEDICAL CENTRE L85044 3 FROME MEDICAL CENTRE L85008 29 • GP practice range: 0.0% to 100.0% WEST SOMERSET HEALTHCARE L85009 4 GLASTONBURY SURGERY L85039 4 BURNHAM MEDICAL CENTRE L85016 6 QUANTOCK MEDICAL CENTRE L85013 1 LANGPORT SURGERY L85033 2 TAUNTON ROAD MEDICAL CENTRE L85042 7 WARWICK HOUSE MEDICAL PRACTICE L85052 1 NORTH PETHERTON SURGERY L85056 1 L85060 (VINE SURGERY) L85060 1 LYNGFORD PARK L85062 1 L85029 (VINE SURGERY) L85029 2 ESSEX HOUSE MEDICAL CENTRE, CHARD L85030 2 CANNINGTON HEALTH CENTRE L85018 3 WINCANTON HEALTH CENTRE L85027 3 BECKINGTON FAMILY PRACTICE L85020 2 ST JAMES MEDICAL CENTRE L85023 2 BRUTON SURGERY L85032 1 GROVE HOUSE SURGERY L85053 3 OAKHILL SURGERY L85611 1 WESTLAKE (S) Y01163 1 CRANLEIGH GARDENS MEDICAL CENTRE L85025 3 CREWKERNE HEALTH CENTRE, CREWKERNE L85004 2 PENN HILL SURGERY, YEOVIL L85017 2 EAST QUAY MEDICAL CENTRE L85035 2 PRESTON GROVE MEDICAL CENTRE, YEOVIL L85015 1 WELLS CITY PRACTICE L85034 1 LISTER HOUSE PARTNERSHIP L85038 1 DUNSTER SURGERY L85065 1 EXMOOR MEDICAL CENTRE L85003 1 COLLEGE WAY SURGERY L85021 1 POLDEN MEDICAL PRACTICE L85024 1 MENDIP COUNTRY PRACTICE L85046 1 PARK MEDICAL PRACTICE L85043 1 BUTTERCROSS HEALTH CENTRE L85005 CROWN MEDICAL CENTRE L85006 THE BLACKBROOK SURGERY L85014 HARLEY HOUSE SURGERY L85019 MILLBROOK SURGERY, CASTLE CARY L85040 IRNHAM LODGE SURGERY L85041 RYALLS PARK MEDICAL CENTRE, YEOVIL L85048 LUSON L85050 REDGATE MEDICAL CENTRE L85051 AXBRIDGE SURGERY L85055 BRENT AREA MEDICAL CENTRE L85601 VICTORIA PARK MEDICAL CENTRE L85612 CHURCH VIEW SURGERY, ILLMINSTER L85624 ABBEY MANOR MEDICAL PRACTICE Y00189 NHS YEOVIL HEALTH CENTRE Y02778 WEST ONE SURGERY L85620 TAWSTOCK MEDICAL CENTRE, CHARD L85619 VICTORIA GATE SURGERY L85616 CREECH L85609 OAKLANDS SURGERY, YEOVIL L85064 HAMDON MEDICAL CENTRE, STOKE-SUB-HAMDON L85026 CHURCH STREET SURGERY, MARTOCK L85007 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 Somerset CCG 0.78 • the ratio of those diagnosed with atrial fibrillation versus those expected to have atrial fibrillation is 0.78. This compares to 0.7 for England • this suggests that 78% of people with atrial fibrillation have been diagnosed.
Note: This slide compares the prevalence of atrial fibrillation recorded in QOF in 2015/16 to the estimated prevalence of atrial fibrillation, England 0.70 taken from National Cardiovascular Intelligence Network estimates produced in 2017. The estimates were developed by applying age-sex specific prevalence rates as reported by Norberg et al (2013) to GP population estimates from 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 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 Somerset CCG 0.78
NHS Gloucestershire CCG 0.74
NHS Wiltshire CCG 0.73
NHS Coastal West Sussex CCG 0.72
NHS Ipswich and East Suffolk CCG 0.72
NHS Kernow CCG 0.72
NHS Cumbria CCG 0.71
NHS East Riding of Yorkshire CCG 0.71
NHS South Worcestershire CCG 0.71
NHS West Hampshire CCG 0.70
NHS Southern Derbyshire CCG 0.69
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
RYALLS PARK MEDICAL CENTRE, YEOVIL L85048 1.0 ILCHESTER SURGERY, ILCHESTER L85066 1.0 PORLOCK MEDICAL CENTRE L85608 1.0 CHEDDAR MEDICAL CENTRE L85011 0.9 ST JAMES MEDICAL CENTRE L85023 0.9 POLDEN MEDICAL PRACTICE L85024 0.9 BRUTON SURGERY L85032 0.9 LANGPORT SURGERY L85033 0.9 GLASTONBURY HEALTH CENTRE L85047 0.9 GROVE HOUSE SURGERY L85053 0.9 • it is estimated that there are 17,915 SUMMERVALE SURGERY L85054 0.9 DUNSTER SURGERY L85065 0.9 WESTLAKE (S) Y01163 0.9 people with undiagnosed atrial WELLS HEALTH CENTRE L85002 0.8 EXMOOR MEDICAL CENTRE L85003 0.8 CREWKERNE HEALTH CENTRE, CREWKERNE L85004 0.8 BUTTERCROSS HEALTH CENTRE L85005 0.8 fibrillation in NHS Somerset CCG CROWN MEDICAL CENTRE L85006 0.8 CHURCH STREET SURGERY, MARTOCK L85007 0.8 WEST SOMERSET HEALTHCARE L85009 0.8 • GP practice range of observed to HIGHBRIDGE MEDICAL CENTRE L85010 0.8 THE BLACKBROOK SURGERY L85014 0.8 PRESTON GROVE MEDICAL CENTRE, YEOVIL L85015 0.8 expected atrial fibrillation prevalence CANNINGTON HEALTH CENTRE L85018 0.8 HARLEY HOUSE SURGERY L85019 0.8 BECKINGTON FAMILY PRACTICE L85020 0.8 COLLEGE WAY SURGERY L85021 0.8 0.5 to 1 HENDFORD LODGE MEDICAL CENTRE, YEOVIL L85022 0.8 HAMDON MEDICAL CENTRE, STOKE-SUB-HAMDON L85026 0.8 WINCANTON HEALTH CENTRE L85027 0.8 L85029 (VINE SURGERY) L85029 0.8 ESSEX HOUSE MEDICAL CENTRE, CHARD L85030 0.8 QUANTOCK VALE SURGERY L85036 0.8 GLASTONBURY SURGERY L85039 0.8 IRNHAM LODGE SURGERY L85041 0.8 QUEEN CAMEL MEDICAL CENTRE L85044 0.8 WESTLAKE SURGERY L85045 0.8 MENDIP COUNTRY PRACTICE L85046 0.8 REDGATE MEDICAL CENTRE L85051 0.8 WARWICK HOUSE MEDICAL PRACTICE L85052 0.8 AXBRIDGE SURGERY L85055 0.8 NORTH PETHERTON SURGERY L85056 0.8 LYNGFORD PARK L85062 0.8 CREECH L85609 0.8 VICTORIA PARK MEDICAL CENTRE L85612 0.8 TAWSTOCK MEDICAL CENTRE, CHARD L85619 0.8 CHURCH VIEW SURGERY, ILLMINSTER L85624 0.8 FRENCH WEIR HEALTH CENTRE L85001 0.7 FROME MEDICAL CENTRE L85008 0.7 WELLINGTON MEDICAL CENTRE L85012 0.7 QUANTOCK MEDICAL CENTRE L85013 0.7 BURNHAM MEDICAL CENTRE L85016 0.7 PENN HILL SURGERY, YEOVIL L85017 0.7 CRANLEIGH GARDENS MEDICAL CENTRE L85025 0.7 SPRINGMEAD SURGERY, CHARD L85028 0.7 MILBORNE PORT SURGERY L85031 0.7 EAST QUAY MEDICAL CENTRE L85035 0.7 NORTH CURRY L85037 0.7 LISTER HOUSE PARTNERSHIP L85038 0.7 MILLBROOK SURGERY, CASTLE CARY L85040 0.7 TAUNTON ROAD MEDICAL CENTRE L85042 0.7 PARK MEDICAL PRACTICE L85043 0.7 LUSON L85050 0.7 L85060 (VINE SURGERY) L85060 0.7 OAKLANDS SURGERY, YEOVIL L85064 0.7 BRENT AREA MEDICAL CENTRE L85601 0.7 SOMERSET BRIDGE MEDICAL CENTRE L85607 0.7 OAKHILL SURGERY L85611 0.7 WELLS CITY PRACTICE L85034 0.6 THE MEADOWS SURGERY L85061 0.6 VICTORIA GATE SURGERY L85616 0.6 ABBEY MANOR MEDICAL PRACTICE Y00189 0.6 NHS YEOVIL HEALTH CENTRE Y02778 0.6 WEST ONE SURGERY L85620 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
• 10,598 people with atrial fibrillation* NHS Somerset CCG 79.5% with a CHA2DS2-VASc score >= 2 in NHS Somerset CCG • 8,426 (79.5%) people treated with anti-coagulation therapy • 594 (5.6%) people who are exceptions • 1,578 (14.9%) additional people with a recorded CHA2DS2-VASc score >= 2 who are not treated
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 West Hampshire CCG 81.0%
NHS Kernow CCG 80.2%
NHS Wiltshire CCG 80.2%
NHS Ipswich and East Suffolk CCG 79.8%
NHS Somerset CCG 79.5%
NHS South Worcestershire CCG 78.9%
NHS East Riding of Yorkshire CCG 76.6%
NHS Southern Derbyshire CCG 76.0%
NHS Coastal West Sussex CCG 74.7%
NHS Cumbria CCG 73.7%
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
SPRINGMEAD SURGERY, CHARD L85028 38 NHS YEOVIL HEALTH CENTRE Y02778 8 PORLOCK MEDICAL CENTRE L85608 29 CREECH L85609 7 ABBEY MANOR MEDICAL PRACTICE Y00189 11 TAUNTON ROAD MEDICAL CENTRE L85042 61 ST JAMES MEDICAL CENTRE L85023 79 BURNHAM MEDICAL CENTRE L85016 104 IRNHAM LODGE SURGERY L85041 54 • in total, including exceptions, there REDGATE MEDICAL CENTRE L85051 23 CHEDDAR MEDICAL CENTRE L85011 53 CROWN MEDICAL CENTRE L85006 19 are 2,172 people with a recorded EXMOOR MEDICAL CENTRE L85003 28 QUANTOCK VALE SURGERY L85036 29 THE BLACKBROOK SURGERY L85014 30 HIGHBRIDGE MEDICAL CENTRE L85010 75 CHA2DS2-VASc score >= 2 who are RYALLS PARK MEDICAL CENTRE, YEOVIL L85048 25 FRENCH WEIR HEALTH CENTRE L85001 65 HAMDON MEDICAL CENTRE, STOKE-SUB-HAMDON L85026 26 not treated CHURCH VIEW SURGERY, ILLMINSTER L85624 17 CRANLEIGH GARDENS MEDICAL CENTRE L85025 36 ESSEX HOUSE MEDICAL CENTRE, CHARD L85030 50 • GP practice range: 7.0% to 36.2% VICTORIA PARK MEDICAL CENTRE L85612 13 WELLINGTON MEDICAL CENTRE L85012 56 LYNGFORD PARK L85062 14 HARLEY HOUSE SURGERY L85019 52 HENDFORD LODGE MEDICAL CENTRE, YEOVIL L85022 50 EAST QUAY MEDICAL CENTRE L85035 47 PRESTON GROVE MEDICAL CENTRE, YEOVIL L85015 55 AXBRIDGE SURGERY L85055 30 FROME MEDICAL CENTRE L85008 92 GLASTONBURY HEALTH CENTRE L85047 20 WESTLAKE (S) Y01163 9 DUNSTER SURGERY L85065 22 CHURCH STREET SURGERY, MARTOCK L85007 63 WARWICK HOUSE MEDICAL PRACTICE L85052 25 POLDEN MEDICAL PRACTICE L85024 45 LANGPORT SURGERY L85033 76 L85029 (VINE SURGERY) L85029 29 LUSON L85050 23 VICTORIA GATE SURGERY L85616 5 BUTTERCROSS HEALTH CENTRE L85005 21 L85060 (VINE SURGERY) L85060 18 GROVE HOUSE SURGERY L85053 27 WESTLAKE SURGERY L85045 9 TAWSTOCK MEDICAL CENTRE, CHARD L85619 17 SUMMERVALE SURGERY L85054 28 GLASTONBURY SURGERY L85039 46 SOMERSET BRIDGE MEDICAL CENTRE L85607 6 WEST SOMERSET HEALTHCARE L85009 52 COLLEGE WAY SURGERY L85021 62 OAKHILL SURGERY L85611 5 CANNINGTON HEALTH CENTRE L85018 18 OAKLANDS SURGERY, YEOVIL L85064 7 WINCANTON HEALTH CENTRE L85027 28 BRUTON SURGERY L85032 15 PENN HILL SURGERY, YEOVIL L85017 30 THE MEADOWS SURGERY L85061 9 QUANTOCK MEDICAL CENTRE L85013 10 MILBORNE PORT SURGERY L85031 14 WELLS HEALTH CENTRE L85002 19 NORTH CURRY L85037 8 WEST ONE SURGERY L85620 1 MILLBROOK SURGERY, CASTLE CARY L85040 11 MENDIP COUNTRY PRACTICE L85046 11 ILCHESTER SURGERY, ILCHESTER L85066 6 BECKINGTON FAMILY PRACTICE L85020 17 CREWKERNE HEALTH CENTRE, CREWKERNE L85004 32 QUEEN CAMEL MEDICAL CENTRE L85044 11 NORTH PETHERTON SURGERY L85056 12 LISTER HOUSE PARTNERSHIP L85038 4 PARK MEDICAL PRACTICE L85043 14 BRENT AREA MEDICAL CENTRE L85601 4 WELLS CITY PRACTICE L85034 7 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
33 CVD: Primary Care Intelligence Packs In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage treated with anti-coagulation therapy by GP practice – opportunities compared to GP cluster
15% 10% 5% 0% -5% -10% -15% -20% -25%
SPRINGMEAD SURGERY, CHARD 22
NHS YEOVIL HEALTH CENTRE 5
CREECH 4 • using the GP cluster method of ABBEY MANOR MEDICAL PRACTICE 5 calculating potential gains, if each PORLOCK MEDICAL CENTRE 12 practice was to achieve as well as the REDGATE MEDICAL CENTRE 10 upper quartile of its national cluster, then an additional 494 people would TAUNTON ROAD MEDICAL CENTRE 24 be treated ST JAMES MEDICAL CENTRE 31
QUANTOCK VALE SURGERY 12
CHEDDAR MEDICAL CENTRE 19
ILCHESTER SURGERY, ILCHESTER
BECKINGTON FAMILY PRACTICE
WELLS HEALTH CENTRE
QUEEN CAMEL MEDICAL CENTRE
NORTH PETHERTON SURGERY
LISTER HOUSE PARTNERSHIP
CREWKERNE HEALTH CENTRE, CREWKERNE
BRENT AREA MEDICAL CENTRE
WELLS CITY PRACTICE
PARK MEDICAL PRACTICE Details of this methodology are available on slide 9. Click here to view them.
34 CVD: Primary Care Intelligence Packs Percentage of patients with a history of stroke whose last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less by CCG Comparison with CCGs in the STP
Below 150/90 Not below 150/90 Exceptions reported
• 12,768 people with a history of stroke NHS Somerset CCG 77.5% or TIA* in NHS Somerset CCG • 9,900 (77.5%) people whose blood pressure is <= 150 / 90 • 466 (3.6%) people who are exceptions • 2,402 (18.8%) additional people whose blood pressure is not <= 150 / 90
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 Worcestershire CCG 88.3%
NHS Cumbria CCG 84.4%
NHS Gloucestershire CCG 84.2%
NHS Ipswich and East Suffolk CCG 84.0%
NHS Wiltshire CCG 83.2%
NHS Southern Derbyshire CCG 83.1%
NHS East Riding of Yorkshire CCG 82.9%
NHS Kernow CCG 82.6%
NHS West Hampshire CCG 82.3%
NHS Coastal West Sussex CCG 79.7%
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
WEST ONE SURGERY L85620 16 ABBEY MANOR MEDICAL PRACTICE Y00189 18 SPRINGMEAD SURGERY, CHARD L85028 71 LISTER HOUSE PARTNERSHIP L85038 61 RYALLS PARK MEDICAL CENTRE, YEOVIL L85048 39 VICTORIA GATE SURGERY L85616 26 THE BLACKBROOK SURGERY L85014 71 SUMMERVALE SURGERY L85054 64 BURNHAM MEDICAL CENTRE L85016 165 • in total, including exceptions, there LUSON L85050 48 FROME MEDICAL CENTRE L85008 168 LANGPORT SURGERY L85033 104 are 2,868 people whose blood CREECH L85609 26 GLASTONBURY HEALTH CENTRE L85047 33 COLLEGE WAY SURGERY L85021 98 WARWICK HOUSE MEDICAL PRACTICE L85052 48 pressure is not <= 150 / 90 WINCANTON HEALTH CENTRE L85027 46 PRESTON GROVE MEDICAL CENTRE, YEOVIL L85015 69 FRENCH WEIR HEALTH CENTRE L85001 86 • GP practice range: 2.3% to 50.0% HENDFORD LODGE MEDICAL CENTRE, YEOVIL L85022 57 PARK MEDICAL PRACTICE L85043 45 CREWKERNE HEALTH CENTRE, CREWKERNE L85004 65 HIGHBRIDGE MEDICAL CENTRE L85010 79 MILLBROOK SURGERY, CASTLE CARY L85040 26 LYNGFORD PARK L85062 27 PENN HILL SURGERY, YEOVIL L85017 48 CRANLEIGH GARDENS MEDICAL CENTRE L85025 43 BUTTERCROSS HEALTH CENTRE L85005 31 TAWSTOCK MEDICAL CENTRE, CHARD L85619 23 NORTH CURRY L85037 15 QUEEN CAMEL MEDICAL CENTRE L85044 30 HAMDON MEDICAL CENTRE, STOKE-SUB-HAMDON L85026 26 WELLS CITY PRACTICE L85034 29 L85029 (VINE SURGERY) L85029 40 WELLINGTON MEDICAL CENTRE L85012 70 WESTLAKE SURGERY L85045 12 GLASTONBURY SURGERY L85039 59 ST JAMES MEDICAL CENTRE L85023 61 MILBORNE PORT SURGERY L85031 22 NHS YEOVIL HEALTH CENTRE Y02778 6 BRUTON SURGERY L85032 20 WEST SOMERSET HEALTHCARE L85009 63 WELLS HEALTH CENTRE L85002 61 EAST QUAY MEDICAL CENTRE L85035 60 OAKLANDS SURGERY, YEOVIL L85064 12 CHURCH STREET SURGERY, MARTOCK L85007 56 QUANTOCK VALE SURGERY L85036 24 GROVE HOUSE SURGERY L85053 25 ILCHESTER SURGERY, ILCHESTER L85066 9 DUNSTER SURGERY L85065 16 HARLEY HOUSE SURGERY L85019 41 NORTH PETHERTON SURGERY L85056 24 IRNHAM LODGE SURGERY L85041 44 THE MEADOWS SURGERY L85061 12 REDGATE MEDICAL CENTRE L85051 16 CHURCH VIEW SURGERY, ILLMINSTER L85624 12 BRENT AREA MEDICAL CENTRE L85601 10 CROWN MEDICAL CENTRE L85006 28 VICTORIA PARK MEDICAL CENTRE L85612 10 MENDIP COUNTRY PRACTICE L85046 19 TAUNTON ROAD MEDICAL CENTRE L85042 43 CANNINGTON HEALTH CENTRE L85018 22 AXBRIDGE SURGERY L85055 26 EXMOOR MEDICAL CENTRE L85003 15 BECKINGTON FAMILY PRACTICE L85020 26 POLDEN MEDICAL PRACTICE L85024 27 SOMERSET BRIDGE MEDICAL CENTRE L85607 6 QUANTOCK MEDICAL CENTRE L85013 10 CHEDDAR MEDICAL CENTRE L85011 23 WESTLAKE (S) Y01163 4 ESSEX HOUSE MEDICAL CENTRE, CHARD L85030 20 OAKHILL SURGERY L85611 4 L85060 (VINE SURGERY) L85060 7 PORLOCK MEDICAL CENTRE L85608 2 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
• 7,936 people with a stroke shown to NHS Somerset CCG 88.9% be non-haemorrhagic* in NHS Somerset CCG • 7,052 (88.9%) people who are taking an anti-platetet agent or anti- coagulant • 213 (2.7%) people who are exceptions • 671 (8.5%) additional people with no treatment
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 Kernow CCG 92.3%
NHS South Worcestershire CCG 92.1%
NHS West Hampshire CCG 91.9%
NHS Ipswich and East Suffolk CCG 91.8%
NHS Wiltshire CCG 91.8%
NHS East Riding of Yorkshire CCG 91.7%
NHS Gloucestershire CCG 91.7%
NHS Southern Derbyshire CCG 91.3%
NHS Cumbria CCG 91.1%
NHS Coastal West Sussex CCG 90.2%
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
VICTORIA GATE SURGERY L85616 15 MILLBROOK SURGERY, CASTLE CARY L85040 15 ILCHESTER SURGERY, ILCHESTER L85066 5 LYNGFORD PARK L85062 12 HENDFORD LODGE MEDICAL CENTRE, YEOVIL L85022 32 GLASTONBURY HEALTH CENTRE L85047 12 LISTER HOUSE PARTNERSHIP L85038 23 WINCANTON HEALTH CENTRE L85027 21 SUMMERVALE SURGERY L85054 18 • in total, including exceptions, there QUANTOCK VALE SURGERY L85036 12 ST JAMES MEDICAL CENTRE L85023 26 BURNHAM MEDICAL CENTRE L85016 44 are 884 people who are not taking an HAMDON MEDICAL CENTRE, STOKE-SUB-HAMDON L85026 11 OAKHILL SURGERY L85611 5 DUNSTER SURGERY L85065 7 PENN HILL SURGERY, YEOVIL L85017 16 anti-platelet agent or anti-coagulant BUTTERCROSS HEALTH CENTRE L85005 13 WELLS HEALTH CENTRE L85002 29 WELLINGTON MEDICAL CENTRE L85012 27 • GP practice range: 1.7% to 26.8% HARLEY HOUSE SURGERY L85019 20 MILBORNE PORT SURGERY L85031 8 PARK MEDICAL PRACTICE L85043 15 CHURCH VIEW SURGERY, ILLMINSTER L85624 6 RYALLS PARK MEDICAL CENTRE, YEOVIL L85048 7 AXBRIDGE SURGERY L85055 15 WELLS CITY PRACTICE L85034 13 GLASTONBURY SURGERY L85039 21 BECKINGTON FAMILY PRACTICE L85020 15 CHEDDAR MEDICAL CENTRE L85011 18 FRENCH WEIR HEALTH CENTRE L85001 24 VICTORIA PARK MEDICAL CENTRE L85612 5 ABBEY MANOR MEDICAL PRACTICE Y00189 2 CHURCH STREET SURGERY, MARTOCK L85007 20 PRESTON GROVE MEDICAL CENTRE, YEOVIL L85015 15 CREWKERNE HEALTH CENTRE, CREWKERNE L85004 18 L85029 (VINE SURGERY) L85029 11 THE BLACKBROOK SURGERY L85014 15 WARWICK HOUSE MEDICAL PRACTICE L85052 10 LANGPORT SURGERY L85033 22 LUSON L85050 9 EAST QUAY MEDICAL CENTRE L85035 18 TAWSTOCK MEDICAL CENTRE, CHARD L85619 5 WESTLAKE SURGERY L85045 4 IRNHAM LODGE SURGERY L85041 15 COLLEGE WAY SURGERY L85021 18 GROVE HOUSE SURGERY L85053 8 CROWN MEDICAL CENTRE L85006 8 QUANTOCK MEDICAL CENTRE L85013 4 HIGHBRIDGE MEDICAL CENTRE L85010 18 SPRINGMEAD SURGERY, CHARD L85028 13 FROME MEDICAL CENTRE L85008 29 TAUNTON ROAD MEDICAL CENTRE L85042 17 OAKLANDS SURGERY, YEOVIL L85064 3 BRUTON SURGERY L85032 5 ESSEX HOUSE MEDICAL CENTRE, CHARD L85030 14 SOMERSET BRIDGE MEDICAL CENTRE L85607 3 QUEEN CAMEL MEDICAL CENTRE L85044 8 MENDIP COUNTRY PRACTICE L85046 6 WEST ONE SURGERY L85620 2 PORLOCK MEDICAL CENTRE L85608 3 POLDEN MEDICAL PRACTICE L85024 9 CRANLEIGH GARDENS MEDICAL CENTRE L85025 7 BRENT AREA MEDICAL CENTRE L85601 2 NORTH PETHERTON SURGERY L85056 4 NHS YEOVIL HEALTH CENTRE Y02778 1 THE MEADOWS SURGERY L85061 2 WEST SOMERSET HEALTHCARE L85009 11 L85060 (VINE SURGERY) L85060 3 CANNINGTON HEALTH CENTRE L85018 4 REDGATE MEDICAL CENTRE L85051 3 CREECH L85609 2 WESTLAKE (S) Y01163 1 NORTH CURRY L85037 1 EXMOOR MEDICAL CENTRE L85003 1 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
• 0.74 ratio of observed to expected NHS Somerset CCG 0.74 diabetes prevalence in NHS Somerset CCG, compared to 0.77 in England
• this suggests 74% of people have been diagnosed
England 0.77 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 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 East Riding of Yorkshire CCG 0.82
NHS Southern Derbyshire CCG 0.81
NHS Cumbria CCG 0.79
NHS South Worcestershire CCG 0.79
NHS Gloucestershire CCG 0.77
NHS Coastal West Sussex CCG 0.76
NHS Somerset CCG 0.74
NHS Wiltshire CCG 0.73
NHS Ipswich and East Suffolk CCG 0.68
NHS West Hampshire CCG 0.66
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
DUNSTER SURGERY L85065 10.1% BURNHAM MEDICAL CENTRE L85016 8.8% CHURCH VIEW SURGERY, ILLMINSTER L85624 8.7% WEST ONE SURGERY L85620 8.3% ESSEX HOUSE MEDICAL CENTRE, CHARD L85030 8.2% BUTTERCROSS HEALTH CENTRE L85005 8.2% HIGHBRIDGE MEDICAL CENTRE L85010 8.1% WEST SOMERSET HEALTHCARE L85009 7.9% HARLEY HOUSE SURGERY L85019 7.8% • GP practice range of observed POLDEN MEDICAL PRACTICE L85024 7.8% TAUNTON ROAD MEDICAL CENTRE L85042 7.7% PORLOCK MEDICAL CENTRE L85608 7.6% LYNGFORD PARK L85062 7.6% diabetes 3.1% to 10.1% SPRINGMEAD SURGERY, CHARD L85028 7.5% TAWSTOCK MEDICAL CENTRE, CHARD L85619 7.4% ILCHESTER SURGERY, ILCHESTER L85066 7.4% • there are an estimated 10,990 people NORTH PETHERTON SURGERY L85056 7.4% CREWKERNE HEALTH CENTRE, CREWKERNE L85004 7.3% WARWICK HOUSE MEDICAL PRACTICE L85052 7.3% with undiagnosed diabetes in NHS L85060 (VINE SURGERY) L85060 7.3% SUMMERVALE SURGERY L85054 7.3% REDGATE MEDICAL CENTRE L85051 7.3% Somerset CCG LANGPORT SURGERY L85033 7.3% CHURCH STREET SURGERY, MARTOCK L85007 7.2% MENDIP COUNTRY PRACTICE L85046 7.2% HENDFORD LODGE MEDICAL CENTRE, YEOVIL L85022 7.2% IRNHAM LODGE SURGERY L85041 7.0% BRENT AREA MEDICAL CENTRE L85601 7.0% PENN HILL SURGERY, YEOVIL L85017 6.9% LISTER HOUSE PARTNERSHIP L85038 6.9% WINCANTON HEALTH CENTRE L85027 6.9% CANNINGTON HEALTH CENTRE L85018 6.9% RYALLS PARK MEDICAL CENTRE, YEOVIL L85048 6.8% WELLS HEALTH CENTRE L85002 6.7% THE BLACKBROOK SURGERY L85014 6.7% HAMDON MEDICAL CENTRE, STOKE-SUB-HAMDON L85026 6.6% QUANTOCK MEDICAL CENTRE L85013 6.6% QUANTOCK VALE SURGERY L85036 6.6% GLASTONBURY SURGERY L85039 6.6% WESTLAKE (S) Y01163 6.5% THE MEADOWS SURGERY L85061 6.5% CREECH L85609 6.5% LUSON L85050 6.4% MILBORNE PORT SURGERY L85031 6.4% WELLINGTON MEDICAL CENTRE L85012 6.3% COLLEGE WAY SURGERY L85021 6.3% FRENCH WEIR HEALTH CENTRE L85001 6.2% L85029 (VINE SURGERY) L85029 6.2% NORTH CURRY L85037 6.2% QUEEN CAMEL MEDICAL CENTRE L85044 6.2% CRANLEIGH GARDENS MEDICAL CENTRE L85025 6.1% EAST QUAY MEDICAL CENTRE L85035 6.1% WESTLAKE SURGERY L85045 6.1% OAKLANDS SURGERY, YEOVIL L85064 6.1% PRESTON GROVE MEDICAL CENTRE, YEOVIL L85015 6.1% PARK MEDICAL PRACTICE L85043 6.1% FROME MEDICAL CENTRE L85008 6.1% VICTORIA GATE SURGERY L85616 6.0% MILLBROOK SURGERY, CASTLE CARY L85040 6.0% EXMOOR MEDICAL CENTRE L85003 6.0% BECKINGTON FAMILY PRACTICE L85020 5.9% VICTORIA PARK MEDICAL CENTRE L85612 5.9% CROWN MEDICAL CENTRE L85006 5.9% GROVE HOUSE SURGERY L85053 5.9% CHEDDAR MEDICAL CENTRE L85011 5.9% SOMERSET BRIDGE MEDICAL CENTRE L85607 5.7% ST JAMES MEDICAL CENTRE L85023 5.6% WELLS CITY PRACTICE L85034 5.3% BRUTON SURGERY L85032 5.2% ABBEY MANOR MEDICAL PRACTICE Y00189 5.0% Note: The estimated number of undiagnosed AXBRIDGE SURGERY L85055 5.0% OAKHILL SURGERY L85611 4.9% people with diabetes has been calculated by GLASTONBURY HEALTH CENTRE L85047 4.7% NHS YEOVIL HEALTH CENTRE Y02778 3.1% multiplying the estimated prevalence rate to the 0% 2% 4% 6% 8% 10% 12% 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 diabetes in NHS Somerset CCG is 9.1% (diagnosed and undiagnosed) NHS Somerset CCG 6.7% 2.4% 12.2% • in addition, there are an estimated 12.2% of people in NHS Somerset CCG who are at increased risk of developing diabetes (i.e. with non- diabetic hyperglycaemia)
• this means that 21.3% of the population in NHS Somerset CCG are estimated to have diabetes, or at high risk of developing of diabetes
Note: Prevalence estimates of non-diabetic England 6.5% 1.9% 11.2% hyperglycaemia were developed using Health Survey for England (HSE) data. Five years of 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
• data on care processes and treatment NHS Somerset CCG 47.7% targets are taken from the National Diabetes Audit (NDA) • overall practice participation in the 2015/16 audit was 81.4% in England
• in NHS Somerset CCG, 65 out of 75 practices (86.7%) participated in the NDA. Data is not available for the remaining practices
• 47.7% of people with diabetes (of practices who participated in the audit) had the eight recommended care processes in NHS Somerset CCG, compared to 52.6% in England England 52.6%
0% 10% 20% 30% 40% 50% 60%
47 CVD: Primary Care Intelligence Packs People with diabetes who had eight care processes by GP practice, 2015/16
GP practice Average of practices in the CCG who participated in the audit
WARWICK HOUSE MEDICAL PRACTICE L85052 80.8% NORTH PETHERTON SURGERY L85056 73.6% COLLEGE WAY SURGERY L85021 73.5% LYNGFORD PARK L85062 72.1% CANNINGTON HEALTH CENTRE L85018 70.8% WELLS CITY PRACTICE L85034 70.8% BECKINGTON FAMILY PRACTICE L85020 68.3% • achievement - 8 care processes: in NHS YEOVIL HEALTH CENTRE Y02778 68.1% IRNHAM LODGE SURGERY L85041 66.9% GLASTONBURY SURGERY L85039 65.6% practices who provided data via the DUNSTER SURGERY L85065 65.4% CHEDDAR MEDICAL CENTRE L85011 65.4% REDGATE MEDICAL CENTRE L85051 61.9% NDA, between 1.8% and 80.8% of PORLOCK MEDICAL CENTRE L85608 61.4% SOMERSET BRIDGE MEDICAL CENTRE L85607 61.2% BRUTON SURGERY L85032 60.7% patients received all 8 care processes OAKHILL SURGERY L85611 60.6% GLASTONBURY HEALTH CENTRE L85047 60.2% WELLS HEALTH CENTRE L85002 59.5% THE BLACKBROOK SURGERY L85014 58.5% OAKLANDS SURGERY, YEOVIL L85064 58.2% CROWN MEDICAL CENTRE L85006 57.8% QUEEN CAMEL MEDICAL CENTRE L85044 55.6% WINCANTON HEALTH CENTRE L85027 54.9% • at least 14,223 people did not receive WELLINGTON MEDICAL CENTRE L85012 54.8% TAUNTON ROAD MEDICAL CENTRE L85042 54.7% FRENCH WEIR HEALTH CENTRE L85001 54.5% the eight care processes FROME MEDICAL CENTRE L85008 54.3% QUANTOCK MEDICAL CENTRE L85013 53.7% CREWKERNE HEALTH CENTRE, CREWKERNE L85004 53.6% HARLEY HOUSE SURGERY L85019 53.5% LISTER HOUSE PARTNERSHIP L85038 53.3% GROVE HOUSE SURGERY L85053 52.7% LANGPORT SURGERY L85033 51.4% ST JAMES MEDICAL CENTRE L85023 50.7% CRANLEIGH GARDENS MEDICAL CENTRE L85025 50.5% ILCHESTER SURGERY, ILCHESTER L85066 48.6% POLDEN MEDICAL PRACTICE L85024 47.6% PRESTON GROVE MEDICAL CENTRE, YEOVIL L85015 47.4% EAST QUAY MEDICAL CENTRE L85035 46.3% MILBORNE PORT SURGERY L85031 46.3% HENDFORD LODGE MEDICAL CENTRE, YEOVIL L85022 45.5% BUTTERCROSS HEALTH CENTRE L85005 43.2% TAWSTOCK MEDICAL CENTRE, CHARD L85619 42.6% VICTORIA PARK MEDICAL CENTRE L85612 41.6% L85060 (VINE SURGERY) L85060 41.1% L85029 (VINE SURGERY) L85029 40.6% BRENT AREA MEDICAL CENTRE L85601 39.6% PARK MEDICAL PRACTICE L85043 36.7% ABBEY MANOR MEDICAL PRACTICE Y00189 33.3% AXBRIDGE SURGERY L85055 32.8% BURNHAM MEDICAL CENTRE L85016 32.3% QUANTOCK VALE SURGERY L85036 26.4% EXMOOR MEDICAL CENTRE L85003 25.4% SPRINGMEAD SURGERY, CHARD L85028 24.5% ESSEX HOUSE MEDICAL CENTRE, CHARD L85030 24.2% LUSON L85050 23.7% VICTORIA GATE SURGERY L85616 22.2% MILLBROOK SURGERY, CASTLE CARY L85040 22.1% HAMDON MEDICAL CENTRE, STOKE-SUB-HAMDON L85026 17.6% SUMMERVALE SURGERY L85054 17.2% CHURCH STREET SURGERY, MARTOCK L85007 12.4% MENDIP COUNTRY PRACTICE L85046 9.5% THE MEADOWS SURGERY L85061 5.6% PENN HILL SURGERY, YEOVIL L85017 1.8% WESTLAKE (S) Y01163 CHURCH VIEW SURGERY, ILLMINSTER L85624 WEST ONE SURGERY L85620 CREECH L85609 RYALLS PARK MEDICAL CENTRE, YEOVIL L85048 WESTLAKE SURGERY L85045 NORTH CURRY L85037 HIGHBRIDGE MEDICAL CENTRE L85010 WEST SOMERSET HEALTHCARE L85009 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
• 35.0% of people with diabetes (of NHS Somerset CCG 35.0% practices who participated in the audit) met the three treatment targets in NHS Somerset CCG, compared to 39.0% in England
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
ILCHESTER SURGERY, ILCHESTER L85066 47.1% LYNGFORD PARK L85062 46.5% L85060 (VINE SURGERY) L85060 45.6% VICTORIA PARK MEDICAL CENTRE L85612 43.5% HAMDON MEDICAL CENTRE, STOKE-SUB-HAMDON L85026 43.5% MENDIP COUNTRY PRACTICE L85046 43.4% BRUTON SURGERY L85032 43.3% • achievement - 3 treatment targets: in PORLOCK MEDICAL CENTRE L85608 42.4% BURNHAM MEDICAL CENTRE L85016 42.1% DUNSTER SURGERY L85065 41.6% practices who provided data via the PENN HILL SURGERY, YEOVIL L85017 40.4% QUANTOCK MEDICAL CENTRE L85013 40.4% EXMOOR MEDICAL CENTRE L85003 39.8% NDA, between 0.0% and 47.1% of OAKLANDS SURGERY, YEOVIL L85064 39.2% COLLEGE WAY SURGERY L85021 38.8% WARWICK HOUSE MEDICAL PRACTICE L85052 38.7% patients achieved all 3 treatment EAST QUAY MEDICAL CENTRE L85035 38.7% CREWKERNE HEALTH CENTRE, CREWKERNE L85004 37.8% WELLINGTON MEDICAL CENTRE L85012 37.7% targets ESSEX HOUSE MEDICAL CENTRE, CHARD L85030 37.6% LANGPORT SURGERY L85033 37.5% NORTH PETHERTON SURGERY L85056 37.1% L85029 (VINE SURGERY) L85029 37.0% GROVE HOUSE SURGERY L85053 36.7% • at least 15,533 people did not meet POLDEN MEDICAL PRACTICE L85024 36.7% BUTTERCROSS HEALTH CENTRE L85005 36.6% FRENCH WEIR HEALTH CENTRE L85001 36.5% the three treatment targets HENDFORD LODGE MEDICAL CENTRE, YEOVIL L85022 36.2% CANNINGTON HEALTH CENTRE L85018 35.7% ST JAMES MEDICAL CENTRE L85023 35.5% QUANTOCK VALE SURGERY L85036 35.4% PARK MEDICAL PRACTICE L85043 35.4% CRANLEIGH GARDENS MEDICAL CENTRE L85025 35.3% CHEDDAR MEDICAL CENTRE L85011 34.8% REDGATE MEDICAL CENTRE L85051 34.6% IRNHAM LODGE SURGERY L85041 34.5% LUSON L85050 34.5% PRESTON GROVE MEDICAL CENTRE, YEOVIL L85015 34.2% HARLEY HOUSE SURGERY L85019 34.2% QUEEN CAMEL MEDICAL CENTRE L85044 34.2% TAUNTON ROAD MEDICAL CENTRE L85042 33.8% BRENT AREA MEDICAL CENTRE L85601 33.8% MILLBROOK SURGERY, CASTLE CARY L85040 33.8% SUMMERVALE SURGERY L85054 33.2% BECKINGTON FAMILY PRACTICE L85020 33.0% CROWN MEDICAL CENTRE L85006 32.7% WELLS CITY PRACTICE L85034 31.9% GLASTONBURY SURGERY L85039 30.8% MILBORNE PORT SURGERY L85031 30.7% FROME MEDICAL CENTRE L85008 30.6% GLASTONBURY HEALTH CENTRE L85047 30.0% AXBRIDGE SURGERY L85055 29.4% WELLS HEALTH CENTRE L85002 29.1% SPRINGMEAD SURGERY, CHARD L85028 28.4% WINCANTON HEALTH CENTRE L85027 27.7% OAKHILL SURGERY L85611 27.3% THE BLACKBROOK SURGERY L85014 27.1% VICTORIA GATE SURGERY L85616 24.7% THE MEADOWS SURGERY L85061 24.5% CHURCH STREET SURGERY, MARTOCK L85007 24.3% SOMERSET BRIDGE MEDICAL CENTRE L85607 23.6% NHS YEOVIL HEALTH CENTRE Y02778 23.4% ABBEY MANOR MEDICAL PRACTICE Y00189 22.0% TAWSTOCK MEDICAL CENTRE, CHARD L85619 20.5% LISTER HOUSE PARTNERSHIP L85038 WESTLAKE (S) Y01163 CHURCH VIEW SURGERY, ILLMINSTER L85624 WEST ONE SURGERY L85620 CREECH L85609 RYALLS PARK MEDICAL CENTRE, YEOVIL L85048 WESTLAKE SURGERY L85045 NORTH CURRY L85037 HIGHBRIDGE MEDICAL CENTRE L85010 WEST SOMERSET HEALTHCARE L85009 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% 0% -10% -20% -30% -40% -50%
LISTER HOUSE PARTNERSHIP 1
TAWSTOCK MEDICAL CENTRE, CHARD 78
ABBEY MANOR MEDICAL PRACTICE 22 • using the GP cluster method of VICTORIA GATE SURGERY 39 calculating potential gains, if each THE MEADOWS SURGERY 32 practice was to achieve as well as the CHURCH STREET SURGERY, MARTOCK 120 upper quartile of its national cluster, then an additional 2,311 people would NHS YEOVIL HEALTH CENTRE 25 be treated SOMERSET BRIDGE MEDICAL CENTRE 31
OAKHILL SURGERY 16
WINCANTON HEALTH CENTRE 76
DUNSTER SURGERY 7
BRUTON SURGERY 6
MENDIP COUNTRY PRACTICE 7
HAMDON MEDICAL CENTRE, STOKE-SUB-HAMDON 6
VICTORIA PARK MEDICAL CENTRE 4
BURNHAM MEDICAL CENTRE 21
PORLOCK MEDICAL CENTRE 2
L85060 (VINE SURGERY)
LYNGFORD PARK
ILCHESTER SURGERY, ILCHESTER 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 Somerset CCG 0.64 • the ratio of those diagnosed with chronic kidney disease versus those expected to have chronic kidney disease is 0.64. This compares to 0.68 for England • this suggests that 64% of people with chronic kidney disease have been diagnosed
Note: This slide compares the prevalence of CKD recorded in QOF in 2015/16 to the expected England 0.68 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 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 South Worcestershire CCG 0.78
NHS Ipswich and East Suffolk CCG 0.78
NHS Kernow CCG 0.72
NHS Cumbria CCG 0.71
NHS East Riding of Yorkshire CCG 0.71
NHS Somerset CCG 0.64
NHS Wiltshire CCG 0.61
NHS Coastal West Sussex CCG 0.58
NHS West Hampshire CCG 0.50
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
CHURCH VIEW SURGERY, ILLMINSTER L85624 10.4% PORLOCK MEDICAL CENTRE L85608 10.3% DUNSTER SURGERY L85065 10.1% SPRINGMEAD SURGERY, CHARD L85028 7.8% COLLEGE WAY SURGERY L85021 7.6% ESSEX HOUSE MEDICAL CENTRE, CHARD L85030 7.0% MENDIP COUNTRY PRACTICE L85046 6.8% BURNHAM MEDICAL CENTRE L85016 6.5% WEST SOMERSET HEALTHCARE L85009 6.5% • it is estimated that there are 11,885 WELLS HEALTH CENTRE L85002 6.4% QUANTOCK MEDICAL CENTRE L85013 6.3% WEST ONE SURGERY L85620 6.3% people with undiagnosed chronic TAUNTON ROAD MEDICAL CENTRE L85042 6.0% WELLINGTON MEDICAL CENTRE L85012 5.8% GLASTONBURY SURGERY L85039 5.8% POLDEN MEDICAL PRACTICE L85024 5.8% kidney disease in NHS Somerset CHURCH STREET SURGERY, MARTOCK L85007 5.7% IRNHAM LODGE SURGERY L85041 5.6% THE BLACKBROOK SURGERY L85014 5.5% CCG WARWICK HOUSE MEDICAL PRACTICE L85052 5.4% L85060 (VINE SURGERY) L85060 5.4% WINCANTON HEALTH CENTRE L85027 5.4% • GP practice range of observed CKD: BECKINGTON FAMILY PRACTICE L85020 5.4% NORTH PETHERTON SURGERY L85056 5.2% PARK MEDICAL PRACTICE L85043 5.2% 1.3% to 10.4% HENDFORD LODGE MEDICAL CENTRE, YEOVIL L85022 5.0% LYNGFORD PARK L85062 5.0% SUMMERVALE SURGERY L85054 5.0% LISTER HOUSE PARTNERSHIP L85038 4.9% EXMOOR MEDICAL CENTRE L85003 4.9% ILCHESTER SURGERY, ILCHESTER L85066 4.8% BUTTERCROSS HEALTH CENTRE L85005 4.7% HARLEY HOUSE SURGERY L85019 4.7% ST JAMES MEDICAL CENTRE L85023 4.7% CHEDDAR MEDICAL CENTRE L85011 4.7% L85029 (VINE SURGERY) L85029 4.6% CROWN MEDICAL CENTRE L85006 4.6% LANGPORT SURGERY L85033 4.6% CREWKERNE HEALTH CENTRE, CREWKERNE L85004 4.6% CRANLEIGH GARDENS MEDICAL CENTRE L85025 4.5% CANNINGTON HEALTH CENTRE L85018 4.5% LUSON L85050 4.4% REDGATE MEDICAL CENTRE L85051 4.4% WESTLAKE (S) Y01163 4.4% QUANTOCK VALE SURGERY L85036 4.3% SOMERSET BRIDGE MEDICAL CENTRE L85607 4.3% HAMDON MEDICAL CENTRE, STOKE-SUB-HAMDON L85026 4.2% GROVE HOUSE SURGERY L85053 4.2% MILBORNE PORT SURGERY L85031 4.1% WESTLAKE SURGERY L85045 4.1% WELLS CITY PRACTICE L85034 3.9% FRENCH WEIR HEALTH CENTRE L85001 3.9% TAWSTOCK MEDICAL CENTRE, CHARD L85619 3.9% VICTORIA GATE SURGERY L85616 3.9% BRENT AREA MEDICAL CENTRE L85601 3.9% QUEEN CAMEL MEDICAL CENTRE L85044 3.8% BRUTON SURGERY L85032 3.8% OAKLANDS SURGERY, YEOVIL L85064 3.8% EAST QUAY MEDICAL CENTRE L85035 3.6% PRESTON GROVE MEDICAL CENTRE, YEOVIL L85015 3.5% CREECH L85609 3.4% GLASTONBURY HEALTH CENTRE L85047 3.3% PENN HILL SURGERY, YEOVIL L85017 3.2% THE MEADOWS SURGERY L85061 3.2% MILLBROOK SURGERY, CASTLE CARY L85040 3.1% Note: CCG estimates for the estimated HIGHBRIDGE MEDICAL CENTRE L85010 3.1% FROME MEDICAL CENTRE L85008 3.0% OAKHILL SURGERY L85611 2.9% number of people with CKD are based on ABBEY MANOR MEDICAL PRACTICE Y00189 2.8% AXBRIDGE SURGERY L85055 2.7% applying a proportion from a resident based NORTH CURRY L85037 2.7% VICTORIA PARK MEDICAL CENTRE L85612 2.6% RYALLS PARK MEDICAL CENTRE, YEOVIL L85048 2.5% population estimate to a GP registered NHS YEOVIL HEALTH CENTRE Y02778 1.3% population. The characteristics of registered 0% 2% 4% 6% 8% 10% 12% and resident populations may vary in some CCGs, and local interpretation is required.
56 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding 12 months) is 140/85 mmHg or less by CCG, 2014/15 Comparison with CCGs in the STP Below 140/85 Not below 140/85 Exceptions reported
• 21,691 people with CKD (diagnosed*) NHS Somerset CCG 67.3% in NHS Somerset CCG • 14,591 (67.3%) people whose blood pressure is <= 140 /85 • 1,495 (6.9%) people who are exceptions • 5,605 (25.8%) additional people whose blood pressure is not <= 140 / 85
England 74.4%
*Using the QOF clinical indicator CKD002 denominator plus exceptions. Note: as the CKD002 indicator was removed from 0% 20% 40% 60% 80% 100% the QOF in 15/16 this is historic data taken from the 2014/15 QOF.
57 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding 12 months) is 140/85 mmHg or less by CCG, 2014/15 Comparison with demographically similar CCGs Below 140/85 Not below 140/85 Exceptions reported
NHS South Worcestershire CCG 76.5%
NHS Cumbria CCG 74.4%
NHS Gloucestershire CCG 74.4%
NHS Wiltshire CCG 73.3%
NHS Southern Derbyshire CCG 72.7%
NHS East Riding of Yorkshire CCG 72.7%
NHS Kernow CCG 72.5%
NHS Ipswich and East Suffolk CCG 72.0%
NHS West Hampshire CCG 69.6%
NHS Coastal West Sussex CCG 68.6%
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
WEST ONE SURGERY L85620 52 SUMMERVALE SURGERY L85054 180 NHS YEOVIL HEALTH CENTRE Y02778 19 LISTER HOUSE SURGERY. CROFT WAY. WIVELISCOMBE L85038 139 FROME MEDICAL CENTRE L85008 309 WINCANTON HEALTH CENTRE L85027 184 LUSON SURGERY. FORE STREET. WELLINGTON L85050 98 BURNHAM MEDICAL CENTRE. LOVE LANE. BURNHAM-ON-SEA L85016 441 LANGPORT SURGERY L85033 216 • in total, including exceptions, there VICTORIA GATE SURGERY L85616 61 PRESTON GROVE MEDICAL CENTRE. YEOVIL L85015 163 SPRINGMEAD SURGERY, CHARD L85028 186 OAKHILL SURGERY L85611 24 are 7,100 people whose blood WESTLAKE SURGERY. HIGH STREET. WEST COKER L85045 29 CREECH MEDICAL CENTRE L85609 38 WELLS HEALTH CENTRE L85002 259 pressure is not <= 140 / 85 FRENCH WEIR HEALTH CENTRE L85001 180 BLACKBROOK SURGERY. LISIEUX WAY. TAUNTON L85014 194 PENN HILL SURGERY, YEOVIL L85017 107 • GP practice range: 0.0% to 59.8% ST JAMES MEDICAL CENTRE. ST JAMES STREET. TAUNTON L85023 180 ABBEY MANOR MEDICAL PRACTICE Y00189 25 CHURCH STREET SURGERY, MARTOCK L85007 182 MILBORNE PORT SURGERY L85031 70 RYALLS PARK MEDICAL CENTRE L85048 46 GLASTONBURY HEALTH CENTRE. WELLS ROAD. GLASTONBURY L85047 66 HAMDON MEDICAL CENTRE, STOKE-SUB-HAMDON L85026 51 WARWICK HOUSE MEDICAL PRACTICE. TAUNTON L85052 96 QUANTOCK VALE SURGERY L85036 70 SOMERTON SURGERY COX'S YARD SOMERTON L85005 72 WELLINGTON MEDICAL CENTRE. BULFORD. WELLINGTON L85012 240 COLLEGE WAY SURGERY. COMEYTROWE CENTRE. TAUNTON L85021 248 GLASTONBURY SURGERY L85039 207 WELLS CITY PRACTICE L85034 79 QUEEN CAMEL MEDICAL CENTRE L85044 58 NORTH CURRY HEALTH CENTRE L85037 30 HENDFORD LODGE MEDICAL CENTRE, YEOVIL L85022 150 PARK ROAD MEDICAL PRACTICE. SHEPTON MALLET L85043 131 CREWKERNE HEALTH CENTRE. MIDDLE PATH. CREWKERNE L85004 147 CROWN MEDICAL CENTRE L85006 103 BRENT AREA MEDICAL CENTRE L85601 29 IRNHAM LODGE SURGERY L85041 101 POLDEN MP. QUARRY GROUND. BROADWAY. EDINGTON L85024 93 ILCHESTER SURGERY, ILCHESTER L85066 33 THE SURGERY. HOULGATE WAY. AXBRIDGE L85055 53 NORTH PETHERTON SURGERY L85056 73 HIGHBRIDGE MEDICAL CENTRE L85010 98 BECKINGTON FAMILY PRACTICE L85020 96 MENDIP COUNTRY PRACTICE L85046 73 BRENDON HILLS SURGERY L85602 18 BRUTON SURGERY L85032 46 MILLBROOK SURGERY, CASTLE CARY L85040 33 PORLOCK MEDICAL CENTRE L85608 41 TAWSTOCK MEDICAL CENTRE. ST. MARYS CRESCENT. CHARD L85619 47 LYNGFORD PARK SURGERY L85062 60 CANNINGTON HEALTH CENTRE L85018 52 GROVE HOUSE SURGERY L85053 57 CHEDDAR MEDICAL CENTRE. ROYNON WAY. CHEDDAR L85011 72 REDGATE MEDICAL CENTRE L85051 55 DUNSTER SURGERY L85065 39 THE SURGERY. ROBERT STREET. WILLTON L85009 141 VICTORIA PARK MEDICAL CENTRE L85612 21 ESSEX HOUSE SURGERY. 59 FORE STREET. CHARD L85030 128 SOMERSET BRIDGE MEDICAL CENTRE L85607 28 EAST QUAY MEDICAL CENTRE. EAST QUAY. BRIDGWATER L85035 97 OAKLANDS SURGERY, YEOVIL L85064 24 VINE SURGERY. HINDHAYES LANE. STREET L85029 72 EXMOOR MEDICAL CENTRE L85003 38 CRANLEIGH GARDENS MEDICAL CENTRE L85025 70 HARLEY HOUSE SURGERY L85019 58 CHURCH VIEW SURGERY, ILLMINSTER L85624 34 L85060 (VINE SURGERY) L85060 34 QUANTOCK MEDICAL CENTRE L85013 29 THE MEADOWS SURGERY L85061 17 WESTLAKE SURGERY (S) Y01163 10 TAUNTON ROAD MEDICAL CENTRE. BRIDGWATER L85042 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
30% 20% 10% 0% -10% -20% -30% -40% -50%
WEST ONE SURGERY 36
SUMMERVALE SURGERY 113
NHS YEOVIL HEALTH CENTRE 13 • using the GP cluster method of LISTER HOUSE SURGERY. CROFT WAY. WIVELISCOMBE 89 calculating potential gains, if each WINCANTON HEALTH CENTRE 111 practice was to achieve as well as the LUSON SURGERY. FORE STREET. WELLINGTON 59 upper quartile of its national cluster, then an additional 2,897 people would VICTORIA GATE SURGERY 38 be treated OAKHILL SURGERY 15
FROME MEDICAL CENTRE 167
SPRINGMEAD SURGERY, CHARD 108
EXMOOR MEDICAL CENTRE
VINE SURGERY. HINDHAYES LANE. STREET
L85060 (VINE SURGERY)
QUANTOCK MEDICAL CENTRE
THE MEADOWS SURGERY
CRANLEIGH GARDENS MEDICAL CENTRE
HARLEY HOUSE SURGERY
CHURCH VIEW SURGERY, ILLMINSTER
WESTLAKE SURGERY (S)
TAUNTON ROAD MEDICAL CENTRE. BRIDGWATER 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
• 21,716 people with CKD (diagnosed*) NHS Somerset CCG 61.5% in NHS Somerset CCG • 13,361 (61.5%) people who have a record of urine albumin:creatinine ratio test • 742 (3.4%) people who are exceptions • 7,613 (35.1%) additional people who have no record of urine albumin:creatinine ratio test
England 75.4%
*Using the QOF clinical indicator CKD004 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 Kernow CCG 77.0%
NHS Cumbria CCG 76.9%
NHS South Worcestershire CCG 76.7%
NHS East Riding of Yorkshire CCG 74.7%
NHS Gloucestershire CCG 74.1%
NHS Wiltshire CCG 73.9%
NHS Ipswich and East Suffolk CCG 71.5%
NHS West Hampshire CCG 71.2%
NHS Coastal West Sussex CCG 67.4%
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
PENN HILL SURGERY, YEOVIL L85017 255 THE MEADOWS SURGERY L85061 90 RYALLS PARK MEDICAL CENTRE L85048 99 WEST ONE SURGERY L85620 67 QUANTOCK VALE SURGERY L85036 145 CREWKERNE HEALTH CENTRE. MIDDLE PATH. CREWKERNE L85004 330 CHURCH STREET SURGERY, MARTOCK L85007 341 FRENCH WEIR HEALTH CENTRE L85001 305 SUMMERVALE SURGERY L85054 210 • in total, including exceptions, there SOMERTON SURGERY COX'S YARD SOMERTON L85005 136 PRESTON GROVE MEDICAL CENTRE. YEOVIL L85015 232 BLACKBROOK SURGERY. LISIEUX WAY. TAUNTON L85014 291 VICTORIA GATE SURGERY L85616 81 are 8,355 people who have no record CREECH MEDICAL CENTRE L85609 53 WARWICK HOUSE MEDICAL PRACTICE. TAUNTON L85052 156 HENDFORD LODGE MEDICAL CENTRE, YEOVIL L85022 268 of urine albumin:creatinine ratio test HAMDON MEDICAL CENTRE, STOKE-SUB-HAMDON L85026 77 NHS YEOVIL HEALTH CENTRE Y02778 20 POLDEN MP. QUARRY GROUND. BROADWAY. EDINGTON L85024 168 • GP practice range: 0.0% to 95.1% LISTER HOUSE SURGERY. CROFT WAY. WIVELISCOMBE L85038 145 WELLINGTON MEDICAL CENTRE. BULFORD. WELLINGTON L85012 342 CROWN MEDICAL CENTRE L85006 158 SPRINGMEAD SURGERY, CHARD L85028 204 QUEEN CAMEL MEDICAL CENTRE L85044 83 FROME MEDICAL CENTRE L85008 311 ABBEY MANOR MEDICAL PRACTICE Y00189 31 ST JAMES MEDICAL CENTRE. ST JAMES STREET. TAUNTON L85023 216 THE SURGERY. HOULGATE WAY. AXBRIDGE L85055 83 LUSON SURGERY. FORE STREET. WELLINGTON L85050 93 MILLBROOK SURGERY, CASTLE CARY L85040 54 WESTLAKE SURGERY. HIGH STREET. WEST COKER L85045 29 BRENDON HILLS SURGERY L85602 28 WELLS CITY PRACTICE L85034 99 PARK ROAD MEDICAL PRACTICE. SHEPTON MALLET L85043 170 L85060 (VINE SURGERY) L85060 81 LANGPORT SURGERY L85033 201 WELLS HEALTH CENTRE L85002 242 COLLEGE WAY SURGERY. COMEYTROWE CENTRE. TAUNTON L85021 275 MILBORNE PORT SURGERY L85031 70 BURNHAM MEDICAL CENTRE. LOVE LANE. BURNHAM-ON-SEA L85016 355 WINCANTON HEALTH CENTRE L85027 134 BECKINGTON FAMILY PRACTICE L85020 119 BRENT AREA MEDICAL CENTRE L85601 32 GLASTONBURY HEALTH CENTRE. WELLS ROAD. GLASTONBURY L85047 60 LYNGFORD PARK SURGERY L85062 75 REDGATE MEDICAL CENTRE L85051 72 CANNINGTON HEALTH CENTRE L85018 64 VINE SURGERY. HINDHAYES LANE. STREET L85029 84 IRNHAM LODGE SURGERY L85041 80 THE SURGERY. ROBERT STREET. WILLTON L85009 139 PORLOCK MEDICAL CENTRE L85608 36 DUNSTER SURGERY L85065 36 TAWSTOCK MEDICAL CENTRE. ST. MARYS CRESCENT. CHARD L85619 39 BRUTON SURGERY L85032 36 GROVE HOUSE SURGERY L85053 47 HARLEY HOUSE SURGERY L85019 60 WESTLAKE SURGERY (S) Y01163 13 EXMOOR MEDICAL CENTRE L85003 35 VICTORIA PARK MEDICAL CENTRE L85612 17 NORTH PETHERTON SURGERY L85056 49 HIGHBRIDGE MEDICAL CENTRE L85010 65 GLASTONBURY SURGERY L85039 111 CRANLEIGH GARDENS MEDICAL CENTRE L85025 64 NORTH CURRY HEALTH CENTRE L85037 15 CHEDDAR MEDICAL CENTRE. ROYNON WAY. CHEDDAR L85011 47 OAKLANDS SURGERY, YEOVIL L85064 15 EAST QUAY MEDICAL CENTRE. EAST QUAY. BRIDGWATER L85035 58 CHURCH VIEW SURGERY, ILLMINSTER L85624 24 OAKHILL SURGERY L85611 7 SOMERSET BRIDGE MEDICAL CENTRE L85607 15 MENDIP COUNTRY PRACTICE L85046 29 QUANTOCK MEDICAL CENTRE L85013 17 ESSEX HOUSE SURGERY. 59 FORE STREET. CHARD L85030 56 ILCHESTER SURGERY, ILCHESTER L85066 11 TAUNTON ROAD MEDICAL CENTRE. BRIDGWATER L85042 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 Somerset CCG 0.89% • prevalence of 0.89% in NHS Somerset CCG compared to 0.76% in England
England 0.76%
0.0% 0.1% 0.2% 0.3% 0.4% 0.5% 0.6% 0.7% 0.8% 0.9% 1.0%
66 CVD: Primary Care Intelligence Packs Heart failure prevalence by CCG Comparison with demographically similar CCGs
NHS Cumbria CCG 1.13%
NHS Kernow CCG 1.03%
NHS South Worcestershire CCG 0.93%
NHS Southern Derbyshire CCG 0.92%
NHS Somerset CCG 0.89%
NHS East Riding of Yorkshire CCG 0.88%
NHS Coastal West Sussex CCG 0.88%
NHS Ipswich and East Suffolk CCG 0.87%
NHS Wiltshire CCG 0.86%
NHS West Hampshire CCG 0.78%
NHS Gloucestershire CCG 0.77%
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
RYALLS PARK MEDICAL CENTRE, YEOVIL L85048 1.6% IRNHAM LODGE SURGERY L85041 1.5% BUTTERCROSS HEALTH CENTRE L85005 1.5% L85060 (VINE SURGERY) L85060 1.4% HARLEY HOUSE SURGERY L85019 1.3% ILCHESTER SURGERY, ILCHESTER L85066 1.3% SPRINGMEAD SURGERY, CHARD L85028 1.2% WESTLAKE SURGERY L85045 1.2% BURNHAM MEDICAL CENTRE L85016 1.2% • 5,009 people with diagnosed heart BRUTON SURGERY L85032 1.2% POLDEN MEDICAL PRACTICE L85024 1.2% EXMOOR MEDICAL CENTRE L85003 1.1% failure in NHS Somerset CCG LANGPORT SURGERY L85033 1.1% WELLS HEALTH CENTRE L85002 1.1% L85029 (VINE SURGERY) L85029 1.1% MILBORNE PORT SURGERY L85031 1.1% • GP practice range: 0.2% to 1.6% DUNSTER SURGERY L85065 1.1% CHURCH VIEW SURGERY, ILLMINSTER L85624 1.1% SUMMERVALE SURGERY L85054 1.1% WESTLAKE (S) Y01163 1.0% COLLEGE WAY SURGERY L85021 1.0% GROVE HOUSE SURGERY L85053 1.0% ESSEX HOUSE MEDICAL CENTRE, CHARD L85030 1.0% CHEDDAR MEDICAL CENTRE L85011 1.0% PENN HILL SURGERY, YEOVIL L85017 1.0% HENDFORD LODGE MEDICAL CENTRE, YEOVIL L85022 1.0% WELLINGTON MEDICAL CENTRE L85012 1.0% LISTER HOUSE PARTNERSHIP L85038 0.9% WINCANTON HEALTH CENTRE L85027 0.9% TAWSTOCK MEDICAL CENTRE, CHARD L85619 0.9% WARWICK HOUSE MEDICAL PRACTICE L85052 0.9% WEST SOMERSET HEALTHCARE L85009 0.9% MENDIP COUNTRY PRACTICE L85046 0.9% CREWKERNE HEALTH CENTRE, CREWKERNE L85004 0.9% OAKLANDS SURGERY, YEOVIL L85064 0.9% HIGHBRIDGE MEDICAL CENTRE L85010 0.9% FRENCH WEIR HEALTH CENTRE L85001 0.9% PRESTON GROVE MEDICAL CENTRE, YEOVIL L85015 0.9% LYNGFORD PARK L85062 0.9% CANNINGTON HEALTH CENTRE L85018 0.8% EAST QUAY MEDICAL CENTRE L85035 0.8% NORTH CURRY L85037 0.8% PORLOCK MEDICAL CENTRE L85608 0.8% FROME MEDICAL CENTRE L85008 0.8% HAMDON MEDICAL CENTRE, STOKE-SUB-HAMDON L85026 0.8% OAKHILL SURGERY L85611 0.8% ST JAMES MEDICAL CENTRE L85023 0.8% THE BLACKBROOK SURGERY L85014 0.8% AXBRIDGE SURGERY L85055 0.8% CROWN MEDICAL CENTRE L85006 0.8% CHURCH STREET SURGERY, MARTOCK L85007 0.8% CREECH L85609 0.8% BECKINGTON FAMILY PRACTICE L85020 0.8% PARK MEDICAL PRACTICE L85043 0.7% QUANTOCK VALE SURGERY L85036 0.7% BRENT AREA MEDICAL CENTRE L85601 0.7% NORTH PETHERTON SURGERY L85056 0.7% GLASTONBURY SURGERY L85039 0.7% QUANTOCK MEDICAL CENTRE L85013 0.7% LUSON L85050 0.7% QUEEN CAMEL MEDICAL CENTRE L85044 0.7% WELLS CITY PRACTICE L85034 0.7% MILLBROOK SURGERY, CASTLE CARY L85040 0.6% TAUNTON ROAD MEDICAL CENTRE L85042 0.6% GLASTONBURY HEALTH CENTRE L85047 0.6% THE MEADOWS SURGERY L85061 0.6% SOMERSET BRIDGE MEDICAL CENTRE L85607 0.6% REDGATE MEDICAL CENTRE L85051 0.6% ABBEY MANOR MEDICAL PRACTICE Y00189 0.5% VICTORIA PARK MEDICAL CENTRE L85612 0.5% WEST ONE SURGERY L85620 0.5% VICTORIA GATE SURGERY L85616 0.5% CRANLEIGH GARDENS MEDICAL CENTRE L85025 0.5% NHS YEOVIL HEALTH CENTRE Y02778 0.2% 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6% 1.8%
68 CVD: Primary Care Intelligence Packs Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who are treated with ACE-I / ARB by CCG Comparison with CCGs in the STP Treatment No treatment Exceptions reported
• 1,062 people with heart failure* with NHS Somerset CCG 80.1% LVSD in NHS Somerset CCG • 851 (80.1%) people treated with ACE- I or ARB • 79 (7.4%) people who are exceptions • 132 (12.4%) additional people who are not treated with ACE-I or ARB
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 Riding of Yorkshire CCG 87.0%
NHS Cumbria CCG 86.5%
NHS Gloucestershire CCG 85.4%
NHS Wiltshire CCG 85.0%
NHS South Worcestershire CCG 84.5%
NHS West Hampshire CCG 84.0%
NHS Ipswich and East Suffolk CCG 81.9%
NHS Kernow CCG 81.0%
NHS Southern Derbyshire CCG 80.8%
NHS Somerset CCG 80.1%
NHS Coastal West Sussex CCG 79.4%
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
REDGATE MEDICAL CENTRE L85051 1 WESTLAKE SURGERY L85045 2 WESTLAKE (S) Y01163 2 CREWKERNE HEALTH CENTRE, CREWKERNE L85004 8 ST JAMES MEDICAL CENTRE L85023 32 BUTTERCROSS HEALTH CENTRE L85005 2 NORTH CURRY L85037 1 QUEEN CAMEL MEDICAL CENTRE L85044 3 BECKINGTON FAMILY PRACTICE L85020 6 • in total, including exceptions, there GLASTONBURY SURGERY L85039 3 CREECH L85609 2 SPRINGMEAD SURGERY, CHARD L85028 6 are 211 people who are not treated LUSON L85050 4 COLLEGE WAY SURGERY L85021 6 CHEDDAR MEDICAL CENTRE L85011 6 GROVE HOUSE SURGERY L85053 4 with ACE-I or ARB AXBRIDGE SURGERY L85055 3 OAKHILL SURGERY L85611 1 TAWSTOCK MEDICAL CENTRE, CHARD L85619 1 • GP practice range: 0.0% to 50.0% L85029 (VINE SURGERY) L85029 7 CROWN MEDICAL CENTRE L85006 13 MENDIP COUNTRY PRACTICE L85046 3 FROME MEDICAL CENTRE L85008 5 TAUNTON ROAD MEDICAL CENTRE L85042 2 DUNSTER SURGERY L85065 2 L85060 (VINE SURGERY) L85060 7 HIGHBRIDGE MEDICAL CENTRE L85010 5 CANNINGTON HEALTH CENTRE L85018 1 IRNHAM LODGE SURGERY L85041 3 NORTH PETHERTON SURGERY L85056 1 LYNGFORD PARK L85062 1 FRENCH WEIR HEALTH CENTRE L85001 7 WELLINGTON MEDICAL CENTRE L85012 7 RYALLS PARK MEDICAL CENTRE, YEOVIL L85048 3 ESSEX HOUSE MEDICAL CENTRE, CHARD L85030 13 POLDEN MEDICAL PRACTICE L85024 7 THE BLACKBROOK SURGERY L85014 1 EAST QUAY MEDICAL CENTRE L85035 2 CHURCH STREET SURGERY, MARTOCK L85007 3 ILCHESTER SURGERY, ILCHESTER L85066 2 BRUTON SURGERY L85032 3 WELLS HEALTH CENTRE L85002 3 QUANTOCK VALE SURGERY L85036 3 PRESTON GROVE MEDICAL CENTRE, YEOVIL L85015 1 CRANLEIGH GARDENS MEDICAL CENTRE L85025 1 WINCANTON HEALTH CENTRE L85027 1 CHURCH VIEW SURGERY, ILLMINSTER L85624 2 WEST SOMERSET HEALTHCARE L85009 1 BRENT AREA MEDICAL CENTRE L85601 1 PENN HILL SURGERY, YEOVIL L85017 3 HENDFORD LODGE MEDICAL CENTRE, YEOVIL L85022 1 LANGPORT SURGERY L85033 1 PARK MEDICAL PRACTICE L85043 1 WARWICK HOUSE MEDICAL PRACTICE L85052 1 EXMOOR MEDICAL CENTRE L85003 QUANTOCK MEDICAL CENTRE L85013 BURNHAM MEDICAL CENTRE L85016 HARLEY HOUSE SURGERY L85019 HAMDON MEDICAL CENTRE, STOKE-SUB-HAMDON L85026 MILBORNE PORT SURGERY L85031 WELLS CITY PRACTICE L85034 MILLBROOK SURGERY, CASTLE CARY L85040 GLASTONBURY HEALTH CENTRE L85047 SUMMERVALE SURGERY L85054 THE MEADOWS SURGERY L85061 OAKLANDS SURGERY, YEOVIL L85064 SOMERSET BRIDGE MEDICAL CENTRE L85607 PORLOCK MEDICAL CENTRE L85608 VICTORIA PARK MEDICAL CENTRE L85612 VICTORIA GATE SURGERY L85616 ABBEY MANOR MEDICAL PRACTICE Y00189 NHS YEOVIL HEALTH CENTRE Y02778 WEST ONE SURGERY L85620 LISTER HOUSE PARTNERSHIP L85038 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
• 851 people with heart failure* with NHS Somerset CCG 72.5% LVSD treated with ACE-I/ARB in NHS Somerset CCG • 617 (72.5%) people treated with ACE- I/ARB and BB • 136 (16%) people who are exceptions • 98 (11.5%) additional people who are not treated with ACE-I/ARB and BB
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 Cumbria CCG 77.4%
NHS West Hampshire CCG 77.4%
NHS Ipswich and East Suffolk CCG 77.4%
NHS Gloucestershire CCG 75.9%
NHS South Worcestershire CCG 74.4%
NHS Coastal West Sussex CCG 73.8%
NHS Kernow CCG 73.4%
NHS Somerset CCG 72.5%
NHS Southern Derbyshire CCG 72.2%
NHS Wiltshire CCG 71.5%
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
BUTTERCROSS HEALTH CENTRE L85005 3 MILBORNE PORT SURGERY L85031 2 GLASTONBURY HEALTH CENTRE L85047 4 WEST SOMERSET HEALTHCARE L85009 4 HIGHBRIDGE MEDICAL CENTRE L85010 10 QUANTOCK MEDICAL CENTRE L85013 1 HAMDON MEDICAL CENTRE, STOKE-SUB-HAMDON L85026 1 NHS YEOVIL HEALTH CENTRE Y02778 1 FRENCH WEIR HEALTH CENTRE L85001 14 • in total, including exceptions, there HENDFORD LODGE MEDICAL CENTRE, YEOVIL L85022 5 CHURCH STREET SURGERY, MARTOCK L85007 7 CRANLEIGH GARDENS MEDICAL CENTRE L85025 3 are 234 people who are not treated GLASTONBURY SURGERY L85039 3 BRUTON SURGERY L85032 7 THE BLACKBROOK SURGERY L85014 2 LUSON L85050 4 with ACE-I or ARB EXMOOR MEDICAL CENTRE L85003 2 CROWN MEDICAL CENTRE L85006 14 WELLINGTON MEDICAL CENTRE L85012 10 • GP practice range: 0.0% to 75.0% QUANTOCK VALE SURGERY L85036 6 QUEEN CAMEL MEDICAL CENTRE L85044 2 WESTLAKE SURGERY L85045 1 OAKHILL SURGERY L85611 1 TAWSTOCK MEDICAL CENTRE, CHARD L85619 1 WESTLAKE (S) Y01163 1 ST JAMES MEDICAL CENTRE L85023 20 CREWKERNE HEALTH CENTRE, CREWKERNE L85004 4 PARK MEDICAL PRACTICE L85043 6 FROME MEDICAL CENTRE L85008 5 PENN HILL SURGERY, YEOVIL L85017 8 BECKINGTON FAMILY PRACTICE L85020 4 L85029 (VINE SURGERY) L85029 6 ESSEX HOUSE MEDICAL CENTRE, CHARD L85030 15 BURNHAM MEDICAL CENTRE L85016 1 CANNINGTON HEALTH CENTRE L85018 1 THE MEADOWS SURGERY L85061 1 LYNGFORD PARK L85062 1 L85060 (VINE SURGERY) L85060 6 RYALLS PARK MEDICAL CENTRE, YEOVIL L85048 3 WELLS HEALTH CENTRE L85002 4 CHEDDAR MEDICAL CENTRE L85011 4 SUMMERVALE SURGERY L85054 2 POLDEN MEDICAL PRACTICE L85024 7 WELLS CITY PRACTICE L85034 1 EAST QUAY MEDICAL CENTRE L85035 2 CREECH L85609 1 WARWICK HOUSE MEDICAL PRACTICE L85052 5 COLLEGE WAY SURGERY L85021 3 LANGPORT SURGERY L85033 2 IRNHAM LODGE SURGERY L85041 2 PRESTON GROVE MEDICAL CENTRE, YEOVIL L85015 1 WINCANTON HEALTH CENTRE L85027 1 TAUNTON ROAD MEDICAL CENTRE L85042 1 DUNSTER SURGERY L85065 1 BRENT AREA MEDICAL CENTRE L85601 1 AXBRIDGE SURGERY L85055 1 MENDIP COUNTRY PRACTICE L85046 1 ILCHESTER SURGERY, ILCHESTER L85066 1 GROVE HOUSE SURGERY L85053 1 CHURCH VIEW SURGERY, ILLMINSTER L85624 1 SPRINGMEAD SURGERY, CHARD L85028 1 HARLEY HOUSE SURGERY L85019 NORTH CURRY L85037 MILLBROOK SURGERY, CASTLE CARY L85040 REDGATE MEDICAL CENTRE L85051 NORTH PETHERTON SURGERY L85056 OAKLANDS SURGERY, YEOVIL L85064 SOMERSET BRIDGE MEDICAL CENTRE L85607 PORLOCK MEDICAL CENTRE L85608 VICTORIA PARK MEDICAL CENTRE L85612 VICTORIA GATE SURGERY L85616 ABBEY MANOR MEDICAL PRACTICE Y00189 WEST ONE SURGERY L85620 LISTER HOUSE PARTNERSHIP L85038 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
• 21,313 people with coronary heart NHS Somerset CCG 82.4% disease* in NHS Somerset CCG • 17,553 (82.4%) people whose blood pressure <= 150 / 90 • 556 (2.6%) people who are exceptions • 3,204 (15%) additional people whose blood pressure is not <= 150 / 90
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 Worcestershire CCG 91.5%
NHS Cumbria CCG 89.2%
NHS Kernow CCG 88.5%
NHS Gloucestershire CCG 88.2%
NHS Ipswich and East Suffolk CCG 87.7%
NHS Southern Derbyshire CCG 87.6%
NHS Wiltshire CCG 87.6%
NHS East Riding of Yorkshire CCG 87.0%
NHS West Hampshire CCG 86.8%
NHS Coastal West Sussex CCG 84.3%
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
ABBEY MANOR MEDICAL PRACTICE Y00189 26 RYALLS PARK MEDICAL CENTRE, YEOVIL L85048 60 LISTER HOUSE PARTNERSHIP L85038 84 WEST ONE SURGERY L85620 19 SPRINGMEAD SURGERY, CHARD L85028 121 VICTORIA GATE SURGERY L85616 37 TAWSTOCK MEDICAL CENTRE, CHARD L85619 52 PRESTON GROVE MEDICAL CENTRE, YEOVIL L85015 127 FROME MEDICAL CENTRE L85008 238 • in total, including exceptions, there SUMMERVALE SURGERY L85054 84 LANGPORT SURGERY L85033 142 CREECH L85609 36 are 3,760 people whose blood BURNHAM MEDICAL CENTRE L85016 203 QUEEN CAMEL MEDICAL CENTRE L85044 45 THE MEADOWS SURGERY L85061 30 GLASTONBURY HEALTH CENTRE L85047 40 pressure is not <= 150 / 90 COLLEGE WAY SURGERY L85021 114 THE BLACKBROOK SURGERY L85014 78 HARLEY HOUSE SURGERY L85019 83 • GP practice range: 4.1% to 33.8% WINCANTON HEALTH CENTRE L85027 63 HENDFORD LODGE MEDICAL CENTRE, YEOVIL L85022 91 PARK MEDICAL PRACTICE L85043 71 LUSON L85050 45 WELLS HEALTH CENTRE L85002 105 FRENCH WEIR HEALTH CENTRE L85001 111 WARWICK HOUSE MEDICAL PRACTICE L85052 61 BUTTERCROSS HEALTH CENTRE L85005 45 ST JAMES MEDICAL CENTRE L85023 87 MILLBROOK SURGERY, CASTLE CARY L85040 25 HIGHBRIDGE MEDICAL CENTRE L85010 111 NORTH CURRY L85037 28 PENN HILL SURGERY, YEOVIL L85017 76 L85029 (VINE SURGERY) L85029 46 GLASTONBURY SURGERY L85039 75 CROWN MEDICAL CENTRE L85006 47 BRUTON SURGERY L85032 30 IRNHAM LODGE SURGERY L85041 51 LYNGFORD PARK L85062 31 WELLINGTON MEDICAL CENTRE L85012 82 HAMDON MEDICAL CENTRE, STOKE-SUB-HAMDON L85026 32 WELLS CITY PRACTICE L85034 34 WESTLAKE SURGERY L85045 10 NHS YEOVIL HEALTH CENTRE Y02778 7 MENDIP COUNTRY PRACTICE L85046 25 QUANTOCK VALE SURGERY L85036 27 AXBRIDGE SURGERY L85055 38 WEST SOMERSET HEALTHCARE L85009 64 NORTH PETHERTON SURGERY L85056 26 CHURCH STREET SURGERY, MARTOCK L85007 58 CHURCH VIEW SURGERY, ILLMINSTER L85624 14 CRANLEIGH GARDENS MEDICAL CENTRE L85025 37 CREWKERNE HEALTH CENTRE, CREWKERNE L85004 55 DUNSTER SURGERY L85065 22 MILBORNE PORT SURGERY L85031 25 OAKLANDS SURGERY, YEOVIL L85064 12 VICTORIA PARK MEDICAL CENTRE L85612 13 PORLOCK MEDICAL CENTRE L85608 12 POLDEN MEDICAL PRACTICE L85024 36 SOMERSET BRIDGE MEDICAL CENTRE L85607 11 ILCHESTER SURGERY, ILCHESTER L85066 10 TAUNTON ROAD MEDICAL CENTRE L85042 50 OAKHILL SURGERY L85611 7 EAST QUAY MEDICAL CENTRE L85035 50 GROVE HOUSE SURGERY L85053 24 CHEDDAR MEDICAL CENTRE L85011 28 CANNINGTON HEALTH CENTRE L85018 17 REDGATE MEDICAL CENTRE L85051 19 L85060 (VINE SURGERY) L85060 16 BECKINGTON FAMILY PRACTICE L85020 24 WESTLAKE (S) Y01163 5 ESSEX HOUSE MEDICAL CENTRE, CHARD L85030 27 EXMOOR MEDICAL CENTRE L85003 13 BRENT AREA MEDICAL CENTRE L85601 6 QUANTOCK MEDICAL CENTRE L85013 6 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
77 CVD: Primary Care Intelligence Packs Percentage of patients with CHD whose blood pressure reading (measured in the preceding 12 months) is not 150/90 mmHg or less by GP practice – opportunities compared to GP cluster
5% 0% -5% -10% -15% -20% -25% -30%
ABBEY MANOR MEDICAL PRACTICE 21
RYALLS PARK MEDICAL CENTRE, YEOVIL 48
LISTER HOUSE PARTNERSHIP 66 • using the GP cluster method of WEST ONE SURGERY 15 calculating potential gains, if each SPRINGMEAD SURGERY, CHARD 94 practice was to achieve as well as the VICTORIA GATE SURGERY 29 upper quartile of its national cluster, then an additional 2,081 people would TAWSTOCK MEDICAL CENTRE, CHARD 39 be treated PRESTON GROVE MEDICAL CENTRE, YEOVIL 89
SUMMERVALE SURGERY 59
LANGPORT SURGERY 98
TAUNTON ROAD MEDICAL CENTRE 5
EAST QUAY MEDICAL CENTRE 5
L85060 (VINE SURGERY) 2
BECKINGTON FAMILY PRACTICE 2
WESTLAKE (S) 0
CHEDDAR MEDICAL CENTRE
ESSEX HOUSE MEDICAL CENTRE, CHARD
BRENT AREA MEDICAL CENTRE
EXMOOR MEDICAL CENTRE
QUANTOCK 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
• 21,313 people with coronary heart NHS Somerset CCG 88.9% disease* in NHS Somerset CCG • 18,939 (88.9%) people who are taking aspirin, an alternative anti- platelet therapy, or an anti-coagulant • 429 (2%) people who are exceptions • 1,945 (9.1%) additional people who are not taking aspirin, an alternative anti-platelet therapy, or an anti- coagulant
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 South Worcestershire CCG 92.9%
NHS Kernow CCG 92.6%
NHS West Hampshire CCG 92.6%
NHS Cumbria CCG 91.9%
NHS Gloucestershire CCG 91.5%
NHS Wiltshire CCG 90.8%
NHS East Riding of Yorkshire CCG 90.6%
NHS Southern Derbyshire CCG 90.6%
NHS Ipswich and East Suffolk CCG 90.5%
NHS Coastal West Sussex CCG 89.8%
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
VICTORIA GATE SURGERY L85616 42 LISTER HOUSE PARTNERSHIP L85038 62 HENDFORD LODGE MEDICAL CENTRE, YEOVIL L85022 82 GLASTONBURY SURGERY L85039 87 WEST ONE SURGERY L85620 11 ABBEY MANOR MEDICAL PRACTICE Y00189 14 HARLEY HOUSE SURGERY L85019 67 RYALLS PARK MEDICAL CENTRE, YEOVIL L85048 31 PRESTON GROVE MEDICAL CENTRE, YEOVIL L85015 75 • in total, including exceptions, there PENN HILL SURGERY, YEOVIL L85017 67 SPRINGMEAD SURGERY, CHARD L85028 58 GROVE HOUSE SURGERY L85053 40 are 2,374 people are not taking MILLBROOK SURGERY, CASTLE CARY L85040 19 SUMMERVALE SURGERY L85054 42 ST JAMES MEDICAL CENTRE L85023 63 FRENCH WEIR HEALTH CENTRE L85001 73 aspirin, an alternative anti-platelet WARWICK HOUSE MEDICAL PRACTICE L85052 41 HIGHBRIDGE MEDICAL CENTRE L85010 81 ILCHESTER SURGERY, ILCHESTER L85066 14 therapy, or an anti-coagulant LUSON L85050 28 VICTORIA PARK MEDICAL CENTRE L85612 16 HAMDON MEDICAL CENTRE, STOKE-SUB-HAMDON L85026 29 • GP practice range: 3.0% to 34.7% CHURCH STREET SURGERY, MARTOCK L85007 64 THE BLACKBROOK SURGERY L85014 42 WELLS CITY PRACTICE L85034 29 BURNHAM MEDICAL CENTRE L85016 98 MILBORNE PORT SURGERY L85031 27 LANGPORT SURGERY L85033 60 CREECH L85609 16 FROME MEDICAL CENTRE L85008 98 WELLS HEALTH CENTRE L85002 56 GLASTONBURY HEALTH CENTRE L85047 19 THE MEADOWS SURGERY L85061 14 WELLINGTON MEDICAL CENTRE L85012 61 BUTTERCROSS HEALTH CENTRE L85005 25 L85029 (VINE SURGERY) L85029 28 TAWSTOCK MEDICAL CENTRE, CHARD L85619 19 QUEEN CAMEL MEDICAL CENTRE L85044 19 TAUNTON ROAD MEDICAL CENTRE L85042 53 AXBRIDGE SURGERY L85055 31 WINCANTON HEALTH CENTRE L85027 28 LYNGFORD PARK L85062 20 NHS YEOVIL HEALTH CENTRE Y02778 5 CHURCH VIEW SURGERY, ILLMINSTER L85624 11 PORLOCK MEDICAL CENTRE L85608 10 PARK MEDICAL PRACTICE L85043 28 DUNSTER SURGERY L85065 17 QUANTOCK VALE SURGERY L85036 18 CROWN MEDICAL CENTRE L85006 24 OAKLANDS SURGERY, YEOVIL L85064 9 OAKHILL SURGERY L85611 6 EXMOOR MEDICAL CENTRE L85003 14 EAST QUAY MEDICAL CENTRE L85035 41 WEST SOMERSET HEALTHCARE L85009 40 BECKINGTON FAMILY PRACTICE L85020 22 IRNHAM LODGE SURGERY L85041 25 COLLEGE WAY SURGERY L85021 36 WESTLAKE SURGERY L85045 5 NORTH PETHERTON SURGERY L85056 15 POLDEN MEDICAL PRACTICE L85024 24 CANNINGTON HEALTH CENTRE L85018 14 ESSEX HOUSE MEDICAL CENTRE, CHARD L85030 23 BRUTON SURGERY L85032 13 CHEDDAR MEDICAL CENTRE L85011 21 BRENT AREA MEDICAL CENTRE L85601 6 SOMERSET BRIDGE MEDICAL CENTRE L85607 7 CRANLEIGH GARDENS MEDICAL CENTRE L85025 20 REDGATE MEDICAL CENTRE L85051 14 CREWKERNE HEALTH CENTRE, CREWKERNE L85004 27 QUANTOCK MEDICAL CENTRE L85013 7 WESTLAKE (S) Y01163 3 MENDIP COUNTRY PRACTICE L85046 9 NORTH CURRY L85037 5 L85060 (VINE SURGERY) L85060 6 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 Somerset CCG England 800
700 • in NHS Somerset CCG, the hospital admission rate for coronary heart disease in 2015/16 was 415.1 (2,589) 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 Somerset CCG England 250
• in NHS Somerset CCG, the hospital admission rate for stroke in 2015/16 200 was 184.4 (1,196) 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 Somerset CCG England
123.4% Angina 136.8% • The risk of a stroke was 93.7% higher and the risk of a heart attack was 119.9% 119.9% higher compared to people Heart Attack 108.6% without diabetes. The risk of a major amputation was 644.6% higher. 159.5% Heart failure 150.0%
93.7% Stroke 81.3%
644.6% Major amputation 445.8%
967.6% Minor amputation 753.5%
341.1% RRT 293.0%
0% 200% 400% 600% 800% 1000% 1200% 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 Somerset CCG England 90
80 • in NHS Somerset CCG, the early mortality rate for coronary heart 70 disease in 2013-15 was 33.6, 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 Somerset CCG England 30
• in NHS Somerset CCG, the early 25 mortality rate for stroke in 2013-15 was 11.9, 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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