CVD: Primary Care Intelligence Packs NHS Sunderland 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 Sunderland CCG are: NHS South Sefton CCG NHS Wirral CCG NHS South Tyneside CCG NHS South Tees CCG NHS St Helens CCG NHS Wakefield CCG NHS Stoke On Trent CCG NHS Tameside and Glossop CCG NHS Rotherham CCG NHS Stockport 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 Stoke On Trent CCG 22.6%

NHS Tameside and Glossop CCG 21.9% • prevalence of 21.2% in NHS Sunderland CCG NHS Sunderland CCG 21.2%

NHS South Tees CCG 21.2%

NHS Wakefield CCG 21.2%

NHS South Tyneside CCG 21.1%

NHS Rotherham CCG 20.5%

NHS South Sefton CCG 19.4% Note: It has been found that the proportion of patients recorded as smokers correlates well NHS St Helens CCG 18.9% with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, NHS Wirral CCG 18.5% http://bmjopen.bmj.com/content/4/7/e005217.abs tract

NHS Stockport CCG 17.3% Definition: denominator of QOF clinical indicator SMOKE004 ( number of patients 15+ who are 0% 5% 10% 15% 20% 25% recorded as current smokers) divided by GP practice’s estimated number of patients 15+

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

GP Practice CCG

DR WEATHERHEAD & ASSOCIATES A89604 38.7% PENNYWELL MEDICAL CENTRE A89621 37.0% NATHAN JR A89612 32.4% DR S M BHATE & DR H EL-SHAKANKERY A89002 31.4% HAPPY HOUSE SURGERY A89041 29.4% DR. R. OBONNA A89603 28.8% • 50,723 people who are recorded as RED HOUSE MEDICAL CENTRE A89008 28.7% DR. N.J. BHATT & DR. H.M. BENN A89624 28.7% smokers in NHS Sunderland CCG ASHBURN MEDICAL CENTRE A89018 26.1% BARMSTON MEDICAL CENTRE A89038 25.7% DR AKK HEGDE A89003 25.5% • GP practice range: 11.1% to 38.7% DEERNESS PARK MEDICAL GROUP A89001 25.1% THE NEW CITY MEDICAL GROUP A89013 24.8% ROKER FAMILY PRACTICE A89014 24.1% DRS CLOAK, CHOI AND MILLIGAN A89019 23.2% SPRINGWELL MEDICAL GROUP A89027 23.0% THE OLD FORGE SURGERY A89020 22.9% CASTLETOWN MEDICAL CENTRE A89036 22.5% WESTBOURNE MEDICAL GROUP A89030 22.4% WEARSIDE MEDICAL PRACTICE - PALLION A89006 22.2% SOUTH HYLTON SURGERY A89614 22.2% MILLFIELD MEDICAL GROUP A89017 21.5% HYLTON MEDICAL GROUP A89031 21.4% SOUTHLANDS MEDICAL GROUP A89035 21.4% HETTON GROUP PRACTICE A89004 20.9% DR DIXIT'S PRACTICE A89012 20.9% VICTORIA MEDICAL PRACTICE A89026 20.7% SPRINGWELL HOUSE A89029 20.4% ENCOMPASS HEALTH CARE A89025 20.3% DR BRIGHAM & PARTNERS A89005 20.2% HOUGHTON MEDICAL GROUP, A89023 20.0% KEPIER MEDICAL PRACTICE A89021 19.6% CONCORD MEDICAL PRACTICE A89022 19.3% CONISHEAD MEDICAL GROUP A89610 18.5% COLLIERY MEDICAL GROUP A89032 18.4% PALLION FAMILY PRACTICE A89007 18.4% THE BROADWAY MEDICAL PRACTICE A89024 18.4% DR THOMAS A89620 18.2% HARRATON SURGERY A89617 18.2% DR STEPHENSON & PARTNERS A89010 18.1% EDEN TERRACE SURGERY A89611 18.1% HERRINGTON MEDICAL CENTRE A89009 18.0% ST BEDE MEDICAL CENTRE A89016 17.5% Note: This method is thought to be a reasonably JOSHI NA A89011 17.3% CHURCH VIEW MEDICAL CENTRE A89042 16.9% robust method in estimating smoking prevalence GRANGEWOOD SURGERY A89028 16.7% for the majority of GP practices. However, MONKWEARMOUTH HEALTH CENTRE A89040 16.6% PARK LANE PRACTICE A89034 15.8% caution is advised for extreme estimates of CHESTER SURGERY A89623 12.9% RICKLETON MEDICAL CENTRE A89616 12.1% smoking prevalence and those with high FULWELL MEDICAL CENTRE, A89015 11.1% numbers of smoking status not recorded and 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 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 Sunderland CCG 0.61

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

NHS North Tyneside CCG 0.60

NHS Newcastle Gateshead CCG 0.59

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 St Helens CCG 0.64

NHS South Sefton CCG 0.63

NHS Stoke On Trent CCG 0.62

NHS Rotherham CCG 0.62

NHS Sunderland CCG 0.61

NHS Tameside and Glossop CCG 0.61

NHS Wirral CCG 0.60

NHS South Tyneside CCG 0.60

NHS Wakefield CCG 0.60

NHS Stockport CCG 0.60

NHS South Tees CCG 0.60

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

PALLION FAMILY PRACTICE A89007 0.85 KEPIER MEDICAL PRACTICE A89021 0.77 MONKWEARMOUTH HEALTH CENTRE A89040 0.74 SOUTH HYLTON SURGERY A89614 0.74 HYLTON MEDICAL GROUP A89031 0.73 ASHBURN MEDICAL CENTRE A89018 0.73 SPRINGWELL HOUSE A89029 0.69 • it is estimated that there are 29,523 RICKLETON MEDICAL CENTRE A89616 0.69 THE BROADWAY MEDICAL PRACTICE A89024 0.69 people with undiagnosed PENNYWELL MEDICAL CENTRE A89621 0.68 RED HOUSE MEDICAL CENTRE A89008 0.67 NATHAN JR A89612 0.67 hypertension in NHS Sunderland COLLIERY MEDICAL GROUP A89032 0.67 CASTLETOWN MEDICAL CENTRE A89036 0.66 CCG JOSHI NA A89011 0.66 SOUTHLANDS MEDICAL GROUP A89035 0.66 • GP practice range of observed to CONCORD MEDICAL PRACTICE A89022 0.65 THE NEW CITY MEDICAL GROUP A89013 0.65 DR WEATHERHEAD & ASSOCIATES A89604 0.64 expected hypertension prevalence BARMSTON MEDICAL CENTRE A89038 0.64 GRANGEWOOD SURGERY A89028 0.64 0.38 to 0.85 DR DIXIT'S PRACTICE A89012 0.64 CONISHEAD MEDICAL GROUP A89610 0.64 VICTORIA MEDICAL PRACTICE A89026 0.63 HOUGHTON MEDICAL GROUP, A89023 0.63 HARRATON SURGERY A89617 0.63 DR. N.J. BHATT & DR. H.M. BENN A89624 0.63 DR BRIGHAM & PARTNERS A89005 0.63 HAPPY HOUSE SURGERY A89041 0.63 CHURCH VIEW MEDICAL CENTRE A89042 0.62 DRS CLOAK, CHOI AND MILLIGAN A89019 0.62 DEERNESS PARK MEDICAL GROUP A89001 0.62 DR THOMAS A89620 0.62 SPRINGWELL MEDICAL GROUP A89027 0.61 HETTON GROUP PRACTICE A89004 0.61 MILLFIELD MEDICAL GROUP A89017 0.61 THE OLD FORGE SURGERY A89020 0.60 WESTBOURNE MEDICAL GROUP A89030 0.59 ST BEDE MEDICAL CENTRE A89016 0.59 DR. R. OBONNA A89603 0.57 HERRINGTON MEDICAL CENTRE A89009 0.57 DR S M BHATE & DR H EL-SHAKANKERY A89002 0.57 FULWELL MEDICAL CENTRE, A89015 0.57 DR AKK HEGDE A89003 0.54 ENCOMPASS HEALTH CARE A89025 0.54 ROKER FAMILY PRACTICE A89014 0.52 EDEN TERRACE SURGERY A89611 0.51 WEARSIDE MEDICAL PRACTICE - PALLION A89006 0.51 DR STEPHENSON & PARTNERS A89010 0.48 CHESTER SURGERY A89623 0.46 PARK LANE PRACTICE A89034 0.38 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 Northumberland CCG 81.8%

• 46,850 people with hypertension NHS North Tyneside CCG 81.5% (diagnosed)* in NHS Sunderland CCG • 37,261 (79.5%) people whose blood pressure is <= 150/90 NHS Newcastle Gateshead CCG 81.3% • 1,569 (3.3%) people who are excepted from optimal control • 8,020 (17.1%) additional people NHS South Tyneside CCG 80.0% whose blood pressure is not <= 150/90

NHS Sunderland CCG 79.5%

England 79.6%

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

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

NHS Stockport 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 St Helens CCG 80.5%

NHS South Tees CCG 80.0%

NHS South Tyneside CCG 80.0%

NHS Sunderland CCG 79.5%

NHS Wirral CCG 79.4%

NHS South Sefton CCG 77.5%

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

DEERNESS PARK MEDICAL GROUP A89001 693 DR THOMAS A89620 115 HYLTON MEDICAL GROUP A89031 255 CHURCH VIEW MEDICAL CENTRE A89042 249 COLLIERY MEDICAL GROUP A89032 221 DRS CLOAK, CHOI AND MILLIGAN A89019 420 PARK LANE PRACTICE A89034 92 • in total, including exceptions, there SOUTH HYLTON SURGERY A89614 180 THE BROADWAY MEDICAL PRACTICE A89024 272 are 9,589 people whose blood EDEN TERRACE SURGERY A89611 69 PALLION FAMILY PRACTICE A89007 533 pressure is not <= 150/90 KEPIER MEDICAL PRACTICE A89021 407 WEARSIDE MEDICAL PRACTICE - PALLION A89006 227 • GP practice range: 10.6% to 29.1% BARMSTON MEDICAL CENTRE A89038 133 THE NEW CITY MEDICAL GROUP A89013 266 DR AKK HEGDE A89003 168 DR. N.J. BHATT & DR. H.M. BENN A89624 64 DR BRIGHAM & PARTNERS A89005 233 HAPPY HOUSE SURGERY A89041 169 MILLFIELD MEDICAL GROUP A89017 426 HETTON GROUP PRACTICE A89004 419 RICKLETON MEDICAL CENTRE A89616 64 WESTBOURNE MEDICAL GROUP A89030 215 HERRINGTON MEDICAL CENTRE A89009 236 VICTORIA MEDICAL PRACTICE A89026 113 SOUTHLANDS MEDICAL GROUP A89035 184 DR S M BHATE & DR H EL-SHAKANKERY A89002 110 HOUGHTON MEDICAL GROUP, A89023 263 ST BEDE MEDICAL CENTRE A89016 243 THE OLD FORGE SURGERY A89020 227 CONCORD MEDICAL PRACTICE A89022 172 FULWELL MEDICAL CENTRE, A89015 299 ASHBURN MEDICAL CENTRE A89018 173 DR DIXIT'S PRACTICE A89012 132 HARRATON SURGERY A89617 63 SPRINGWELL HOUSE A89029 71 SPRINGWELL MEDICAL GROUP A89027 152 DR WEATHERHEAD & ASSOCIATES A89604 97 JOSHI NA A89011 117 GRANGEWOOD SURGERY A89028 190 ROKER FAMILY PRACTICE A89014 58 RED HOUSE MEDICAL CENTRE A89008 131 NATHAN JR A89612 52 DR STEPHENSON & PARTNERS A89010 219 PENNYWELL MEDICAL CENTRE A89621 47 CHESTER SURGERY A89623 40 CONISHEAD MEDICAL GROUP A89610 67 CASTLETOWN MEDICAL CENTRE A89036 45 ENCOMPASS HEALTH CARE A89025 92 DR. R. OBONNA A89603 32 MONKWEARMOUTH HEALTH CENTRE A89040 74 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 Newcastle Gateshead CCG 73.6%

• 173 people with a new diagnosis* of NHS North Tyneside CCG 64.3% hypertension with a CVD risk of 20% or higher in NHS Sunderland CCG • 107 (61.8%) people who are currently treated with statins NHS Northumberland CCG 61.9% • 64 (37%) people who are exempted from treatment with statins • 2 (1.2%) additional people who are NHS Sunderland CCG 61.8% not currently treated with statins

NHS South Tyneside CCG 58.2%

England 66.5%

0% 10% 20% 30% 40% 50% 60% 70% 80% *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 South Tees CCG 74.5%

NHS Tameside and Glossop CCG 74.4%

NHS Rotherham CCG 71.7%

NHS South Sefton CCG 71.1%

NHS St Helens CCG 70.2%

NHS Wirral CCG 69.2%

NHS Stoke On Trent CCG 68.8%

NHS Sunderland CCG 61.8%

NHS Stockport CCG 60.1%

NHS South Tyneside CCG 58.2%

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

COLLIERY MEDICAL GROUP A89032 1 PARK LANE PRACTICE A89034 1 HAPPY HOUSE SURGERY A89041 9 DR. N.J. BHATT & DR. H.M. BENN A89624 1 THE BROADWAY MEDICAL PRACTICE A89024 5 MILLFIELD MEDICAL GROUP A89017 2 HOUGHTON MEDICAL GROUP, A89023 2 • in total, including exceptions, there SOUTHLANDS MEDICAL GROUP A89035 2 WEARSIDE MEDICAL PRACTICE - PALLION A89006 5 are 66 people who are not treated DR AKK HEGDE A89003 5 DR STEPHENSON & PARTNERS A89010 3 with statins FULWELL MEDICAL CENTRE, A89015 3 ST BEDE MEDICAL CENTRE A89016 3 • GP practice range: 0.0% to 100.0% THE OLD FORGE SURGERY A89020 1 VICTORIA MEDICAL PRACTICE A89026 1 GRANGEWOOD SURGERY A89028 1 SPRINGWELL HOUSE A89029 1 DR DIXIT'S PRACTICE A89012 2 ASHBURN MEDICAL CENTRE A89018 2 KEPIER MEDICAL PRACTICE A89021 2 CONISHEAD MEDICAL GROUP A89610 2 HERRINGTON MEDICAL CENTRE A89009 1 NATHAN JR A89612 2 DRS CLOAK, CHOI AND MILLIGAN A89019 3 WESTBOURNE MEDICAL GROUP A89030 1 BARMSTON MEDICAL CENTRE A89038 1 SOUTH HYLTON SURGERY A89614 1 THE NEW CITY MEDICAL GROUP A89013 1 SPRINGWELL MEDICAL GROUP A89027 1 HETTON GROUP PRACTICE A89004 1 DEERNESS PARK MEDICAL GROUP A89001 PALLION FAMILY PRACTICE A89007 RED HOUSE MEDICAL CENTRE A89008 JOSHI NA A89011 ROKER FAMILY PRACTICE A89014 CONCORD MEDICAL PRACTICE A89022 ENCOMPASS HEALTH CARE A89025 HYLTON MEDICAL GROUP A89031 CASTLETOWN MEDICAL CENTRE A89036 MONKWEARMOUTH HEALTH CENTRE A89040 CHURCH VIEW MEDICAL CENTRE A89042 DR. R. OBONNA A89603 DR WEATHERHEAD & ASSOCIATES A89604 EDEN TERRACE SURGERY A89611 HARRATON SURGERY A89617 DR THOMAS A89620 PENNYWELL MEDICAL CENTRE A89621 CHESTER SURGERY A89623 RICKLETON MEDICAL CENTRE A89616 DR BRIGHAM & PARTNERS A89005 DR S M BHATE & DR H EL-SHAKANKERY A89002 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 Sunderland CCG 0.74

• the ratio of those diagnosed with atrial NHS South Tyneside CCG 0.73 fibrillation versus those expected to have atrial fibrillation is 0.74. This compares to 0.7 for England • this suggests that 74% of people with NHS Northumberland CCG 0.73 atrial fibrillation have been diagnosed.

NHS North Tyneside CCG 0.70

NHS Newcastle Gateshead CCG 0.70

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 Wirral CCG 0.86

NHS South Sefton CCG 0.80

NHS St Helens CCG 0.76

NHS Stoke On Trent CCG 0.75

NHS Wakefield CCG 0.74

NHS Sunderland CCG 0.74

NHS Stockport CCG 0.74

NHS Rotherham CCG 0.73

NHS South Tyneside CCG 0.73

NHS South Tees CCG 0.72

NHS Tameside and Glossop CCG 0.70

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

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

GP practice CCG

PENNYWELL MEDICAL CENTRE A89621 1.0 DEERNESS PARK MEDICAL GROUP A89001 0.9 FULWELL MEDICAL CENTRE, A89015 0.9 SPRINGWELL MEDICAL GROUP A89027 0.9 SOUTHLANDS MEDICAL GROUP A89035 0.9 MONKWEARMOUTH HEALTH CENTRE A89040 0.9 PALLION FAMILY PRACTICE A89007 0.8 • it is estimated that there are 7,327 DR DIXIT'S PRACTICE A89012 0.8 THE NEW CITY MEDICAL GROUP A89013 0.8 people with undiagnosed atrial MILLFIELD MEDICAL GROUP A89017 0.8 DRS CLOAK, CHOI AND MILLIGAN A89019 0.8 HOUGHTON MEDICAL GROUP, A89023 0.8 fibrillation in NHS Sunderland CCG THE BROADWAY MEDICAL PRACTICE A89024 0.8 ENCOMPASS HEALTH CARE A89025 0.8 • GP practice range of observed to VICTORIA MEDICAL PRACTICE A89026 0.8 GRANGEWOOD SURGERY A89028 0.8 expected atrial fibrillation prevalence HYLTON MEDICAL GROUP A89031 0.8 DR WEATHERHEAD & ASSOCIATES A89604 0.8 DR THOMAS A89620 0.8 0.5 to 1 CHESTER SURGERY A89623 0.8 HETTON GROUP PRACTICE A89004 0.7 DR BRIGHAM & PARTNERS A89005 0.7 WEARSIDE MEDICAL PRACTICE - PALLION A89006 0.7 HERRINGTON MEDICAL CENTRE A89009 0.7 DR STEPHENSON & PARTNERS A89010 0.7 ST BEDE MEDICAL CENTRE A89016 0.7 ASHBURN MEDICAL CENTRE A89018 0.7 KEPIER MEDICAL PRACTICE A89021 0.7 WESTBOURNE MEDICAL GROUP A89030 0.7 COLLIERY MEDICAL GROUP A89032 0.7 PARK LANE PRACTICE A89034 0.7 HAPPY HOUSE SURGERY A89041 0.7 CHURCH VIEW MEDICAL CENTRE A89042 0.7 SOUTH HYLTON SURGERY A89614 0.7 RICKLETON MEDICAL CENTRE A89616 0.7 DR. N.J. BHATT & DR. H.M. BENN A89624 0.7 DR S M BHATE & DR H EL-SHAKANKERY A89002 0.6 DR AKK HEGDE A89003 0.6 RED HOUSE MEDICAL CENTRE A89008 0.6 JOSHI NA A89011 0.6 ROKER FAMILY PRACTICE A89014 0.6 THE OLD FORGE SURGERY A89020 0.6 CONCORD MEDICAL PRACTICE A89022 0.6 SPRINGWELL HOUSE A89029 0.6 CASTLETOWN MEDICAL CENTRE A89036 0.6 BARMSTON MEDICAL CENTRE A89038 0.6 CONISHEAD MEDICAL GROUP A89610 0.6 NATHAN JR A89612 0.6 HARRATON SURGERY A89617 0.6 DR. R. OBONNA A89603 0.5 EDEN TERRACE SURGERY A89611 0.5 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Ratio

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

NHS South Tyneside CCG 80.0% • 4,579 people with atrial fibrillation* with a CHA2DS2-VASc score >= 2 in NHS Sunderland CCG NHS Sunderland CCG 80.0% • 3,662 (80%) people treated with anti- coagulation therapy • 396 (8.6%) people who are NHS Newcastle Gateshead CCG 78.4% exceptions • 521 (11.4%) additional people with a recorded CHA2DS2-VASc score >= 2 NHS North Tyneside CCG 73.8% who are not treated

NHS Northumberland CCG 72.3%

England 77.9%

0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator AF007 denominator plus exceptions

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

NHS South Tees CCG 81.9%

NHS Tameside and Glossop CCG 80.9%

NHS South Tyneside CCG 80.0%

NHS Sunderland CCG 80.0%

NHS Wakefield CCG 79.7%

NHS Wirral CCG 79.3%

NHS Stockport CCG 79.2%

NHS Stoke On Trent CCG 79.0%

NHS St Helens CCG 77.8%

NHS Rotherham CCG 76.5%

NHS South Sefton CCG 76.2%

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

WEARSIDE MEDICAL PRACTICE - PALLION A89006 33 ROKER FAMILY PRACTICE A89014 9 BARMSTON MEDICAL CENTRE A89038 12 FULWELL MEDICAL CENTRE, A89015 66 RED HOUSE MEDICAL CENTRE A89008 19 ST BEDE MEDICAL CENTRE A89016 36 WESTBOURNE MEDICAL GROUP A89030 29 • in total, including exceptions, there DR DIXIT'S PRACTICE A89012 15 THE NEW CITY MEDICAL GROUP A89013 34 are 917 people with a recorded THE BROADWAY MEDICAL PRACTICE A89024 27 PALLION FAMILY PRACTICE A89007 41 CHA2DS2-VASc score >= 2 who are SOUTHLANDS MEDICAL GROUP A89035 28 HAPPY HOUSE SURGERY A89041 14 not treated DR WEATHERHEAD & ASSOCIATES A89604 11 HERRINGTON MEDICAL CENTRE A89009 25 • GP practice range: 5.8% to 32.7% DR STEPHENSON & PARTNERS A89010 43 THE OLD FORGE SURGERY A89020 23 DR BRIGHAM & PARTNERS A89005 25 DRS CLOAK, CHOI AND MILLIGAN A89019 38 CHESTER SURGERY A89623 11 HOUGHTON MEDICAL GROUP, A89023 29 ENCOMPASS HEALTH CARE A89025 14 HYLTON MEDICAL GROUP A89031 17 RICKLETON MEDICAL CENTRE A89616 4 DR THOMAS A89620 9 HARRATON SURGERY A89617 4 DR. N.J. BHATT & DR. H.M. BENN A89624 4 MILLFIELD MEDICAL GROUP A89017 36 PARK LANE PRACTICE A89034 9 COLLIERY MEDICAL GROUP A89032 15 DEERNESS PARK MEDICAL GROUP A89001 49 MONKWEARMOUTH HEALTH CENTRE A89040 15 HETTON GROUP PRACTICE A89004 38 CHURCH VIEW MEDICAL CENTRE A89042 16 SPRINGWELL HOUSE A89029 5 CASTLETOWN MEDICAL CENTRE A89036 4 ASHBURN MEDICAL CENTRE A89018 13 CONCORD MEDICAL PRACTICE A89022 11 KEPIER MEDICAL PRACTICE A89021 23 CONISHEAD MEDICAL GROUP A89610 7 DR. R. OBONNA A89603 3 DR S M BHATE & DR H EL-SHAKANKERY A89002 6 PENNYWELL MEDICAL CENTRE A89621 4 SPRINGWELL MEDICAL GROUP A89027 11 EDEN TERRACE SURGERY A89611 1 GRANGEWOOD SURGERY A89028 12 SOUTH HYLTON SURGERY A89614 5 JOSHI NA A89011 5 VICTORIA MEDICAL PRACTICE A89026 5 NATHAN JR A89612 1 DR AKK HEGDE A89003 3 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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

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

WEARSIDE MEDICAL PRACTICE - PALLION 18

ROKER FAMILY PRACTICE 5

BARMSTON MEDICAL CENTRE 6 • using the GP cluster method of RED HOUSE MEDICAL CENTRE 9 calculating potential gains, if each ST BEDE MEDICAL CENTRE 17 practice was to achieve as well as the FULWELL MEDICAL CENTRE, 27 upper quartile of its national cluster, then an additional 231 people would WESTBOURNE MEDICAL GROUP 12 be treated THE NEW CITY MEDICAL GROUP 13

DR DIXIT'S PRACTICE 6

THE BROADWAY MEDICAL PRACTICE 10

DR S M BHATE & DR H EL-SHAKANKERY

PENNYWELL MEDICAL CENTRE

SPRINGWELL MEDICAL GROUP

GRANGEWOOD SURGERY

EDEN TERRACE SURGERY

SOUTH HYLTON SURGERY

JOSHI NA

VICTORIA MEDICAL PRACTICE

NATHAN JR

DR AKK HEGDE 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 Newcastle Gateshead CCG 85.7% • 6,128 people with a history of stroke or TIA* in NHS Sunderland CCG • 5,084 (83%) people whose blood NHS Northumberland CCG 84.7% pressure is <= 150 / 90 • 224 (3.7%) people who are exceptions NHS North Tyneside CCG 84.5% • 820 (13.4%) additional people whose blood pressure is not <= 150 / 90

NHS South Tyneside CCG 84.2%

NHS Sunderland CCG 83.0%

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 Stockport CCG 87.1%

NHS Wakefield CCG 86.9%

NHS Tameside and Glossop CCG 86.4%

NHS Rotherham CCG 85.1%

NHS St Helens CCG 85.1%

NHS Stoke On Trent CCG 84.9%

NHS Wirral CCG 84.3%

NHS South Tyneside CCG 84.2%

NHS South Tees CCG 83.2%

NHS Sunderland CCG 83.0%

NHS South Sefton CCG 82.4%

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

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

No treatment Exceptions reported

DR. N.J. BHATT & DR. H.M. BENN A89624 8 COLLIERY MEDICAL GROUP A89032 31 MILLFIELD MEDICAL GROUP A89017 66 PARK LANE PRACTICE A89034 13 DEERNESS PARK MEDICAL GROUP A89001 78 BARMSTON MEDICAL CENTRE A89038 11 HYLTON MEDICAL GROUP A89031 16 • in total, including exceptions, there PENNYWELL MEDICAL CENTRE A89621 8 HARRATON SURGERY A89617 7 are 1,044 people whose blood DRS CLOAK, CHOI AND MILLIGAN A89019 50 ROKER FAMILY PRACTICE A89014 9 pressure is not <= 150 / 90 RICKLETON MEDICAL CENTRE A89616 5 SPRINGWELL HOUSE A89029 6 • GP practice range: 4.8% to 28.6% KEPIER MEDICAL PRACTICE A89021 47 HERRINGTON MEDICAL CENTRE A89009 35 VICTORIA MEDICAL PRACTICE A89026 14 HETTON GROUP PRACTICE A89004 58 THE NEW CITY MEDICAL GROUP A89013 28 DR THOMAS A89620 10 THE OLD FORGE SURGERY A89020 32 CHESTER SURGERY A89623 7 SOUTH HYLTON SURGERY A89614 16 ST BEDE MEDICAL CENTRE A89016 36 FULWELL MEDICAL CENTRE, A89015 45 HOUGHTON MEDICAL GROUP, A89023 30 CONCORD MEDICAL PRACTICE A89022 22 DR WEATHERHEAD & ASSOCIATES A89604 20 PALLION FAMILY PRACTICE A89007 32 WESTBOURNE MEDICAL GROUP A89030 25 DR AKK HEGDE A89003 16 CASTLETOWN MEDICAL CENTRE A89036 6 THE BROADWAY MEDICAL PRACTICE A89024 21 CHURCH VIEW MEDICAL CENTRE A89042 21 JOSHI NA A89011 11 RED HOUSE MEDICAL CENTRE A89008 15 DR S M BHATE & DR H EL-SHAKANKERY A89002 13 DR BRIGHAM & PARTNERS A89005 20 HAPPY HOUSE SURGERY A89041 10 NATHAN JR A89612 5 ENCOMPASS HEALTH CARE A89025 13 WEARSIDE MEDICAL PRACTICE - PALLION A89006 16 SOUTHLANDS MEDICAL GROUP A89035 15 SPRINGWELL MEDICAL GROUP A89027 18 MONKWEARMOUTH HEALTH CENTRE A89040 11 DR STEPHENSON & PARTNERS A89010 30 GRANGEWOOD SURGERY A89028 14 ASHBURN MEDICAL CENTRE A89018 11 CONISHEAD MEDICAL GROUP A89610 5 DR DIXIT'S PRACTICE A89012 5 DR. R. OBONNA A89603 2 EDEN TERRACE SURGERY A89611 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 South Tyneside CCG 93.5% • 3,619 people with a stroke shown to be non-haemorrhagic* in NHS Sunderland CCG NHS Newcastle Gateshead CCG 93.4% • 3,374 (93.2%) people who are taking an anti-platetet agent or anti- coagulant NHS Sunderland CCG 93.2% • 159 (4.4%) people who are exceptions • 86 (2.4%) additional people with no NHS North Tyneside CCG 92.8% treatment

NHS Northumberland CCG 92.3%

England 91.8%

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

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

NHS Stockport CCG 93.7%

NHS South Tyneside CCG 93.5%

NHS Wakefield CCG 93.2%

NHS Sunderland CCG 93.2%

NHS South Tees CCG 92.9%

NHS South Sefton CCG 92.6%

NHS Tameside and Glossop CCG 92.5%

NHS Stoke On Trent CCG 92.2%

NHS Rotherham CCG 91.9%

NHS St Helens CCG 90.0%

NHS Wirral CCG 89.7%

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

PENNYWELL MEDICAL CENTRE A89621 3 NATHAN JR A89612 4 PALLION FAMILY PRACTICE A89007 15 JOSHI NA A89011 7 SPRINGWELL MEDICAL GROUP A89027 13 BARMSTON MEDICAL CENTRE A89038 3 COLLIERY MEDICAL GROUP A89032 11 • in total, including exceptions, there ROKER FAMILY PRACTICE A89014 3 CONCORD MEDICAL PRACTICE A89022 10 are 245 people who are not taking an EDEN TERRACE SURGERY A89611 1 HERRINGTON MEDICAL CENTRE A89009 10 anti-platelet agent or anti-coagulant CHESTER SURGERY A89623 3 HAPPY HOUSE SURGERY A89041 4 • GP practice range: 0.0% to 17.6% ST BEDE MEDICAL CENTRE A89016 10 ENCOMPASS HEALTH CARE A89025 5 THE OLD FORGE SURGERY A89020 6 HYLTON MEDICAL GROUP A89031 3 DR THOMAS A89620 2 KEPIER MEDICAL PRACTICE A89021 13 THE BROADWAY MEDICAL PRACTICE A89024 6 THE NEW CITY MEDICAL GROUP A89013 5 DR. N.J. BHATT & DR. H.M. BENN A89624 1 WESTBOURNE MEDICAL GROUP A89030 6 DEERNESS PARK MEDICAL GROUP A89001 13 RICKLETON MEDICAL CENTRE A89616 1 DR STEPHENSON & PARTNERS A89010 8 DR AKK HEGDE A89003 4 ASHBURN MEDICAL CENTRE A89018 5 VICTORIA MEDICAL PRACTICE A89026 2 RED HOUSE MEDICAL CENTRE A89008 3 DR. R. OBONNA A89603 1 HARRATON SURGERY A89617 1 DRS CLOAK, CHOI AND MILLIGAN A89019 7 CHURCH VIEW MEDICAL CENTRE A89042 4 DR BRIGHAM & PARTNERS A89005 4 MILLFIELD MEDICAL GROUP A89017 7 DR WEATHERHEAD & ASSOCIATES A89604 3 GRANGEWOOD SURGERY A89028 4 FULWELL MEDICAL CENTRE, A89015 8 CONISHEAD MEDICAL GROUP A89610 2 HETTON GROUP PRACTICE A89004 8 DR DIXIT'S PRACTICE A89012 2 HOUGHTON MEDICAL GROUP, A89023 5 WEARSIDE MEDICAL PRACTICE - PALLION A89006 3 SOUTH HYLTON SURGERY A89614 2 SOUTHLANDS MEDICAL GROUP A89035 2 MONKWEARMOUTH HEALTH CENTRE A89040 1 DR S M BHATE & DR H EL-SHAKANKERY A89002 1 SPRINGWELL HOUSE A89029 PARK LANE PRACTICE A89034 CASTLETOWN MEDICAL CENTRE A89036 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

40 CVD: Primary Care Intelligence Packs Diabetes

41 CVD: Primary Care Intelligence Packs Diabetes prevention and management

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

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

NHS North Tyneside CCG 0.84 • 0.78 ratio of observed to expected diabetes prevalence in NHS

NHS Northumberland CCG 0.83 Sunderland CCG, compared to 0.77 in England

• this suggests 78% of people have NHS Newcastle Gateshead CCG 0.81 been diagnosed

NHS South Tyneside CCG 0.79

NHS Sunderland CCG 0.78

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

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

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

NHS Stoke On Trent CCG 0.89

NHS Tameside and Glossop CCG 0.85

NHS Wakefield CCG 0.83

NHS St Helens CCG 0.83

NHS Wirral CCG 0.79

NHS South Tyneside CCG 0.79

NHS Rotherham CCG 0.78

NHS Sunderland CCG 0.78

NHS South Tees CCG 0.76

NHS South Sefton CCG 0.76

NHS Stockport CCG 0.74

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

DR THOMAS A89620 9.0% ASHBURN MEDICAL CENTRE A89018 8.2% HETTON GROUP PRACTICE A89004 8.1% DR WEATHERHEAD & ASSOCIATES A89604 8.1% DR AKK HEGDE A89003 7.9% DRS CLOAK, CHOI AND MILLIGAN A89019 7.7% DR STEPHENSON & PARTNERS A89010 7.7% • GP practice range of observed THE NEW CITY MEDICAL GROUP A89013 7.7% THE BROADWAY MEDICAL PRACTICE A89024 7.6% diabetes 4.1% to 9.0% SOUTHLANDS MEDICAL GROUP A89035 7.6% DR DIXIT'S PRACTICE A89012 7.5% • there are an estimated 4,446 people HARRATON SURGERY A89617 7.3% JOSHI NA A89011 7.3% with undiagnosed diabetes in NHS MONKWEARMOUTH HEALTH CENTRE A89040 7.3% DR BRIGHAM & PARTNERS A89005 7.3% Sunderland CCG SPRINGWELL HOUSE A89029 7.2% CONCORD MEDICAL PRACTICE A89022 7.2% HOUGHTON MEDICAL GROUP, A89023 7.1% KEPIER MEDICAL PRACTICE A89021 7.1% RED HOUSE MEDICAL CENTRE A89008 7.1% DEERNESS PARK MEDICAL GROUP A89001 7.0% WEARSIDE MEDICAL PRACTICE - PALLION A89006 7.0% DR S M BHATE & DR H EL-SHAKANKERY A89002 6.9% SOUTH HYLTON SURGERY A89614 6.9% BARMSTON MEDICAL CENTRE A89038 6.8% COLLIERY MEDICAL GROUP A89032 6.8% VICTORIA MEDICAL PRACTICE A89026 6.8% CASTLETOWN MEDICAL CENTRE A89036 6.7% DR. N.J. BHATT & DR. H.M. BENN A89624 6.6% WESTBOURNE MEDICAL GROUP A89030 6.6% ENCOMPASS HEALTH CARE A89025 6.5% HAPPY HOUSE SURGERY A89041 6.5% PALLION FAMILY PRACTICE A89007 6.4% ROKER FAMILY PRACTICE A89014 6.3% HYLTON MEDICAL GROUP A89031 6.3% MILLFIELD MEDICAL GROUP A89017 6.3% HERRINGTON MEDICAL CENTRE A89009 6.1% RICKLETON MEDICAL CENTRE A89616 6.1% CONISHEAD MEDICAL GROUP A89610 6.1% GRANGEWOOD SURGERY A89028 6.1% THE OLD FORGE SURGERY A89020 6.0% CHESTER SURGERY A89623 5.9% CHURCH VIEW MEDICAL CENTRE A89042 5.8% SPRINGWELL MEDICAL GROUP A89027 5.8% FULWELL MEDICAL CENTRE, A89015 5.7% DR. R. OBONNA A89603 5.7% PENNYWELL MEDICAL CENTRE A89621 5.6% ST BEDE MEDICAL CENTRE A89016 5.4% Note: The estimated number of undiagnosed NATHAN JR A89612 5.3% EDEN TERRACE SURGERY A89611 4.6% people with diabetes has been calculated by PARK LANE PRACTICE A89034 4.1% multiplying the estimated prevalence rate to the 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 2015/16 QOF list size and subtracting the number of people on the diabetes register.

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

Diabetes prevalence Undiagnosed diabetes prevalence Expected non-diabetic hyperglycaemia prevalence

• the estimated total prevalence of NHS Northumberland CCG 7.6% 1.6% 12.2% diabetes in NHS Sunderland CCG is 8.7% (diagnosed and undiagnosed)

NHS South Tyneside CCG 7.1% 1.9% 11.4% • in addition, there are an estimated 11.1% of people in NHS Sunderland CCG who are at increased risk of NHS North Tyneside CCG 7.1% 1.3% 11.5% developing diabetes (i.e. with non- diabetic hyperglycaemia)

NHS Sunderland CCG 6.8% 1.9% 11.1% • this means that 19.8% of the population in NHS Sunderland CCG are estimated to have diabetes, or at NHS Newcastle Gateshead CCG 6.2% 1.5% 10.1% high risk of developing of diabetes

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

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

NHS South Tyneside CCG 77.8%

• data on care processes and treatment targets are taken from the National NHS North Tyneside CCG 68.4% Diabetes Audit (NDA) • overall practice participation in the 2015/16 audit was 81.4% in England NHS Northumberland CCG 66.2% • in NHS Sunderland CCG, 50 out of 53 practices (94.3%) participated in the NDA. Data is not available for the NHS Newcastle Gateshead CCG 61.0% remaining practices

NHS Sunderland CCG 54.8% • 54.8% of people with diabetes (of practices who participated in the audit) had the eight recommended care processes in NHS Sunderland CCG, compared to 52.6% in England

England 52.6%

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

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

RICKLETON MEDICAL CENTRE A89616 78.1% HOUGHTON MEDICAL GROUP, A89023 74.9% DR STEPHENSON & PARTNERS A89010 74.2% DR THOMAS A89620 71.7% FULWELL MEDICAL CENTRE, A89015 71.5% • achievement - 8 care processes: in CHURCH VIEW MEDICAL CENTRE A89042 70.7% DRS CLOAK, CHOI AND MILLIGAN A89019 66.8% practices who provided data via the CHESTER SURGERY A89623 65.9% PALLION FAMILY PRACTICE A89007 65.4% NDA, between 17.3% and 78.1% of ENCOMPASS HEALTH CARE A89025 64.0% JOSHI NA A89011 63.3% patients received all 8 care processes DR S M BHATE & DR H EL-SHAKANKERY A89002 62.4% DR. R. OBONNA A89603 62.0% THE BROADWAY MEDICAL PRACTICE A89024 61.0% PARK LANE PRACTICE A89034 60.3% THE NEW CITY MEDICAL GROUP A89013 60.3% DR BRIGHAM & PARTNERS A89005 60.2% • at least 6,710 people did not receive WEARSIDE MEDICAL PRACTICE - PALLION A89006 60.1% PENNYWELL MEDICAL CENTRE A89621 59.1% the eight care processes VICTORIA MEDICAL PRACTICE A89026 59.0% RED HOUSE MEDICAL CENTRE A89008 58.2% MONKWEARMOUTH HEALTH CENTRE A89040 57.4% GRANGEWOOD SURGERY A89028 57.3% HETTON GROUP PRACTICE A89004 57.2% BARMSTON MEDICAL CENTRE A89038 57.0% KEPIER MEDICAL PRACTICE A89021 56.9% MILLFIELD MEDICAL GROUP A89017 56.8% WESTBOURNE MEDICAL GROUP A89030 56.6% COLLIERY MEDICAL GROUP A89032 53.9% ST BEDE MEDICAL CENTRE A89016 53.7% SOUTHLANDS MEDICAL GROUP A89035 51.1% SPRINGWELL MEDICAL GROUP A89027 50.5% THE OLD FORGE SURGERY A89020 48.3% DR. N.J. BHATT & DR. H.M. BENN A89624 47.0% NATHAN JR A89612 45.9% SOUTH HYLTON SURGERY A89614 45.5% ROKER FAMILY PRACTICE A89014 45.0% HYLTON MEDICAL GROUP A89031 44.6% CASTLETOWN MEDICAL CENTRE A89036 43.5% CONCORD MEDICAL PRACTICE A89022 41.5% HAPPY HOUSE SURGERY A89041 38.4% ASHBURN MEDICAL CENTRE A89018 38.3% EDEN TERRACE SURGERY A89611 34.5% DR AKK HEGDE A89003 31.4% CONISHEAD MEDICAL GROUP A89610 29.9% HERRINGTON MEDICAL CENTRE A89009 26.6% DR DIXIT'S PRACTICE A89012 25.0% SPRINGWELL HOUSE A89029 24.4% DR WEATHERHEAD & ASSOCIATES A89604 18.3% HARRATON SURGERY A89617 17.3% DEERNESS PARK MEDICAL GROUP A89001 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 Northumberland CCG 41.1%

• 41.1% of people with diabetes (of practices who participated in the NHS Sunderland CCG 41.1% audit) met the three treatment targets in NHS Sunderland CCG, compared to 39.0% in England

NHS South Tyneside CCG 40.5%

NHS North Tyneside CCG 40.0%

NHS Newcastle Gateshead CCG 38.9%

England 39.0%

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

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

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

THE NEW CITY MEDICAL GROUP A89013 52.2% GRANGEWOOD SURGERY A89028 49.7% CASTLETOWN MEDICAL CENTRE A89036 49.6% VICTORIA MEDICAL PRACTICE A89026 49.4% SPRINGWELL MEDICAL GROUP A89027 49.2% • achievement - 3 treatment targets: in JOSHI NA A89011 49.1% HARRATON SURGERY A89617 48.7% practices who provided data via the CHURCH VIEW MEDICAL CENTRE A89042 48.2% HOUGHTON MEDICAL GROUP, A89023 47.0% NDA, between 27.5% and 52.2% of ST BEDE MEDICAL CENTRE A89016 46.9% DR. R. OBONNA A89603 46.9% patients achieved all 3 treatment DR STEPHENSON & PARTNERS A89010 46.8% SPRINGWELL HOUSE A89029 46.4% ASHBURN MEDICAL CENTRE A89018 46.2% targets MONKWEARMOUTH HEALTH CENTRE A89040 46.1% DR S M BHATE & DR H EL-SHAKANKERY A89002 45.9% PENNYWELL MEDICAL CENTRE A89621 45.5% • at least 7,870 people did not meet the DR AKK HEGDE A89003 44.8% CHESTER SURGERY A89623 44.3% three treatment targets FULWELL MEDICAL CENTRE, A89015 44.3% DRS CLOAK, CHOI AND MILLIGAN A89019 43.6% SOUTHLANDS MEDICAL GROUP A89035 43.2% RED HOUSE MEDICAL CENTRE A89008 42.8% DR THOMAS A89620 42.0% WEARSIDE MEDICAL PRACTICE - PALLION A89006 41.9% THE BROADWAY MEDICAL PRACTICE A89024 41.4% DR WEATHERHEAD & ASSOCIATES A89604 40.7% MILLFIELD MEDICAL GROUP A89017 40.5% HETTON GROUP PRACTICE A89004 40.5% EDEN TERRACE SURGERY A89611 40.2% COLLIERY MEDICAL GROUP A89032 39.8% WESTBOURNE MEDICAL GROUP A89030 39.1% THE OLD FORGE SURGERY A89020 38.6% PARK LANE PRACTICE A89034 38.5% DR DIXIT'S PRACTICE A89012 36.7% RICKLETON MEDICAL CENTRE A89616 36.4% KEPIER MEDICAL PRACTICE A89021 36.1% DR BRIGHAM & PARTNERS A89005 36.1% HAPPY HOUSE SURGERY A89041 36.1% BARMSTON MEDICAL CENTRE A89038 34.7% CONCORD MEDICAL PRACTICE A89022 34.1% HERRINGTON MEDICAL CENTRE A89009 33.5% PALLION FAMILY PRACTICE A89007 33.2% SOUTH HYLTON SURGERY A89614 31.1% DR. N.J. BHATT & DR. H.M. BENN A89624 30.8% HYLTON MEDICAL GROUP A89031 30.6% NATHAN JR A89612 30.4% ENCOMPASS HEALTH CARE A89025 30.2% ROKER FAMILY PRACTICE A89014 29.8% CONISHEAD MEDICAL GROUP A89610 27.5% DEERNESS PARK MEDICAL GROUP A89001 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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

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

CONISHEAD MEDICAL GROUP 31

ROKER FAMILY PRACTICE 18

HYLTON MEDICAL GROUP 41 • using the GP cluster method of SOUTH HYLTON SURGERY 36 calculating potential gains, if each ENCOMPASS HEALTH CARE 46 practice was to achieve as well as the NATHAN JR 15 upper quartile of its national cluster, then an additional 806 people would DR. N.J. BHATT & DR. H.M. BENN 15 be treated PALLION FAMILY PRACTICE 68

HERRINGTON MEDICAL CENTRE 48

CONCORD MEDICAL PRACTICE 37

ST BEDE MEDICAL CENTRE

JOSHI NA

VICTORIA MEDICAL PRACTICE

CASTLETOWN MEDICAL CENTRE

PENNYWELL MEDICAL CENTRE

DR STEPHENSON & PARTNERS

HARRATON SURGERY

SPRINGWELL MEDICAL GROUP

GRANGEWOOD SURGERY

THE NEW CITY MEDICAL GROUP 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 Newcastle Gateshead CCG 0.89

• the ratio of those diagnosed with NHS North Tyneside CCG 0.86 chronic kidney disease versus those expected to have chronic kidney disease is 0.68. This compares to NHS Northumberland CCG 0.85 0.68 for England • this suggests that 68% of people with chronic kidney disease have been diagnosed NHS Sunderland CCG 0.68

NHS South Tyneside CCG 0.58

Note: This slide compares the prevalence of CKD recorded in QOF in 2015/16 to the expected prevalence of CKD produced by the University of Southampton in 2011. A small number of CCGs England 0.68 have a ratio greater than 1. It is unlikely that all people with CKD will be diagnosed in any CCG and therefore a ratio greater than 1 suggests that 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 the figures are underestimating the true CKD Ratio prevalence in the area. These ratios should be taken as an indication of the comparative scale of undiagnosed CKD rather than absolute figures.

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

NHS South Sefton CCG 0.90

NHS Wakefield CCG 0.75

NHS Rotherham CCG 0.72

NHS Wirral CCG 0.71

NHS Sunderland CCG 0.68

NHS St Helens CCG 0.68

NHS Stoke On Trent CCG 0.66

NHS South Tees CCG 0.59

NHS South Tyneside CCG 0.58

NHS Tameside and Glossop CCG 0.52

NHS Stockport CCG 0.47

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

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

GP practice CCG

RED HOUSE MEDICAL CENTRE A89008 11.4% CONISHEAD MEDICAL GROUP A89610 7.2% GRANGEWOOD SURGERY A89028 7.1% VICTORIA MEDICAL PRACTICE A89026 6.9% HOUGHTON MEDICAL GROUP, A89023 6.6% COLLIERY MEDICAL GROUP A89032 6.1% SOUTH HYLTON SURGERY A89614 6.0% • it is estimated that there are 4,457 ASHBURN MEDICAL CENTRE A89018 5.9% THE NEW CITY MEDICAL GROUP A89013 5.8% people with undiagnosed chronic MONKWEARMOUTH HEALTH CENTRE A89040 5.5% SPRINGWELL MEDICAL GROUP A89027 5.5% kidney disease in NHS Sunderland FULWELL MEDICAL CENTRE, A89015 5.1% KEPIER MEDICAL PRACTICE A89021 5.1% CCG WEARSIDE MEDICAL PRACTICE - PALLION A89006 4.9% DR WEATHERHEAD & ASSOCIATES A89604 4.7% • GP practice range of observed CKD: DEERNESS PARK MEDICAL GROUP A89001 4.7% WESTBOURNE MEDICAL GROUP A89030 4.7% 1.0% to 11.4% HETTON GROUP PRACTICE A89004 4.6% DRS CLOAK, CHOI AND MILLIGAN A89019 4.5% HARRATON SURGERY A89617 4.4% PENNYWELL MEDICAL CENTRE A89621 4.4% JOSHI NA A89011 4.3% DR BRIGHAM & PARTNERS A89005 4.0% MILLFIELD MEDICAL GROUP A89017 3.9% THE OLD FORGE SURGERY A89020 3.9% CASTLETOWN MEDICAL CENTRE A89036 3.7% HERRINGTON MEDICAL CENTRE A89009 3.7% SPRINGWELL HOUSE A89029 3.6% THE BROADWAY MEDICAL PRACTICE A89024 3.5% DR THOMAS A89620 3.3% DR DIXIT'S PRACTICE A89012 3.3% DR AKK HEGDE A89003 3.3% ST BEDE MEDICAL CENTRE A89016 3.2% SOUTHLANDS MEDICAL GROUP A89035 3.0% DR S M BHATE & DR H EL-SHAKANKERY A89002 2.8% CHURCH VIEW MEDICAL CENTRE A89042 2.8% DR STEPHENSON & PARTNERS A89010 2.7% EDEN TERRACE SURGERY A89611 2.7% PALLION FAMILY PRACTICE A89007 2.7% BARMSTON MEDICAL CENTRE A89038 2.7% RICKLETON MEDICAL CENTRE A89616 2.6% ENCOMPASS HEALTH CARE A89025 2.6% HAPPY HOUSE SURGERY A89041 2.5% CONCORD MEDICAL PRACTICE A89022 2.4% ROKER FAMILY PRACTICE A89014 2.2% Note: CCG estimates for the estimated DR. R. OBONNA A89603 2.1% CHESTER SURGERY A89623 2.1% number of people with CKD are based on PARK LANE PRACTICE A89034 1.6% DR. N.J. BHATT & DR. H.M. BENN A89624 1.2% applying a proportion from a resident based NATHAN JR A89612 1.2% population estimate to a GP registered HYLTON MEDICAL GROUP A89031 1.0% population. The characteristics of registered 0% 2% 4% 6% 8% 10% 12% 14% and resident populations may vary in some CCGs, and local interpretation is required.

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

NHS South Tyneside CCG 78.2% • 9,479 people with CKD (diagnosed*) in NHS Sunderland CCG • 7,075 (74.6%) people whose blood NHS Northumberland CCG 76.5% pressure is <= 140 /85 • 844 (8.9%) people who are exceptions NHS Newcastle Gateshead CCG 74.9% • 1,560 (16.5%) additional people whose blood pressure is not <= 140 / 85 NHS Sunderland CCG 74.6%

NHS North Tyneside CCG 73.7%

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

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

NHS Stockport CCG 79.4%

NHS St Helens CCG 78.9%

NHS South Sefton CCG 78.4%

NHS Stoke On Trent CCG 78.3%

NHS South Tyneside CCG 78.2%

NHS Tameside and Glossop CCG 78.1%

NHS Wakefield CCG 78.0%

NHS Wirral CCG 75.6%

NHS Sunderland CCG 74.6%

NHS South Tees CCG 73.9%

NHS Rotherham CCG 73.8%

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

DR PARRY & PARTNERS A89018 218 DR BHATT A89624 10 COLLIERY MEDICAL GROUP A89032 94 THE OLD FORGE SURGERY A89020 99 DR BRIGHAM & PARTNERS A89005 64 DR THOMAS A89620 26 BARMSTON MEDICAL CENTRE A89038 28 • in total, including exceptions, there ROKER FAMILY PRACTICE A89014 14 HAPPY HOUSE SURGERY A89041 33 are 2,404 people whose blood MILLFIELD MEDICAL CENTRE A89017 126 DR HUBBARD A89030 61 pressure is not <= 140 / 85 DR SHETTY & PARTNERS A89006 86 MONKWEARMOUTH HEALTH CENTRE A89040 38 • GP practice range: 8.3% to 55.5% HOUGHTON MEDICAL GROUP A89023 106 SOUTH HYLTON SURGERY A89614 50 THE NEW CITY MEDICAL GROUP A89013 80 DR AIYEGBAYO A89616 11 DR REDDY & PARTNER A89008 101 DR BIRRELL AND PARTNERS A89009 64 DR AL-KHALIDI A89031 11 PALLION FAMILY PRACTICE A89007 53 SPRINGWELL MEDICAL GROUP A89027 67 DR M C HIPWELL A89610 46 DR PATTISON A89035 29 KEPIER MEDICAL PRACTICE A89021 81 CHURCH VIEW MEDICAL CENTRE A89042 31 DR WALLACE & PARTNERS A89028 80 DR AK MANDAL A89611 14 CASTLETOWN MEDICAL CENTRE A89036 16 DEERNESS PARK MEDICAL GROUP A89001 116 ENCOMPASS HEALTH CARE A89025 30 THE BROADWAY MEDICAL PRACTICE A89024 34 PEPPER HM A89004 74 FULWELL MEDICAL CENTRE A89015 67 DR STEPHENSON & PARTNERS A89010 55 DR CLOAK & PARTNERS A89019 58 DR MADATHIL A89026 31 DR VAKHARIA & HEGDE A89003 29 NATHAN JR A89612 5 CONCORD MEDICAL CENTRE A89022 17 DR O'BONNA A89603 6 ST BEDE MEDICAL CENTRE A89016 37 DR EL SAFY A89623 8 PENNYWELL MEDICAL CENTRE A89621 13 DR WEATHERHEAD A89604 19 DR JOSHI & PARTNER A89011 19 RIVERVIEW HEALTH CENTRE A89002 12 SPRINGWELL HOUSE A89029 8 HARRATON SURGERY A89617 10 DR DIXIT'S PRACTICE A89012 14 PARK LANE PRACTICE A89034 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

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

DR PARRY & PARTNERS 151

DR BHATT 6

COLLIERY MEDICAL GROUP 54 • using the GP cluster method of THE OLD FORGE SURGERY 51 calculating potential gains, if each DR BRIGHAM & PARTNERS 31 practice was to achieve as well as the DR THOMAS 13 upper quartile of its national cluster, then an additional 766 people would BARMSTON MEDICAL CENTRE 13 be treated HAPPY HOUSE SURGERY 15

ROKER FAMILY PRACTICE 6

DR HUBBARD 25

ST BEDE MEDICAL CENTRE

DR WEATHERHEAD

FULWELL MEDICAL CENTRE

DR STEPHENSON & PARTNERS

DR JOSHI & PARTNER

RIVERVIEW HEALTH CENTRE

HARRATON SURGERY

SPRINGWELL HOUSE

DR DIXIT'S PRACTICE

PARK LANE PRACTICE Details of this methodology are available on slide 9. Click here to view them.

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

NHS South Tyneside CCG 80.9% • 9,315 people with CKD (diagnosed*) in NHS Sunderland CCG • 6,958 (74.7%) people who have a NHS Northumberland CCG 78.9% record of urine albumin:creatinine ratio test • 352 (3.8%) people who are NHS North Tyneside CCG 76.4% exceptions • 2,005 (21.5%) additional people who have no record of urine NHS Newcastle Gateshead CCG 76.1% albumin:creatinine ratio test

NHS Sunderland CCG 74.7%

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

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

NHS South Tyneside CCG 80.9%

NHS Wakefield CCG 80.1%

NHS Stockport CCG 79.9%

NHS Tameside and Glossop CCG 79.8%

NHS Stoke On Trent CCG 79.2%

NHS South Sefton CCG 78.6%

NHS St Helens CCG 77.8%

NHS South Tees CCG 76.1%

NHS Sunderland CCG 74.7%

NHS Rotherham CCG 72.5%

NHS Wirral CCG 71.1%

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

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

Not recorded Exceptions reported

THE OLD FORGE SURGERY A89020 224 DR BHATT A89624 13 MILLFIELD MEDICAL CENTRE A89017 191 ROKER FAMILY PRACTICE A89014 20 THE NEW CITY MEDICAL GROUP A89013 123 DR BIRRELL AND PARTNERS A89009 99 DR AL-KHALIDI A89031 17 • in total, including exceptions, there PALLION FAMILY PRACTICE A89007 82 DR BRIGHAM & PARTNERS A89005 62 are 2,357 people who have no record DR VAKHARIA & HEGDE A89003 50 HARRATON SURGERY A89617 24 of urine albumin:creatinine ratio test DR M C HIPWELL A89610 55 DR AK MANDAL A89611 18 • GP practice range: 8.3% to 79.7% SPRINGWELL MEDICAL GROUP A89027 79 SOUTH HYLTON SURGERY A89614 51 PARK LANE PRACTICE A89034 15 ENCOMPASS HEALTH CARE A89025 35 DR CLOAK & PARTNERS A89019 76 PEPPER HM A89004 91 DEERNESS PARK MEDICAL GROUP A89001 128 HAPPY HOUSE SURGERY A89041 26 HOUGHTON MEDICAL GROUP A89023 85 DR REDDY & PARTNER A89008 85 COLLIERY MEDICAL GROUP A89032 52 ST BEDE MEDICAL CENTRE A89016 44 SPRINGWELL HOUSE A89029 12 DR MADATHIL A89026 32 MONKWEARMOUTH HEALTH CENTRE A89040 26 BARMSTON MEDICAL CENTRE A89038 16 DR WEATHERHEAD A89604 23 DR STEPHENSON & PARTNERS A89010 52 DR WALLACE & PARTNERS A89028 60 THE BROADWAY MEDICAL PRACTICE A89024 29 DR AIYEGBAYO A89616 7 DR PARRY & PARTNERS A89018 39 FULWELL MEDICAL CENTRE A89015 56 DR PATTISON A89035 19 DR HUBBARD A89030 34 CONCORD MEDICAL CENTRE A89022 15 RIVERVIEW HEALTH CENTRE A89002 13 KEPIER MEDICAL PRACTICE A89021 53 DR O'BONNA A89603 5 DR SHETTY & PARTNERS A89006 44 DR DIXIT'S PRACTICE A89012 17 PENNYWELL MEDICAL CENTRE A89621 10 DR THOMAS A89620 9 CASTLETOWN MEDICAL CENTRE A89036 8 NATHAN JR A89612 3 DR JOSHI & PARTNER A89011 13 CHURCH VIEW MEDICAL CENTRE A89042 13 DR EL SAFY A89623 4 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 North Tyneside CCG 1.18%

• prevalence of 1.01% in NHS NHS South Tyneside CCG 1.16% Sunderland CCG compared to 0.76% in England

NHS Northumberland CCG 1.07%

NHS Sunderland CCG 1.01%

NHS Newcastle Gateshead CCG 0.82%

England 0.76%

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

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

NHS South Sefton CCG 1.28%

NHS South Tyneside CCG 1.16%

NHS St Helens CCG 1.12%

NHS Sunderland CCG 1.01%

NHS Stockport CCG 0.94%

NHS Wirral CCG 0.94%

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%

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

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

GP practice CCG

ASHBURN MEDICAL CENTRE A89018 1.8% MONKWEARMOUTH HEALTH CENTRE A89040 1.8% JOSHI NA A89011 1.7% DR WEATHERHEAD & ASSOCIATES A89604 1.7% THE NEW CITY MEDICAL GROUP A89013 1.6% DR BRIGHAM & PARTNERS A89005 1.5% KEPIER MEDICAL PRACTICE A89021 1.5% • 2,864 people with diagnosed heart HERRINGTON MEDICAL CENTRE A89009 1.3% CONISHEAD MEDICAL GROUP A89610 1.3% failure in NHS Sunderland CCG CHURCH VIEW MEDICAL CENTRE A89042 1.3% DEERNESS PARK MEDICAL GROUP A89001 1.2% • GP practice range: 0.3% to 1.8% DRS CLOAK, CHOI AND MILLIGAN A89019 1.2% HETTON GROUP PRACTICE A89004 1.1% ST BEDE MEDICAL CENTRE A89016 1.1% GRANGEWOOD SURGERY A89028 1.1% THE BROADWAY MEDICAL PRACTICE A89024 1.1% FULWELL MEDICAL CENTRE, A89015 1.1% SOUTHLANDS MEDICAL GROUP A89035 1.1% SOUTH HYLTON SURGERY A89614 1.1% DR THOMAS A89620 1.1% DR. R. OBONNA A89603 1.1% WESTBOURNE MEDICAL GROUP A89030 1.0% DR STEPHENSON & PARTNERS A89010 1.0% THE OLD FORGE SURGERY A89020 1.0% PALLION FAMILY PRACTICE A89007 1.0% WEARSIDE MEDICAL PRACTICE - PALLION A89006 1.0% SPRINGWELL MEDICAL GROUP A89027 0.9% DR S M BHATE & DR H EL-SHAKANKERY A89002 0.9% COLLIERY MEDICAL GROUP A89032 0.9% ROKER FAMILY PRACTICE A89014 0.9% VICTORIA MEDICAL PRACTICE A89026 0.8% RED HOUSE MEDICAL CENTRE A89008 0.8% MILLFIELD MEDICAL GROUP A89017 0.8% HAPPY HOUSE SURGERY A89041 0.8% CONCORD MEDICAL PRACTICE A89022 0.8% HOUGHTON MEDICAL GROUP, A89023 0.7% HYLTON MEDICAL GROUP A89031 0.7% DR. N.J. BHATT & DR. H.M. BENN A89624 0.7% PARK LANE PRACTICE A89034 0.7% CASTLETOWN MEDICAL CENTRE A89036 0.7% DR DIXIT'S PRACTICE A89012 0.6% HARRATON SURGERY A89617 0.6% SPRINGWELL HOUSE A89029 0.6% PENNYWELL MEDICAL CENTRE A89621 0.6% BARMSTON MEDICAL CENTRE A89038 0.5% ENCOMPASS HEALTH CARE A89025 0.5% RICKLETON MEDICAL CENTRE A89616 0.5% DR AKK HEGDE A89003 0.4% EDEN TERRACE SURGERY A89611 0.4% CHESTER SURGERY A89623 0.3% NATHAN JR A89612 0.3% 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6% 1.8% 2.0%

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 North Tyneside CCG 87.4% • 1,807 people with heart failure* with LVSD in NHS Sunderland CCG • 1,561 (86.4%) people treated with NHS Newcastle Gateshead CCG 87.0% ACE-I or ARB • 238 (13.2%) people who are exceptions NHS Sunderland CCG 86.4% • 8 (0.4%) additional people who are not treated with ACE-I or ARB

NHS Northumberland CCG 85.1%

NHS South Tyneside CCG 84.1%

England 84.7%

0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator HF003 denominator plus exceptions

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

NHS Stoke On Trent CCG 89.1%

NHS Wakefield CCG 88.0%

NHS South Tees CCG 87.8%

NHS Sunderland CCG 86.4%

NHS Tameside and Glossop CCG 85.6%

NHS Stockport CCG 85.5%

NHS St Helens CCG 84.6%

NHS South Tyneside CCG 84.1%

NHS Wirral CCG 82.4%

NHS Rotherham CCG 80.4%

NHS South Sefton CCG 78.9%

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

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

No treatment Exceptions reported

CHESTER SURGERY A89623 1 CONISHEAD MEDICAL GROUP A89610 11 DR THOMAS A89620 4 SOUTHLANDS MEDICAL GROUP A89035 5 HARRATON SURGERY A89617 1 HYLTON MEDICAL GROUP A89031 5 COLLIERY MEDICAL GROUP A89032 5 • in total, including exceptions, there THE OLD FORGE SURGERY A89020 5 DR DIXIT'S PRACTICE A89012 3 are 246 people who are not treated DR BRIGHAM & PARTNERS A89005 13 ST BEDE MEDICAL CENTRE A89016 12 with ACE-I or ARB EDEN TERRACE SURGERY A89611 1 DR. N.J. BHATT & DR. H.M. BENN A89624 1 • GP practice range: 0.0% to 33.3% HERRINGTON MEDICAL CENTRE A89009 15 WESTBOURNE MEDICAL GROUP A89030 4 RED HOUSE MEDICAL CENTRE A89008 5 ENCOMPASS HEALTH CARE A89025 2 DRS CLOAK, CHOI AND MILLIGAN A89019 18 WEARSIDE MEDICAL PRACTICE - PALLION A89006 4 THE BROADWAY MEDICAL PRACTICE A89024 4 KEPIER MEDICAL PRACTICE A89021 14 DR STEPHENSON & PARTNERS A89010 17 RICKLETON MEDICAL CENTRE A89616 1 PARK LANE PRACTICE A89034 3 MILLFIELD MEDICAL GROUP A89017 7 DEERNESS PARK MEDICAL GROUP A89001 8 PALLION FAMILY PRACTICE A89007 6 GRANGEWOOD SURGERY A89028 8 DR AKK HEGDE A89003 1 ROKER FAMILY PRACTICE A89014 1 FULWELL MEDICAL CENTRE, A89015 9 BARMSTON MEDICAL CENTRE A89038 2 DR WEATHERHEAD & ASSOCIATES A89604 6 HETTON GROUP PRACTICE A89004 11 SPRINGWELL MEDICAL GROUP A89027 4 THE NEW CITY MEDICAL GROUP A89013 5 SOUTH HYLTON SURGERY A89614 3 JOSHI NA A89011 5 MONKWEARMOUTH HEALTH CENTRE A89040 3 PENNYWELL MEDICAL CENTRE A89621 1 CONCORD MEDICAL PRACTICE A89022 1 ASHBURN MEDICAL CENTRE A89018 4 CHURCH VIEW MEDICAL CENTRE A89042 4 DR S M BHATE & DR H EL-SHAKANKERY A89002 1 HOUGHTON MEDICAL GROUP, A89023 2 VICTORIA MEDICAL PRACTICE A89026 SPRINGWELL HOUSE A89029 CASTLETOWN MEDICAL CENTRE A89036 HAPPY HOUSE SURGERY A89041 DR. R. OBONNA A89603 NATHAN JR A89612 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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

NHS North Tyneside CCG 79.8% • 1,561 people with heart failure* with LVSD treated with ACE-I/ARB in NHS Sunderland CCG NHS Sunderland CCG 79.8% • 1,245 (79.8%) people treated with ACE-I/ARB and BB • 259 (16.6%) people who are NHS Northumberland CCG 78.8% exceptions • 57 (3.7%) additional people who are not treated with ACE-I/ARB and BB NHS Newcastle Gateshead CCG 78.7%

NHS South Tyneside CCG 72.5%

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 South Tees CCG 87.3%

NHS Wakefield CCG 85.6%

NHS Stoke On Trent CCG 82.5%

NHS Rotherham CCG 82.2%

NHS Stockport CCG 81.3%

NHS Tameside and Glossop CCG 79.8%

NHS Sunderland CCG 79.8%

NHS Wirral CCG 77.1%

NHS St Helens CCG 74.1%

NHS South Tyneside CCG 72.5%

NHS South Sefton CCG 71.5%

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

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

No treatment Exceptions reported

CHESTER SURGERY A89623 1 ENCOMPASS HEALTH CARE A89025 4 DR. R. OBONNA A89603 3 SOUTH HYLTON SURGERY A89614 11 SPRINGWELL MEDICAL GROUP A89027 13 CONISHEAD MEDICAL GROUP A89610 8 RICKLETON MEDICAL CENTRE A89616 2 • in total, including exceptions, there FULWELL MEDICAL CENTRE, A89015 21 THE BROADWAY MEDICAL PRACTICE A89024 6 are 316 people who are not treated DR STEPHENSON & PARTNERS A89010 26 MONKWEARMOUTH HEALTH CENTRE A89040 9 with ACE-I or ARB PENNYWELL MEDICAL CENTRE A89621 3 PARK LANE PRACTICE A89034 5 • GP practice range: 0.0% to 50.0% DR BRIGHAM & PARTNERS A89005 13 ASHBURN MEDICAL CENTRE A89018 14 DR S M BHATE & DR H EL-SHAKANKERY A89002 5 ST BEDE MEDICAL CENTRE A89016 12 SOUTHLANDS MEDICAL GROUP A89035 3 BARMSTON MEDICAL CENTRE A89038 4 DR. N.J. BHATT & DR. H.M. BENN A89624 1 DR WEATHERHEAD & ASSOCIATES A89604 12 WEARSIDE MEDICAL PRACTICE - PALLION A89006 5 THE NEW CITY MEDICAL GROUP A89013 12 WESTBOURNE MEDICAL GROUP A89030 4 RED HOUSE MEDICAL CENTRE A89008 5 PALLION FAMILY PRACTICE A89007 9 KEPIER MEDICAL PRACTICE A89021 16 HERRINGTON MEDICAL CENTRE A89009 13 COLLIERY MEDICAL GROUP A89032 3 THE OLD FORGE SURGERY A89020 3 NATHAN JR A89612 1 MILLFIELD MEDICAL GROUP A89017 7 JOSHI NA A89011 8 HAPPY HOUSE SURGERY A89041 1 CHURCH VIEW MEDICAL CENTRE A89042 9 DRS CLOAK, CHOI AND MILLIGAN A89019 13 HOUGHTON MEDICAL GROUP, A89023 6 VICTORIA MEDICAL PRACTICE A89026 2 HYLTON MEDICAL GROUP A89031 2 HETTON GROUP PRACTICE A89004 11 DR THOMAS A89620 1 GRANGEWOOD SURGERY A89028 5 DEERNESS PARK MEDICAL GROUP A89001 4 DR AKK HEGDE A89003 DR DIXIT'S PRACTICE A89012 ROKER FAMILY PRACTICE A89014 CONCORD MEDICAL PRACTICE A89022 SPRINGWELL HOUSE A89029 CASTLETOWN MEDICAL CENTRE A89036 EDEN TERRACE SURGERY A89611 HARRATON SURGERY A89617 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 Newcastle Gateshead CCG 89.2% • 13,536 people with coronary heart disease* in NHS Sunderland CCG • 11,939 (88.2%) people whose blood NHS Northumberland CCG 88.8% pressure <= 150 / 90 • 490 (3.6%) people who are exceptions NHS South Tyneside CCG 88.3% • 1,107 (8.2%) additional people whose blood pressure is not <= 150 / 90

NHS Sunderland CCG 88.2%

NHS North Tyneside CCG 88.1%

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 Stockport CCG 91.1%

NHS Tameside and Glossop CCG 90.1%

NHS St Helens CCG 89.9%

NHS Stoke On Trent CCG 89.9%

NHS Wakefield CCG 89.3%

NHS South Tees CCG 88.6%

NHS South Tyneside CCG 88.3%

NHS Rotherham CCG 88.3%

NHS Sunderland CCG 88.2%

NHS Wirral CCG 88.2%

NHS South Sefton CCG 86.8%

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

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

Not below 150/90 Exceptions reported

HYLTON MEDICAL GROUP A89031 50 DR S M BHATE & DR H EL-SHAKANKERY A89002 32 THE NEW CITY MEDICAL GROUP A89013 65 DEERNESS PARK MEDICAL GROUP A89001 143 COLLIERY MEDICAL GROUP A89032 48 PALLION FAMILY PRACTICE A89007 85 BARMSTON MEDICAL CENTRE A89038 21 • in total, including exceptions, there SOUTH HYLTON SURGERY A89614 30 WEARSIDE MEDICAL PRACTICE - PALLION A89006 50 are 1,597 people whose blood RICKLETON MEDICAL CENTRE A89616 12 DRS CLOAK, CHOI AND MILLIGAN A89019 76 pressure is not <= 150 / 90 DR BRIGHAM & PARTNERS A89005 42 THE BROADWAY MEDICAL PRACTICE A89024 46 • GP practice range: 3.2% to 22.3% MILLFIELD MEDICAL GROUP A89017 78 KEPIER MEDICAL PRACTICE A89021 59 EDEN TERRACE SURGERY A89611 7 THE OLD FORGE SURGERY A89020 49 HETTON GROUP PRACTICE A89004 82 CONCORD MEDICAL PRACTICE A89022 25 ENCOMPASS HEALTH CARE A89025 28 RED HOUSE MEDICAL CENTRE A89008 26 HAPPY HOUSE SURGERY A89041 24 ST BEDE MEDICAL CENTRE A89016 38 DR AKK HEGDE A89003 23 HARRATON SURGERY A89617 11 DR WEATHERHEAD & ASSOCIATES A89604 20 HOUGHTON MEDICAL GROUP, A89023 38 VICTORIA MEDICAL PRACTICE A89026 12 CONISHEAD MEDICAL GROUP A89610 14 SPRINGWELL MEDICAL GROUP A89027 26 PARK LANE PRACTICE A89034 9 ASHBURN MEDICAL CENTRE A89018 25 FULWELL MEDICAL CENTRE, A89015 44 HERRINGTON MEDICAL CENTRE A89009 31 DR. N.J. BHATT & DR. H.M. BENN A89624 6 CHURCH VIEW MEDICAL CENTRE A89042 28 GRANGEWOOD SURGERY A89028 28 PENNYWELL MEDICAL CENTRE A89621 9 JOSHI NA A89011 16 DR STEPHENSON & PARTNERS A89010 45 ROKER FAMILY PRACTICE A89014 7 CHESTER SURGERY A89623 8 MONKWEARMOUTH HEALTH CENTRE A89040 12 SPRINGWELL HOUSE A89029 6 DR THOMAS A89620 7 DR. R. OBONNA A89603 5 WESTBOURNE MEDICAL GROUP A89030 20 SOUTHLANDS MEDICAL GROUP A89035 17 DR DIXIT'S PRACTICE A89012 8 NATHAN JR A89612 3 CASTLETOWN MEDICAL CENTRE A89036 3 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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

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

HYLTON MEDICAL GROUP 34

THE NEW CITY MEDICAL GROUP 40

DR S M BHATE & DR H EL-SHAKANKERY 20 • using the GP cluster method of COLLIERY MEDICAL GROUP 29 calculating potential gains, if each PALLION FAMILY PRACTICE 51 practice was to achieve as well as the BARMSTON MEDICAL CENTRE 13 upper quartile of its national cluster, then an additional 639 people would DEERNESS PARK MEDICAL GROUP 77 be treated SOUTH HYLTON SURGERY 16

RICKLETON MEDICAL CENTRE 7

WEARSIDE MEDICAL PRACTICE - PALLION 27

DR STEPHENSON & PARTNERS

MONKWEARMOUTH HEALTH CENTRE

SPRINGWELL HOUSE

DR THOMAS

DR. R. OBONNA

WESTBOURNE MEDICAL GROUP

SOUTHLANDS MEDICAL GROUP

DR DIXIT'S PRACTICE

NATHAN JR

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

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

NHS Newcastle Gateshead CCG 93.7% • 13,536 people with coronary heart disease* in NHS Sunderland CCG • 12,674 (93.6%) people who are NHS Sunderland CCG 93.6% taking aspirin, an alternative anti- platelet therapy, or an anti-coagulant • 433 (3.2%) people who are NHS South Tyneside CCG 93.6% exceptions • 429 (3.2%) additional people who are not taking aspirin, an alternative anti- NHS North Tyneside CCG 92.2% platelet therapy, or an anti-coagulant

NHS Northumberland CCG 92.2%

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 South Tyneside CCG 93.6%

NHS Stockport CCG 93.0%

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 South Sefton CCG 92.4%

NHS Rotherham CCG 91.6%

NHS St Helens CCG 91.1%

NHS Wirral CCG 89.6%

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

80 CVD: Primary Care Intelligence Packs Percentage of patients with CHD without a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken by GP practice

No treatment Exceptions reported

ROKER FAMILY PRACTICE A89014 18 HAPPY HOUSE SURGERY A89041 32 RICKLETON MEDICAL CENTRE A89616 8 HYLTON MEDICAL GROUP A89031 21 EDEN TERRACE SURGERY A89611 5 THE NEW CITY MEDICAL GROUP A89013 31 ENCOMPASS HEALTH CARE A89025 22 • in total, including exceptions, there DR. R. OBONNA A89603 7 ST BEDE MEDICAL CENTRE A89016 29 are 862 people are not taking aspirin, CONISHEAD MEDICAL GROUP A89610 12 DEERNESS PARK MEDICAL GROUP A89001 64 an alternative anti-platelet therapy, or DR BRIGHAM & PARTNERS A89005 24 NATHAN JR A89612 5 an anti-coagulant KEPIER MEDICAL PRACTICE A89021 36 DRS CLOAK, CHOI AND MILLIGAN A89019 41 • GP practice range: 1.0% to 18.0% PALLION FAMILY PRACTICE A89007 37 WESTBOURNE MEDICAL GROUP A89030 26 THE BROADWAY MEDICAL PRACTICE A89024 25 DR DIXIT'S PRACTICE A89012 12 DR. N.J. BHATT & DR. H.M. BENN A89624 5 BARMSTON MEDICAL CENTRE A89038 9 RED HOUSE MEDICAL CENTRE A89008 16 ASHBURN MEDICAL CENTRE A89018 18 PARK LANE PRACTICE A89034 6 HOUGHTON MEDICAL GROUP, A89023 22 COLLIERY MEDICAL GROUP A89032 16 THE OLD FORGE SURGERY A89020 23 GRANGEWOOD SURGERY A89028 19 DR WEATHERHEAD & ASSOCIATES A89604 11 HARRATON SURGERY A89617 6 CONCORD MEDICAL PRACTICE A89022 13 SPRINGWELL MEDICAL GROUP A89027 16 WEARSIDE MEDICAL PRACTICE - PALLION A89006 19 VICTORIA MEDICAL PRACTICE A89026 7 DR STEPHENSON & PARTNERS A89010 31 SOUTH HYLTON SURGERY A89614 10 HERRINGTON MEDICAL CENTRE A89009 18 JOSHI NA A89011 10 HETTON GROUP PRACTICE A89004 34 MONKWEARMOUTH HEALTH CENTRE A89040 8 CASTLETOWN MEDICAL CENTRE A89036 4 SOUTHLANDS MEDICAL GROUP A89035 12 DR S M BHATE & DR H EL-SHAKANKERY A89002 7 MILLFIELD MEDICAL GROUP A89017 23 DR AKK HEGDE A89003 8 PENNYWELL MEDICAL CENTRE A89621 4 DR THOMAS A89620 4 FULWELL MEDICAL CENTRE, A89015 17 CHESTER SURGERY A89623 4 CHURCH VIEW MEDICAL CENTRE A89042 6 SPRINGWELL HOUSE A89029 1 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

81 CVD: Primary Care Intelligence Packs Some data on outcomes for people with cardiovascular disease

82 CVD: Primary Care Intelligence Packs Hospital admissions for coronary heart disease for all ages 2002/03 – 2015/16

NHS Sunderland CCG England 1200

• in NHS Sunderland CCG, the hospital 1000 admission rate for coronary heart disease in 2015/16 was 717.3 (1,945) compared to 527.9 for England

800

600

400 Age Age standardised (per rate 100,000)

200

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 Sunderland CCG England 250

• in NHS Sunderland CCG, the hospital admission rate for stroke in 2015/16 200 was 200.3 (522) compared to 172.8 for England

150

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

50

0 2002/032003/042004/052005/062006/072007/082008/092009/102010/112011/122012/132013/142014/152015/16 Source: Hospital Episode Statistics (HES), 2002/03 - 2015/16, Copyright © 2017, Re‐used with the permission of NHS Digital. All rights reserved

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

NHS Sunderland CCG England

96.6% Angina 136.8% • The risk of a stroke was 68.6% higher and the risk of a heart attack was 69.8% 69.8% higher compared to people Heart Attack 108.6% without diabetes. The risk of a major amputation was 224.4% higher. 113.6% Heart failure 150.0%

68.6% Stroke 81.3%

224.4% Major amputation 445.8%

373.7% Minor amputation 753.5%

304.1% 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 Sunderland CCG England 120

• in NHS Sunderland CCG, the early 100 mortality rate for coronary heart disease in 2013-15 was 50.8, compared to 40.6 for England

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 Sunderland CCG England 35

• in NHS Sunderland CCG, the early 30 mortality rate for stroke in 2013-15 was 18, 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

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Published June 2017 Gateway number 2017095

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