CVD: Primary Care Intelligence Packs NHS Stoke On Trent 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 Stoke On Trent CCG are: NHS Tameside and Glossop CCG NHS South Tees CCG NHS Salford CCG NHS Rotherham CCG NHS Hull CCG NHS Wakefield CCG NHS Sunderland CCG NHS Hartlepool and Stockton-on-Tees CCG NHS Bury CCG NHS Barnsley 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 Hull CCG 25.1%

NHS Salford CCG 22.7% • prevalence of 22.6% in NHS Stoke On Trent CCG NHS Stoke On Trent CCG 22.6%

NHS Tameside and Glossop CCG 21.9%

NHS Barnsley CCG 21.6%

NHS Sunderland CCG 21.2%

NHS South Tees CCG 21.2%

NHS Wakefield CCG 21.2% Note: It has been found that the proportion of patients recorded as smokers correlates well NHS Rotherham CCG 20.5% with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, NHS Hartlepool and Stockton-on-Tees CCG 19.3% http://bmjopen.bmj.com/content/4/7/e005217.abs tract

NHS Bury CCG 18.3% Definition: denominator of QOF clinical indicator SMOKE004 ( number of patients 15+ who are 0% 5% 10% 15% 20% 25% 30% 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

MIDDLEPORT MEDICAL CENTRE Y02867 37.2% PRACTICE OF DR JA MIR M83725 37.0% HANLEY HEALTH & WELL BEING CENTRE Y02868 35.1% MOSS GREEN SURGERY Y00592 34.2% LUCIE WEDGWOOD HEALTH CTR M83682 31.2% PRACTICE OF DR BD PATEL M83631 29.8% DR SONNATHI'S SURGERY M83669 29.8% • 52,691 people who are recorded as WILLOW BANK SURGERY Y02521 28.3% CAMBRIDGE HOUSE M83624 27.6% smokers in NHS Stoke On Trent CCG GLEBEDALE MEDICAL PRACTICE M83028 27.3% POTTERIES MEDICAL CENTRE M83102 27.0% • GP practice range: 9.1% to 37.2% ADDERLEY GREEN SURGERY M83661 26.9% DRAYTON ROAD SURGERY M83629 26.8% DR BOSE & DR BOYAPATI'S PRACTICE M83650 26.8% FURLONG MEDICAL CENTRE M83021 26.8% THE SURGERY FODEN STREET M83134 26.7% APSLEY SURGERY M83627 26.3% PRACTICE OF DR GT CHAND M83133 26.1% NORFOLK STREET SURGERY M83075 26.0% WESTON COYNEY MEDICAL PRACTICE M83708 26.0% THE HAYMARKET HEALTH CTR M83082 25.2% GOLDENHILL MEDICAL CENTRE M83143 24.7% SNOWHILL MEDICAL CENTRE M83623 24.6% COBRIDGE SURGERY M83127 24.5% PRACTICE OF DR AK SINHA M83712 24.4% DR VSR CHADALAVADA M83625 24.2% DR H P BORSE & PARTNER M83713 24.2% BIRCHES HEAD MEDICAL CTR. M83123 23.9% TRENT VALE MEDICAL PRACTICE M83014 23.1% HARLEY STREET MEDICAL CTR M83076 22.6% BROOK MEDICAL CENTRE M83094 22.5% THE MOORCROFT MEDICAL CTR M83146 21.4% PRACTICE OF DR SB KULKARNI M83714 21.2% MERTON SURGERY M83128 20.4% FIVE TOWNS GP SURGERY M83700 20.1% LONGTON HALL SURGERY M83126 19.4% BELGRAVE MEDICAL CENTRE M83068 19.0% ORCHARD SURGERY M83038 18.9% PRACTICE OF DR HA TALPUR M83678 18.5% MILLRISE MEDICAL PRACTICE M83061 17.7% DR P D MILES AND DR R VALASAPALLI M83100 16.8% DRS REES & LEFROY M83619 16.8% DUNROBIN STREET MEDICAL CENTRE M83090 16.7% HARTSHILL MEDICAL CENTRE M83066 15.8% Note: This method is thought to be a reasonably MAYFIELD SURGERY M83004 15.6% robust method in estimating smoking prevalence PACKMOOR MEDICAL CENTRE M83739 15.4% DRS SHAH & TALPUR M83138 14.7% for the majority of GP practices. However, TRINITY MEDICAL CENTRE M83632 14.5% MEIR PARK SURGERY M83047 14.2% caution is advised for extreme estimates of BADDELEY GREEN SURGERY M83709 12.0% TRENTHAM MEWS MEDICAL CENTRE M83711 10.3% smoking prevalence and those with high BRINSLEY AVENUE PRACTICE M83601 9.1% 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 Cannock Chase CCG 0.62

• the ratio of those diagnosed with NHS Stoke On Trent CCG 0.62 hypertension versus those expected to have hypertension is 0.62. This compares to 0.59 for England NHS North Staffordshire CCG 0.62 • this suggests that 62% of people with hypertension have been diagnosed

NHS Stafford And Surrounds CCG 0.60

NHS South East Staffordshire And Seisdon Peninsula 0.59 CCG

NHS East Staffordshire CCG 0.57

Note: this slide shows Hypertension prevalence England 0.59 estimates created using data from QOF hypertension registers 2014/15 and Undiagnosed hypertension estimates for adults 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 16 years and older. 2014. Department of Primary Ratio Care & Public Health, Imperial College London

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

NHS Stoke On Trent CCG 0.62

NHS Rotherham CCG 0.62

NHS Hartlepool and Stockton-on-Tees CCG 0.61

NHS Sunderland CCG 0.61

NHS Tameside and Glossop CCG 0.61

NHS Barnsley CCG 0.61

NHS Wakefield CCG 0.60

NHS South Tees CCG 0.60

NHS Hull CCG 0.59

NHS Bury CCG 0.58

NHS Salford CCG 0.57

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

DUNROBIN STREET MEDICAL CENTRE M83090 0.87 PRACTICE OF DR BD PATEL M83631 0.81 MEIR PARK SURGERY M83047 0.76 GOLDENHILL MEDICAL CENTRE M83143 0.75 MERTON SURGERY M83128 0.74 TRENTHAM MEWS MEDICAL CENTRE M83711 0.74 CAMBRIDGE HOUSE M83624 0.73 • it is estimated that there are 28,470 PRACTICE OF DR SB KULKARNI M83714 0.73 DRAYTON ROAD SURGERY M83629 0.73 FURLONG MEDICAL CENTRE M83021 0.72 people with undiagnosed TRINITY MEDICAL CENTRE M83632 0.72 ADDERLEY GREEN SURGERY M83661 0.71 hypertension in NHS Stoke On Trent POTTERIES MEDICAL CENTRE M83102 0.71 PRACTICE OF DR HA TALPUR M83678 0.70 CCG PRACTICE OF DR JA MIR M83725 0.69 THE MOORCROFT MEDICAL CTR M83146 0.68 THE HAYMARKET HEALTH CTR M83082 0.67 • GP practice range of observed to DRS SHAH & TALPUR M83138 0.67 MAYFIELD SURGERY M83004 0.67 expected hypertension prevalence LUCIE WEDGWOOD HEALTH CTR M83682 0.66 TRENT VALE MEDICAL PRACTICE M83014 0.66 0.42 to 0.87 MOSS GREEN SURGERY Y00592 0.66 ORCHARD SURGERY M83038 0.66 BIRCHES HEAD MEDICAL CTR. M83123 0.66 WESTON COYNEY MEDICAL PRACTICE M83708 0.66 PACKMOOR MEDICAL CENTRE M83739 0.65 DR H P BORSE & PARTNER M83713 0.65 PRACTICE OF DR AK SINHA M83712 0.65 BELGRAVE MEDICAL CENTRE M83068 0.65 WILLOW BANK SURGERY Y02521 0.65 LONGTON HALL SURGERY M83126 0.64 DR VSR CHADALAVADA M83625 0.64 GLEBEDALE MEDICAL PRACTICE M83028 0.64 HARLEY STREET MEDICAL CTR M83076 0.64 BADDELEY GREEN SURGERY M83709 0.64 DR P D MILES AND DR R VALASAPALLI M83100 0.63 MILLRISE MEDICAL PRACTICE M83061 0.63 BROOK MEDICAL CENTRE M83094 0.61 APSLEY SURGERY M83627 0.59 THE SURGERY FODEN STREET M83134 0.58 HARTSHILL MEDICAL CENTRE M83066 0.58 FIVE TOWNS GP SURGERY M83700 0.58 BRINSLEY AVENUE PRACTICE M83601 0.57 DR SONNATHI'S SURGERY M83669 0.57 PRACTICE OF DR GT CHAND M83133 0.57 SNOWHILL MEDICAL CENTRE M83623 0.57 COBRIDGE SURGERY M83127 0.54 DRS REES & LEFROY M83619 0.53 DR BOSE & DR BOYAPATI'S PRACTICE M83650 0.50 HANLEY HEALTH & WELL BEING CENTRE Y02868 0.49 MIDDLEPORT MEDICAL CENTRE Y02867 0.48 NORFOLK STREET SURGERY M83075 0.42 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 Stoke On Trent CCG 81.5%

• 46,906 people with hypertension NHS East Staffordshire CCG 80.4% (diagnosed)* in NHS Stoke On Trent CCG • 38,236 (81.5%) people whose blood NHS North Staffordshire CCG 79.6% pressure is <= 150/90 • 1,564 (3.3%) people who are NHS South East Staffordshire And Seisdon Peninsula excepted from optimal control 79.4% CCG • 7,106 (15.1%) additional people whose blood pressure is not <= 150/90 NHS Cannock Chase CCG 79.4%

NHS Stafford And Surrounds CCG 76.8%

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 Hartlepool and Stockton-on-Tees CCG 82.2%

NHS Bury CCG 81.9%

NHS Wakefield CCG 81.7%

NHS Stoke On Trent CCG 81.5%

NHS Tameside and Glossop CCG 81.4%

NHS Rotherham CCG 81.2%

NHS South Tees CCG 80.0%

NHS Salford CCG 79.8%

NHS Sunderland CCG 79.5%

NHS Barnsley CCG 78.8%

NHS Hull CCG 78.1%

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

LONGTON HALL SURGERY M83126 319 FURLONG MEDICAL CENTRE M83021 502 DRAYTON ROAD SURGERY M83629 151 MILLRISE MEDICAL PRACTICE M83061 400 MOSS GREEN SURGERY Y00592 268 THE MOORCROFT MEDICAL CTR M83146 366 TRENTHAM MEWS MEDICAL CENTRE M83711 164 • in total, including exceptions, there GOLDENHILL MEDICAL CENTRE M83143 162 MEIR PARK SURGERY M83047 210 are 8,670 people whose blood WILLOW BANK SURGERY Y02521 244 MAYFIELD SURGERY M83004 500 pressure is not <= 150/90 HARLEY STREET MEDICAL CTR M83076 263 PRACTICE OF DR JA MIR M83725 103 • GP practice range: 6.7% to 29.5% TRENT VALE MEDICAL PRACTICE M83014 296 DR BOSE & DR BOYAPATI'S PRACTICE M83650 66 LUCIE WEDGWOOD HEALTH CTR M83682 196 COBRIDGE SURGERY M83127 110 DUNROBIN STREET MEDICAL CENTRE M83090 182 NORFOLK STREET SURGERY M83075 165 BROOK MEDICAL CENTRE M83094 432 BELGRAVE MEDICAL CENTRE M83068 342 DR H P BORSE & PARTNER M83713 168 PRACTICE OF DR AK SINHA M83712 63 PRACTICE OF DR HA TALPUR M83678 78 DR SONNATHI'S SURGERY M83669 99 ORCHARD SURGERY M83038 351 THE HAYMARKET HEALTH CTR M83082 325 DR P D MILES AND DR R VALASAPALLI M83100 120 HANLEY HEALTH & WELL BEING CENTRE Y02868 52 BADDELEY GREEN SURGERY M83709 133 TRINITY MEDICAL CENTRE M83632 129 MERTON SURGERY M83128 124 FIVE TOWNS GP SURGERY M83700 44 APSLEY SURGERY M83627 127 BIRCHES HEAD MEDICAL CTR. M83123 159 SNOWHILL MEDICAL CENTRE M83623 83 PRACTICE OF DR GT CHAND M83133 54 DR VSR CHADALAVADA M83625 169 MIDDLEPORT MEDICAL CENTRE Y02867 39 WESTON COYNEY MEDICAL PRACTICE M83708 57 DRS SHAH & TALPUR M83138 107 PRACTICE OF DR BD PATEL M83631 75 PACKMOOR MEDICAL CENTRE M83739 69 HARTSHILL MEDICAL CENTRE M83066 127 BRINSLEY AVENUE PRACTICE M83601 82 THE SURGERY FODEN STREET M83134 58 ADDERLEY GREEN SURGERY M83661 38 POTTERIES MEDICAL CENTRE M83102 86 PRACTICE OF DR SB KULKARNI M83714 28 GLEBEDALE MEDICAL PRACTICE M83028 125 DRS REES & LEFROY M83619 24 CAMBRIDGE HOUSE M83624 36 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 Cannock Chase CCG 76.6%

• 208 people with a new diagnosis* of NHS Stoke On Trent CCG 68.8% hypertension with a CVD risk of 20% or higher in NHS Stoke On Trent CCG NHS East Staffordshire CCG 65.8% • 143 (68.8%) people who are currently treated with statins NHS South East Staffordshire And Seisdon Peninsula • 62 (29.8%) people who are exempted 61.8% CCG from treatment with statins • 3 (1.4%) additional people who are not currently treated with statins NHS North Staffordshire CCG 57.0%

NHS Stafford And Surrounds CCG 53.7%

England 66.5%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% *Using the QOF clinical indicator CVD-PP001 denominator plus exceptions

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

NHS Wakefield CCG 78.4%

NHS Hartlepool and Stockton-on-Tees CCG 75.9%

NHS South Tees CCG 74.5%

NHS Tameside and Glossop CCG 74.4%

NHS Rotherham CCG 71.7%

NHS Salford CCG 70.5%

NHS Stoke On Trent CCG 68.8%

NHS Bury CCG 68.2%

NHS Hull CCG 67.2%

NHS Sunderland CCG 61.8%

NHS Barnsley CCG 60.3%

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

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

No treatment Exceptions reported

MEIR PARK SURGERY M83047 3 DRAYTON ROAD SURGERY M83629 2 MILLRISE MEDICAL PRACTICE M83061 2 DRS SHAH & TALPUR M83138 2 BROOK MEDICAL CENTRE M83094 5 LUCIE WEDGWOOD HEALTH CTR M83682 3 MAYFIELD SURGERY M83004 7 • in total, including exceptions, there HARTSHILL MEDICAL CENTRE M83066 2 HARLEY STREET MEDICAL CTR M83076 2 are 65 people who are not treated DR P D MILES AND DR R VALASAPALLI M83100 1 POTTERIES MEDICAL CENTRE M83102 1 with statins COBRIDGE SURGERY M83127 1 MERTON SURGERY M83128 1 • GP practice range: 0.0% to 100.0% DRS REES & LEFROY M83619 1 WILLOW BANK SURGERY Y02521 1 DUNROBIN STREET MEDICAL CENTRE M83090 3 TRENTHAM MEWS MEDICAL CENTRE M83711 2 TRENT VALE MEDICAL PRACTICE M83014 6 LONGTON HALL SURGERY M83126 1 BRINSLEY AVENUE PRACTICE M83601 1 DR VSR CHADALAVADA M83625 3 PRACTICE OF DR BD PATEL M83631 1 FURLONG MEDICAL CENTRE M83021 3 MOSS GREEN SURGERY Y00592 3 GLEBEDALE MEDICAL PRACTICE M83028 2 THE HAYMARKET HEALTH CTR M83082 2 BIRCHES HEAD MEDICAL CTR. M83123 1 DR SONNATHI'S SURGERY M83669 1 FIVE TOWNS GP SURGERY M83700 1 THE MOORCROFT MEDICAL CTR M83146 1 ORCHARD SURGERY M83038 BELGRAVE MEDICAL CENTRE M83068 NORFOLK STREET SURGERY M83075 PRACTICE OF DR GT CHAND M83133 THE SURGERY FODEN STREET M83134 GOLDENHILL MEDICAL CENTRE M83143 SNOWHILL MEDICAL CENTRE M83623 CAMBRIDGE HOUSE M83624 APSLEY SURGERY M83627 TRINITY MEDICAL CENTRE M83632 ADDERLEY GREEN SURGERY M83661 PRACTICE OF DR HA TALPUR M83678 WESTON COYNEY MEDICAL PRACTICE M83708 BADDELEY GREEN SURGERY M83709 PRACTICE OF DR AK SINHA M83712 DR H P BORSE & PARTNER M83713 PRACTICE OF DR SB KULKARNI M83714 PRACTICE OF DR JA MIR M83725 MIDDLEPORT MEDICAL CENTRE Y02867 HANLEY HEALTH & WELL BEING CENTRE Y02868 PACKMOOR MEDICAL CENTRE M83739 DR BOSE & DR BOYAPATI'S PRACTICE M83650 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 North Staffordshire CCG 0.75

• the ratio of those diagnosed with atrial NHS Stoke On Trent CCG 0.75 fibrillation versus those expected to have atrial fibrillation is 0.75. This compares to 0.7 for England NHS Stafford And Surrounds CCG 0.72 • this suggests that 75% of people with atrial fibrillation have been diagnosed.

NHS Cannock Chase CCG 0.72

NHS South East Staffordshire And Seisdon Peninsula 0.71 CCG

NHS East Staffordshire CCG 0.69

Note: This slide compares the prevalence of atrial fibrillation recorded in QOF in 2015/16 to the estimated prevalence of atrial fibrillation, taken from National Cardiovascular Intelligence Network estimates produced in 2017. The estimates were developed by applying age-sex England 0.70 specific prevalence rates as reported by Norberg et al (2013) to GP population estimates from 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 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 Salford CCG 0.79

NHS Hartlepool and Stockton-on-Tees CCG 0.78

NHS Stoke On Trent CCG 0.75

NHS Wakefield CCG 0.74

NHS Sunderland CCG 0.74

NHS Rotherham CCG 0.73

NHS South Tees CCG 0.72

NHS Barnsley CCG 0.72

NHS Tameside and Glossop CCG 0.70

NHS Bury CCG 0.63

NHS Hull CCG 0.63

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

DR SONNATHI'S SURGERY M83669 1.0 HARTSHILL MEDICAL CENTRE M83066 0.9 THE HAYMARKET HEALTH CTR M83082 0.9 BROOK MEDICAL CENTRE M83094 0.9 THE MOORCROFT MEDICAL CTR M83146 0.9 PRACTICE OF DR BD PATEL M83631 0.9 DR BOSE & DR BOYAPATI'S PRACTICE M83650 0.9 • it is estimated that there are 6,816 LUCIE WEDGWOOD HEALTH CTR M83682 0.9 MOSS GREEN SURGERY Y00592 0.9 people with undiagnosed atrial MAYFIELD SURGERY M83004 0.8 TRENT VALE MEDICAL PRACTICE M83014 0.8 fibrillation in NHS Stoke On Trent ORCHARD SURGERY M83038 0.8 MILLRISE MEDICAL PRACTICE M83061 0.8 NORFOLK STREET SURGERY M83075 0.8 CCG HARLEY STREET MEDICAL CTR M83076 0.8 THE SURGERY FODEN STREET M83134 0.8 • GP practice range of observed to GOLDENHILL MEDICAL CENTRE M83143 0.8 WESTON COYNEY MEDICAL PRACTICE M83708 0.8 expected atrial fibrillation prevalence BADDELEY GREEN SURGERY M83709 0.8 DR H P BORSE & PARTNER M83713 0.8 WILLOW BANK SURGERY Y02521 0.8 0.2 to 1 FURLONG MEDICAL CENTRE M83021 0.7 GLEBEDALE MEDICAL PRACTICE M83028 0.7 BELGRAVE MEDICAL CENTRE M83068 0.7 DR P D MILES AND DR R VALASAPALLI M83100 0.7 POTTERIES MEDICAL CENTRE M83102 0.7 BIRCHES HEAD MEDICAL CTR. M83123 0.7 LONGTON HALL SURGERY M83126 0.7 BRINSLEY AVENUE PRACTICE M83601 0.7 CAMBRIDGE HOUSE M83624 0.7 DR VSR CHADALAVADA M83625 0.7 DRAYTON ROAD SURGERY M83629 0.7 TRINITY MEDICAL CENTRE M83632 0.7 TRENTHAM MEWS MEDICAL CENTRE M83711 0.7 MEIR PARK SURGERY M83047 0.6 MERTON SURGERY M83128 0.6 APSLEY SURGERY M83627 0.6 ADDERLEY GREEN SURGERY M83661 0.6 PRACTICE OF DR AK SINHA M83712 0.6 PRACTICE OF DR JA MIR M83725 0.6 PACKMOOR MEDICAL CENTRE M83739 0.6 MIDDLEPORT MEDICAL CENTRE Y02867 0.6 HANLEY HEALTH & WELL BEING CENTRE Y02868 0.6 DUNROBIN STREET MEDICAL CENTRE M83090 0.5 COBRIDGE SURGERY M83127 0.5 DRS SHAH & TALPUR M83138 0.5 DRS REES & LEFROY M83619 0.5 SNOWHILL MEDICAL CENTRE M83623 0.5 PRACTICE OF DR SB KULKARNI M83714 0.5 FIVE TOWNS GP SURGERY M83700 0.2 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Ratio

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

NHS Stoke On Trent CCG 79.0% • 4,287 people with atrial fibrillation* with a CHA2DS2-VASc score >= 2 in NHS Cannock Chase CCG 78.2% NHS Stoke On Trent CCG • 3,386 (79%) people treated with anti- coagulation therapy NHS Stafford And Surrounds CCG 78.2% • 407 (9.5%) people who are exceptions • 494 (11.5%) additional people with a NHS North Staffordshire CCG 77.7% recorded CHA2DS2-VASc score >= 2 who are not treated NHS South East Staffordshire And Seisdon Peninsula 77.4% CCG

NHS East Staffordshire CCG 76.0%

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 Bury CCG 85.8%

NHS Salford CCG 82.7%

NHS South Tees CCG 81.9%

NHS Tameside and Glossop CCG 80.9%

NHS Sunderland CCG 80.0%

NHS Wakefield CCG 79.7%

NHS Barnsley CCG 79.1%

NHS Stoke On Trent CCG 79.0%

NHS Hull CCG 77.0%

NHS Hartlepool and Stockton-on-Tees CCG 76.6%

NHS Rotherham CCG 76.5%

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

32 CVD: Primary Care Intelligence Packs In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage treated with anti-coagulation therapy by GP practice

No treatment Exceptions reported

ADDERLEY GREEN SURGERY M83661 8 BRINSLEY AVENUE PRACTICE M83601 42 HANLEY HEALTH & WELL BEING CENTRE Y02868 9 TRENTHAM MEWS MEDICAL CENTRE M83711 28 LONGTON HALL SURGERY M83126 32 PRACTICE OF DR GT CHAND M83133 9 PRACTICE OF DR JA MIR M83725 10 • in total, including exceptions, there DR H P BORSE & PARTNER M83713 19 PRACTICE OF DR BD PATEL M83631 14 are 901 people with a recorded TRENT VALE MEDICAL PRACTICE M83014 38 DRS SHAH & TALPUR M83138 21 CHA2DS2-VASc score >= 2 who are MERTON SURGERY M83128 16 PRACTICE OF DR AK SINHA M83712 5 not treated WESTON COYNEY MEDICAL PRACTICE M83708 12 FIVE TOWNS GP SURGERY M83700 1 • GP practice range: 0.0% to 47.1% MIDDLEPORT MEDICAL CENTRE Y02867 5 DR SONNATHI'S SURGERY M83669 13 HARLEY STREET MEDICAL CTR M83076 24 MILLRISE MEDICAL PRACTICE M83061 42 WILLOW BANK SURGERY Y02521 22 HARTSHILL MEDICAL CENTRE M83066 28 PRACTICE OF DR HA TALPUR M83678 11 GLEBEDALE MEDICAL PRACTICE M83028 20 TRINITY MEDICAL CENTRE M83632 16 CAMBRIDGE HOUSE M83624 9 FURLONG MEDICAL CENTRE M83021 26 PACKMOOR MEDICAL CENTRE M83739 7 LUCIE WEDGWOOD HEALTH CTR M83682 19 THE HAYMARKET HEALTH CTR M83082 37 APSLEY SURGERY M83627 11 THE SURGERY FODEN STREET M83134 9 MAYFIELD SURGERY M83004 46 DRS REES & LEFROY M83619 4 MOSS GREEN SURGERY Y00592 22 MEIR PARK SURGERY M83047 10 BADDELEY GREEN SURGERY M83709 15 ORCHARD SURGERY M83038 44 GOLDENHILL MEDICAL CENTRE M83143 9 POTTERIES MEDICAL CENTRE M83102 9 COBRIDGE SURGERY M83127 6 DRAYTON ROAD SURGERY M83629 6 BROOK MEDICAL CENTRE M83094 47 DR P D MILES AND DR R VALASAPALLI M83100 13 DR VSR CHADALAVADA M83625 16 DR BOSE & DR BOYAPATI'S PRACTICE M83650 6 THE MOORCROFT MEDICAL CTR M83146 25 NORFOLK STREET SURGERY M83075 16 BIRCHES HEAD MEDICAL CTR. M83123 12 BELGRAVE MEDICAL CENTRE M83068 23 SNOWHILL MEDICAL CENTRE M83623 3 DUNROBIN STREET MEDICAL CENTRE M83090 6 PRACTICE OF DR SB KULKARNI M83714 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

20% 10% 0% -10% -20% -30% -40%

ADDERLEY GREEN SURGERY 5

BRINSLEY AVENUE PRACTICE 24

HANLEY HEALTH & WELL BEING CENTRE 5 • using the GP cluster method of TRENTHAM MEWS MEDICAL CENTRE 16 calculating potential gains, if each PRACTICE OF DR JA MIR 6 practice was to achieve as well as the LONGTON HALL SURGERY 17 upper quartile of its national cluster, then an additional 242 people would PRACTICE OF DR GT CHAND 5 be treated DR H P BORSE & PARTNER 10

PRACTICE OF DR BD PATEL 7

DRS SHAH & TALPUR 10

DR VSR CHADALAVADA 0

DR BOSE & DR BOYAPATI'S PRACTICE

THE MOORCROFT MEDICAL CTR

NORFOLK STREET SURGERY

BIRCHES HEAD MEDICAL CTR.

BROOK MEDICAL CENTRE

BELGRAVE MEDICAL CENTRE

SNOWHILL MEDICAL CENTRE

DUNROBIN STREET MEDICAL CENTRE

PRACTICE OF DR SB KULKARNI Details of this methodology are available on slide 9. Click here to view them.

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

Below 150/90 Not below 150/90 Exceptions reported

NHS Stoke On Trent CCG 84.9% • 5,961 people with a history of stroke or TIA* in NHS Stoke On Trent CCG NHS North Staffordshire CCG 84.3% • 5,060 (84.9%) people whose blood pressure is <= 150 / 90 • 221 (3.7%) people who are NHS East Staffordshire CCG 83.8% exceptions • 680 (11.4%) additional people whose

NHS South East Staffordshire And Seisdon Peninsula blood pressure is not <= 150 / 90 83.1% CCG

NHS Cannock Chase CCG 82.9%

NHS Stafford And Surrounds CCG 80.4%

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 Wakefield CCG 86.9%

NHS Tameside and Glossop CCG 86.4%

NHS Salford CCG 85.2%

NHS Rotherham CCG 85.1%

NHS Bury CCG 84.9%

NHS Stoke On Trent CCG 84.9%

NHS Hartlepool and Stockton-on-Tees CCG 84.5%

NHS South Tees CCG 83.2%

NHS Barnsley CCG 83.0%

NHS Sunderland CCG 83.0%

NHS Hull CCG 82.5%

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

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

No treatment Exceptions reported

MAYFIELD SURGERY M83004 81 DRAYTON ROAD SURGERY M83629 14 MOSS GREEN SURGERY Y00592 35 COBRIDGE SURGERY M83127 14 TRENTHAM MEWS MEDICAL CENTRE M83711 15 WILLOW BANK SURGERY Y02521 36 MILLRISE MEDICAL PRACTICE M83061 43 • in total, including exceptions, there THE MOORCROFT MEDICAL CTR M83146 47 BROOK MEDICAL CENTRE M83094 64 are 901 people whose blood pressure THE HAYMARKET HEALTH CTR M83082 52 PRACTICE OF DR BD PATEL M83631 9 is not <= 150 / 90 LONGTON HALL SURGERY M83126 27 DR P D MILES AND DR R VALASAPALLI M83100 16 • GP practice range: 3.3% to 26.5% SNOWHILL MEDICAL CENTRE M83623 10 TRENT VALE MEDICAL PRACTICE M83014 35 FURLONG MEDICAL CENTRE M83021 29 NORFOLK STREET SURGERY M83075 23 HARLEY STREET MEDICAL CTR M83076 29 LUCIE WEDGWOOD HEALTH CTR M83682 20 MEIR PARK SURGERY M83047 14 ORCHARD SURGERY M83038 44 PRACTICE OF DR HA TALPUR M83678 6 WESTON COYNEY MEDICAL PRACTICE M83708 10 PRACTICE OF DR AK SINHA M83712 5 PRACTICE OF DR JA MIR M83725 5 GOLDENHILL MEDICAL CENTRE M83143 10 PRACTICE OF DR GT CHAND M83133 7 TRINITY MEDICAL CENTRE M83632 13 DR H P BORSE & PARTNER M83713 13 GLEBEDALE MEDICAL PRACTICE M83028 15 DUNROBIN STREET MEDICAL CENTRE M83090 10 DRS SHAH & TALPUR M83138 12 APSLEY SURGERY M83627 10 BELGRAVE MEDICAL CENTRE M83068 22 DR BOSE & DR BOYAPATI'S PRACTICE M83650 4 DR SONNATHI'S SURGERY M83669 7 BIRCHES HEAD MEDICAL CTR. M83123 15 FIVE TOWNS GP SURGERY M83700 3 DR VSR CHADALAVADA M83625 13 BRINSLEY AVENUE PRACTICE M83601 12 THE SURGERY FODEN STREET M83134 6 DRS REES & LEFROY M83619 4 CAMBRIDGE HOUSE M83624 4 MIDDLEPORT MEDICAL CENTRE Y02867 5 HARTSHILL MEDICAL CENTRE M83066 11 PRACTICE OF DR SB KULKARNI M83714 1 BADDELEY GREEN SURGERY M83709 8 PACKMOOR MEDICAL CENTRE M83739 3 POTTERIES MEDICAL CENTRE M83102 4 MERTON SURGERY M83128 4 ADDERLEY GREEN SURGERY M83661 1 HANLEY HEALTH & WELL BEING CENTRE Y02868 1 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

37 CVD: Primary Care Intelligence Packs Percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record in the preceding 12 months that an anti-platelet agent, or an anti-coagulant is being taken by CCG Comparison with CCGs in the STP Below 150/90 Not below 150/90 Exceptions reported

NHS North Staffordshire CCG 92.8% • 3,699 people with a stroke shown to be non-haemorrhagic* in NHS Stoke NHS Stoke On Trent CCG 92.2% On Trent CCG • 3,412 (92.2%) people who are taking

NHS South East Staffordshire And Seisdon Peninsula an anti-platetet agent or anti- 91.8% CCG coagulant • 192 (5.2%) people who are exceptions NHS East Staffordshire CCG 91.5% • 95 (2.6%) additional people with no treatment

NHS Cannock Chase CCG 91.4%

NHS Stafford And Surrounds CCG 90.6%

England 91.8%

0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator STIA007 denominator plus exceptions

38 CVD: Primary Care Intelligence Packs Percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record in the preceding 12 months that an anti-platelet agent, or an anti-coagulant is being taken by CCG Comparison with demographically similar CCGs Below 150/90 Not below 150/90 Exceptions reported

NHS Hartlepool and Stockton-on-Tees CCG 93.7%

NHS Wakefield CCG 93.2%

NHS Sunderland CCG 93.2%

NHS South Tees CCG 92.9%

NHS Bury CCG 92.8%

NHS Tameside and Glossop CCG 92.5%

NHS Stoke On Trent CCG 92.2%

NHS Salford CCG 92.1%

NHS Rotherham CCG 91.9%

NHS Barnsley CCG 91.4%

NHS Hull CCG 91.0%

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

MIDDLEPORT MEDICAL CENTRE Y02867 7 ADDERLEY GREEN SURGERY M83661 4 TRINITY MEDICAL CENTRE M83632 13 MEIR PARK SURGERY M83047 10 DUNROBIN STREET MEDICAL CENTRE M83090 7 PRACTICE OF DR AK SINHA M83712 3 MERTON SURGERY M83128 8 • in total, including exceptions, there HANLEY HEALTH & WELL BEING CENTRE Y02868 3 MAYFIELD SURGERY M83004 26 are 287 people who are not taking an HARLEY STREET MEDICAL CTR M83076 19 PACKMOOR MEDICAL CENTRE M83739 4 anti-platelet agent or anti-coagulant GLEBEDALE MEDICAL PRACTICE M83028 10 NORFOLK STREET SURGERY M83075 12 • GP practice range: 0.0% to 21.2% LUCIE WEDGWOOD HEALTH CTR M83682 9 FURLONG MEDICAL CENTRE M83021 13 DRS REES & LEFROY M83619 3 LONGTON HALL SURGERY M83126 9 BRINSLEY AVENUE PRACTICE M83601 7 PRACTICE OF DR HA TALPUR M83678 2 PRACTICE OF DR SB KULKARNI M83714 1 PRACTICE OF DR GT CHAND M83133 3 BELGRAVE MEDICAL CENTRE M83068 10 APSLEY SURGERY M83627 5 WILLOW BANK SURGERY Y02521 7 MILLRISE MEDICAL PRACTICE M83061 8 DR VSR CHADALAVADA M83625 5 ORCHARD SURGERY M83038 14 MOSS GREEN SURGERY Y00592 6 HARTSHILL MEDICAL CENTRE M83066 7 CAMBRIDGE HOUSE M83624 1 DR P D MILES AND DR R VALASAPALLI M83100 3 BADDELEY GREEN SURGERY M83709 5 DR SONNATHI'S SURGERY M83669 2 THE MOORCROFT MEDICAL CTR M83146 8 WESTON COYNEY MEDICAL PRACTICE M83708 2 BROOK MEDICAL CENTRE M83094 9 TRENT VALE MEDICAL PRACTICE M83014 6 DR H P BORSE & PARTNER M83713 3 DRS SHAH & TALPUR M83138 3 COBRIDGE SURGERY M83127 1 DRAYTON ROAD SURGERY M83629 1 BIRCHES HEAD MEDICAL CTR. M83123 2 SNOWHILL MEDICAL CENTRE M83623 1 POTTERIES MEDICAL CENTRE M83102 1 GOLDENHILL MEDICAL CENTRE M83143 1 THE HAYMARKET HEALTH CTR M83082 3 THE SURGERY FODEN STREET M83134 PRACTICE OF DR BD PATEL M83631 DR BOSE & DR BOYAPATI'S PRACTICE M83650 FIVE TOWNS GP SURGERY M83700 TRENTHAM MEWS MEDICAL CENTRE M83711 PRACTICE OF DR JA MIR M83725 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

40 CVD: Primary Care Intelligence Packs Diabetes

41 CVD: Primary Care Intelligence Packs Diabetes prevention and management

Type 2 Diabetes in numbers Diabetes costs the NHS • diagnosed prevalence – 3.0 million £9.8 billion per year – and the • undiagnosed diabetes – 900,000 • non-diabetic hyperglycaemia (high risk of diabetes) – 5 million prevalence is rising What questions should we ask in our CCG? 1. for each indicator how wide is the variation in achievement and exception reporting? Type 2 diabetes is often preventable 2. how many people would benefit if all practices performed as well People at high risk of developing type 2 diabetes as the best? can be identified through the NHS Health Check, 3. how can we support practices who are average and below and the disease can be prevented or delayed in average to perform as well as the best in: many through intensive behaviour change support. • detection of diabetes • delivery of the 8 care processes and achievement of the 3 treatment targets Complications of diabetes are preventable • identification and management of Non-diabetic hyperglycaemia Diabetes is a major cause of premature death and disability and greatly increases the risk of heart disease and stroke, kidney failure, amputations and What might help blindness. 80% of NHS spending on diabetes goes • ensure universal participation by practices in the National on managing these complications, most of which Diabetes Audit (NDA) could be prevented. There are 8 essential care • benchmark practice level data from the NDA – and support processes, in addition to retinal screening, that practices to explore variation together substantially reduce complication rates. • increase support for patient education and shared Despite this, around a half of people with diabetes management do not receive all 8 care processes, and there is • maximise uptake of the NHS Health Check to aid detection of widespread variation between CCGs and practices diabetes and Non Diabetic Hyperglycaemia in levels of achievement • maximise uptake of the NHS Diabetes Prevention Programme

42 CVD: Primary Care Intelligence Packs Diabetes observed prevalence compared with expected prevalence by CCG Comparison with CCGs in the STP

NHS Cannock Chase CCG 0.91 • 0.89 ratio of observed to expected diabetes prevalence in NHS Stoke On NHS Stoke On Trent CCG 0.89 Trent CCG, compared to 0.77 in England

NHS North Staffordshire CCG 0.87 • this suggests 89% of people have been diagnosed

NHS South East Staffordshire And Seisdon Peninsula 0.82 CCG

NHS East Staffordshire CCG 0.81

NHS Stafford And Surrounds CCG 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 England 0.77 from the NCVIN diabetes prevalence model produced in 2015.

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

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

NHS Stoke On Trent CCG 0.89

NHS Bury CCG 0.86

NHS Tameside and Glossop CCG 0.85

NHS Wakefield CCG 0.83

NHS Barnsley CCG 0.83

NHS Hull CCG 0.81

NHS Salford CCG 0.81

NHS Rotherham CCG 0.78

NHS Sunderland CCG 0.78

NHS Hartlepool and Stockton-on-Tees CCG 0.78

NHS South Tees CCG 0.76

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

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

GP practice CCG

CAMBRIDGE HOUSE M83624 10.9% DUNROBIN STREET MEDICAL CENTRE M83090 10.5% FIVE TOWNS GP SURGERY M83700 10.4% MOSS GREEN SURGERY Y00592 9.9% PRACTICE OF DR BD PATEL M83631 9.8% PRACTICE OF DR AK SINHA M83712 9.6% THE HAYMARKET HEALTH CTR M83082 9.0% • GP practice range of observed ADDERLEY GREEN SURGERY M83661 9.0% THE MOORCROFT MEDICAL CTR M83146 9.0% diabetes 5.1% to 10.9% PRACTICE OF DR GT CHAND M83133 8.7% APSLEY SURGERY M83627 8.6% • there are an estimated 2,277 people MAYFIELD SURGERY M83004 8.6% LUCIE WEDGWOOD HEALTH CTR M83682 8.6% with undiagnosed diabetes in NHS FURLONG MEDICAL CENTRE M83021 8.6% DR H P BORSE & PARTNER M83713 8.5% GOLDENHILL MEDICAL CENTRE M83143 8.3% Stoke On Trent CCG BIRCHES HEAD MEDICAL CTR. M83123 8.2% SNOWHILL MEDICAL CENTRE M83623 8.1% PRACTICE OF DR JA MIR M83725 8.1% WILLOW BANK SURGERY Y02521 8.1% BELGRAVE MEDICAL CENTRE M83068 8.0% TRINITY MEDICAL CENTRE M83632 8.0% PRACTICE OF DR HA TALPUR M83678 8.0% MEIR PARK SURGERY M83047 7.9% DR P D MILES AND DR R VALASAPALLI M83100 7.9% BROOK MEDICAL CENTRE M83094 7.8% WESTON COYNEY MEDICAL PRACTICE M83708 7.8% DR SONNATHI'S SURGERY M83669 7.7% GLEBEDALE MEDICAL PRACTICE M83028 7.7% COBRIDGE SURGERY M83127 7.7% LONGTON HALL SURGERY M83126 7.6% DRAYTON ROAD SURGERY M83629 7.6% ORCHARD SURGERY M83038 7.5% DR VSR CHADALAVADA M83625 7.4% MERTON SURGERY M83128 7.4% NORFOLK STREET SURGERY M83075 7.2% DRS REES & LEFROY M83619 7.1% PRACTICE OF DR SB KULKARNI M83714 7.1% TRENT VALE MEDICAL PRACTICE M83014 7.1% POTTERIES MEDICAL CENTRE M83102 7.1% MILLRISE MEDICAL PRACTICE M83061 7.0% MIDDLEPORT MEDICAL CENTRE Y02867 6.9% THE SURGERY FODEN STREET M83134 6.8% TRENTHAM MEWS MEDICAL CENTRE M83711 6.8% BRINSLEY AVENUE PRACTICE M83601 6.7% DRS SHAH & TALPUR M83138 6.6% DR BOSE & DR BOYAPATI'S PRACTICE M83650 6.4% PACKMOOR MEDICAL CENTRE M83739 6.4% BADDELEY GREEN SURGERY M83709 6.2% Note: The estimated number of undiagnosed HARTSHILL MEDICAL CENTRE M83066 6.0% HARLEY STREET MEDICAL CTR M83076 5.8% people with diabetes has been calculated by HANLEY HEALTH & WELL BEING CENTRE Y02868 5.1% 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 NHS Stafford And Surrounds CCG 6.5% 1.9% 12.0% diabetes in NHS Stoke On Trent CCG is 8.8% (diagnosed and undiagnosed) NHS North Staffordshire CCG 7.4% 1.1% 11.7% • in addition, there are an estimated 11.0% of people in NHS Stoke On NHS East Staffordshire CCG 6.9% 1.6% 11.6% Trent CCG who are at increased risk of developing diabetes (i.e. with non- diabetic hyperglycaemia) NHS Stoke On Trent CCG 7.8% 1.0% 11.0%

• this means that 19.9% of the NHS South East Staffordshire And Seisdon Peninsula 6.8% 1.5% 11.6% population in NHS Stoke On Trent CCG CCG are estimated to have diabetes, or at high risk of developing of NHS Cannock Chase CCG 7.6% 0.7% 11.1% diabetes

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

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

NHS South East Staffordshire And Seisdon Peninsula 59.0% CCG • data on care processes and treatment NHS Stafford And Surrounds CCG 57.7% targets are taken from the National Diabetes Audit (NDA) • overall practice participation in the NHS East Staffordshire CCG 56.2% 2015/16 audit was 81.4% in England

• in NHS Stoke On Trent CCG, 51 out NHS North Staffordshire CCG 52.3% of 51 practices (100.0%) participated in the NDA

NHS Stoke On Trent CCG 46.3%

• 46.3% of people with diabetes (of NHS Cannock Chase CCG 43.1% practices who participated in the audit) had the eight recommended care processes in NHS Stoke On Trent CCG, compared to 52.6% in England

England 52.6%

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

47 CVD: Primary Care Intelligence Packs People with diabetes who had eight care processes by GP practice, 2015/16

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

HARTSHILL MEDICAL CENTRE M83066 80.3% TRENT VALE MEDICAL PRACTICE M83014 71.2% BADDELEY GREEN SURGERY M83709 71.1% ORCHARD SURGERY M83038 69.7% BROOK MEDICAL CENTRE M83094 69.3% • achievement - 8 care processes: in MAYFIELD SURGERY M83004 68.6% MEIR PARK SURGERY M83047 67.0% practices who provided data via the LUCIE WEDGWOOD HEALTH CTR M83682 66.6% MILLRISE MEDICAL PRACTICE M83061 65.6% NDA, between 3.4% and 80.3% of POTTERIES MEDICAL CENTRE M83102 64.2% DRS SHAH & TALPUR M83138 63.1% THE SURGERY FODEN STREET M83134 61.8% patients received all 8 care processes THE HAYMARKET HEALTH CTR M83082 59.4% FURLONG MEDICAL CENTRE M83021 58.6% NORFOLK STREET SURGERY M83075 58.0% ADDERLEY GREEN SURGERY M83661 57.7% HARLEY STREET MEDICAL CTR M83076 55.0% • at least 9,517 people did not receive WILLOW BANK SURGERY Y02521 54.6% LONGTON HALL SURGERY M83126 51.8% the eight care processes APSLEY SURGERY M83627 51.5% DR BOSE & DR BOYAPATI'S PRACTICE M83650 50.8% HANLEY HEALTH & WELL BEING CENTRE Y02868 48.3% THE MOORCROFT MEDICAL CTR M83146 47.4% MIDDLEPORT MEDICAL CENTRE Y02867 46.9% GLEBEDALE MEDICAL PRACTICE M83028 44.9% WESTON COYNEY MEDICAL PRACTICE M83708 43.5% SNOWHILL MEDICAL CENTRE M83623 42.8% DUNROBIN STREET MEDICAL CENTRE M83090 39.7% COBRIDGE SURGERY M83127 37.7% PRACTICE OF DR AK SINHA M83712 37.1% MOSS GREEN SURGERY Y00592 37.1% PACKMOOR MEDICAL CENTRE M83739 36.6% MERTON SURGERY M83128 35.3% PRACTICE OF DR SB KULKARNI M83714 34.7% BRINSLEY AVENUE PRACTICE M83601 34.6% DR VSR CHADALAVADA M83625 33.4% DRS REES & LEFROY M83619 33.0% FIVE TOWNS GP SURGERY M83700 28.4% PRACTICE OF DR JA MIR M83725 27.8% PRACTICE OF DR HA TALPUR M83678 26.5% DR SONNATHI'S SURGERY M83669 25.4% CAMBRIDGE HOUSE M83624 21.6% DRAYTON ROAD SURGERY M83629 18.3% PRACTICE OF DR BD PATEL M83631 15.2% TRINITY MEDICAL CENTRE M83632 14.4% BIRCHES HEAD MEDICAL CTR. M83123 13.6% TRENTHAM MEWS MEDICAL CENTRE M83711 11.8% GOLDENHILL MEDICAL CENTRE M83143 11.3% DR H P BORSE & PARTNER M83713 4.3% DR P D MILES AND DR R VALASAPALLI M83100 3.9% BELGRAVE MEDICAL CENTRE M83068 3.4% PRACTICE OF DR GT CHAND M83133 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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

NHS Stoke On Trent CCG 46.8%

• 46.8% of people with diabetes (of NHS North Staffordshire CCG 44.8% practices who participated in the audit) met the three treatment targets in NHS Stoke On Trent CCG, compared to 39.0% in England NHS Cannock Chase CCG 42.7%

NHS East Staffordshire CCG 39.9%

NHS South East Staffordshire And Seisdon Peninsula 39.8% CCG

NHS Stafford And Surrounds CCG 37.8%

England 39.0%

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

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

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

DR H P BORSE & PARTNER M83713 59.6% DRS SHAH & TALPUR M83138 59.5% CAMBRIDGE HOUSE M83624 59.2% PRACTICE OF DR JA MIR M83725 59.0% DUNROBIN STREET MEDICAL CENTRE M83090 58.9% • achievement - 3 treatment targets: in BIRCHES HEAD MEDICAL CTR. M83123 58.3% POTTERIES MEDICAL CENTRE M83102 57.6% practices who provided data via the TRINITY MEDICAL CENTRE M83632 57.1% THE SURGERY FODEN STREET M83134 57.0% NDA, between 28.3% and 59.6% of BRINSLEY AVENUE PRACTICE M83601 56.7% BROOK MEDICAL CENTRE M83094 56.5% HARTSHILL MEDICAL CENTRE M83066 55.0% patients achieved all 3 treatment DRS REES & LEFROY M83619 53.9% BADDELEY GREEN SURGERY M83709 52.2% targets DR P D MILES AND DR R VALASAPALLI M83100 51.1% THE HAYMARKET HEALTH CTR M83082 50.6% APSLEY SURGERY M83627 50.6% • at least 8,194 people did not meet the GLEBEDALE MEDICAL PRACTICE M83028 50.4% DR VSR CHADALAVADA M83625 50.3% three treatment targets DR SONNATHI'S SURGERY M83669 49.8% SNOWHILL MEDICAL CENTRE M83623 49.2% TRENT VALE MEDICAL PRACTICE M83014 47.8% MAYFIELD SURGERY M83004 47.7% MEIR PARK SURGERY M83047 47.5% PRACTICE OF DR SB KULKARNI M83714 47.2% WESTON COYNEY MEDICAL PRACTICE M83708 46.6% LUCIE WEDGWOOD HEALTH CTR M83682 46.3% DR BOSE & DR BOYAPATI'S PRACTICE M83650 46.2% MERTON SURGERY M83128 44.8% FIVE TOWNS GP SURGERY M83700 44.0% THE MOORCROFT MEDICAL CTR M83146 43.8% ORCHARD SURGERY M83038 43.5% FURLONG MEDICAL CENTRE M83021 43.2% NORFOLK STREET SURGERY M83075 42.6% TRENTHAM MEWS MEDICAL CENTRE M83711 42.1% PACKMOOR MEDICAL CENTRE M83739 41.6% MOSS GREEN SURGERY Y00592 41.5% HARLEY STREET MEDICAL CTR M83076 41.3% PRACTICE OF DR HA TALPUR M83678 41.2% PRACTICE OF DR BD PATEL M83631 39.6% BELGRAVE MEDICAL CENTRE M83068 39.1% GOLDENHILL MEDICAL CENTRE M83143 37.6% MIDDLEPORT MEDICAL CENTRE Y02867 37.2% DRAYTON ROAD SURGERY M83629 36.4% ADDERLEY GREEN SURGERY M83661 35.5% WILLOW BANK SURGERY Y02521 35.0% LONGTON HALL SURGERY M83126 34.9% HANLEY HEALTH & WELL BEING CENTRE Y02868 34.7% MILLRISE MEDICAL PRACTICE M83061 34.6% COBRIDGE SURGERY M83127 31.8% PRACTICE OF DR AK SINHA M83712 28.3% PRACTICE OF DR GT CHAND M83133 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

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

PRACTICE OF DR AK SINHA 20

LONGTON HALL SURGERY 41

COBRIDGE SURGERY 22 • using the GP cluster method of HANLEY HEALTH & WELL BEING CENTRE 13 calculating potential gains, if each ADDERLEY GREEN SURGERY 12 practice was to achieve as well as the MILLRISE MEDICAL PRACTICE 39 upper quartile of its national cluster, then an additional 369 people would DRAYTON ROAD SURGERY 15 be treated MIDDLEPORT MEDICAL CENTRE 7

WILLOW BANK SURGERY 41

PRACTICE OF DR BD PATEL 13

TRINITY MEDICAL CENTRE

CAMBRIDGE HOUSE

BROOK MEDICAL CENTRE

POTTERIES MEDICAL CENTRE

DR H P BORSE & PARTNER

BRINSLEY AVENUE PRACTICE

BIRCHES HEAD MEDICAL CTR.

DUNROBIN STREET MEDICAL CENTRE

DRS SHAH & TALPUR

PRACTICE OF DR JA MIR Details of this methodology are available on slide 9. Click here to view them.

51 CVD: Primary Care Intelligence Packs Kidney

52 CVD: Primary Care Intelligence Packs Management of chronic kidney disease

Chronic Kidney Disease can progress to kidney failure and it Late diagnosis of CKD is common. substantially increases the risk Around a third of people with CKD are undiagnosed. More of heart attack and stroke. opportunistic testing and improved uptake of the NHS Health Check will increase detection rates.

Chronic Kidney Disease (CKD) is common. What questions should we ask in our CCG? It is one of the commonest co-morbidities and affects a third 1. for each indicator how wide is the variation in of people over 75. In 2010 it was estimated to cost the NHS achievement and exception reporting? around £1.5bn. Average length of stay in hospital tends to 2. how many people would benefit if all practices be longer and outcomes are considerably worse: performed as well as the best? approximately 7,000 excess strokes and 12,000 excess 3. how can we support practices who are average and heart attacks occur each year in people with CKD below average to perform as well as the best in: compared to those without. • detection of CKD Individuals with CKD are also at much higher risk of • more systematic delivery of evidence based care developing acute kidney injury when they have an intercurrent illness such as pneumonia What might help • Support practices to share audit data and systematically Evidence based guidance from NICE highlights CVD identify gaps and opportunities for improved detection risk reduction, good blood pressure control and and management of CKD. management of proteinuria as essential steps to reduce the • Promote uptake of and follow up from the NHS Health risk of cardiovascular events and progression to kidney Check to aid detection and management of CKD failure. Despite this there is often significant variation • Offer local training and education in the detection and between practices in achievement and exception reporting. management of CKD

53 CVD: Primary Care Intelligence Packs Chronic kidney disease (CKD) observed prevalence (2015/16) compared with expected prevalence (2011) by CCG Comparison with CCGs in the STP

NHS South East Staffordshire And Seisdon Peninsula 0.69 CCG

NHS East Staffordshire CCG 0.67 • the ratio of those diagnosed with chronic kidney disease versus those expected to have chronic kidney NHS Stoke On Trent CCG 0.66 disease is 0.66. This compares to 0.68 for England • this suggests that 66% of people with NHS Cannock Chase CCG 0.64 chronic kidney disease have been diagnosed

NHS North Staffordshire CCG 0.60

NHS Stafford And Surrounds CCG 0.52

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

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

NHS Barnsley CCG 0.82

NHS Bury CCG 0.75

NHS Wakefield CCG 0.75

NHS Hull CCG 0.73

NHS Rotherham CCG 0.72

NHS Sunderland CCG 0.68

NHS Stoke On Trent CCG 0.66

NHS Salford CCG 0.64

NHS Hartlepool and Stockton-on-Tees CCG 0.64

NHS South Tees CCG 0.59

NHS Tameside and Glossop CCG 0.52

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 Ratio

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

GP practice CCG

DUNROBIN STREET MEDICAL CENTRE M83090 6.3% ORCHARD SURGERY M83038 5.9% DRS REES & LEFROY M83619 5.6% BRINSLEY AVENUE PRACTICE M83601 5.4% THE MOORCROFT MEDICAL CTR M83146 5.4% PRACTICE OF DR HA TALPUR M83678 5.3% MILLRISE MEDICAL PRACTICE M83061 5.3% • it is estimated that there are 4,492 DR H P BORSE & PARTNER M83713 5.1% TRINITY MEDICAL CENTRE M83632 5.0% people with undiagnosed chronic LONGTON HALL SURGERY M83126 5.0% LUCIE WEDGWOOD HEALTH CTR M83682 4.7% kidney disease in NHS Stoke On MEIR PARK SURGERY M83047 4.7% PRACTICE OF DR SB KULKARNI M83714 4.6% Trent CCG CAMBRIDGE HOUSE M83624 4.5% THE HAYMARKET HEALTH CTR M83082 4.5% BIRCHES HEAD MEDICAL CTR. M83123 4.4% • GP practice range of observed CKD: PRACTICE OF DR GT CHAND M83133 4.4% TRENT VALE MEDICAL PRACTICE M83014 4.4% 1.7% to 6.3% POTTERIES MEDICAL CENTRE M83102 4.3% GOLDENHILL MEDICAL CENTRE M83143 4.2% APSLEY SURGERY M83627 4.2% DR P D MILES AND DR R VALASAPALLI M83100 4.2% WESTON COYNEY MEDICAL PRACTICE M83708 4.1% MOSS GREEN SURGERY Y00592 4.1% PRACTICE OF DR JA MIR M83725 4.0% PRACTICE OF DR BD PATEL M83631 4.0% FURLONG MEDICAL CENTRE M83021 3.9% HARTSHILL MEDICAL CENTRE M83066 3.9% GLEBEDALE MEDICAL PRACTICE M83028 3.9% ADDERLEY GREEN SURGERY M83661 3.7% BELGRAVE MEDICAL CENTRE M83068 3.7% DR SONNATHI'S SURGERY M83669 3.6% DRS SHAH & TALPUR M83138 3.5% DRAYTON ROAD SURGERY M83629 3.4% TRENTHAM MEWS MEDICAL CENTRE M83711 3.4% BROOK MEDICAL CENTRE M83094 3.3% MAYFIELD SURGERY M83004 3.3% BADDELEY GREEN SURGERY M83709 3.3% DR BOSE & DR BOYAPATI'S PRACTICE M83650 3.2% MERTON SURGERY M83128 3.2% PACKMOOR MEDICAL CENTRE M83739 3.0% HARLEY STREET MEDICAL CTR M83076 2.9% NORFOLK STREET SURGERY M83075 2.6% COBRIDGE SURGERY M83127 2.6% PRACTICE OF DR AK SINHA M83712 2.5% DR VSR CHADALAVADA M83625 2.5% Note: CCG estimates for the estimated WILLOW BANK SURGERY Y02521 2.4% MIDDLEPORT MEDICAL CENTRE Y02867 2.4% number of people with CKD are based on THE SURGERY FODEN STREET M83134 2.4% SNOWHILL MEDICAL CENTRE M83623 2.4% applying a proportion from a resident based FIVE TOWNS GP SURGERY M83700 1.8% population estimate to a GP registered HANLEY HEALTH & WELL BEING CENTRE Y02868 1.7% population. The characteristics of registered 0% 1% 2% 3% 4% 5% 6% 7% and resident populations may vary in some CCGs, and local interpretation is required.

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

NHS Stoke On Trent CCG 78.3% • 8,891 people with CKD (diagnosed*) in NHS Stoke On Trent CCG NHS Cannock Chase CCG 78.2% • 6,961 (78.3%) people whose blood pressure is <= 140 /85 • 721 (8.1%) people who are NHS East Staffordshire CCG 76.1% exceptions • 1,209 (13.6%) additional people whose blood pressure is not <= 140 / NHS North Staffordshire CCG 74.5% 85

NHS South East Staffordshire And Seisdon Peninsula 72.3% CCG

NHS Stafford And Surrounds CCG 71.6%

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

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

NHS Stoke On Trent CCG 78.3%

NHS Hartlepool and Stockton-on-Tees CCG 78.1%

NHS Bury CCG 78.1%

NHS Tameside and Glossop CCG 78.1%

NHS Wakefield CCG 78.0%

NHS Salford CCG 77.6%

NHS Sunderland CCG 74.6%

NHS Hull CCG 74.1%

NHS South Tees CCG 73.9%

NHS Rotherham CCG 73.8%

NHS Barnsley CCG 72.9%

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

PRACTICE OF DR HA TALPUR M83678 104 DRAYTON ROAD MEDICAL PRACTICE M83629 33 PRACTICE OF DR AK SINHA M83712 17 THE SURGERY TRENTHAM MEWS M83711 30 DR A M GATH & PTRS M83075 48 GOLDENHILL MEDICAL CENTRE M83143 38 DR F R PRZYSLO & PTRS M83076 71 • in total, including exceptions, there MOSS GREEN SURGERY Y00592 60 THE MOORCROFT MEDICAL CTR M83146 94 are 1,930 people whose blood BROOK MEDICAL CENTRE M83094 107 DR A D CRESSWELL & PTRS M83061 90 pressure is not <= 140 / 85 DR M MCCARTHY & PARTNERS M83004 84 DR P GOLIK & PTRS M83038 119 • GP practice range: 6.4% to 56.2% DR S SHANMUGASUNDARAM M83661 13 PRACTICE OF DR R SARIN M83047 41 DR A D PULLAN & PTRS M83021 74 THE HAYMARKET HEALTH CTR M83082 98 DR S PATHAK M83127 23 WILLOW BANK SURGERY Y02521 31 PRACTICE OF DR BD PATEL M83631 20 SNOWHILL MEDICAL CENTRE M83623 20 BELGRAVE MEDICAL CENTRE M83068 70 DR PD MILES M83100 28 DR G PETRAUSKAS & PARTNER M83028 47 MERTON SURGERY M83128 23 THE SURGERY M83625 35 DR R JAISWAL & PARTNER M83708 18 DR V SUCHAK & PTRS M83066 37 MIDDLEPORT MEDICAL CENTRE Y02867 7 DR G REES & DR J LEFROY M83619 13 TRENT VALE MEDICAL PRACTICE M83014 50 BRINSLEY AVENUE PRACTICE M83601 36 LONGTON HALL SURGERY M83126 39 BIRCHES HEAD MEDICAL CTR. M83123 41 DR BOSE & PARTNER M83650 10 PRACTICE OF DR HP BORSE M83713 33 TUNSTALL PRIMARY CARE CENTRE M83669 16 LUCIE WEDGWOOD HEALTH CTR M83682 33 TRINITY MEDICAL CENTRE M83632 26 APSLEY SURGERY M83627 22 HANLEY HEALTH & WELL BEING CENTRE Y02868 7 PRACTICE OF DR GT CHAND M83133 10 FIVE TOWN GP SURGERY M83700 6 MEDICAL CENTRE DUNROBIN STREET M83090 22 DR K T TATTUM M83709 18 DR P H SHAH & PTRS M83138 16 POTTERIES MEDICAL CENTRE M83102 17 DR SB KULKARNI M83714 5 PACKMOOR MEDICAL CENTRE M83739 9 CAMBRIDGE HOUSE M83624 8 PRACTICE OF DR JA MIR M83725 8 THE SURGERY FODEN STREET M83134 5 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

20% 10% 0% -10% -20% -30% -40% -50%

PRACTICE OF DR HA TALPUR 71

DRAYTON ROAD MEDICAL PRACTICE 17

PRACTICE OF DR AK SINHA 9 • using the GP cluster method of THE SURGERY TRENTHAM MEWS 13 calculating potential gains, if each GOLDENHILL MEDICAL CENTRE 18 practice was to achieve as well as the DR A M GATH & PTRS 21 upper quartile of its national cluster, then an additional 434 people would DR F R PRZYSLO & PTRS 31 be treated MOSS GREEN SURGERY 26

THE MOORCROFT MEDICAL CTR 35

DR S SHANMUGASUNDARAM 4

FIVE TOWN GP SURGERY

DR P H SHAH & PTRS

POTTERIES MEDICAL CENTRE

MEDICAL CENTRE DUNROBIN STREET

PACKMOOR MEDICAL CENTRE

DR SB KULKARNI

DR K T TATTUM

PRACTICE OF DR JA MIR

CAMBRIDGE HOUSE

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

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

NHS Stoke On Trent CCG 79.2% • 8,823 people with CKD (diagnosed*) in NHS Stoke On Trent CCG NHS North Staffordshire CCG 77.6% • 6,984 (79.2%) people who have a record of urine albumin:creatinine ratio test NHS East Staffordshire CCG 76.9% • 473 (5.4%) people who are exceptions

NHS South East Staffordshire And Seisdon Peninsula • 1,366 (15.5%) additional people who 74.9% CCG have no record of urine albumin:creatinine ratio test

NHS Cannock Chase CCG 73.6%

NHS Stafford And Surrounds CCG 72.9%

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

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

NHS Wakefield CCG 80.1%

NHS Tameside and Glossop CCG 79.8%

NHS Salford CCG 79.3%

NHS Stoke On Trent CCG 79.2%

NHS Hartlepool and Stockton-on-Tees CCG 78.0%

NHS Bury CCG 76.6%

NHS South Tees CCG 76.1%

NHS Hull CCG 75.0%

NHS Sunderland CCG 74.7%

NHS Rotherham CCG 72.5%

NHS Barnsley CCG 72.2%

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

62 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose notes do not have a record of a urine albumin: creatinine ratio test in the preceding 12 months by GP practice, 2014/15

Not recorded Exceptions reported

DR S PATHAK M83127 63 MERTON SURGERY M83128 71 DR F R PRZYSLO & PTRS M83076 108 DRAYTON ROAD MEDICAL PRACTICE M83629 34 TUNSTALL PRIMARY CARE CENTRE M83669 32 BROOK MEDICAL CENTRE M83094 119 THE HAYMARKET HEALTH CTR M83082 117 • in total, including exceptions, there DR M MCCARTHY & PARTNERS M83004 84 DR A D PULLAN & PTRS M83021 76 are 1,839 people who have no record PRACTICE OF DR BD PATEL M83631 21 DR A M GATH & PTRS M83075 37 of urine albumin:creatinine ratio test PRACTICE OF DR R SARIN M83047 40 DR A D CRESSWELL & PTRS M83061 75 • GP practice range: 8.3% to 63.0% WILLOW BANK SURGERY Y02521 29 DR S SHANMUGASUNDARAM M83661 11 PACKMOOR MEDICAL CENTRE M83739 18 THE SURGERY M83625 36 PRACTICE OF DR AK SINHA M83712 10 THE SURGERY TRENTHAM MEWS M83711 18 BRINSLEY AVENUE PRACTICE M83601 40 GOLDENHILL MEDICAL CENTRE M83143 25 MEDICAL CENTRE DUNROBIN STREET M83090 34 MOSS GREEN SURGERY Y00592 41 PRACTICE OF DR HP BORSE M83713 39 BIRCHES HEAD MEDICAL CTR. M83123 45 BELGRAVE MEDICAL CENTRE M83068 64 APSLEY SURGERY M83627 28 DR G PETRAUSKAS & PARTNER M83028 40 PRACTICE OF DR GT CHAND M83133 12 DR P GOLIK & PTRS M83038 78 PRACTICE OF DR JA MIR M83725 16 PRACTICE OF DR HA TALPUR M83678 16 LUCIE WEDGWOOD HEALTH CTR M83682 35 DR PD MILES M83100 21 TRINITY MEDICAL CENTRE M83632 25 TRENT VALE MEDICAL PRACTICE M83014 40 POTTERIES MEDICAL CENTRE M83102 21 DR P H SHAH & PTRS M83138 19 THE MOORCROFT MEDICAL CTR M83146 49 THE SURGERY FODEN STREET M83134 11 DR V SUCHAK & PTRS M83066 27 DR R JAISWAL & PARTNER M83708 13 LONGTON HALL SURGERY M83126 31 MIDDLEPORT MEDICAL CENTRE Y02867 5 CAMBRIDGE HOUSE M83624 12 DR SB KULKARNI M83714 6 HANLEY HEALTH & WELL BEING CENTRE Y02868 6 DR BOSE & PARTNER M83650 7 FIVE TOWN GP SURGERY M83700 5 SNOWHILL MEDICAL CENTRE M83623 10 DR K T TATTUM M83709 13 DR G REES & DR J LEFROY M83619 6 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 Cannock Chase CCG 0.92%

• prevalence of 0.8% in NHS Stoke On NHS North Staffordshire CCG 0.80% Trent CCG compared to 0.76% in England

NHS East Staffordshire CCG 0.80%

NHS Stoke On Trent CCG 0.80%

NHS South East Staffordshire And Seisdon Peninsula 0.79% CCG

NHS Stafford And Surrounds CCG 0.77%

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 Sunderland CCG 1.01%

NHS Salford CCG 0.94%

NHS Hartlepool and Stockton-on-Tees CCG 0.90%

NHS Barnsley CCG 0.89%

NHS Bury CCG 0.89%

NHS Rotherham CCG 0.85%

NHS Tameside and Glossop CCG 0.83%

NHS South Tees CCG 0.82%

NHS Stoke On Trent CCG 0.80%

NHS Wakefield CCG 0.74%

NHS Hull CCG 0.67%

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

DR P D MILES AND DR R VALASAPALLI M83100 1.4% DR H P BORSE & PARTNER M83713 1.4% LUCIE WEDGWOOD HEALTH CTR M83682 1.2% DUNROBIN STREET MEDICAL CENTRE M83090 1.2% CAMBRIDGE HOUSE M83624 1.1% PRACTICE OF DR GT CHAND M83133 1.1% ORCHARD SURGERY M83038 1.1% • 2,283 people with diagnosed heart BROOK MEDICAL CENTRE M83094 1.0% BRINSLEY AVENUE PRACTICE M83601 1.0% failure in NHS Stoke On Trent CCG DR SONNATHI'S SURGERY M83669 1.0% MAYFIELD SURGERY M83004 1.0% • GP practice range: 0.3% to 1.4% THE MOORCROFT MEDICAL CTR M83146 1.0% BIRCHES HEAD MEDICAL CTR. M83123 0.9% TRINITY MEDICAL CENTRE M83632 0.9% DR VSR CHADALAVADA M83625 0.9% GOLDENHILL MEDICAL CENTRE M83143 0.9% TRENTHAM MEWS MEDICAL CENTRE M83711 0.9% WESTON COYNEY MEDICAL PRACTICE M83708 0.8% MOSS GREEN SURGERY Y00592 0.8% HARTSHILL MEDICAL CENTRE M83066 0.8% MILLRISE MEDICAL PRACTICE M83061 0.8% THE HAYMARKET HEALTH CTR M83082 0.8% PRACTICE OF DR HA TALPUR M83678 0.8% DRS REES & LEFROY M83619 0.8% APSLEY SURGERY M83627 0.8% PRACTICE OF DR AK SINHA M83712 0.8% GLEBEDALE MEDICAL PRACTICE M83028 0.8% DRAYTON ROAD SURGERY M83629 0.8% MERTON SURGERY M83128 0.7% LONGTON HALL SURGERY M83126 0.7% MEIR PARK SURGERY M83047 0.7% NORFOLK STREET SURGERY M83075 0.7% BELGRAVE MEDICAL CENTRE M83068 0.7% PRACTICE OF DR BD PATEL M83631 0.7% MIDDLEPORT MEDICAL CENTRE Y02867 0.7% HARLEY STREET MEDICAL CTR M83076 0.7% BADDELEY GREEN SURGERY M83709 0.7% PRACTICE OF DR JA MIR M83725 0.7% TRENT VALE MEDICAL PRACTICE M83014 0.6% FURLONG MEDICAL CENTRE M83021 0.6% SNOWHILL MEDICAL CENTRE M83623 0.6% POTTERIES MEDICAL CENTRE M83102 0.6% DRS SHAH & TALPUR M83138 0.6% PRACTICE OF DR SB KULKARNI M83714 0.5% COBRIDGE SURGERY M83127 0.5% DR BOSE & DR BOYAPATI'S PRACTICE M83650 0.5% WILLOW BANK SURGERY Y02521 0.5% HANLEY HEALTH & WELL BEING CENTRE Y02868 0.4% FIVE TOWNS GP SURGERY M83700 0.4% ADDERLEY GREEN SURGERY M83661 0.4% THE SURGERY FODEN STREET M83134 0.3% PACKMOOR MEDICAL CENTRE M83739 0.3% 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6%

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

NHS Stoke On Trent CCG 89.1% • 506 people with heart failure* with LVSD in NHS Stoke On Trent CCG NHS North Staffordshire CCG 87.9% • 451 (89.1%) people treated with ACE- I or ARB • 49 (9.7%) people who are exceptions NHS Cannock Chase CCG 86.7% • 6 (1.2%) additional people who are not treated with ACE-I or ARB

NHS Stafford And Surrounds CCG 84.3%

NHS South East Staffordshire And Seisdon Peninsula 83.0% CCG

NHS East Staffordshire CCG 80.6%

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 Stoke On Trent CCG 89.1%

NHS Hartlepool and Stockton-on-Tees CCG 88.1%

NHS Bury CCG 88.0%

NHS Wakefield CCG 88.0%

NHS Hull CCG 87.9%

NHS South Tees CCG 87.8%

NHS Barnsley CCG 86.7%

NHS Sunderland CCG 86.4%

NHS Tameside and Glossop CCG 85.6%

NHS Salford CCG 83.6%

NHS Rotherham CCG 80.4%

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

GLEBEDALE MEDICAL PRACTICE M83028 2 LONGTON HALL SURGERY M83126 1 PRACTICE OF DR BD PATEL M83631 3 COBRIDGE SURGERY M83127 2 CAMBRIDGE HOUSE M83624 2 BADDELEY GREEN SURGERY M83709 2 APSLEY SURGERY M83627 1 • in total, including exceptions, there MIDDLEPORT MEDICAL CENTRE Y02867 1 TRINITY MEDICAL CENTRE M83632 2 are 55 people who are not treated NORFOLK STREET SURGERY M83075 2 LUCIE WEDGWOOD HEALTH CTR M83682 2 with ACE-I or ARB DRS SHAH & TALPUR M83138 1 DR SONNATHI'S SURGERY M83669 4 • GP practice range: 0.0% to 40.0% HARLEY STREET MEDICAL CTR M83076 2 POTTERIES MEDICAL CENTRE M83102 2 THE MOORCROFT MEDICAL CTR M83146 5 MAYFIELD SURGERY M83004 2 ORCHARD SURGERY M83038 4 MERTON SURGERY M83128 1 THE HAYMARKET HEALTH CTR M83082 4 DR VSR CHADALAVADA M83625 2 BROOK MEDICAL CENTRE M83094 3 MILLRISE MEDICAL PRACTICE M83061 1 BRINSLEY AVENUE PRACTICE M83601 1 DR H P BORSE & PARTNER M83713 1 DR P D MILES AND DR R VALASAPALLI M83100 1 MOSS GREEN SURGERY Y00592 1 TRENT VALE MEDICAL PRACTICE M83014 FURLONG MEDICAL CENTRE M83021 MEIR PARK SURGERY M83047 HARTSHILL MEDICAL CENTRE M83066 BELGRAVE MEDICAL CENTRE M83068 DUNROBIN STREET MEDICAL CENTRE M83090 BIRCHES HEAD MEDICAL CTR. M83123 PRACTICE OF DR GT CHAND M83133 THE SURGERY FODEN STREET M83134 GOLDENHILL MEDICAL CENTRE M83143 DRS REES & LEFROY M83619 SNOWHILL MEDICAL CENTRE M83623 DR BOSE & DR BOYAPATI'S PRACTICE M83650 ADDERLEY GREEN SURGERY M83661 PRACTICE OF DR HA TALPUR M83678 FIVE TOWNS GP SURGERY M83700 WESTON COYNEY MEDICAL PRACTICE M83708 TRENTHAM MEWS MEDICAL CENTRE M83711 PRACTICE OF DR AK SINHA M83712 PRACTICE OF DR SB KULKARNI M83714 PRACTICE OF DR JA MIR M83725 PACKMOOR MEDICAL CENTRE M83739 WILLOW BANK SURGERY Y02521 HANLEY HEALTH & WELL BEING CENTRE Y02868 DRAYTON ROAD SURGERY M83629 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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

NHS Stoke On Trent CCG 82.5% • 451 people with heart failure* with LVSD treated with ACE-I/ARB in NHS NHS North Staffordshire CCG 81.9% Stoke On Trent CCG • 372 (82.5%) people treated with ACE- I/ARB and BB NHS Stafford And Surrounds CCG 77.7% • 44 (9.8%) people who are exceptions • 35 (7.8%) additional people who are not treated with ACE-I/ARB and BB NHS Cannock Chase CCG 77.4%

NHS East Staffordshire CCG 74.1%

NHS South East Staffordshire And Seisdon Peninsula 66.8% CCG

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 Hull CCG 87.6%

NHS South Tees CCG 87.3%

NHS Wakefield CCG 85.6%

NHS Stoke On Trent CCG 82.5%

NHS Rotherham CCG 82.2%

NHS Salford CCG 80.4%

NHS Tameside and Glossop CCG 79.8%

NHS Sunderland CCG 79.8%

NHS Bury CCG 78.8%

NHS Barnsley CCG 75.5%

NHS Hartlepool and Stockton-on-Tees CCG 75.4%

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

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

No treatment Exceptions reported

GOLDENHILL MEDICAL CENTRE M83143 2 SNOWHILL MEDICAL CENTRE M83623 1 MAYFIELD SURGERY M83004 5 FURLONG MEDICAL CENTRE M83021 2 HARTSHILL MEDICAL CENTRE M83066 3 THE SURGERY FODEN STREET M83134 1 APSLEY SURGERY M83627 1 • in total, including exceptions, there DR BOSE & DR BOYAPATI'S PRACTICE M83650 1 MIDDLEPORT MEDICAL CENTRE Y02867 1 are 79 people who are not treated TRINITY MEDICAL CENTRE M83632 2 THE MOORCROFT MEDICAL CTR M83146 8 with ACE-I or ARB NORFOLK STREET SURGERY M83075 2 BRINSLEY AVENUE PRACTICE M83601 3 • GP practice range: 0.0% to 66.7% PRACTICE OF DR HA TALPUR M83678 1 PRACTICE OF DR JA MIR M83725 1 DR SONNATHI'S SURGERY M83669 5 LUCIE WEDGWOOD HEALTH CTR M83682 2 TRENTHAM MEWS MEDICAL CENTRE M83711 2 DR P D MILES AND DR R VALASAPALLI M83100 3 COBRIDGE SURGERY M83127 1 WESTON COYNEY MEDICAL PRACTICE M83708 1 BADDELEY GREEN SURGERY M83709 1 HARLEY STREET MEDICAL CTR M83076 2 POTTERIES MEDICAL CENTRE M83102 2 ORCHARD SURGERY M83038 4 MILLRISE MEDICAL PRACTICE M83061 2 PRACTICE OF DR BD PATEL M83631 1 BROOK MEDICAL CENTRE M83094 4 BIRCHES HEAD MEDICAL CTR. M83123 3 THE HAYMARKET HEALTH CTR M83082 4 DRS REES & LEFROY M83619 1 MOSS GREEN SURGERY Y00592 2 TRENT VALE MEDICAL PRACTICE M83014 1 BELGRAVE MEDICAL CENTRE M83068 1 DUNROBIN STREET MEDICAL CENTRE M83090 1 DR H P BORSE & PARTNER M83713 1 DR VSR CHADALAVADA M83625 1 GLEBEDALE MEDICAL PRACTICE M83028 MEIR PARK SURGERY M83047 LONGTON HALL SURGERY M83126 MERTON SURGERY M83128 PRACTICE OF DR GT CHAND M83133 DRS SHAH & TALPUR M83138 CAMBRIDGE HOUSE M83624 ADDERLEY GREEN SURGERY M83661 FIVE TOWNS GP SURGERY M83700 PRACTICE OF DR AK SINHA M83712 PRACTICE OF DR SB KULKARNI M83714 PACKMOOR MEDICAL CENTRE M83739 WILLOW BANK SURGERY Y02521 HANLEY HEALTH & WELL BEING CENTRE Y02868 DRAYTON ROAD SURGERY M83629 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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

NHS Stoke On Trent CCG 89.9% • 10,614 people with coronary heart disease* in NHS Stoke On Trent CCG NHS Cannock Chase CCG 88.2% • 9,546 (89.9%) people whose blood pressure <= 150 / 90 • 314 (3%) people who are exceptions NHS East Staffordshire CCG 87.7% • 754 (7.1%) additional people whose blood pressure is not <= 150 / 90

NHS South East Staffordshire And Seisdon Peninsula 87.3% CCG

NHS North Staffordshire CCG 86.9%

NHS Stafford And Surrounds CCG 83.8%

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 Bury CCG 90.4%

NHS Tameside and Glossop CCG 90.1%

NHS Stoke On Trent CCG 89.9%

NHS Wakefield CCG 89.3%

NHS Hartlepool and Stockton-on-Tees CCG 89.0%

NHS South Tees CCG 88.6%

NHS Rotherham CCG 88.3%

NHS Sunderland CCG 88.2%

NHS Salford CCG 87.9%

NHS Hull CCG 86.4%

NHS Barnsley CCG 86.1%

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

MILLRISE MEDICAL PRACTICE M83061 79 FURLONG MEDICAL CENTRE M83021 74 DRAYTON ROAD SURGERY M83629 20 LONGTON HALL SURGERY M83126 43 MOSS GREEN SURGERY Y00592 45 NORFOLK STREET SURGERY M83075 35 WILLOW BANK SURGERY Y02521 33 • in total, including exceptions, there TRENTHAM MEWS MEDICAL CENTRE M83711 20 MAYFIELD SURGERY M83004 78 are 1,068 people whose blood HARLEY STREET MEDICAL CTR M83076 40 BROOK MEDICAL CENTRE M83094 71 pressure is not <= 150 / 90 THE MOORCROFT MEDICAL CTR M83146 41 WESTON COYNEY MEDICAL PRACTICE M83708 11 • GP practice range: 0.0% to 21.1% THE HAYMARKET HEALTH CTR M83082 46 APSLEY SURGERY M83627 18 GOLDENHILL MEDICAL CENTRE M83143 14 ORCHARD SURGERY M83038 45 DUNROBIN STREET MEDICAL CENTRE M83090 14 BELGRAVE MEDICAL CENTRE M83068 33 TRENT VALE MEDICAL PRACTICE M83014 28 MEIR PARK SURGERY M83047 16 MERTON SURGERY M83128 16 DR SONNATHI'S SURGERY M83669 12 PRACTICE OF DR AK SINHA M83712 8 PRACTICE OF DR BD PATEL M83631 11 DRS SHAH & TALPUR M83138 12 DR H P BORSE & PARTNER M83713 19 PRACTICE OF DR JA MIR M83725 9 LUCIE WEDGWOOD HEALTH CTR M83682 18 COBRIDGE SURGERY M83127 9 GLEBEDALE MEDICAL PRACTICE M83028 19 DR P D MILES AND DR R VALASAPALLI M83100 14 BIRCHES HEAD MEDICAL CTR. M83123 17 DR VSR CHADALAVADA M83625 18 PRACTICE OF DR HA TALPUR M83678 6 PRACTICE OF DR GT CHAND M83133 6 HANLEY HEALTH & WELL BEING CENTRE Y02868 3 BRINSLEY AVENUE PRACTICE M83601 10 SNOWHILL MEDICAL CENTRE M83623 7 THE SURGERY FODEN STREET M83134 5 POTTERIES MEDICAL CENTRE M83102 7 TRINITY MEDICAL CENTRE M83632 9 FIVE TOWNS GP SURGERY M83700 3 MIDDLEPORT MEDICAL CENTRE Y02867 4 PACKMOOR MEDICAL CENTRE M83739 5 DR BOSE & DR BOYAPATI'S PRACTICE M83650 3 BADDELEY GREEN SURGERY M83709 7 HARTSHILL MEDICAL CENTRE M83066 5 CAMBRIDGE HOUSE M83624 2 DRS REES & LEFROY M83619 ADDERLEY GREEN SURGERY M83661 PRACTICE OF DR SB KULKARNI M83714 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

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

MILLRISE MEDICAL PRACTICE 47

FURLONG MEDICAL CENTRE 46

DRAYTON ROAD SURGERY 12 • using the GP cluster method of LONGTON HALL SURGERY 25 calculating potential gains, if each MOSS GREEN SURGERY 25 practice was to achieve as well as the NORFOLK STREET SURGERY 19 upper quartile of its national cluster, then an additional 339 people would WILLOW BANK SURGERY 16 be treated HARLEY STREET MEDICAL CTR 21

TRENTHAM MEWS MEDICAL CENTRE 10

MAYFIELD SURGERY 28

TRINITY MEDICAL CENTRE

MIDDLEPORT MEDICAL CENTRE

BRINSLEY AVENUE PRACTICE

DR BOSE & DR BOYAPATI'S PRACTICE

BADDELEY GREEN SURGERY

HARTSHILL MEDICAL CENTRE

CAMBRIDGE HOUSE

ADDERLEY GREEN SURGERY

PRACTICE OF DR SB KULKARNI

DRS REES & LEFROY Details of this methodology are available on slide 9. Click here to view them.

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

NHS Stoke On Trent CCG 92.6% • 10,614 people with coronary heart disease* in NHS Stoke On Trent CCG NHS Stafford And Surrounds CCG 92.3% • 9,827 (92.6%) people who are taking aspirin, an alternative anti-platelet

NHS South East Staffordshire And Seisdon Peninsula therapy, or an anti-coagulant 92.1% CCG • 462 (4.4%) people who are exceptions • 325 (3.1%) additional people who are NHS North Staffordshire CCG 92.0% not taking aspirin, an alternative anti- platelet therapy, or an anti-coagulant

NHS Cannock Chase CCG 91.6%

NHS East Staffordshire CCG 91.0%

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 Sunderland CCG 93.6%

NHS Bury CCG 93.1%

NHS Stoke On Trent CCG 92.6%

NHS Wakefield CCG 92.5%

NHS South Tees CCG 92.5%

NHS Tameside and Glossop CCG 92.4%

NHS Hartlepool and Stockton-on-Tees CCG 92.4%

NHS Salford CCG 92.4%

NHS Rotherham CCG 91.6%

NHS Barnsley CCG 91.4%

NHS Hull CCG 89.5%

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

FURLONG MEDICAL CENTRE M83021 64 MIDDLEPORT MEDICAL CENTRE Y02867 13 DRAYTON ROAD SURGERY M83629 18 MERTON SURGERY M83128 26 WILLOW BANK SURGERY Y02521 32 PRACTICE OF DR AK SINHA M83712 12 TRINITY MEDICAL CENTRE M83632 22 • in total, including exceptions, there HANLEY HEALTH & WELL BEING CENTRE Y02868 6 HARLEY STREET MEDICAL CTR M83076 38 are 787 people are not taking aspirin, GLEBEDALE MEDICAL PRACTICE M83028 29 PRACTICE OF DR GT CHAND M83133 10 an alternative anti-platelet therapy, or DR P D MILES AND DR R VALASAPALLI M83100 20 NORFOLK STREET SURGERY M83075 24 an anti-coagulant GOLDENHILL MEDICAL CENTRE M83143 15 MAYFIELD SURGERY M83004 56 • GP practice range: 0.0% to 15.7% BADDELEY GREEN SURGERY M83709 14 MEIR PARK SURGERY M83047 16 DUNROBIN STREET MEDICAL CENTRE M83090 13 ADDERLEY GREEN SURGERY M83661 4 DR VSR CHADALAVADA M83625 20 LUCIE WEDGWOOD HEALTH CTR M83682 18 BROOK MEDICAL CENTRE M83094 42 LONGTON HALL SURGERY M83126 17 BRINSLEY AVENUE PRACTICE M83601 11 MOSS GREEN SURGERY Y00592 19 MILLRISE MEDICAL PRACTICE M83061 24 PRACTICE OF DR BD PATEL M83631 8 ORCHARD SURGERY M83038 29 POTTERIES MEDICAL CENTRE M83102 8 DR SONNATHI'S SURGERY M83669 8 DRS REES & LEFROY M83619 3 THE MOORCROFT MEDICAL CTR M83146 21 APSLEY SURGERY M83627 10 DR H P BORSE & PARTNER M83713 12 COBRIDGE SURGERY M83127 6 DRS SHAH & TALPUR M83138 7 TRENT VALE MEDICAL PRACTICE M83014 15 DR BOSE & DR BOYAPATI'S PRACTICE M83650 3 THE SURGERY FODEN STREET M83134 4 HARTSHILL MEDICAL CENTRE M83066 9 TRENTHAM MEWS MEDICAL CENTRE M83711 6 SNOWHILL MEDICAL CENTRE M83623 5 WESTON COYNEY MEDICAL PRACTICE M83708 4 PACKMOOR MEDICAL CENTRE M83739 4 BELGRAVE MEDICAL CENTRE M83068 13 PRACTICE OF DR JA MIR M83725 4 PRACTICE OF DR HA TALPUR M83678 3 BIRCHES HEAD MEDICAL CTR. M83123 7 THE HAYMARKET HEALTH CTR M83082 13 CAMBRIDGE HOUSE M83624 2 FIVE TOWNS GP SURGERY M83700 PRACTICE OF DR SB KULKARNI M83714 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 Stoke On Trent CCG England 900

800 • in NHS Stoke On Trent CCG, the hospital admission rate for coronary 700 heart disease in 2015/16 was 423.9 (977) compared to 527.9 for England

600

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 Stoke On Trent CCG England 300

• in NHS Stoke On Trent CCG, the 250 hospital admission rate for stroke in 2015/16 was 211.8 (481) compared to 172.8 for England

200

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 Stoke On Trent CCG England

126.7% Angina 136.8% • The risk of a stroke was 66.3% higher and the risk of a heart attack was 74.3% 74.3% higher compared to people Heart Attack 108.6% without diabetes. The risk of a major amputation was 474.9% higher. 148.5% Heart failure 150.0%

66.3% Stroke 81.3%

474.9% Major amputation 445.8%

683.3% Minor amputation 753.5%

336.5% RRT 293.0%

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

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

NHS Stoke On Trent CCG England 140

• in NHS Stoke On Trent CCG, the 120 early mortality rate for coronary heart disease in 2013-15 was 49.6, compared to 40.6 for England 100

80

60

40 Age Age standardised (per rate 1000,000)

20

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

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

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

NHS Stoke On Trent CCG England 35

• in NHS Stoke On Trent CCG, the 30 early mortality rate for stroke in 2013- 15 was 12.6, compared to 13.6 for England 25

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

Public Health England exists to protect and improve the nation’s health and wellbeing, and reduce health inequalities. We do this through world-class science, knowledge and intelligence, advocacy, partnerships and the delivery of specialist public health services. We are an executive agency of the Department of Health, and are a distinct delivery organisation with operational autonomy to advise and support government, local authorities and the NHS in a professionally independent manner.

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Published June 2017 Gateway number 2017095

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