CVD: Primary Care Intelligence Packs NHS 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 . 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 Sheffield CCG are: NHS Coventry and Rugby CCG NHS Southern Derbyshire CCG NHS Bristol CCG NHS West Leicestershire CCG NHS Liverpool CCG NHS North Durham CCG NHS Portsmouth CCG NHS Greater Huddersfield CCG NHS Newcastle Gateshead CCG NHS Lincolnshire West 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 Liverpool CCG 21.9%

NHS Portsmouth CCG 21.6% • prevalence of 17.4% in NHS Sheffield CCG NHS Bristol CCG 20.9%

NHS Newcastle Gateshead CCG 19.6%

NHS Coventry and Rugby CCG 18.7%

NHS Greater Huddersfield CCG 18.7%

NHS Lincolnshire West CCG 18.2%

NHS Southern Derbyshire CCG 17.6% Note: It has been found that the proportion of patients recorded as smokers correlates well NHS Sheffield CCG 17.4% with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, NHS North Durham CCG 16.2% http://bmjopen.bmj.com/content/4/7/e005217.abs tract

NHS West Leicestershire CCG 16.2% 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

WESTFIELD HEALTH CENTRE Y04887 37.0% BUCHANAN ROAD SURGERY C88011 32.9% WHITE HOUSE SURGERY C88020 31.2% HAROLD STREET MEDICAL CENTRE C88059 30.3% MANOR PARK MEDICAL CENTRE C88090 30.2% THE FLOWERS HEALTH CENTRE C88033 30.0% EAST BANK MEDICAL CENTRE C88088 29.8% PARK HEALTH CENTRE C88042 28.4% GLEADLESS MEDICAL CENTRE C88019 28.2% SOUTHEY GREEN MEDICAL CTR C88086 28.1% • 85,520 people who are recorded as CARRFIELD MEDICAL CENTRE C88082 27.9% FOXHILL MEDICAL CENTRE C88009 27.2% THE HEALTH CARE SURGERY C88077 26.9% DUKE MEDICAL CENTRE C88030 26.5% smokers in NHS Sheffield CCG NORWOOD MEDICAL CENTRE C88014 26.0% SURGERY C88048 25.7% NORFOLK PARK HEALTH CENTRE C88006 25.6% • GP practice range: 0.1% to 37.0% MANOR TOP MEDICAL CENTRE C88638 25.0% BARNSLEY ROAD SURGERY C88091 25.0% DUNNINC ROAD SURGERY C88643 24.9% DOVERCOURT GROUP PRACTICE C88087 24.4% HEALTH CENTRE (MEHROTRA) C88084 24.0% SHIREGREEN MEDICAL CENTRE C88070 23.7% CLOVER GROUP PRACTICE C88069 23.5% SURGERY C88035 23.2% MEDICAL CENTRE C88096 23.1% GREEN SURGERY C88073 22.9% DEVONSHIRE GREEN MEDICAL CENTRE C88076 22.8% UPWELL STREET SURGERY C88027 22.1% SURGERY C88008 22.0% SHEFFIELD MEDICAL CENTRE C88622 21.9% MANOR TOP MEDICAL CENTRE (READ) C88626 21.7% RICHMOND MEDICAL CENTRE C88085 21.6% WOODHOUSE MEDICAL CENTRE C88072 21.2% MEADOWGREEN HEALTH CENTRE C88015 20.6% SHEFFIELD CITY GP HC (REG) Y02566 20.6% VERITAS HEALTH CENTRE C88631 20.4% WINCOBANK MEDICAL CENTRE C88047 20.2% VALLEY MEDICAL CENTRE C88057 20.1% LANE MEDICAL CENTRE C88060 19.6% DYKES HALL MEDICAL CENTRE C88045 19.1% SLOAN MEDICAL CENTRE C88026 19.0% PAGE HALL MEDICAL CENTRE C88051 18.6% THE MEDICAL CENTRE DR OKORIE C88655 18.5% GROUP PRACT C88039 18.4% JAUNTY SPRINGS HEALTH CENTRE C88050 18.0% MEDICAL CENTRE C88074 17.7% HEALTH CENTRE C88025 17.5% SURGERY C88054 16.2% TRAMWAYS MEDICAL CENTRE (O'CONNELL) C88018 16.0% TRAMWAYS 54A MC C88043 15.9% VALLEY MEDICAL CENTRE C88092 15.8% CRYSTAL PEAKS MEDICAL CENTRE C88648 15.8% PORTER BROOK MEDICAL CENTRE C88007 15.7% ELM LANE SURGERY C88049 15.7% FAR LANE MEDICAL CENTRE C88021 15.3% CHAPELGREEN PRACTICE C88010 15.3% BASLOW RD, SHOREHAM ST & YORK RD SRGIES C88037 15.1% HANDSWORTH MEDICAL PRACTICE C88036 15.1% SOTHALL & HEALTH CENTRES C88023 14.4% HOUSE MEDICAL CENTRE C88005 14.1% STONECROFT MEDICAL CENTRE C88022 14.1% MEDICAL CENTRE C88041 13.9% HEALTH CENTRE C88078 13.4% UPPERTHORPE MEDICAL CENTRE C88031 12.8% AVENUE MEDICAL PRACTICE C88024 12.8% SURGERY C88040 12.4% ABBEY LANE SURGERY C88046 12.4% CHARNOCK HEALTH PRIMARY CARE CENTRE C88032 12.2% MILL ROAD SURGERY C88095 12.1% CROOKES PRACTICE C88079 12.0% GREYSTONES MEDICAL CENTRE C88652 11.8% Note: This method is thought to be a reasonably HOLLIES MEDICAL CENTRE C88052 11.6% MEDICAL CENTRE C88656 11.3% THE MATHEWS PRACTICE BELGRAVE C88038 10.6% robust method in estimating smoking prevalence MANCHESTER ROAD SURGERY C88044 10.4% RISE MEDICAL CENTRE C88068 10.2% CARTERKNOWLE & DORE MEDICAL PRACTICE C88016 10.2% for the majority of GP practices. However, OWLTHORPE MEDICAL CENTRE C88647 9.0% RUSTLINGS ROAD MEDICAL CENTRE C88062 8.0% BROOMHILL SURGERY C88028 8.0% caution is advised for extreme estimates of UNIVERSITY HEALTH SERVICE HEALTH CENTRE C88627 7.8% NETHERGREEN SURGERY C88034 7.4% FALKLAND HOUSE SURGERY C88053 6.2% smoking prevalence and those with high SELBORNE ROAD MEDICAL CENTRE C88083 3.6% BENTS GREEN SURGERY C88061 0.1% numbers of smoking status not recorded and 0% 5% 10% 15% 20% 25% 30% 35% 40% exceptions.

14 CVD: Primary Care Intelligence Packs Hypertension

15 CVD: Primary Care Intelligence Packs Hypertension

The Missing Millions On average, each CCG in England has 26,000 residents with The Global Burden of Disease undiagnosed hypertension – these individuals are unaware of Study confirmed high blood pressure as their increased cardiovascular risk and are untreated. a leading cause of premature death and disability What questions should we ask in our CCG? 1. for each indicator how wide is the variation in achievement and exception reporting? 2. how many people would benefit if all practices performed High blood pressure is common and costly as well as the best? • it affects around a quarter of all adults 3. how can we support practices who are average or below • the NHS costs of hypertension are around £2bn average to perform as well as the best in: • social costs are probably considerably higher • detection of hypertension • management of hypertension What do we know? • at least half of all heart attacks and strokes are caused by high blood pressure and it is a major risk What might help? factor for chronic kidney disease and cognitive decline • support practices to share audit data and systematically • treatment is very effective – every 10mmHg reduction identify gaps and opportunities for improved detection and in systolic blood pressure lowers risk of heart attack management of hypertension and stroke by 20% • work with practices and local authorities to maximise • despite this 4 out of 10 adults with hypertension, over uptake and follow up in the NHS Health Check 5 and a half million people in England, remain • support access to self-test BP stations in waiting rooms undiagnosed and to ambulatory blood pressure monitoring. • and even when the condition is identified, treatment is • commission community pharmacists to offer blood often suboptimal, with blood pressure poorly pressure measurement, diagnosis and management controlled in about 1 out of 3 individuals support, including support for adherence to medication

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

NHS Rotherham CCG 0.62

• the ratio of those diagnosed with NHS Barnsley CCG 0.61 hypertension versus those expected to have hypertension is 0.58. This compares to 0.59 for England • this suggests that 58% of people with NHS Bassetlaw CCG 0.59 hypertension have been diagnosed

NHS Doncaster CCG 0.59

NHS Sheffield CCG 0.58

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 North Durham CCG 0.60

NHS West Leicestershire CCG 0.60

NHS Southern Derbyshire CCG 0.59

NHS Coventry and Rugby CCG 0.59

NHS Newcastle Gateshead CCG 0.59

NHS Lincolnshire West CCG 0.58

NHS Sheffield CCG 0.58

NHS Liverpool CCG 0.58

NHS Greater Huddersfield CCG 0.57

NHS Portsmouth CCG 0.56

NHS Bristol CCG 0.54

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

CRYSTAL PEAKS MEDICAL CENTRE C88648 0.77 MANOR TOP MEDICAL CENTRE (READ) C88626 0.72 ECCLESFIELD GROUP PRACT C88039 0.72 BARNSLEY ROAD SURGERY C88091 0.71 MEADOWGREEN HEALTH CENTRE C88015 0.70 MILL ROAD SURGERY C88095 0.70 HAROLD STREET MEDICAL CENTRE C88059 0.69 OWLTHORPE MEDICAL CENTRE C88647 0.67 THE HEALTH CARE SURGERY C88077 0.66 CARRFIELD MEDICAL CENTRE C88082 0.65 DUNNINC ROAD SURGERY C88643 0.65 • it is estimated that there are 55,041 DEEPCAR MEDICAL CENTRE C88074 0.65 ABBEY LANE SURGERY C88046 0.64 VERITAS HEALTH CENTRE C88631 0.64 DARNALL HEALTH CENTRE (MEHROTRA) C88084 0.64 people with undiagnosed ELM LANE SURGERY C88049 0.63 SOTHALL & BEIGHTON HEALTH CENTRES C88023 0.63 SHEFFIELD MEDICAL CENTRE C88622 0.62 STONECROFT MEDICAL CENTRE C88022 0.62 hypertension in NHS Sheffield CCG HANDSWORTH MEDICAL PRACTICE C88036 0.62 NORWOOD MEDICAL CENTRE C88014 0.62 WINCOBANK MEDICAL CENTRE C88047 0.61 MOSBOROUGH HEALTH CENTRE C88078 0.61 • GP practice range of observed to BIRLEY HEALTH CENTRE C88025 0.61 WOODHOUSE MEDICAL CENTRE C88072 0.61 VALLEY MEDICAL CENTRE C88092 0.61 GLEADLESS MEDICAL CENTRE C88019 0.61 expected hypertension prevalence GRENOSIDE SURGERY C88054 0.61 HACKENTHORPE MEDICAL CENTRE C88096 0.60 AVENUE MEDICAL PRACTICE C88024 0.60 DOVERCOURT GROUP PRACTICE C88087 0.60 0.03 to 0.77 THE MEDICAL CENTRE DR OKORIE C88655 0.59 MANOR TOP MEDICAL CENTRE C88638 0.58 JAUNTY SPRINGS HEALTH CENTRE C88050 0.57 WOODSEATS MEDICAL CENTRE C88041 0.57 CROOKES VALLEY MEDICAL CENTRE C88057 0.57 WHITE HOUSE SURGERY C88020 0.57 THE MATHEWS PRACTICE BELGRAVE C88038 0.57 THE FLOWERS HEALTH CENTRE C88033 0.57 SHIREGREEN MEDICAL CENTRE C88070 0.56 EAST BANK MEDICAL CENTRE C88088 0.56 MANOR PARK MEDICAL CENTRE C88090 0.56 FOXHILL MEDICAL CENTRE C88009 0.55 NETHERGREEN SURGERY C88034 0.55 STANNINGTON MEDICAL CENTRE C88656 0.55 RICHMOND MEDICAL CENTRE C88085 0.55 CHARNOCK HEALTH PRIMARY CARE CENTRE C88032 0.55 DYKES HALL MEDICAL CENTRE C88045 0.55 SLOAN MEDICAL CENTRE C88026 0.54 BUCHANAN ROAD SURGERY C88011 0.54 SELBORNE ROAD MEDICAL CENTRE C88083 0.54 FIRTH PARK SURGERY C88035 0.53 CHAPELGREEN PRACTICE C88010 0.53 BASLOW RD, SHOREHAM ST & YORK RD SRGIES C88037 0.52 CLOVER GROUP PRACTICE C88069 0.52 GREYSTONES MEDICAL CENTRE C88652 0.52 CARTERKNOWLE & DORE MEDICAL PRACTICE C88016 0.52 NORFOLK PARK HEALTH CENTRE C88006 0.52 HOLLIES MEDICAL CENTRE C88052 0.51 SOUTHEY GREEN MEDICAL CTR C88086 0.51 UPWELL STREET SURGERY C88027 0.51 TRAMWAYS 54A MC C88043 0.51 PARK HEALTH CENTRE C88042 0.51 SHARROW LANE MEDICAL CENTRE C88060 0.50 HEELEY GREEN SURGERY C88073 0.50 RUSTLINGS ROAD MEDICAL CENTRE C88062 0.50 DUKE MEDICAL CENTRE C88030 0.50 FAR LANE MEDICAL CENTRE C88021 0.50 PITSMOOR SURGERY C88008 0.49 CROOKES PRACTICE C88079 0.49 TRAMWAYS MEDICAL CENTRE (O'CONNELL) C88018 0.47 FALKLAND HOUSE SURGERY C88053 0.47 BROOMHILL SURGERY C88028 0.47 MANCHESTER ROAD SURGERY C88044 0.47 PAGE HALL MEDICAL CENTRE C88051 0.46 OUGHTIBRIDGE SURGERY C88040 0.46 WALKLEY HOUSE MEDICAL CENTRE C88005 0.45 TOTLEY RISE MEDICAL CENTRE C88068 0.45 UPPERTHORPE MEDICAL CENTRE C88031 0.44 DEVONSHIRE GREEN MEDICAL CENTRE C88076 0.44 BURNGREAVE SURGERY C88048 0.41 SHEFFIELD CITY GP HC (REG) Y02566 0.29 PORTER BROOK MEDICAL CENTRE C88007 0.24 BENTS GREEN SURGERY C88061 0.04 UNIVERSITY HEALTH SERVICE HEALTH CENTRE C88627 0.03 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 Doncaster CCG 83.5%

• 76,519 people with hypertension NHS Rotherham CCG 81.2% (diagnosed)* in NHS Sheffield CCG • 61,854 (80.8%) people whose blood pressure is <= 150/90 • 2,856 (3.7%) people who are NHS Bassetlaw CCG 80.9% excepted from optimal control • 11,809 (15.4%) additional people whose blood pressure is not <= NHS Sheffield CCG 80.8% 150/90

NHS Barnsley CCG 78.8%

England 79.6%

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

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

NHS Lincolnshire West CCG 82.3%

NHS North Durham CCG 82.1%

NHS Newcastle Gateshead CCG 81.3%

NHS Greater Huddersfield CCG 80.8%

NHS Sheffield CCG 80.8%

NHS Southern Derbyshire CCG 80.6%

NHS West Leicestershire CCG 80.5%

NHS Liverpool CCG 80.3%

NHS Coventry and Rugby CCG 80.1%

NHS Portsmouth CCG 80.0%

NHS Bristol CCG 77.8%

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

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

No treatment Exceptions reported

SHEFFIELD CITY GP HC (REG) Y02566 74 THE MEDICAL CENTRE DR OKORIE C88655 58 UNIVERSITY HEALTH SERVICE HEALTH CENTRE C88627 17 MANOR TOP MEDICAL CENTRE C88638 68 MANOR PARK MEDICAL CENTRE C88090 166 MANOR TOP MEDICAL CENTRE (READ) C88626 102 THE MATHEWS PRACTICE BELGRAVE C88038 417 SLOAN MEDICAL CENTRE C88026 447 GLEADLESS MEDICAL CENTRE C88019 361 NETHERGREEN SURGERY C88034 348 BURNGREAVE SURGERY C88048 159 • in total, including exceptions, there HANDSWORTH MEDICAL PRACTICE C88036 411 VALLEY MEDICAL CENTRE C88092 408 CROOKES PRACTICE C88079 168 are 14,665 people whose blood BIRLEY HEALTH CENTRE C88025 320 BASLOW RD, SHOREHAM ST & YORK RD SRGIES C88037 430 TOTLEY RISE MEDICAL CENTRE C88068 99 HOLLIES MEDICAL CENTRE C88052 215 pressure is not <= 150/90 UPWELL STREET SURGERY C88027 116 PAGE HALL MEDICAL CENTRE C88051 132 CHAPELGREEN PRACTICE C88010 556 AVENUE MEDICAL PRACTICE C88024 288 • GP practice range: 6.3% to 46.0% SHIREGREEN MEDICAL CENTRE C88070 218 BARNSLEY ROAD SURGERY C88091 102 SHEFFIELD MEDICAL CENTRE C88622 52 DARNALL HEALTH CENTRE (MEHROTRA) C88084 126 DUNNINC ROAD SURGERY C88643 99 SELBORNE ROAD MEDICAL CENTRE C88083 84 MOSBOROUGH HEALTH CENTRE C88078 217 SOTHALL & BEIGHTON HEALTH CENTRES C88023 329 WESTFIELD HEALTH CENTRE Y04887 31 HAROLD STREET MEDICAL CENTRE C88059 52 GRENOSIDE SURGERY C88054 243 STONECROFT MEDICAL CENTRE C88022 164 THE FLOWERS HEALTH CENTRE C88033 120 PITSMOOR SURGERY C88008 200 MILL ROAD SURGERY C88095 199 BUCHANAN ROAD SURGERY C88011 124 WALKLEY HOUSE MEDICAL CENTRE C88005 276 JAUNTY SPRINGS HEALTH CENTRE C88050 133 HACKENTHORPE MEDICAL CENTRE C88096 203 OUGHTIBRIDGE SURGERY C88040 145 MANCHESTER ROAD SURGERY C88044 106 ECCLESFIELD GROUP PRACT C88039 318 UPPERTHORPE MEDICAL CENTRE C88031 250 PORTER BROOK MEDICAL CENTRE C88007 128 DEEPCAR MEDICAL CENTRE C88074 158 GREYSTONES MEDICAL CENTRE C88652 65 BROOMHILL SURGERY C88028 210 ABBEY LANE SURGERY C88046 93 MEADOWGREEN HEALTH CENTRE C88015 353 HEELEY GREEN SURGERY C88073 116 CLOVER GROUP PRACTICE C88069 312 THE HEALTH CARE SURGERY C88077 127 WHITE HOUSE SURGERY C88020 136 FOXHILL MEDICAL CENTRE C88009 145 RUSTLINGS ROAD MEDICAL CENTRE C88062 76 WOODSEATS MEDICAL CENTRE C88041 217 CARTERKNOWLE & DORE MEDICAL PRACTICE C88016 281 FIRTH PARK SURGERY C88035 188 DUKE MEDICAL CENTRE C88030 143 EAST BANK MEDICAL CENTRE C88088 120 TRAMWAYS MEDICAL CENTRE (O'CONNELL) C88018 180 DYKES HALL MEDICAL CENTRE C88045 224 PARK HEALTH CENTRE C88042 94 WOODHOUSE MEDICAL CENTRE C88072 334 CARRFIELD MEDICAL CENTRE C88082 37 DOVERCOURT GROUP PRACTICE C88087 110 VERITAS HEALTH CENTRE C88631 35 CRYSTAL PEAKS MEDICAL CENTRE C88648 196 OWLTHORPE MEDICAL CENTRE C88647 98 DEVONSHIRE GREEN MEDICAL CENTRE C88076 94 CROOKES VALLEY MEDICAL CENTRE C88057 40 SOUTHEY GREEN MEDICAL CTR C88086 61 FALKLAND HOUSE SURGERY C88053 67 RICHMOND MEDICAL CENTRE C88085 163 NORWOOD MEDICAL CENTRE C88014 167 SHARROW LANE MEDICAL CENTRE C88060 51 TRAMWAYS 54A MC C88043 147 FAR LANE MEDICAL CENTRE C88021 132 WINCOBANK MEDICAL CENTRE C88047 126 CHARNOCK HEALTH PRIMARY CARE CENTRE C88032 96 NORFOLK PARK HEALTH CENTRE C88006 57 STANNINGTON MEDICAL CENTRE C88656 52 ELM LANE SURGERY C88049 84 BENTS GREEN SURGERY C88061 1 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 Doncaster CCG 74.6%

• 266 people with a new diagnosis* of NHS Rotherham CCG 71.7% hypertension with a CVD risk of 20% or higher in NHS Sheffield CCG • 159 (59.8%) people who are currently treated with statins NHS Bassetlaw CCG 63.3% • 99 (37.2%) people who are exempted from treatment with statins • 8 (3%) additional people who are not NHS Barnsley CCG 60.3% currently treated with statins

NHS Sheffield CCG 59.8%

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 Newcastle Gateshead CCG 73.6%

NHS Portsmouth CCG 71.6%

NHS North Durham CCG 71.2%

NHS Liverpool CCG 70.9%

NHS Coventry and Rugby CCG 70.0%

NHS Lincolnshire West CCG 68.4%

NHS Bristol CCG 68.1%

NHS West Leicestershire CCG 65.8%

NHS Southern Derbyshire CCG 61.5%

NHS Sheffield CCG 59.8%

NHS Greater Huddersfield CCG 58.2%

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

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

No treatment Exceptions reported

DOVERCOURT GROUP PRACTICE C88087 3 VERITAS HEALTH CENTRE C88631 2 GREYSTONES MEDICAL CENTRE C88652 1 WESTFIELD HEALTH CENTRE Y04887 1 BURNGREAVE SURGERY C88048 4 SOTHALL & BEIGHTON HEALTH CENTRES C88023 3 UPPERTHORPE MEDICAL CENTRE C88031 3 RUSTLINGS ROAD MEDICAL CENTRE C88062 3 CHAPELGREEN PRACTICE C88010 5 PORTER BROOK MEDICAL CENTRE C88007 2 GLEADLESS MEDICAL CENTRE C88019 4 • in total, including exceptions, there AVENUE MEDICAL PRACTICE C88024 4 NETHERGREEN SURGERY C88034 3 EAST BANK MEDICAL CENTRE C88088 3 are 107 people who are not treated CLOVER GROUP PRACTICE C88069 7 BASLOW RD, SHOREHAM ST & YORK RD SRGIES C88037 4 WINCOBANK MEDICAL CENTRE C88047 4 PITSMOOR SURGERY C88008 1 with statins TRAMWAYS MEDICAL CENTRE (O'CONNELL) C88018 1 STONECROFT MEDICAL CENTRE C88022 1 DUKE MEDICAL CENTRE C88030 1 CHARNOCK HEALTH PRIMARY CARE CENTRE C88032 2 • GP practice range: 0.0% to 100.0% HANDSWORTH MEDICAL PRACTICE C88036 5 OUGHTIBRIDGE SURGERY C88040 1 HOLLIES MEDICAL CENTRE C88052 2 THE HEALTH CARE SURGERY C88077 2 MOSBOROUGH HEALTH CENTRE C88078 3 CARRFIELD MEDICAL CENTRE C88082 1 DARNALL HEALTH CENTRE (MEHROTRA) C88084 1 MANOR PARK MEDICAL CENTRE C88090 1 BARNSLEY ROAD SURGERY C88091 1 HACKENTHORPE MEDICAL CENTRE C88096 1 BROOMHILL SURGERY C88028 2 DYKES HALL MEDICAL CENTRE C88045 2 CRYSTAL PEAKS MEDICAL CENTRE C88648 3 BIRLEY HEALTH CENTRE C88025 1 THE FLOWERS HEALTH CENTRE C88033 1 WOODHOUSE MEDICAL CENTRE C88072 1 DEVONSHIRE GREEN MEDICAL CENTRE C88076 1 SOUTHEY GREEN MEDICAL CTR C88086 1 MANOR TOP MEDICAL CENTRE (READ) C88626 1 NORWOOD MEDICAL CENTRE C88014 4 FOXHILL MEDICAL CENTRE C88009 2 FAR LANE MEDICAL CENTRE C88021 1 UPWELL STREET SURGERY C88027 1 FIRTH PARK SURGERY C88035 1 WOODSEATS MEDICAL CENTRE C88041 2 PARK HEALTH CENTRE C88042 1 CARTERKNOWLE & DORE MEDICAL PRACTICE C88016 1 SLOAN MEDICAL CENTRE C88026 1 WALKLEY HOUSE MEDICAL CENTRE C88005 NORFOLK PARK HEALTH CENTRE C88006 BUCHANAN ROAD SURGERY C88011 MEADOWGREEN HEALTH CENTRE C88015 WHITE HOUSE SURGERY C88020 THE MATHEWS PRACTICE BELGRAVE C88038 ECCLESFIELD GROUP PRACT C88039 TRAMWAYS 54A MC C88043 ABBEY LANE SURGERY C88046 ELM LANE SURGERY C88049 JAUNTY SPRINGS HEALTH CENTRE C88050 PAGE HALL MEDICAL CENTRE C88051 FALKLAND HOUSE SURGERY C88053 GRENOSIDE SURGERY C88054 CROOKES VALLEY MEDICAL CENTRE C88057 HAROLD STREET MEDICAL CENTRE C88059 SHARROW LANE MEDICAL CENTRE C88060 SHIREGREEN MEDICAL CENTRE C88070 HEELEY GREEN SURGERY C88073 DEEPCAR MEDICAL CENTRE C88074 CROOKES PRACTICE C88079 RICHMOND MEDICAL CENTRE C88085 VALLEY MEDICAL CENTRE C88092 MILL ROAD SURGERY C88095 MANOR TOP MEDICAL CENTRE C88638 DUNNINC ROAD SURGERY C88643 OWLTHORPE MEDICAL CENTRE C88647 SHEFFIELD CITY GP HC (REG) Y02566 STANNINGTON MEDICAL CENTRE C88656 THE MEDICAL CENTRE DR OKORIE C88655 UNIVERSITY HEALTH SERVICE HEALTH CENTRE C88627 SHEFFIELD MEDICAL CENTRE C88622 SELBORNE ROAD MEDICAL CENTRE C88083 TOTLEY RISE MEDICAL CENTRE C88068 BENTS GREEN SURGERY C88061 MANCHESTER ROAD SURGERY C88044 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 Bassetlaw CCG 0.78

• the ratio of those diagnosed with atrial NHS Doncaster CCG 0.77 fibrillation versus those expected to have atrial fibrillation is 0.76. This compares to 0.7 for England • this suggests that 76% of people with NHS Sheffield CCG 0.76 atrial fibrillation have been diagnosed.

NHS Rotherham CCG 0.73

NHS Barnsley CCG 0.72

Note: This slide compares the prevalence of atrial fibrillation recorded in QOF in 2015/16 to the estimated prevalence of atrial fibrillation, taken from National Cardiovascular Intelligence Network estimates produced in 2017. The estimates were developed by applying age-sex England 0.70 specific prevalence rates as reported by Norberg et al (2013) to GP population estimates from 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 NHS Digital. Estimates reported are adjusted for age and sex of the local population.

28 CVD: Primary Care Intelligence Packs Atrial fibrillation observed prevalence compared to expected prevalence by CCG Comparison with demographically similar CCGs

NHS Liverpool CCG 0.79

NHS Sheffield CCG 0.76

NHS Portsmouth CCG 0.74

NHS Bristol CCG 0.74

NHS West Leicestershire CCG 0.71

NHS Newcastle Gateshead CCG 0.70

NHS Lincolnshire West CCG 0.70

NHS North Durham CCG 0.69

NHS Southern Derbyshire CCG 0.69

NHS Greater Huddersfield CCG 0.66

NHS Coventry and Rugby CCG 0.62

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

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

GP practice CCG

NORFOLK PARK HEALTH CENTRE C88006 1.0 MANCHESTER ROAD SURGERY C88044 1.0 VALLEY MEDICAL CENTRE C88092 1.0 MILL ROAD SURGERY C88095 1.0 STANNINGTON MEDICAL CENTRE C88656 1.0 SOTHALL & BEIGHTON HEALTH CENTRES C88023 0.9 ECCLESFIELD GROUP PRACT C88039 0.9 WOODHOUSE MEDICAL CENTRE C88072 0.9 THE HEALTH CARE SURGERY C88077 0.9 RICHMOND MEDICAL CENTRE C88085 0.9 MANOR PARK MEDICAL CENTRE C88090 0.9 • it is estimated that there are 13,498 FOXHILL MEDICAL CENTRE C88009 0.8 CHAPELGREEN PRACTICE C88010 0.8 BUCHANAN ROAD SURGERY C88011 0.8 NORWOOD MEDICAL CENTRE C88014 0.8 people with undiagnosed atrial MEADOWGREEN HEALTH CENTRE C88015 0.8 TRAMWAYS MEDICAL CENTRE (O'CONNELL) C88018 0.8 GLEADLESS MEDICAL CENTRE C88019 0.8 fibrillation in NHS Sheffield CCG WHITE HOUSE SURGERY C88020 0.8 AVENUE MEDICAL PRACTICE C88024 0.8 SLOAN MEDICAL CENTRE C88026 0.8 UPWELL STREET SURGERY C88027 0.8 • GP practice range of observed to DUKE MEDICAL CENTRE C88030 0.8 FIRTH PARK SURGERY C88035 0.8 HANDSWORTH MEDICAL PRACTICE C88036 0.8 OUGHTIBRIDGE SURGERY C88040 0.8 expected atrial fibrillation prevalence PARK HEALTH CENTRE C88042 0.8 DYKES HALL MEDICAL CENTRE C88045 0.8 ABBEY LANE SURGERY C88046 0.8 0.2 to 1 ELM LANE SURGERY C88049 0.8 JAUNTY SPRINGS HEALTH CENTRE C88050 0.8 HOLLIES MEDICAL CENTRE C88052 0.8 GRENOSIDE SURGERY C88054 0.8 CROOKES VALLEY MEDICAL CENTRE C88057 0.8 HEELEY GREEN SURGERY C88073 0.8 MOSBOROUGH HEALTH CENTRE C88078 0.8 EAST BANK MEDICAL CENTRE C88088 0.8 BARNSLEY ROAD SURGERY C88091 0.8 WALKLEY HOUSE MEDICAL CENTRE C88005 0.7 PITSMOOR SURGERY C88008 0.7 CARTERKNOWLE & DORE MEDICAL PRACTICE C88016 0.7 FAR LANE MEDICAL CENTRE C88021 0.7 STONECROFT MEDICAL CENTRE C88022 0.7 BIRLEY HEALTH CENTRE C88025 0.7 BROOMHILL SURGERY C88028 0.7 UPPERTHORPE MEDICAL CENTRE C88031 0.7 NETHERGREEN SURGERY C88034 0.7 BASLOW RD, SHOREHAM ST & YORK RD SRGIES C88037 0.7 THE MATHEWS PRACTICE BELGRAVE C88038 0.7 WOODSEATS MEDICAL CENTRE C88041 0.7 TRAMWAYS 54A MC C88043 0.7 WINCOBANK MEDICAL CENTRE C88047 0.7 RUSTLINGS ROAD MEDICAL CENTRE C88062 0.7 TOTLEY RISE MEDICAL CENTRE C88068 0.7 CLOVER GROUP PRACTICE C88069 0.7 DEEPCAR MEDICAL CENTRE C88074 0.7 DEVONSHIRE GREEN MEDICAL CENTRE C88076 0.7 CROOKES PRACTICE C88079 0.7 CARRFIELD MEDICAL CENTRE C88082 0.7 HACKENTHORPE MEDICAL CENTRE C88096 0.7 VERITAS HEALTH CENTRE C88631 0.7 CRYSTAL PEAKS MEDICAL CENTRE C88648 0.7 GREYSTONES MEDICAL CENTRE C88652 0.7 PORTER BROOK MEDICAL CENTRE C88007 0.6 THE FLOWERS HEALTH CENTRE C88033 0.6 BURNGREAVE SURGERY C88048 0.6 PAGE HALL MEDICAL CENTRE C88051 0.6 FALKLAND HOUSE SURGERY C88053 0.6 SHIREGREEN MEDICAL CENTRE C88070 0.6 SELBORNE ROAD MEDICAL CENTRE C88083 0.6 DARNALL HEALTH CENTRE (MEHROTRA) C88084 0.6 SOUTHEY GREEN MEDICAL CTR C88086 0.6 DUNNINC ROAD SURGERY C88643 0.6 OWLTHORPE MEDICAL CENTRE C88647 0.6 CHARNOCK HEALTH PRIMARY CARE CENTRE C88032 0.5 HAROLD STREET MEDICAL CENTRE C88059 0.5 DOVERCOURT GROUP PRACTICE C88087 0.5 SHARROW LANE MEDICAL CENTRE C88060 0.4 SHEFFIELD MEDICAL CENTRE C88622 0.3 UNIVERSITY HEALTH SERVICE HEALTH CENTRE C88627 0.2 THE MEDICAL CENTRE DR OKORIE C88655 0.2 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Ratio

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

NHS Bassetlaw CCG 83.3% • 8,557 people with atrial fibrillation* with a CHA2DS2-VASc score >= 2 in NHS Sheffield CCG NHS Doncaster CCG 83.2% • 6,823 (79.7%) people treated with anti-coagulation therapy • 778 (9.1%) people who are NHS Sheffield CCG 79.7% exceptions • 956 (11.2%) additional people with a recorded CHA2DS2-VASc score >= 2 NHS Barnsley CCG 79.1% who are not treated

NHS Rotherham CCG 76.5%

England 77.9%

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

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

NHS Lincolnshire West CCG 84.5%

NHS North Durham CCG 83.5%

NHS West Leicestershire CCG 81.4%

NHS Sheffield CCG 79.7%

NHS Bristol CCG 79.1%

NHS Liverpool CCG 79.0%

NHS Newcastle Gateshead CCG 78.4%

NHS Southern Derbyshire CCG 76.0%

NHS Greater Huddersfield CCG 74.4%

NHS Portsmouth CCG 74.2%

NHS Coventry and Rugby CCG 73.1%

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

BENTS GREEN SURGERY C88061 4 THE FLOWERS HEALTH CENTRE C88033 22 SELBORNE ROAD MEDICAL CENTRE C88083 16 DEVONSHIRE GREEN MEDICAL CENTRE C88076 23 MANOR TOP MEDICAL CENTRE (READ) C88626 10 HEELEY GREEN SURGERY C88073 26 EAST BANK MEDICAL CENTRE C88088 20 WESTFIELD HEALTH CENTRE Y04887 3 BURNGREAVE SURGERY C88048 17 CHARNOCK HEALTH PRIMARY CARE CENTRE C88032 23 WHITE HOUSE SURGERY C88020 23 • in total, including exceptions, there BARNSLEY ROAD SURGERY C88091 13 UPWELL STREET SURGERY C88027 16 MANOR TOP MEDICAL CENTRE C88638 6 are 1,734 people with a recorded HANDSWORTH MEDICAL PRACTICE C88036 47 HOLLIES MEDICAL CENTRE C88052 30 CHAPELGREEN PRACTICE C88010 83 ELM LANE SURGERY C88049 25 CHA2DS2-VASc score >= 2 who are SHEFFIELD MEDICAL CENTRE C88622 2 VERITAS HEALTH CENTRE C88631 6 BASLOW RD, SHOREHAM ST & YORK RD SRGIES C88037 59 MANOR PARK MEDICAL CENTRE C88090 17 not treated WALKLEY HOUSE MEDICAL CENTRE C88005 42 NORWOOD MEDICAL CENTRE C88014 33 PORTER BROOK MEDICAL CENTRE C88007 16 • GP practice range: 0.0% to 80.0% FOXHILL MEDICAL CENTRE C88009 24 SLOAN MEDICAL CENTRE C88026 40 BROOMHILL SURGERY C88028 45 PARK HEALTH CENTRE C88042 14 MEADOWGREEN HEALTH CENTRE C88015 51 MANCHESTER ROAD SURGERY C88044 23 BUCHANAN ROAD SURGERY C88011 15 GLEADLESS MEDICAL CENTRE C88019 34 PITSMOOR SURGERY C88008 22 STONECROFT MEDICAL CENTRE C88022 18 DEEPCAR MEDICAL CENTRE C88074 16 FALKLAND HOUSE SURGERY C88053 11 NETHERGREEN SURGERY C88034 31 UPPERTHORPE MEDICAL CENTRE C88031 38 MOSBOROUGH HEALTH CENTRE C88078 27 TRAMWAYS MEDICAL CENTRE (O'CONNELL) C88018 33 PAGE HALL MEDICAL CENTRE C88051 10 SOUTHEY GREEN MEDICAL CTR C88086 6 CLOVER GROUP PRACTICE C88069 30 GRENOSIDE SURGERY C88054 25 CROOKES PRACTICE C88079 15 DYKES HALL MEDICAL CENTRE C88045 34 SHIREGREEN MEDICAL CENTRE C88070 16 DUKE MEDICAL CENTRE C88030 19 CARTERKNOWLE & DORE MEDICAL PRACTICE C88016 46 JAUNTY SPRINGS HEALTH CENTRE C88050 18 ECCLESFIELD GROUP PRACT C88039 37 THE MATHEWS PRACTICE BELGRAVE C88038 35 BIRLEY HEALTH CENTRE C88025 26 SOTHALL & BEIGHTON HEALTH CENTRES C88023 32 CROOKES VALLEY MEDICAL CENTRE C88057 5 FAR LANE MEDICAL CENTRE C88021 23 WOODHOUSE MEDICAL CENTRE C88072 51 RICHMOND MEDICAL CENTRE C88085 25 DUNNINC ROAD SURGERY C88643 5 THE MEDICAL CENTRE DR OKORIE C88655 1 OUGHTIBRIDGE SURGERY C88040 18 TRAMWAYS 54A MC C88043 19 MILL ROAD SURGERY C88095 20 RUSTLINGS ROAD MEDICAL CENTRE C88062 7 CARRFIELD MEDICAL CENTRE C88082 4 NORFOLK PARK HEALTH CENTRE C88006 11 WOODSEATS MEDICAL CENTRE C88041 19 CRYSTAL PEAKS MEDICAL CENTRE C88648 14 FIRTH PARK SURGERY C88035 16 DOVERCOURT GROUP PRACTICE C88087 11 AVENUE MEDICAL PRACTICE C88024 21 VALLEY MEDICAL CENTRE C88092 33 SHARROW LANE MEDICAL CENTRE C88060 3 THE HEALTH CARE SURGERY C88077 9 GREYSTONES MEDICAL CENTRE C88652 5 DARNALL HEALTH CENTRE (MEHROTRA) C88084 5 TOTLEY RISE MEDICAL CENTRE C88068 6 ABBEY LANE SURGERY C88046 6 WINCOBANK MEDICAL CENTRE C88047 9 STANNINGTON MEDICAL CENTRE C88656 7 OWLTHORPE MEDICAL CENTRE C88647 3 HACKENTHORPE MEDICAL CENTRE C88096 5 HAROLD STREET MEDICAL CENTRE C88059 UNIVERSITY HEALTH SERVICE HEALTH CENTRE C88627 SHEFFIELD CITY GP HC (REG) Y02566 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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

20% 15% 10% 5% 0% -5% -10% -15% -20% -25% -30% -35%

THE FLOWERS HEALTH CENTRE 15

SELBORNE ROAD MEDICAL CENTRE 9

MANOR TOP MEDICAL CENTRE (READ) 6 • using the GP cluster method of DEVONSHIRE GREEN MEDICAL CENTRE 12 calculating potential gains, if each HEELEY GREEN SURGERY 14 practice was to achieve as well as the EAST BANK MEDICAL CENTRE 11 upper quartile of its national cluster, then an additional 431 people would BURNGREAVE SURGERY 9 be treated WESTFIELD HEALTH CENTRE 1

CHARNOCK HEALTH PRIMARY CARE CENTRE 11

UPWELL STREET SURGERY 7

DARNALL HEALTH CENTRE (MEHROTRA)

VALLEY MEDICAL CENTRE

ABBEY LANE SURGERY

WINCOBANK MEDICAL CENTRE

STANNINGTON MEDICAL CENTRE

OWLTHORPE MEDICAL CENTRE

HACKENTHORPE MEDICAL CENTRE

SHEFFIELD CITY GP HC (REG)

HAROLD STREET MEDICAL CENTRE

UNIVERSITY HEALTH SERVICE HEALTH CENTRE Details of this methodology are available on slide 9. Click here to view them.

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

Below 150/90 Not below 150/90 Exceptions reported

NHS Doncaster CCG 86.8% • 11,849 people with a history of stroke or TIA* in NHS Sheffield CCG • 10,060 (84.9%) people whose blood NHS Rotherham CCG 85.1% pressure is <= 150 / 90 • 479 (4%) people who are exceptions • 1,310 (11.1%) additional people NHS Sheffield CCG 84.9% whose blood pressure is not <= 150 / 90

NHS Bassetlaw CCG 83.4%

NHS Barnsley 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 Greater Huddersfield CCG 86.2%

NHS Lincolnshire West CCG 86.1%

NHS North Durham CCG 85.7%

NHS Newcastle Gateshead CCG 85.7%

NHS Sheffield CCG 84.9%

NHS Liverpool CCG 84.9%

NHS Coventry and Rugby CCG 84.5%

NHS West Leicestershire CCG 84.5%

NHS Portsmouth CCG 84.4%

NHS Southern Derbyshire CCG 83.1%

NHS Bristol CCG 81.9%

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

MANOR PARK MEDICAL CENTRE C88090 23 UNIVERSITY HEALTH SERVICE HEALTH CENTRE C88627 2 THE MEDICAL CENTRE DR OKORIE C88655 5 WESTFIELD HEALTH CENTRE Y04887 7 THE MATHEWS PRACTICE BELGRAVE C88038 65 MANOR TOP MEDICAL CENTRE C88638 8 SHEFFIELD MEDICAL CENTRE C88622 8 BARNSLEY ROAD SURGERY C88091 11 HAROLD STREET MEDICAL CENTRE C88059 6 BENTS GREEN SURGERY C88061 2 THE FLOWERS HEALTH CENTRE C88033 20 • in total, including exceptions, there TOTLEY RISE MEDICAL CENTRE C88068 14 BIRLEY HEALTH CENTRE C88025 46 MANOR TOP MEDICAL CENTRE (READ) C88626 10 are 1,789 people whose blood TRAMWAYS MEDICAL CENTRE (O'CONNELL) C88018 41 GRENOSIDE SURGERY C88054 29 BASLOW RD, SHOREHAM ST & YORK RD SRGIES C88037 57 VALLEY MEDICAL CENTRE C88092 45 pressure is not <= 150 / 90 SELBORNE ROAD MEDICAL CENTRE C88083 15 PORTER BROOK MEDICAL CENTRE C88007 23 SHIREGREEN MEDICAL CENTRE C88070 28 SLOAN MEDICAL CENTRE C88026 42 • GP practice range: 3.6% to 33.3% DUNNINC ROAD SURGERY C88643 10 GLEADLESS MEDICAL CENTRE C88019 33 NETHERGREEN SURGERY C88034 31 UPWELL STREET SURGERY C88027 20 JAUNTY SPRINGS HEALTH CENTRE C88050 24 CHAPELGREEN PRACTICE C88010 79 BUCHANAN ROAD SURGERY C88011 21 DARNALL HEALTH CENTRE (MEHROTRA) C88084 14 ABBEY LANE SURGERY C88046 12 BURNGREAVE SURGERY C88048 18 AVENUE MEDICAL PRACTICE C88024 28 WHITE HOUSE SURGERY C88020 21 SOTHALL & BEIGHTON HEALTH CENTRES C88023 42 MANCHESTER ROAD SURGERY C88044 18 DOVERCOURT GROUP PRACTICE C88087 18 HACKENTHORPE MEDICAL CENTRE C88096 26 SHEFFIELD CITY GP HC (REG) Y02566 2 PARK HEALTH CENTRE C88042 17 MILL ROAD SURGERY C88095 27 MOSBOROUGH HEALTH CENTRE C88078 25 STONECROFT MEDICAL CENTRE C88022 18 BROOMHILL SURGERY C88028 34 HOLLIES MEDICAL CENTRE C88052 23 WOODHOUSE MEDICAL CENTRE C88072 66 WALKLEY HOUSE MEDICAL CENTRE C88005 30 PITSMOOR SURGERY C88008 23 FALKLAND HOUSE SURGERY C88053 9 NORFOLK PARK HEALTH CENTRE C88006 15 GREYSTONES MEDICAL CENTRE C88652 6 FAR LANE MEDICAL CENTRE C88021 22 DUKE MEDICAL CENTRE C88030 18 WOODSEATS MEDICAL CENTRE C88041 29 OUGHTIBRIDGE SURGERY C88040 22 CHARNOCK HEALTH PRIMARY CARE CENTRE C88032 15 CARTERKNOWLE & DORE MEDICAL PRACTICE C88016 36 CLOVER GROUP PRACTICE C88069 34 CROOKES PRACTICE C88079 15 HANDSWORTH MEDICAL PRACTICE C88036 30 OWLTHORPE MEDICAL CENTRE C88647 11 ECCLESFIELD GROUP PRACT C88039 33 DEEPCAR MEDICAL CENTRE C88074 16 EAST BANK MEDICAL CENTRE C88088 14 UPPERTHORPE MEDICAL CENTRE C88031 31 HEELEY GREEN SURGERY C88073 12 DYKES HALL MEDICAL CENTRE C88045 24 RUSTLINGS ROAD MEDICAL CENTRE C88062 9 PAGE HALL MEDICAL CENTRE C88051 14 VERITAS HEALTH CENTRE C88631 3 MEADOWGREEN HEALTH CENTRE C88015 32 FOXHILL MEDICAL CENTRE C88009 14 TRAMWAYS 54A MC C88043 17 SOUTHEY GREEN MEDICAL CTR C88086 6 DEVONSHIRE GREEN MEDICAL CENTRE C88076 10 THE HEALTH CARE SURGERY C88077 9 NORWOOD MEDICAL CENTRE C88014 18 CROOKES VALLEY MEDICAL CENTRE C88057 3 FIRTH PARK SURGERY C88035 14 CRYSTAL PEAKS MEDICAL CENTRE C88648 14 CARRFIELD MEDICAL CENTRE C88082 2 RICHMOND MEDICAL CENTRE C88085 17 ELM LANE SURGERY C88049 9 WINCOBANK MEDICAL CENTRE C88047 10 STANNINGTON MEDICAL CENTRE C88656 7 SHARROW LANE MEDICAL CENTRE C88060 2 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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

NHS Doncaster CCG 93.7% • 8,178 people with a stroke shown to be non-haemorrhagic* in NHS Sheffield CCG NHS Rotherham CCG 91.9% • 7,477 (91.4%) people who are taking an anti-platetet agent or anti- coagulant NHS Barnsley CCG 91.4% • 378 (4.6%) people who are exceptions • 323 (3.9%) additional people with no NHS Sheffield CCG 91.4% treatment

NHS Bassetlaw CCG 90.2%

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 Liverpool CCG 93.4%

NHS Newcastle Gateshead CCG 93.4%

NHS Coventry and Rugby CCG 93.1%

NHS North Durham CCG 92.5%

NHS Greater Huddersfield CCG 92.0%

NHS West Leicestershire CCG 91.9%

NHS Sheffield CCG 91.4%

NHS Southern Derbyshire CCG 91.3%

NHS Bristol CCG 90.8%

NHS Lincolnshire West CCG 90.6%

NHS Portsmouth CCG 90.6%

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

UNIVERSITY HEALTH SERVICE HEALTH CENTRE C88627 1 BENTS GREEN SURGERY C88061 3 HOLLIES MEDICAL CENTRE C88052 24 TOTLEY RISE MEDICAL CENTRE C88068 8 GREYSTONES MEDICAL CENTRE C88652 5 SELBORNE ROAD MEDICAL CENTRE C88083 11 NETHERGREEN SURGERY C88034 21 UPWELL STREET SURGERY C88027 12 CROOKES PRACTICE C88079 14 THE FLOWERS HEALTH CENTRE C88033 7 GLEADLESS MEDICAL CENTRE C88019 17 • in total, including exceptions, there TRAMWAYS MEDICAL CENTRE (O'CONNELL) C88018 17 PITSMOOR SURGERY C88008 14 PORTER BROOK MEDICAL CENTRE C88007 11 are 701 people who are not taking an CHARNOCK HEALTH PRIMARY CARE CENTRE C88032 10 SOTHALL & BEIGHTON HEALTH CENTRES C88023 21 WALKLEY HOUSE MEDICAL CENTRE C88005 16 SHIREGREEN MEDICAL CENTRE C88070 12 anti-platelet agent or anti-coagulant GRENOSIDE SURGERY C88054 9 VALLEY MEDICAL CENTRE C88092 21 NORWOOD MEDICAL CENTRE C88014 13 WINCOBANK MEDICAL CENTRE C88047 13 • GP practice range: 0.0% to 100.0% FALKLAND HOUSE SURGERY C88053 5 FAR LANE MEDICAL CENTRE C88021 10 STANNINGTON MEDICAL CENTRE C88656 8 MOSBOROUGH HEALTH CENTRE C88078 11 MANOR PARK MEDICAL CENTRE C88090 5 WESTFIELD HEALTH CENTRE Y04887 2 AVENUE MEDICAL PRACTICE C88024 10 CLOVER GROUP PRACTICE C88069 17 CARTERKNOWLE & DORE MEDICAL PRACTICE C88016 19 WOODSEATS MEDICAL CENTRE C88041 16 EAST BANK MEDICAL CENTRE C88088 9 MILL ROAD SURGERY C88095 12 ELM LANE SURGERY C88049 7 WOODHOUSE MEDICAL CENTRE C88072 31 TRAMWAYS 54A MC C88043 10 UPPERTHORPE MEDICAL CENTRE C88031 14 OUGHTIBRIDGE SURGERY C88040 9 PAGE HALL MEDICAL CENTRE C88051 7 BUCHANAN ROAD SURGERY C88011 6 DEVONSHIRE GREEN MEDICAL CENTRE C88076 5 SLOAN MEDICAL CENTRE C88026 15 HAROLD STREET MEDICAL CENTRE C88059 1 DUNNINC ROAD SURGERY C88643 3 DEEPCAR MEDICAL CENTRE C88074 7 BURNGREAVE SURGERY C88048 4 RICHMOND MEDICAL CENTRE C88085 9 OWLTHORPE MEDICAL CENTRE C88647 5 SOUTHEY GREEN MEDICAL CTR C88086 3 THE MEDICAL CENTRE DR OKORIE C88655 1 DYKES HALL MEDICAL CENTRE C88045 9 BASLOW RD, SHOREHAM ST & YORK RD SRGIES C88037 16 HANDSWORTH MEDICAL PRACTICE C88036 11 MANOR TOP MEDICAL CENTRE (READ) C88626 2 MANCHESTER ROAD SURGERY C88044 6 CRYSTAL PEAKS MEDICAL CENTRE C88648 6 STONECROFT MEDICAL CENTRE C88022 5 BIRLEY HEALTH CENTRE C88025 9 THE MATHEWS PRACTICE BELGRAVE C88038 10 CHAPELGREEN PRACTICE C88010 17 SHARROW LANE MEDICAL CENTRE C88060 2 PARK HEALTH CENTRE C88042 5 WHITE HOUSE SURGERY C88020 5 MANOR TOP MEDICAL CENTRE C88638 1 ECCLESFIELD GROUP PRACT C88039 10 HACKENTHORPE MEDICAL CENTRE C88096 6 MEADOWGREEN HEALTH CENTRE C88015 9 DOVERCOURT GROUP PRACTICE C88087 4 ABBEY LANE SURGERY C88046 2 SHEFFIELD MEDICAL CENTRE C88622 1 BARNSLEY ROAD SURGERY C88091 1 CROOKES VALLEY MEDICAL CENTRE C88057 1 NORFOLK PARK HEALTH CENTRE C88006 3 BROOMHILL SURGERY C88028 5 RUSTLINGS ROAD MEDICAL CENTRE C88062 2 JAUNTY SPRINGS HEALTH CENTRE C88050 3 FIRTH PARK SURGERY C88035 3 DARNALL HEALTH CENTRE (MEHROTRA) C88084 2 HEELEY GREEN SURGERY C88073 1 FOXHILL MEDICAL CENTRE C88009 1 DUKE MEDICAL CENTRE C88030 1 THE HEALTH CARE SURGERY C88077 1 CARRFIELD MEDICAL CENTRE C88082 VERITAS HEALTH CENTRE C88631 SHEFFIELD CITY GP HC (REG) Y02566 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 Bassetlaw CCG 0.90 • 0.77 ratio of observed to expected diabetes prevalence in NHS Sheffield

NHS Doncaster CCG 0.88 CCG, compared to 0.77 in England

• this suggests 77% of people have NHS Barnsley CCG 0.83 been diagnosed

NHS Rotherham CCG 0.78

NHS Sheffield CCG 0.77

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

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

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

NHS North Durham CCG 0.86

NHS West Leicestershire CCG 0.84

NHS Lincolnshire West CCG 0.82

NHS Southern Derbyshire CCG 0.81

NHS Newcastle Gateshead CCG 0.81

NHS Portsmouth CCG 0.78

NHS Coventry and Rugby CCG 0.78

NHS Sheffield CCG 0.77

NHS Liverpool CCG 0.76

NHS Bristol CCG 0.71

NHS Greater Huddersfield CCG 0.70

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

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

GP practice CCG

SHARROW LANE MEDICAL CENTRE C88060 12.0% SHEFFIELD MEDICAL CENTRE C88622 11.1% VERITAS HEALTH CENTRE C88631 11.0% THE MEDICAL CENTRE DR OKORIE C88655 10.8% PAGE HALL MEDICAL CENTRE C88051 10.3% PARK HEALTH CENTRE C88042 10.3% CROOKES VALLEY MEDICAL CENTRE C88057 9.8% NORWOOD MEDICAL CENTRE C88014 9.7% CLOVER GROUP PRACTICE C88069 9.6% UPWELL STREET SURGERY C88027 9.3% ECCLESFIELD GROUP PRACT C88039 9.3% • GP practice range of observed BARNSLEY ROAD SURGERY C88091 9.2% HAROLD STREET MEDICAL CENTRE C88059 9.1% PITSMOOR SURGERY C88008 8.8% WINCOBANK MEDICAL CENTRE C88047 8.8% diabetes 0.1% to 12.0% DARNALL HEALTH CENTRE (MEHROTRA) C88084 8.8% NORFOLK PARK HEALTH CENTRE C88006 8.7% SHIREGREEN MEDICAL CENTRE C88070 8.7% • there are an estimated 8,935 people JAUNTY SPRINGS HEALTH CENTRE C88050 8.6% BUCHANAN ROAD SURGERY C88011 8.5% WHITE HOUSE SURGERY C88020 8.5% STONECROFT MEDICAL CENTRE C88022 8.4% with undiagnosed diabetes in NHS BURNGREAVE SURGERY C88048 8.4% MEADOWGREEN HEALTH CENTRE C88015 8.2% FIRTH PARK SURGERY C88035 8.2% WOODHOUSE MEDICAL CENTRE C88072 8.2% Sheffield CCG EAST BANK MEDICAL CENTRE C88088 8.1% VALLEY MEDICAL CENTRE C88092 8.0% DUKE MEDICAL CENTRE C88030 8.0% FOXHILL MEDICAL CENTRE C88009 7.9% THE MATHEWS PRACTICE BELGRAVE C88038 7.8% THE FLOWERS HEALTH CENTRE C88033 7.8% MANOR PARK MEDICAL CENTRE C88090 7.8% CARRFIELD MEDICAL CENTRE C88082 7.7% SOUTHEY GREEN MEDICAL CTR C88086 7.6% GLEADLESS MEDICAL CENTRE C88019 7.6% THE HEALTH CARE SURGERY C88077 7.5% RICHMOND MEDICAL CENTRE C88085 7.4% BIRLEY HEALTH CENTRE C88025 7.3% HACKENTHORPE MEDICAL CENTRE C88096 7.2% CHAPELGREEN PRACTICE C88010 7.2% SOTHALL & BEIGHTON HEALTH CENTRES C88023 7.0% MILL ROAD SURGERY C88095 7.0% STANNINGTON MEDICAL CENTRE C88656 7.0% CRYSTAL PEAKS MEDICAL CENTRE C88648 7.0% OWLTHORPE MEDICAL CENTRE C88647 7.0% DOVERCOURT GROUP PRACTICE C88087 6.9% MOSBOROUGH HEALTH CENTRE C88078 6.8% MANOR TOP MEDICAL CENTRE (READ) C88626 6.8% WOODSEATS MEDICAL CENTRE C88041 6.7% AVENUE MEDICAL PRACTICE C88024 6.6% GRENOSIDE SURGERY C88054 6.6% SLOAN MEDICAL CENTRE C88026 6.6% HANDSWORTH MEDICAL PRACTICE C88036 6.6% DUNNINC ROAD SURGERY C88643 6.5% UPPERTHORPE MEDICAL CENTRE C88031 6.5% HEELEY GREEN SURGERY C88073 6.5% WESTFIELD HEALTH CENTRE Y04887 6.5% BASLOW RD, SHOREHAM ST & YORK RD SRGIES C88037 6.5% MANOR TOP MEDICAL CENTRE C88638 6.4% CHARNOCK HEALTH PRIMARY CARE CENTRE C88032 6.3% DYKES HALL MEDICAL CENTRE C88045 6.3% ELM LANE SURGERY C88049 6.3% SELBORNE ROAD MEDICAL CENTRE C88083 6.3% FAR LANE MEDICAL CENTRE C88021 6.1% DEVONSHIRE GREEN MEDICAL CENTRE C88076 6.0% TRAMWAYS MEDICAL CENTRE (O'CONNELL) C88018 6.0% ABBEY LANE SURGERY C88046 5.9% DEEPCAR MEDICAL CENTRE C88074 5.9% TRAMWAYS 54A MC C88043 5.2% CARTERKNOWLE & DORE MEDICAL PRACTICE C88016 5.0% OUGHTIBRIDGE SURGERY C88040 4.9% WALKLEY HOUSE MEDICAL CENTRE C88005 4.9% NETHERGREEN SURGERY C88034 4.6% MANCHESTER ROAD SURGERY C88044 4.5% TOTLEY RISE MEDICAL CENTRE C88068 4.4% BROOMHILL SURGERY C88028 4.4% HOLLIES MEDICAL CENTRE C88052 4.2% FALKLAND HOUSE SURGERY C88053 4.1% GREYSTONES MEDICAL CENTRE C88652 3.3% CROOKES PRACTICE C88079 3.3% Note: The estimated number of undiagnosed RUSTLINGS ROAD MEDICAL CENTRE C88062 3.0% SHEFFIELD CITY GP HC (REG) Y02566 2.0% PORTER BROOK MEDICAL CENTRE C88007 1.4% people with diabetes has been calculated by UNIVERSITY HEALTH SERVICE HEALTH CENTRE C88627 0.3% BENTS GREEN SURGERY C88061 0.1% multiplying the estimated prevalence rate to the 0% 2% 4% 6% 8% 10% 12% 14% 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 Doncaster CCG 7.9% 1.0% 11.7% diabetes in NHS Sheffield CCG is 8.2% (diagnosed and undiagnosed)

NHS Bassetlaw CCG 7.9% 0.9% 11.5% • in addition, there are an estimated 10.6% of people in NHS Sheffield CCG who are at increased risk of NHS Barnsley CCG 7.2% 1.5% 11.6% developing diabetes (i.e. with non- diabetic hyperglycaemia)

NHS Rotherham CCG 6.9% 1.9% 11.4% • this means that 18.8% of the population in NHS Sheffield CCG are estimated to have diabetes, or at high NHS Sheffield CCG 6.3% 1.9% 10.6% 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 Bassetlaw CCG 64.9%

• data on care processes and treatment targets are taken from the National NHS Doncaster CCG 64.0% Diabetes Audit (NDA) • overall practice participation in the 2015/16 audit was 81.4% in England NHS Barnsley CCG 63.8% • in NHS Sheffield CCG, 73 out of 83 practices (88.0%) participated in the NDA. Data is not available for the NHS Rotherham CCG 56.9% remaining practices

NHS Sheffield CCG 55.7% • 55.7% of people with diabetes (of practices who participated in the audit) had the eight recommended care processes in NHS Sheffield CCG, compared to 52.6% in England

England 52.6%

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

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

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

VERITAS HEALTH CENTRE C88631 77.6% NORWOOD MEDICAL CENTRE C88014 76.7% MOSBOROUGH HEALTH CENTRE C88078 76.7% CHARNOCK HEALTH PRIMARY CARE CENTRE C88032 76.6% MILL ROAD SURGERY C88095 75.4% BURNGREAVE SURGERY C88048 74.7% WOODSEATS MEDICAL CENTRE C88041 74.5% GRENOSIDE SURGERY C88054 74.4% • achievement - 8 care processes: in WINCOBANK MEDICAL CENTRE C88047 70.7% MANCHESTER ROAD SURGERY C88044 70.3% ECCLESFIELD GROUP PRACT C88039 69.3% WOODHOUSE MEDICAL CENTRE C88072 69.2% practices who provided data via the THE MATHEWS PRACTICE BELGRAVE C88038 69.2% NETHERGREEN SURGERY C88034 69.1% JAUNTY SPRINGS HEALTH CENTRE C88050 68.4% NDA, between 0.0% and 77.6% of STANNINGTON MEDICAL CENTRE C88656 67.9% TOTLEY RISE MEDICAL CENTRE C88068 66.9% EAST BANK MEDICAL CENTRE C88088 66.2% BARNSLEY ROAD SURGERY C88091 66.0% patients received all 8 care processes MEADOWGREEN HEALTH CENTRE C88015 65.8% CROOKES VALLEY MEDICAL CENTRE C88057 65.4% SOTHALL & BEIGHTON HEALTH CENTRES C88023 64.8% SHEFFIELD MEDICAL CENTRE C88622 63.4% CRYSTAL PEAKS MEDICAL CENTRE C88648 63.2% PITSMOOR SURGERY C88008 63.1% UPPERTHORPE MEDICAL CENTRE C88031 62.9% OUGHTIBRIDGE SURGERY C88040 62.8% GLEADLESS MEDICAL CENTRE C88019 62.8% • at least 11,452 people did not receive CHAPELGREEN PRACTICE C88010 62.7% AVENUE MEDICAL PRACTICE C88024 62.1% RICHMOND MEDICAL CENTRE C88085 61.9% DYKES HALL MEDICAL CENTRE C88045 61.6% the eight care processes CLOVER GROUP PRACTICE C88069 61.0% RUSTLINGS ROAD MEDICAL CENTRE C88062 60.2% TRAMWAYS MEDICAL CENTRE (O'CONNELL) C88018 59.6% VALLEY MEDICAL CENTRE C88092 58.9% PAGE HALL MEDICAL CENTRE C88051 57.3% NORFOLK PARK HEALTH CENTRE C88006 57.0% UPWELL STREET SURGERY C88027 56.9% PARK HEALTH CENTRE C88042 56.2% ABBEY LANE SURGERY C88046 55.9% DOVERCOURT GROUP PRACTICE C88087 55.7% WHITE HOUSE SURGERY C88020 53.4% SOUTHEY GREEN MEDICAL CTR C88086 52.1% FIRTH PARK SURGERY C88035 50.3% FOXHILL MEDICAL CENTRE C88009 49.2% FAR LANE MEDICAL CENTRE C88021 48.7% BROOMHILL SURGERY C88028 44.0% SHARROW LANE MEDICAL CENTRE C88060 43.6% UNIVERSITY HEALTH SERVICE HEALTH CENTRE C88627 43.0% BIRLEY HEALTH CENTRE C88025 42.5% DUNNINC ROAD SURGERY C88643 41.9% PORTER BROOK MEDICAL CENTRE C88007 39.6% SELBORNE ROAD MEDICAL CENTRE C88083 39.4% THE HEALTH CARE SURGERY C88077 38.8% WALKLEY HOUSE MEDICAL CENTRE C88005 38.1% HOLLIES MEDICAL CENTRE C88052 37.6% CROOKES PRACTICE C88079 34.9% HANDSWORTH MEDICAL PRACTICE C88036 34.0% MANOR PARK MEDICAL CENTRE C88090 32.8% DARNALL HEALTH CENTRE (MEHROTRA) C88084 30.1% DUKE MEDICAL CENTRE C88030 28.0% HACKENTHORPE MEDICAL CENTRE C88096 27.5% DEEPCAR MEDICAL CENTRE C88074 24.8% THE FLOWERS HEALTH CENTRE C88033 24.7% STONECROFT MEDICAL CENTRE C88022 20.1% OWLTHORPE MEDICAL CENTRE C88647 18.0% FALKLAND HOUSE SURGERY C88053 10.8% GREYSTONES MEDICAL CENTRE C88652 10.3% HEELEY GREEN SURGERY C88073 6.6% WESTFIELD HEALTH CENTRE Y04887 SHEFFIELD CITY GP HC (REG) Y02566 THE MEDICAL CENTRE DR OKORIE C88655 MANOR TOP MEDICAL CENTRE C88638 MANOR TOP MEDICAL CENTRE (READ) C88626 CARRFIELD MEDICAL CENTRE C88082 DEVONSHIRE GREEN MEDICAL CENTRE C88076 SHIREGREEN MEDICAL CENTRE C88070 BENTS GREEN SURGERY C88061 HAROLD STREET MEDICAL CENTRE C88059 ELM LANE SURGERY C88049 TRAMWAYS 54A MC C88043 BASLOW RD, SHOREHAM ST & YORK RD SRGIES C88037 SLOAN MEDICAL CENTRE C88026 CARTERKNOWLE & DORE MEDICAL PRACTICE C88016 BUCHANAN ROAD SURGERY C88011 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 Doncaster CCG 47.4%

• 39.6% of people with diabetes (of practices who participated in the NHS Bassetlaw CCG 45.6% audit) met the three treatment targets in NHS Sheffield CCG, compared to 39.0% in England

NHS Barnsley CCG 40.8%

NHS Sheffield CCG 39.6%

NHS Rotherham CCG 37.9%

England 39.0%

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

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

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

STANNINGTON MEDICAL CENTRE C88656 53.3% FAR LANE MEDICAL CENTRE C88021 52.4% EAST BANK MEDICAL CENTRE C88088 51.3% WINCOBANK MEDICAL CENTRE C88047 49.6% BARNSLEY ROAD SURGERY C88091 48.6% OUGHTIBRIDGE SURGERY C88040 47.6% UPPERTHORPE MEDICAL CENTRE C88031 47.6% MANOR PARK MEDICAL CENTRE C88090 47.5% • achievement - 3 treatment targets: in NORWOOD MEDICAL CENTRE C88014 46.8% CRYSTAL PEAKS MEDICAL CENTRE C88648 46.5% SOUTHEY GREEN MEDICAL CTR C88086 46.3% DUNNINC ROAD SURGERY C88643 45.9% practices who provided data via the THE HEALTH CARE SURGERY C88077 45.6% MEADOWGREEN HEALTH CENTRE C88015 45.4% THE MATHEWS PRACTICE BELGRAVE C88038 45.0% NDA, between 19.7% and 53.3% of AVENUE MEDICAL PRACTICE C88024 45.0% RICHMOND MEDICAL CENTRE C88085 44.6% MANCHESTER ROAD SURGERY C88044 43.8% BROOMHILL SURGERY C88028 43.7% patients achieved all 3 treatment FIRTH PARK SURGERY C88035 43.5% SHARROW LANE MEDICAL CENTRE C88060 43.4% WOODHOUSE MEDICAL CENTRE C88072 42.9% TRAMWAYS MEDICAL CENTRE (O'CONNELL) C88018 42.8% targets SELBORNE ROAD MEDICAL CENTRE C88083 42.2% WHITE HOUSE SURGERY C88020 42.1% DYKES HALL MEDICAL CENTRE C88045 41.5% MILL ROAD SURGERY C88095 41.4% STONECROFT MEDICAL CENTRE C88022 41.3% • at least 14,135 people did not meet CROOKES VALLEY MEDICAL CENTRE C88057 40.9% DOVERCOURT GROUP PRACTICE C88087 40.5% BIRLEY HEALTH CENTRE C88025 40.5% SHEFFIELD MEDICAL CENTRE C88622 40.3% the three treatment targets WOODSEATS MEDICAL CENTRE C88041 40.1% FALKLAND HOUSE SURGERY C88053 39.8% CLOVER GROUP PRACTICE C88069 39.5% CHARNOCK HEALTH PRIMARY CARE CENTRE C88032 39.4% ABBEY LANE SURGERY C88046 39.4% OWLTHORPE MEDICAL CENTRE C88647 39.4% ECCLESFIELD GROUP PRACT C88039 39.3% VERITAS HEALTH CENTRE C88631 39.1% BURNGREAVE SURGERY C88048 38.6% DUKE MEDICAL CENTRE C88030 38.0% HEELEY GREEN SURGERY C88073 37.8% GRENOSIDE SURGERY C88054 37.7% FOXHILL MEDICAL CENTRE C88009 37.4% RUSTLINGS ROAD MEDICAL CENTRE C88062 37.2% HACKENTHORPE MEDICAL CENTRE C88096 37.1% PORTER BROOK MEDICAL CENTRE C88007 36.8% DEEPCAR MEDICAL CENTRE C88074 36.8% NORFOLK PARK HEALTH CENTRE C88006 36.8% MOSBOROUGH HEALTH CENTRE C88078 36.7% SOTHALL & BEIGHTON HEALTH CENTRES C88023 36.3% TOTLEY RISE MEDICAL CENTRE C88068 36.1% PAGE HALL MEDICAL CENTRE C88051 35.4% THE FLOWERS HEALTH CENTRE C88033 35.4% WESTFIELD HEALTH CENTRE Y04887 35.3% NETHERGREEN SURGERY C88034 35.0% JAUNTY SPRINGS HEALTH CENTRE C88050 34.8% GREYSTONES MEDICAL CENTRE C88652 34.6% HOLLIES MEDICAL CENTRE C88052 34.4% PITSMOOR SURGERY C88008 33.8% WALKLEY HOUSE MEDICAL CENTRE C88005 32.9% PARK HEALTH CENTRE C88042 32.3% DARNALL HEALTH CENTRE (MEHROTRA) C88084 31.6% HANDSWORTH MEDICAL PRACTICE C88036 31.3% CHAPELGREEN PRACTICE C88010 31.3% VALLEY MEDICAL CENTRE C88092 29.3% UPWELL STREET SURGERY C88027 28.4% GLEADLESS MEDICAL CENTRE C88019 25.1% CROOKES PRACTICE C88079 22.4% UNIVERSITY HEALTH SERVICE HEALTH CENTRE C88627 19.7% SHEFFIELD CITY GP HC (REG) Y02566 THE MEDICAL CENTRE DR OKORIE C88655 MANOR TOP MEDICAL CENTRE C88638 MANOR TOP MEDICAL CENTRE (READ) C88626 CARRFIELD MEDICAL CENTRE C88082 DEVONSHIRE GREEN MEDICAL CENTRE C88076 SHIREGREEN MEDICAL CENTRE C88070 BENTS GREEN SURGERY C88061 HAROLD STREET MEDICAL CENTRE C88059 ELM LANE SURGERY C88049 TRAMWAYS 54A MC C88043 BASLOW RD, SHOREHAM ST & YORK RD SRGIES C88037 SLOAN MEDICAL CENTRE C88026 CARTERKNOWLE & DORE MEDICAL PRACTICE C88016 BUCHANAN ROAD SURGERY C88011 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%

UNIVERSITY HEALTH SERVICE HEALTH CENTRE 15

CROOKES PRACTICE 43

GLEADLESS MEDICAL CENTRE 82 • using the GP cluster method of UPWELL STREET SURGERY 43 calculating potential gains, if each VALLEY MEDICAL CENTRE 85 practice was to achieve as well as the DARNALL HEALTH CENTRE (MEHROTRA) 29 upper quartile of its national cluster, then an additional 1,401 people would HANDSWORTH MEDICAL PRACTICE 59 be treated PARK HEALTH CENTRE 48

CHAPELGREEN PRACTICE 112

WALKLEY HOUSE MEDICAL CENTRE 44

NORWOOD MEDICAL CENTRE

OUGHTIBRIDGE SURGERY

MANOR PARK MEDICAL CENTRE

THE HEALTH CARE SURGERY

BARNSLEY ROAD SURGERY

UPPERTHORPE MEDICAL CENTRE

WINCOBANK MEDICAL CENTRE

FAR LANE MEDICAL CENTRE

STANNINGTON MEDICAL CENTRE

EAST BANK MEDICAL CENTRE 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 Bassetlaw CCG 1.09

• the ratio of those diagnosed with NHS Doncaster CCG 0.97 chronic kidney disease versus those expected to have chronic kidney disease is 0.76. This compares to NHS Barnsley CCG 0.82 0.68 for England • this suggests that 76% of people with chronic kidney disease have been diagnosed NHS Sheffield CCG 0.76

NHS Rotherham CCG 0.72

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 0.2 0.4 0.6 0.8 1.0 1.2 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 Liverpool CCG 1.05

NHS Lincolnshire West CCG 1.00

NHS Newcastle Gateshead CCG 0.89

NHS Bristol CCG 0.87

NHS Southern Derbyshire CCG 0.81

NHS Sheffield CCG 0.76

NHS West Leicestershire CCG 0.72

NHS North Durham CCG 0.71

NHS Coventry and Rugby CCG 0.65

NHS Portsmouth CCG 0.60

NHS Greater Huddersfield CCG 0.57

0.0 0.2 0.4 0.6 0.8 1.0 1.2 Ratio

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

GP practice CCG

MEADOWGREEN HEALTH CENTRE C88015 9.2% CHARNOCK HEALTH PRIMARY CARE CENTRE C88032 9.0% ECCLESFIELD GROUP PRACT C88039 8.8% JAUNTY SPRINGS HEALTH CENTRE C88050 8.4% WOODHOUSE MEDICAL CENTRE C88072 8.3% DUNNINC ROAD SURGERY C88643 8.2% STANNINGTON MEDICAL CENTRE C88656 8.2% THE MATHEWS PRACTICE BELGRAVE C88038 7.8% ABBEY LANE SURGERY C88046 7.2% WOODSEATS MEDICAL CENTRE C88041 6.8% MANOR TOP MEDICAL CENTRE (READ) C88626 6.8% • it is estimated that there are 6,295 SHEFFIELD MEDICAL CENTRE C88622 6.8% BARNSLEY ROAD SURGERY C88091 6.6% RICHMOND MEDICAL CENTRE C88085 6.3% people with undiagnosed chronic DUKE MEDICAL CENTRE C88030 6.2% MILL ROAD SURGERY C88095 6.2% THE FLOWERS HEALTH CENTRE C88033 6.1% ELM LANE SURGERY C88049 6.1% kidney disease in NHS Sheffield CCG BASLOW RD, SHOREHAM ST & YORK RD SRGIES C88037 6.0% CHAPELGREEN PRACTICE C88010 6.0% WHITE HOUSE SURGERY C88020 5.9% NORWOOD MEDICAL CENTRE C88014 5.8% • GP practice range of observed CKD: SOUTHEY GREEN MEDICAL CTR C88086 5.7% VERITAS HEALTH CENTRE C88631 5.6% MANOR TOP MEDICAL CENTRE C88638 5.6% 0.0% to 9.2% SHIREGREEN MEDICAL CENTRE C88070 5.5% AVENUE MEDICAL PRACTICE C88024 5.4% HANDSWORTH MEDICAL PRACTICE C88036 5.4% SOTHALL & BEIGHTON HEALTH CENTRES C88023 5.3% GLEADLESS MEDICAL CENTRE C88019 5.3% BUCHANAN ROAD SURGERY C88011 5.3% DEEPCAR MEDICAL CENTRE C88074 5.2% BIRLEY HEALTH CENTRE C88025 5.2% NORFOLK PARK HEALTH CENTRE C88006 5.2% DOVERCOURT GROUP PRACTICE C88087 5.1% PARK HEALTH CENTRE C88042 5.0% FAR LANE MEDICAL CENTRE C88021 5.0% EAST BANK MEDICAL CENTRE C88088 4.9% BURNGREAVE SURGERY C88048 4.8% OWLTHORPE MEDICAL CENTRE C88647 4.8% FIRTH PARK SURGERY C88035 4.8% WINCOBANK MEDICAL CENTRE C88047 4.8% CARRFIELD MEDICAL CENTRE C88082 4.5% VALLEY MEDICAL CENTRE C88092 4.5% MANOR PARK MEDICAL CENTRE C88090 4.5% HEELEY GREEN SURGERY C88073 4.4% STONECROFT MEDICAL CENTRE C88022 4.4% MOSBOROUGH HEALTH CENTRE C88078 4.4% SELBORNE ROAD MEDICAL CENTRE C88083 4.4% TRAMWAYS 54A MC C88043 4.3% CRYSTAL PEAKS MEDICAL CENTRE C88648 4.3% SLOAN MEDICAL CENTRE C88026 4.3% UPWELL STREET SURGERY C88027 4.2% DARNALL HEALTH CENTRE (MEHROTRA) C88084 4.1% THE HEALTH CARE SURGERY C88077 4.0% CLOVER GROUP PRACTICE C88069 4.0% MANCHESTER ROAD SURGERY C88044 3.9% DYKES HALL MEDICAL CENTRE C88045 3.8% TRAMWAYS MEDICAL CENTRE (O'CONNELL) C88018 3.7% DEVONSHIRE GREEN MEDICAL CENTRE C88076 3.7% NETHERGREEN SURGERY C88034 3.7% CROOKES VALLEY MEDICAL CENTRE C88057 3.7% THE MEDICAL CENTRE DR OKORIE C88655 3.6% WALKLEY HOUSE MEDICAL CENTRE C88005 3.6% OUGHTIBRIDGE SURGERY C88040 3.6% HACKENTHORPE MEDICAL CENTRE C88096 3.5% FOXHILL MEDICAL CENTRE C88009 3.4% PITSMOOR SURGERY C88008 3.3% RUSTLINGS ROAD MEDICAL CENTRE C88062 3.3% HOLLIES MEDICAL CENTRE C88052 3.3% PAGE HALL MEDICAL CENTRE C88051 3.0% BROOMHILL SURGERY C88028 2.9% SHARROW LANE MEDICAL CENTRE C88060 2.8% WESTFIELD HEALTH CENTRE Y04887 2.8% CARTERKNOWLE & DORE MEDICAL PRACTICE C88016 2.7% GREYSTONES MEDICAL CENTRE C88652 2.6% Note: CCG estimates for the estimated UPPERTHORPE MEDICAL CENTRE C88031 2.6% TOTLEY RISE MEDICAL CENTRE C88068 2.5% CROOKES PRACTICE C88079 2.4% number of people with CKD are based on HAROLD STREET MEDICAL CENTRE C88059 2.2% FALKLAND HOUSE SURGERY C88053 2.2% GRENOSIDE SURGERY C88054 1.8% applying a proportion from a resident based PORTER BROOK MEDICAL CENTRE C88007 0.7% BENTS GREEN SURGERY C88061 0.7% SHEFFIELD CITY GP HC (REG) Y02566 0.4% population estimate to a GP registered UNIVERSITY HEALTH SERVICE HEALTH CENTRE C88627 population. The characteristics of registered 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 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 Doncaster CCG 79.3% • 21,455 people with CKD (diagnosed*) in NHS Sheffield CCG • 15,599 (72.7%) people whose blood NHS Rotherham CCG 73.8% pressure is <= 140 /85 • 1,939 (9%) people who are exceptions NHS Bassetlaw CCG 72.9% • 3,917 (18.3%) additional people whose blood pressure is not <= 140 / 85 NHS Barnsley CCG 72.9%

NHS Sheffield CCG 72.7%

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 Portsmouth CCG 78.8%

NHS Liverpool CCG 77.7%

NHS North Durham CCG 76.2%

NHS Lincolnshire West CCG 76.0%

NHS Coventry and Rugby CCG 75.4%

NHS Newcastle Gateshead CCG 74.9%

NHS Bristol CCG 74.4%

NHS Greater Huddersfield CCG 74.0%

NHS West Leicestershire CCG 74.0%

NHS Southern Derbyshire CCG 72.7%

NHS Sheffield CCG 72.7%

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

UNIVERSITY HEALTH SERVICE HEALTH CENTRE C88627 1 SHEFFIELD CITY GP HC (REG) Y02566 10 VALLEY MEDICAL CENTRE C88092 158 SOUTHEY GREEN MEDICAL CENTRE C88086 57 HANDSWORTH MEDICAL PRACTICE C88036 180 MANOR TOP MC (SAVANI) C88626 38 NETHERGREEN SURGERY C88034 105 MANOR PARK MEDICAL CENTRE C88090 66 GLEADLESS MEDICAL CENTRE C88019 146 BUCHANAN ROAD SURGERY C88011 76 THE CROOKES PRACTICE C88079 53 • in total, including exceptions, there PAGE HALL MEDICAL CENTRE C88051 51 GRENOSIDE SURGERY C88054 41 AVENUE MEDICAL PRACTICE C88024 127 MANOR TOP MC (SHARMA) C88638 25 are 5,856 people whose blood BURNCROSS SURGERY C88010 264 UPWELL STREET SURGERY C88027 50 ABBEY LANE SURGERY C88046 63 pressure is not <= 140 / 85 SOTHALL & BEIGHTON HEALTH CENTRES C88023 135 THE SHIREGREEN MEDICAL CENTRE C88070 104 GREYSTONES MEDICAL CENTRE C88652 25 MOSBOROUGH HEALTH CENTRE C88078 76 • GP practice range: 8.2% to 50.0% SLOAN MEDICAL CENTRE C88026 141 TOTLEY RISE MEDICAL CENTRE C88068 24 BENTS GREEN SURGERY C88061 33 BROOMHILL SURGERY C88028 70 WALKLEY HOUSE MEDICAL CENTRE C88005 115 DARNALL HEALTH CENTRE (MEHROTRA) C88084 48 WESTFIELD HEALTH CENTRE Y04887 17 RUSTLINGS ROAD MEDICAL CENTRE C88062 37 THE FOXHILL MEDICAL CENTRE C88009 53 WOODSEATS MEDICAL CENTRE C88041 164 EAST BANK MEDICAL CENTRE C88088 61 PITSMOOR SURGERY C88008 65 THE BIRLEY HEALTH CENTRE C88025 104 MILL ROAD SURGERY C88095 82 DUNNINC ROAD SURGERY C88643 54 THE MATHEWS PRACTICE C88038 197 JAUNTY SPRINGS HEALTH CENTRE C88050 77 WHITE HOUSE SURGERY C88020 80 FIRTH PARK SURGERY C88035 94 BARNSLEY ROAD SURGERY C88091 41 TRAMWAYS 54A MC C88043 111 HOLLIES MEDICAL CENTRE C88052 56 DUKE MEDICAL CENTRE C88030 96 MANCHESTER ROAD SURGERY C88044 18 CLOVER GROUP PRACTICE C88069 132 CHARNOCK HEALTH PRIMARY CARE CENTRE C88032 111 SELBORNE ROAD MEDICAL CENTRE C88083 29 CARTERKNOWLE & DORE MEDICAL PRACTICE C88016 75 NORWOOD MEDICAL CENTRE C88014 90 STONECROFT MEDICAL CENTRE C88022 44 ECCLESFIELD GROUP PRACT C88039 143 THE MEDICAL CENTRE DR OKORIE C88655 8 BURNGREAVE SURGERY C88048 60 THE HEALTH CARE SURGERY C88077 37 OUGHTIBRIDGE SURGERY C88040 39 DYKES HALL MEDICAL CENTRE & DEER PARK SURGERY C88045 76 TRAMWAYS MEDICAL CENTRE (O'CONNELL) C88018 70 FAR LANE MEDICAL CENTRE C88021 84 THE FLOWERS HEALTH CENTRE C88033 50 HAROLD STREET MEDICAL CENTRE C88059 6 BASLOW ROAD AND SHOREHAM STREET SURGERIES C88037 134 WINCOBANK MEDICAL CENTRE C88047 63 WOODHOUSE MEDICAL CENTRE C88072 187 HACKENTHORPE MEDICAL CENTRE C88096 36 ELM LANE SURGERY C88049 54 UPPERTHORPE MEDICAL CENTRE C88031 41 CROOKES VALLEY MEDICAL CENTRE C88057 15 DEVONSHIRE GREEN MEDICAL CENTRE C88076 45 THE MEDICAL CENTRE CRYSTAL PEAKS C88648 48 NORFOLK PARK HEALTH CENTRE C88006 34 FALKLAND HOUSE SURGERY C88053 8 CARRFIELD MEDICAL CENTRE C88082 9 THE MEADOWHEAD GROUP PRACTICE C88015 93 SHEFFIELD MEDICAL CENTRE C88622 17 MEDICAL CENTRE C88631 13 PARK HEALTH CENTRE C88042 39 HEELEY GREEN SURGERY C88073 34 RICHMOND MEDICAL CENTRE C88085 70 DEEPCAR MEDICAL CENTRE C88074 39 PORTER BROOK MEDICAL CENTRE C88007 28 GREENHILL HEALTH CENTRE C88653 33 OWLTHORPE MEDICAL CENTRE C88647 19 DOVERCOURT SURGERY C88087 26 SHARROW LANE MEDICAL CENTRE C88060 11 STANNINGTON MEDICAL CENTRE C88656 17 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

59 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding 12 months) is not 140/85 mmHg or less by GP practice, 2014/15 – opportunities compared to GP cluster

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

SHEFFIELD CITY GP HC (REG) 7

UNIVERSITY HEALTH SERVICE HEALTH CENTRE 1

SOUTHEY GREEN MEDICAL CENTRE 34 • using the GP cluster method of MANOR TOP MC (SAVANI) 22 calculating potential gains, if each MANOR PARK MEDICAL CENTRE 37 practice was to achieve as well as the VALLEY MEDICAL CENTRE 78 upper quartile of its national cluster, then an additional 1,930 people would GLEADLESS MEDICAL CENTRE 80 be treated HANDSWORTH MEDICAL PRACTICE 90

BUCHANAN ROAD SURGERY 41

THE CROOKES PRACTICE 29

RICHMOND MEDICAL CENTRE 1

BASLOW ROAD AND SHOREHAM STREET SURGERIES 2

WOODHOUSE MEDICAL CENTRE

PORTER BROOK MEDICAL CENTRE

DEEPCAR MEDICAL CENTRE

SHARROW LANE MEDICAL CENTRE

THE MEADOWHEAD GROUP PRACTICE

DOVERCOURT SURGERY

OWLTHORPE MEDICAL CENTRE

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

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

NHS Doncaster CCG 79.7% • 21,455 people with CKD (diagnosed*) in NHS Sheffield CCG • 15,343 (71.5%) people who have a NHS Bassetlaw CCG 74.9% record of urine albumin:creatinine ratio test • 1,864 (8.7%) people who are NHS Rotherham CCG 72.5% exceptions • 4,248 (19.8%) additional people who have no record of urine NHS Barnsley CCG 72.2% albumin:creatinine ratio test

NHS Sheffield CCG 71.5%

*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 Liverpool CCG 81.2%

NHS Greater Huddersfield CCG 80.8%

NHS North Durham CCG 80.1%

NHS Coventry and Rugby CCG 79.2%

NHS Southern Derbyshire CCG 78.6%

NHS West Leicestershire CCG 78.6%

NHS Lincolnshire West CCG 78.3%

NHS Bristol CCG 76.8%

NHS Newcastle Gateshead CCG 76.1%

NHS Portsmouth CCG 75.3%

NHS Sheffield CCG 71.5%

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

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

Not recorded Exceptions reported

WESTFIELD HEALTH CENTRE Y04887 34 THE MATHEWS PRACTICE C88038 406 BUCHANAN ROAD SURGERY C88011 110 THE FLOWERS HEALTH CENTRE C88033 113 OUGHTIBRIDGE SURGERY C88040 81 BENTS GREEN SURGERY C88061 50 DUNNINC ROAD SURGERY C88643 85 DARNALL HEALTH CENTRE (MEHROTRA) C88084 69 HOLLIES MEDICAL CENTRE C88052 89 UPWELL STREET SURGERY C88027 63 PORTER BROOK MEDICAL CENTRE C88007 81 • in total, including exceptions, there WALKLEY HOUSE MEDICAL CENTRE C88005 153 SOUTHEY GREEN MEDICAL CENTRE C88086 55 SELBORNE ROAD MEDICAL CENTRE C88083 44 CROOKES VALLEY MEDICAL CENTRE C88057 29 are 6,112 people who have no record TOTLEY RISE MEDICAL CENTRE C88068 30 JAUNTY SPRINGS HEALTH CENTRE C88050 104 VALLEY MEDICAL CENTRE C88092 144 of urine albumin:creatinine ratio test ABBEY LANE SURGERY C88046 70 HANDSWORTH MEDICAL PRACTICE C88036 164 MEERSBROOK MEDICAL CENTRE C88631 27 GREENHILL HEALTH CENTRE C88653 85 • GP practice range: 0.0% to 61.8% THE CROOKES PRACTICE C88079 52 AVENUE MEDICAL PRACTICE C88024 129 FALKLAND HOUSE SURGERY C88053 15 FAR LANE MEDICAL CENTRE C88021 127 HAROLD STREET MEDICAL CENTRE C88059 9 GREYSTONES MEDICAL CENTRE C88652 25 PAGE HALL MEDICAL CENTRE C88051 46 THE BIRLEY HEALTH CENTRE C88025 112 MANOR TOP MC (SAVANI) C88626 31 MOSBOROUGH HEALTH CENTRE C88078 74 PARK HEALTH CENTRE C88042 71 DYKES HALL MEDICAL CENTRE & DEER PARK SURGERY C88045 98 EAST BANK MEDICAL CENTRE C88088 62 SLOAN MEDICAL CENTRE C88026 134 BARNSLEY ROAD SURGERY C88091 44 MANOR TOP MC (SHARMA) C88638 22 BURNCROSS SURGERY C88010 235 HACKENTHORPE MEDICAL CENTRE C88096 51 THE FOXHILL MEDICAL CENTRE C88009 51 MANOR PARK MEDICAL CENTRE C88090 51 THE MEDICAL CENTRE CRYSTAL PEAKS C88648 69 BROOMHILL SURGERY C88028 63 NETHERGREEN SURGERY C88034 73 STONECROFT MEDICAL CENTRE C88022 45 WOODHOUSE MEDICAL CENTRE C88072 234 FIRTH PARK SURGERY C88035 86 RICHMOND MEDICAL CENTRE C88085 106 CLOVER GROUP PRACTICE C88069 127 CARTERKNOWLE & DORE MEDICAL PRACTICE C88016 71 RUSTLINGS ROAD MEDICAL CENTRE C88062 30 NORWOOD MEDICAL CENTRE C88014 85 WOODSEATS MEDICAL CENTRE C88041 124 ECCLESFIELD GROUP PRACT C88039 130 THE SHIREGREEN MEDICAL CENTRE C88070 71 GRENOSIDE SURGERY C88054 26 MILL ROAD SURGERY C88095 61 CHARNOCK HEALTH PRIMARY CARE CENTRE C88032 91 SHEFFIELD MEDICAL CENTRE C88622 20 WINCOBANK MEDICAL CENTRE C88047 61 WHITE HOUSE SURGERY C88020 57 DEEPCAR MEDICAL CENTRE C88074 49 TRAMWAYS 54A MC C88043 77 HEELEY GREEN SURGERY C88073 38 UPPERTHORPE MEDICAL CENTRE C88031 38 TRAMWAYS MEDICAL CENTRE (O'CONNELL) C88018 55 ELM LANE SURGERY C88049 48 MANCHESTER ROAD SURGERY C88044 12 GLEADLESS MEDICAL CENTRE C88019 72 BASLOW ROAD AND SHOREHAM STREET SURGERIES C88037 108 DEVONSHIRE GREEN MEDICAL CENTRE C88076 38 THE HEALTH CARE SURGERY C88077 26 THE MEADOWHEAD GROUP PRACTICE C88015 88 NORFOLK PARK HEALTH CENTRE C88006 30 SOTHALL & BEIGHTON HEALTH CENTRES C88023 67 PITSMOOR SURGERY C88008 35 OWLTHORPE MEDICAL CENTRE C88647 22 THE MEDICAL CENTRE DR OKORIE C88655 5 SHEFFIELD CITY GP HC (REG) Y02566 3 SHARROW LANE MEDICAL CENTRE C88060 13 DOVERCOURT SURGERY C88087 28 STANNINGTON MEDICAL CENTRE C88656 28 DUKE MEDICAL CENTRE C88030 46 BURNGREAVE SURGERY C88048 31 CARRFIELD MEDICAL CENTRE C88082 UNIVERSITY HEALTH SERVICE HEALTH CENTRE C88627 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 Sheffield CCG 1.03%

• prevalence of 1.03% in NHS Sheffield NHS Bassetlaw CCG 1.01% CCG compared to 0.76% in England

NHS Doncaster CCG 0.92%

NHS Barnsley CCG 0.89%

NHS Rotherham CCG 0.85%

England 0.76%

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

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

NHS Sheffield CCG 1.03%

NHS West Leicestershire CCG 1.02%

NHS Southern Derbyshire CCG 0.92%

NHS North Durham CCG 0.89%

NHS Liverpool CCG 0.84%

NHS Newcastle Gateshead CCG 0.82%

NHS Lincolnshire West CCG 0.78%

NHS Greater Huddersfield CCG 0.74%

NHS Coventry and Rugby CCG 0.65%

NHS Bristol CCG 0.64%

NHS Portsmouth CCG 0.64%

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

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

GP practice CCG

CARRFIELD MEDICAL CENTRE C88082 2.4% JAUNTY SPRINGS HEALTH CENTRE C88050 2.0% MANCHESTER ROAD SURGERY C88044 1.9% STANNINGTON MEDICAL CENTRE C88656 1.9% ABBEY LANE SURGERY C88046 1.9% CHAPELGREEN PRACTICE C88010 1.8% WOODHOUSE MEDICAL CENTRE C88072 1.8% ECCLESFIELD GROUP PRACT C88039 1.7% MANOR TOP MEDICAL CENTRE C88638 1.7% VERITAS HEALTH CENTRE C88631 1.6% WINCOBANK MEDICAL CENTRE C88047 1.6% • 6,056 people with diagnosed heart DARNALL HEALTH CENTRE (MEHROTRA) C88084 1.5% MANOR PARK MEDICAL CENTRE C88090 1.5% MEADOWGREEN HEALTH CENTRE C88015 1.4% failure in NHS Sheffield CCG VALLEY MEDICAL CENTRE C88092 1.4% DYKES HALL MEDICAL CENTRE C88045 1.4% MILL ROAD SURGERY C88095 1.4% DOVERCOURT GROUP PRACTICE C88087 1.4% • GP practice range: 0.0% to 2.4% GRENOSIDE SURGERY C88054 1.3% SELBORNE ROAD MEDICAL CENTRE C88083 1.3% NORFOLK PARK HEALTH CENTRE C88006 1.3% BIRLEY HEALTH CENTRE C88025 1.3% HEELEY GREEN SURGERY C88073 1.3% OWLTHORPE MEDICAL CENTRE C88647 1.3% STONECROFT MEDICAL CENTRE C88022 1.3% CROOKES VALLEY MEDICAL CENTRE C88057 1.3% ELM LANE SURGERY C88049 1.3% HANDSWORTH MEDICAL PRACTICE C88036 1.3% FAR LANE MEDICAL CENTRE C88021 1.3% THE MATHEWS PRACTICE BELGRAVE C88038 1.3% HACKENTHORPE MEDICAL CENTRE C88096 1.3% BUCHANAN ROAD SURGERY C88011 1.2% RICHMOND MEDICAL CENTRE C88085 1.2% SOUTHEY GREEN MEDICAL CTR C88086 1.2% MOSBOROUGH HEALTH CENTRE C88078 1.2% UPWELL STREET SURGERY C88027 1.2% FIRTH PARK SURGERY C88035 1.2% SLOAN MEDICAL CENTRE C88026 1.2% SHEFFIELD MEDICAL CENTRE C88622 1.2% TOTLEY RISE MEDICAL CENTRE C88068 1.1% WOODSEATS MEDICAL CENTRE C88041 1.1% AVENUE MEDICAL PRACTICE C88024 1.1% OUGHTIBRIDGE SURGERY C88040 1.1% GLEADLESS MEDICAL CENTRE C88019 1.1% CHARNOCK HEALTH PRIMARY CARE CENTRE C88032 1.1% NORWOOD MEDICAL CENTRE C88014 1.1% WHITE HOUSE SURGERY C88020 1.1% FOXHILL MEDICAL CENTRE C88009 1.0% EAST BANK MEDICAL CENTRE C88088 1.0% THE HEALTH CARE SURGERY C88077 1.0% CLOVER GROUP PRACTICE C88069 1.0% BASLOW RD, SHOREHAM ST & YORK RD SRGIES C88037 1.0% DUNNINC ROAD SURGERY C88643 1.0% DEEPCAR MEDICAL CENTRE C88074 1.0% SOTHALL & BEIGHTON HEALTH CENTRES C88023 1.0% MANOR TOP MEDICAL CENTRE (READ) C88626 1.0% UPPERTHORPE MEDICAL CENTRE C88031 1.0% BURNGREAVE SURGERY C88048 1.0% WESTFIELD HEALTH CENTRE Y04887 0.9% PARK HEALTH CENTRE C88042 0.9% CARTERKNOWLE & DORE MEDICAL PRACTICE C88016 0.9% WALKLEY HOUSE MEDICAL CENTRE C88005 0.9% SHIREGREEN MEDICAL CENTRE C88070 0.9% HAROLD STREET MEDICAL CENTRE C88059 0.9% HOLLIES MEDICAL CENTRE C88052 0.9% DUKE MEDICAL CENTRE C88030 0.9% CRYSTAL PEAKS MEDICAL CENTRE C88648 0.9% BROOMHILL SURGERY C88028 0.8% THE FLOWERS HEALTH CENTRE C88033 0.8% FALKLAND HOUSE SURGERY C88053 0.8% GREYSTONES MEDICAL CENTRE C88652 0.7% PITSMOOR SURGERY C88008 0.7% PAGE HALL MEDICAL CENTRE C88051 0.7% BARNSLEY ROAD SURGERY C88091 0.7% NETHERGREEN SURGERY C88034 0.6% TRAMWAYS 54A MC C88043 0.6% SHARROW LANE MEDICAL CENTRE C88060 0.6% DEVONSHIRE GREEN MEDICAL CENTRE C88076 0.6% THE MEDICAL CENTRE DR OKORIE C88655 0.6% TRAMWAYS MEDICAL CENTRE (O'CONNELL) C88018 0.6% CROOKES PRACTICE C88079 0.6% RUSTLINGS ROAD MEDICAL CENTRE C88062 0.5% BENTS GREEN SURGERY C88061 0.3% PORTER BROOK MEDICAL CENTRE C88007 0.2% SHEFFIELD CITY GP HC (REG) Y02566 0.2% UNIVERSITY HEALTH SERVICE HEALTH CENTRE C88627 0.0% 0.5% 1.0% 1.5% 2.0% 2.5%

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

NHS Barnsley CCG 86.7% • 2,288 people with heart failure* with LVSD in NHS Sheffield CCG • 1,828 (79.9%) people treated with NHS Doncaster CCG 85.4% ACE-I or ARB • 426 (18.6%) people who are exceptions NHS Bassetlaw CCG 84.3% • 34 (1.5%) additional people who are not treated with ACE-I or ARB

NHS Rotherham CCG 80.4%

NHS Sheffield CCG 79.9%

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 North Durham CCG 88.9%

NHS Newcastle Gateshead CCG 87.0%

NHS Portsmouth CCG 86.6%

NHS Greater Huddersfield CCG 86.4%

NHS West Leicestershire CCG 86.1%

NHS Coventry and Rugby CCG 84.1%

NHS Bristol CCG 83.6%

NHS Lincolnshire West CCG 83.0%

NHS Liverpool CCG 81.2%

NHS Southern Derbyshire CCG 80.8%

NHS Sheffield CCG 79.9%

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

SOUTHEY GREEN MEDICAL CTR C88086 7 HOLLIES MEDICAL CENTRE C88052 13 UPWELL STREET SURGERY C88027 3 THE HEALTH CARE SURGERY C88077 7 MOSBOROUGH HEALTH CENTRE C88078 8 CROOKES PRACTICE C88079 7 HAROLD STREET MEDICAL CENTRE C88059 1 THE FLOWERS HEALTH CENTRE C88033 4 DEVONSHIRE GREEN MEDICAL CENTRE C88076 4 PITSMOOR SURGERY C88008 7 DARNALL HEALTH CENTRE (MEHROTRA) C88084 7 • in total, including exceptions, there MILL ROAD SURGERY C88095 9 CLOVER GROUP PRACTICE C88069 14 CARTERKNOWLE & DORE MEDICAL PRACTICE C88016 8 are 460 people who are not treated SOTHALL & BEIGHTON HEALTH CENTRES C88023 5 SLOAN MEDICAL CENTRE C88026 20 PAGE HALL MEDICAL CENTRE C88051 5 FOXHILL MEDICAL CENTRE C88009 4 with ACE-I or ARB DEEPCAR MEDICAL CENTRE C88074 6 GREYSTONES MEDICAL CENTRE C88652 4 NORWOOD MEDICAL CENTRE C88014 4 BIRLEY HEALTH CENTRE C88025 8 • GP practice range: 0.0% to 50.0% UPPERTHORPE MEDICAL CENTRE C88031 8 HACKENTHORPE MEDICAL CENTRE C88096 8 TRAMWAYS MEDICAL CENTRE (O'CONNELL) C88018 6 TRAMWAYS 54A MC C88043 9 DUNNINC ROAD SURGERY C88643 2 THE MEDICAL CENTRE DR OKORIE C88655 1 STANNINGTON MEDICAL CENTRE C88656 8 WESTFIELD HEALTH CENTRE Y04887 3 MANCHESTER ROAD SURGERY C88044 6 BUCHANAN ROAD SURGERY C88011 4 BASLOW RD, SHOREHAM ST & YORK RD SRGIES C88037 7 OUGHTIBRIDGE SURGERY C88040 6 GRENOSIDE SURGERY C88054 7 CHAPELGREEN PRACTICE C88010 25 NORFOLK PARK HEALTH CENTRE C88006 4 MANOR TOP MEDICAL CENTRE (READ) C88626 2 THE MATHEWS PRACTICE BELGRAVE C88038 13 MEADOWGREEN HEALTH CENTRE C88015 10 MANOR PARK MEDICAL CENTRE C88090 9 NETHERGREEN SURGERY C88034 3 RUSTLINGS ROAD MEDICAL CENTRE C88062 2 WOODHOUSE MEDICAL CENTRE C88072 12 ECCLESFIELD GROUP PRACT C88039 17 BROOMHILL SURGERY C88028 5 SELBORNE ROAD MEDICAL CENTRE C88083 4 SHEFFIELD MEDICAL CENTRE C88622 2 ABBEY LANE SURGERY C88046 6 TOTLEY RISE MEDICAL CENTRE C88068 4 VALLEY MEDICAL CENTRE C88092 12 CROOKES VALLEY MEDICAL CENTRE C88057 2 STONECROFT MEDICAL CENTRE C88022 5 GLEADLESS MEDICAL CENTRE C88019 8 FIRTH PARK SURGERY C88035 12 CHARNOCK HEALTH PRIMARY CARE CENTRE C88032 5 WALKLEY HOUSE MEDICAL CENTRE C88005 8 WINCOBANK MEDICAL CENTRE C88047 4 HEELEY GREEN SURGERY C88073 1 DOVERCOURT GROUP PRACTICE C88087 2 WOODSEATS MEDICAL CENTRE C88041 6 DYKES HALL MEDICAL CENTRE C88045 8 RICHMOND MEDICAL CENTRE C88085 2 ELM LANE SURGERY C88049 3 BURNGREAVE SURGERY C88048 3 HANDSWORTH MEDICAL PRACTICE C88036 8 DUKE MEDICAL CENTRE C88030 1 CRYSTAL PEAKS MEDICAL CENTRE C88648 1 JAUNTY SPRINGS HEALTH CENTRE C88050 4 WHITE HOUSE SURGERY C88020 1 SHIREGREEN MEDICAL CENTRE C88070 1 AVENUE MEDICAL PRACTICE C88024 3 PORTER BROOK MEDICAL CENTRE C88007 3 OWLTHORPE MEDICAL CENTRE C88647 2 FAR LANE MEDICAL CENTRE C88021 4 VERITAS HEALTH CENTRE C88631 1 FALKLAND HOUSE SURGERY C88053 1 EAST BANK MEDICAL CENTRE C88088 1 PARK HEALTH CENTRE C88042 SHARROW LANE MEDICAL CENTRE C88060 BENTS GREEN SURGERY C88061 CARRFIELD MEDICAL CENTRE C88082 BARNSLEY ROAD SURGERY C88091 MANOR TOP MEDICAL CENTRE C88638 SHEFFIELD CITY GP HC (REG) Y02566 UNIVERSITY HEALTH SERVICE HEALTH CENTRE C88627 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 Rotherham CCG 82.2% • 1,828 people with heart failure* with LVSD treated with ACE-I/ARB in NHS Sheffield CCG NHS Bassetlaw CCG 81.8% • 1,401 (76.6%) people treated with ACE-I/ARB and BB • 327 (17.9%) people who are NHS Doncaster CCG 80.4% exceptions • 100 (5.5%) additional people who are not treated with ACE-I/ARB and BB NHS Sheffield CCG 76.6%

NHS Barnsley CCG 75.5%

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 Portsmouth CCG 85.5%

NHS Coventry and Rugby CCG 83.0%

NHS Bristol CCG 81.2%

NHS Liverpool CCG 80.5%

NHS Newcastle Gateshead CCG 78.7%

NHS West Leicestershire CCG 78.5%

NHS Greater Huddersfield CCG 76.8%

NHS Sheffield CCG 76.6%

NHS North Durham CCG 76.2%

NHS Lincolnshire West CCG 75.0%

NHS Southern Derbyshire CCG 72.2%

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

BENTS GREEN SURGERY C88061 1 BARNSLEY ROAD SURGERY C88091 2 HAROLD STREET MEDICAL CENTRE C88059 1 BROOMHILL SURGERY C88028 10 WHITE HOUSE SURGERY C88020 4 DEVONSHIRE GREEN MEDICAL CENTRE C88076 4 WINCOBANK MEDICAL CENTRE C88047 10 DOVERCOURT GROUP PRACTICE C88087 5 UPWELL STREET SURGERY C88027 2 DEEPCAR MEDICAL CENTRE C88074 6 RUSTLINGS ROAD MEDICAL CENTRE C88062 3 • in total, including exceptions, there DARNALL HEALTH CENTRE (MEHROTRA) C88084 6 HACKENTHORPE MEDICAL CENTRE C88096 8 NORFOLK PARK HEALTH CENTRE C88006 5 are 427 people who are not treated SLOAN MEDICAL CENTRE C88026 17 ECCLESFIELD GROUP PRACT C88039 25 MEADOWGREEN HEALTH CENTRE C88015 12 PAGE HALL MEDICAL CENTRE C88051 4 with ACE-I or ARB HOLLIES MEDICAL CENTRE C88052 7 SHARROW LANE MEDICAL CENTRE C88060 1 SELBORNE ROAD MEDICAL CENTRE C88083 6 EAST BANK MEDICAL CENTRE C88088 7 • GP practice range: 0.0% to 100.0% GLEADLESS MEDICAL CENTRE C88019 15 HANDSWORTH MEDICAL PRACTICE C88036 19 AVENUE MEDICAL PRACTICE C88024 8 ABBEY LANE SURGERY C88046 8 OWLTHORPE MEDICAL CENTRE C88647 6 CROOKES VALLEY MEDICAL CENTRE C88057 3 CARTERKNOWLE & DORE MEDICAL PRACTICE C88016 5 WALKLEY HOUSE MEDICAL CENTRE C88005 12 DUKE MEDICAL CENTRE C88030 2 OUGHTIBRIDGE SURGERY C88040 5 SHEFFIELD CITY GP HC (REG) Y02566 1 CLOVER GROUP PRACTICE C88069 8 THE MATHEWS PRACTICE BELGRAVE C88038 11 BUCHANAN ROAD SURGERY C88011 3 CROOKES PRACTICE C88079 3 RICHMOND MEDICAL CENTRE C88085 3 TRAMWAYS 54A MC C88043 6 SHIREGREEN MEDICAL CENTRE C88070 2 CHAPELGREEN PRACTICE C88010 19 STONECROFT MEDICAL CENTRE C88022 6 MANCHESTER ROAD SURGERY C88044 4 GRENOSIDE SURGERY C88054 5 STANNINGTON MEDICAL CENTRE C88656 5 VALLEY MEDICAL CENTRE C88092 13 FIRTH PARK SURGERY C88035 14 FOXHILL MEDICAL CENTRE C88009 2 GREYSTONES MEDICAL CENTRE C88652 2 ELM LANE SURGERY C88049 4 WOODHOUSE MEDICAL CENTRE C88072 9 NORWOOD MEDICAL CENTRE C88014 2 BIRLEY HEALTH CENTRE C88025 4 UPPERTHORPE MEDICAL CENTRE C88031 4 JAUNTY SPRINGS HEALTH CENTRE C88050 6 MANOR PARK MEDICAL CENTRE C88090 6 BASLOW RD, SHOREHAM ST & YORK RD SRGIES C88037 4 TRAMWAYS MEDICAL CENTRE (O'CONNELL) C88018 3 SOTHALL & BEIGHTON HEALTH CENTRES C88023 2 NETHERGREEN SURGERY C88034 2 HEELEY GREEN SURGERY C88073 1 VERITAS HEALTH CENTRE C88631 2 WOODSEATS MEDICAL CENTRE C88041 6 TOTLEY RISE MEDICAL CENTRE C88068 3 MOSBOROUGH HEALTH CENTRE C88078 2 SOUTHEY GREEN MEDICAL CTR C88086 1 MILL ROAD SURGERY C88095 3 CHARNOCK HEALTH PRIMARY CARE CENTRE C88032 4 FAR LANE MEDICAL CENTRE C88021 6 PORTER BROOK MEDICAL CENTRE C88007 4 PITSMOOR SURGERY C88008 2 THE FLOWERS HEALTH CENTRE C88033 1 WESTFIELD HEALTH CENTRE Y04887 1 FALKLAND HOUSE SURGERY C88053 2 DYKES HALL MEDICAL CENTRE C88045 5 THE HEALTH CARE SURGERY C88077 1 BURNGREAVE SURGERY C88048 1 PARK HEALTH CENTRE C88042 CARRFIELD MEDICAL CENTRE C88082 SHEFFIELD MEDICAL CENTRE C88622 MANOR TOP MEDICAL CENTRE (READ) C88626 MANOR TOP MEDICAL CENTRE C88638 DUNNINC ROAD SURGERY C88643 CRYSTAL PEAKS MEDICAL CENTRE C88648 THE MEDICAL CENTRE DR OKORIE C88655 UNIVERSITY HEALTH SERVICE HEALTH CENTRE C88627 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 Doncaster CCG 90.8% • 20,811 people with coronary heart disease* in NHS Sheffield CCG • 18,399 (88.4%) people whose blood NHS Sheffield CCG 88.4% pressure <= 150 / 90 • 736 (3.5%) people who are exceptions NHS Rotherham CCG 88.3% • 1,676 (8.1%) additional people whose blood pressure is not <= 150 / 90

NHS Barnsley CCG 86.1%

NHS Bassetlaw CCG 85.5%

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 North Durham CCG 89.4%

NHS Lincolnshire West CCG 89.4%

NHS Coventry and Rugby CCG 89.3%

NHS Newcastle Gateshead CCG 89.2%

NHS Greater Huddersfield CCG 88.9%

NHS Liverpool CCG 88.9%

NHS West Leicestershire CCG 88.7%

NHS Portsmouth CCG 88.5%

NHS Sheffield CCG 88.4%

NHS Southern Derbyshire CCG 87.6%

NHS Bristol CCG 86.9%

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

MANOR TOP MEDICAL CENTRE C88638 27 SHEFFIELD CITY GP HC (REG) Y02566 5 MANOR TOP MEDICAL CENTRE (READ) C88626 25 SELBORNE ROAD MEDICAL CENTRE C88083 19 MANOR PARK MEDICAL CENTRE C88090 38 VALLEY MEDICAL CENTRE C88092 93 THE MATHEWS PRACTICE BELGRAVE C88038 84 WALKLEY HOUSE MEDICAL CENTRE C88005 76 TOTLEY RISE MEDICAL CENTRE C88068 19 GLEADLESS MEDICAL CENTRE C88019 57 DARNALL HEALTH CENTRE (MEHROTRA) C88084 30 • in total, including exceptions, there NETHERGREEN SURGERY C88034 41 BURNGREAVE SURGERY C88048 36 AVENUE MEDICAL PRACTICE C88024 41 are 2,412 people whose blood BASLOW RD, SHOREHAM ST & YORK RD SRGIES C88037 78 PARK HEALTH CENTRE C88042 34 SHEFFIELD MEDICAL CENTRE C88622 9 PAGE HALL MEDICAL CENTRE C88051 31 pressure is not <= 150 / 90 WESTFIELD HEALTH CENTRE Y04887 8 SHIREGREEN MEDICAL CENTRE C88070 39 DUKE MEDICAL CENTRE C88030 37 CHAPELGREEN PRACTICE C88010 104 • GP practice range: 0.0% to 33.8% BUCHANAN ROAD SURGERY C88011 31 SOTHALL & BEIGHTON HEALTH CENTRES C88023 63 WOODSEATS MEDICAL CENTRE C88041 41 SLOAN MEDICAL CENTRE C88026 50 CROOKES PRACTICE C88079 20 HANDSWORTH MEDICAL PRACTICE C88036 57 GRENOSIDE SURGERY C88054 39 ECCLESFIELD GROUP PRACT C88039 58 MILL ROAD SURGERY C88095 34 EAST BANK MEDICAL CENTRE C88088 23 CLOVER GROUP PRACTICE C88069 68 CROOKES VALLEY MEDICAL CENTRE C88057 10 MEADOWGREEN HEALTH CENTRE C88015 54 BARNSLEY ROAD SURGERY C88091 13 HAROLD STREET MEDICAL CENTRE C88059 7 UPWELL STREET SURGERY C88027 22 JAUNTY SPRINGS HEALTH CENTRE C88050 23 BROOMHILL SURGERY C88028 34 HOLLIES MEDICAL CENTRE C88052 23 GREYSTONES MEDICAL CENTRE C88652 8 CARRFIELD MEDICAL CENTRE C88082 5 THE HEALTH CARE SURGERY C88077 22 TRAMWAYS MEDICAL CENTRE (O'CONNELL) C88018 31 PITSMOOR SURGERY C88008 25 SOUTHEY GREEN MEDICAL CTR C88086 14 BIRLEY HEALTH CENTRE C88025 40 HACKENTHORPE MEDICAL CENTRE C88096 30 MOSBOROUGH HEALTH CENTRE C88078 25 RUSTLINGS ROAD MEDICAL CENTRE C88062 8 STONECROFT MEDICAL CENTRE C88022 18 UPPERTHORPE MEDICAL CENTRE C88031 38 CARTERKNOWLE & DORE MEDICAL PRACTICE C88016 43 NORWOOD MEDICAL CENTRE C88014 32 THE FLOWERS HEALTH CENTRE C88033 14 MANCHESTER ROAD SURGERY C88044 16 HEELEY GREEN SURGERY C88073 17 DYKES HALL MEDICAL CENTRE C88045 37 WOODHOUSE MEDICAL CENTRE C88072 62 FALKLAND HOUSE SURGERY C88053 10 OWLTHORPE MEDICAL CENTRE C88647 15 SHARROW LANE MEDICAL CENTRE C88060 12 OUGHTIBRIDGE SURGERY C88040 19 CRYSTAL PEAKS MEDICAL CENTRE C88648 24 DEEPCAR MEDICAL CENTRE C88074 17 FIRTH PARK SURGERY C88035 24 FAR LANE MEDICAL CENTRE C88021 25 DOVERCOURT GROUP PRACTICE C88087 14 DUNNINC ROAD SURGERY C88643 8 PORTER BROOK MEDICAL CENTRE C88007 11 CHARNOCK HEALTH PRIMARY CARE CENTRE C88032 15 RICHMOND MEDICAL CENTRE C88085 27 DEVONSHIRE GREEN MEDICAL CENTRE C88076 11 THE MEDICAL CENTRE DR OKORIE C88655 2 NORFOLK PARK HEALTH CENTRE C88006 11 ELM LANE SURGERY C88049 13 WHITE HOUSE SURGERY C88020 15 TRAMWAYS 54A MC C88043 15 ABBEY LANE SURGERY C88046 7 FOXHILL MEDICAL CENTRE C88009 12 STANNINGTON MEDICAL CENTRE C88656 7 WINCOBANK MEDICAL CENTRE C88047 10 VERITAS HEALTH CENTRE C88631 2 BENTS GREEN SURGERY C88061 UNIVERSITY HEALTH SERVICE HEALTH CENTRE C88627 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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

10% 5% 0% -5% -10% -15% -20% -25% -30%

MANOR TOP MEDICAL CENTRE 21

SHEFFIELD CITY GP HC (REG) 4

MANOR TOP MEDICAL CENTRE (READ) 17 • using the GP cluster method of SELBORNE ROAD MEDICAL CENTRE 13 calculating potential gains, if each MANOR PARK MEDICAL CENTRE 25 practice was to achieve as well as the TOTLEY RISE MEDICAL CENTRE 12 upper quartile of its national cluster, then an additional 900 people would VALLEY MEDICAL CENTRE 54 be treated THE MATHEWS PRACTICE BELGRAVE 48

WALKLEY HOUSE MEDICAL CENTRE 43

GLEADLESS MEDICAL CENTRE 34

NORFOLK PARK HEALTH CENTRE

ELM LANE SURGERY

WHITE HOUSE SURGERY

ABBEY LANE SURGERY

FOXHILL MEDICAL CENTRE

TRAMWAYS 54A MC

STANNINGTON MEDICAL CENTRE

WINCOBANK MEDICAL CENTRE

VERITAS HEALTH CENTRE

UNIVERSITY HEALTH SERVICE HEALTH 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 Doncaster CCG 92.5% • 20,811 people with coronary heart disease* in NHS Sheffield CCG • 18,998 (91.3%) people who are NHS Rotherham CCG 91.6% taking aspirin, an alternative anti- platelet therapy, or an anti-coagulant • 674 (3.2%) people who are NHS Barnsley CCG 91.4% exceptions • 1,139 (5.5%) additional people who are not taking aspirin, an alternative NHS Sheffield CCG 91.3% anti-platelet therapy, or an anti- coagulant

NHS Bassetlaw CCG 91.1%

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 Coventry and Rugby CCG 93.8%

NHS Newcastle Gateshead CCG 93.7%

NHS Liverpool CCG 93.2%

NHS North Durham CCG 92.9%

NHS West Leicestershire CCG 92.8%

NHS Bristol CCG 91.8%

NHS Sheffield CCG 91.3%

NHS Lincolnshire West CCG 91.1%

NHS Southern Derbyshire CCG 90.6%

NHS Greater Huddersfield CCG 90.5%

NHS Portsmouth CCG 89.5%

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

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

No treatment Exceptions reported

MANOR TOP MEDICAL CENTRE C88638 18 BENTS GREEN SURGERY C88061 1 MANOR TOP MEDICAL CENTRE (READ) C88626 17 SHEFFIELD CITY GP HC (REG) Y02566 3 SELBORNE ROAD MEDICAL CENTRE C88083 13 WALKLEY HOUSE MEDICAL CENTRE C88005 56 UPWELL STREET SURGERY C88027 26 HOLLIES MEDICAL CENTRE C88052 27 HANDSWORTH MEDICAL PRACTICE C88036 57 DEEPCAR MEDICAL CENTRE C88074 28 BIRLEY HEALTH CENTRE C88025 49 • in total, including exceptions, there NETHERGREEN SURGERY C88034 30 EAST BANK MEDICAL CENTRE C88088 23 SOTHALL & BEIGHTON HEALTH CENTRES C88023 57 are 1,813 people are not taking CLOVER GROUP PRACTICE C88069 65 BUCHANAN ROAD SURGERY C88011 26 MANOR PARK MEDICAL CENTRE C88090 21 CARTERKNOWLE & DORE MEDICAL PRACTICE C88016 52 aspirin, an alternative anti-platelet WOODSEATS MEDICAL CENTRE C88041 34 TOTLEY RISE MEDICAL CENTRE C88068 11 DARNALL HEALTH CENTRE (MEHROTRA) C88084 19 AVENUE MEDICAL PRACTICE C88024 29 therapy, or an anti-coagulant VALLEY MEDICAL CENTRE C88092 50 BURNGREAVE SURGERY C88048 24 WESTFIELD HEALTH CENTRE Y04887 6 • GP practice range: 0.0% to 22.5% BASLOW RD, SHOREHAM ST & YORK RD SRGIES C88037 53 FALKLAND HOUSE SURGERY C88053 12 THE MATHEWS PRACTICE BELGRAVE C88038 43 NORWOOD MEDICAL CENTRE C88014 34 PORTER BROOK MEDICAL CENTRE C88007 15 CROOKES VALLEY MEDICAL CENTRE C88057 8 WHITE HOUSE SURGERY C88020 25 HACKENTHORPE MEDICAL CENTRE C88096 29 STONECROFT MEDICAL CENTRE C88022 18 PARK HEALTH CENTRE C88042 21 UPPERTHORPE MEDICAL CENTRE C88031 37 FAR LANE MEDICAL CENTRE C88021 30 PAGE HALL MEDICAL CENTRE C88051 20 PITSMOOR SURGERY C88008 21 OUGHTIBRIDGE SURGERY C88040 20 ABBEY LANE SURGERY C88046 11 MILL ROAD SURGERY C88095 23 RUSTLINGS ROAD MEDICAL CENTRE C88062 7 MEADOWGREEN HEALTH CENTRE C88015 38 WOODHOUSE MEDICAL CENTRE C88072 60 SHARROW LANE MEDICAL CENTRE C88060 12 SHEFFIELD MEDICAL CENTRE C88622 5 RICHMOND MEDICAL CENTRE C88085 31 GRENOSIDE SURGERY C88054 24 THE FLOWERS HEALTH CENTRE C88033 12 TRAMWAYS MEDICAL CENTRE (O'CONNELL) C88018 22 JAUNTY SPRINGS HEALTH CENTRE C88050 15 SOUTHEY GREEN MEDICAL CTR C88086 10 DEVONSHIRE GREEN MEDICAL CENTRE C88076 12 CROOKES PRACTICE C88079 11 GREYSTONES MEDICAL CENTRE C88652 5 SLOAN MEDICAL CENTRE C88026 26 NORFOLK PARK HEALTH CENTRE C88006 12 HAROLD STREET MEDICAL CENTRE C88059 4 DYKES HALL MEDICAL CENTRE C88045 28 WINCOBANK MEDICAL CENTRE C88047 21 BROOMHILL SURGERY C88028 20 MOSBOROUGH HEALTH CENTRE C88078 17 CHARNOCK HEALTH PRIMARY CARE CENTRE C88032 14 SHIREGREEN MEDICAL CENTRE C88070 18 CRYSTAL PEAKS MEDICAL CENTRE C88648 19 TRAMWAYS 54A MC C88043 16 FIRTH PARK SURGERY C88035 19 THE HEALTH CARE SURGERY C88077 12 GLEADLESS MEDICAL CENTRE C88019 19 OWLTHORPE MEDICAL CENTRE C88647 10 DUNNINC ROAD SURGERY C88643 6 DOVERCOURT GROUP PRACTICE C88087 10 CHAPELGREEN PRACTICE C88010 40 MANCHESTER ROAD SURGERY C88044 9 FOXHILL MEDICAL CENTRE C88009 13 STANNINGTON MEDICAL CENTRE C88656 9 HEELEY GREEN SURGERY C88073 9 ECCLESFIELD GROUP PRACT C88039 21 ELM LANE SURGERY C88049 7 THE MEDICAL CENTRE DR OKORIE C88655 1 CARRFIELD MEDICAL CENTRE C88082 1 VERITAS HEALTH CENTRE C88631 1 DUKE MEDICAL CENTRE C88030 4 BARNSLEY ROAD SURGERY C88091 1 UNIVERSITY HEALTH SERVICE HEALTH CENTRE C88627 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 Sheffield CCG England 1200

• in NHS Sheffield CCG, the hospital 1000 admission rate for coronary heart disease in 2015/16 was 634.6 (3,013) 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 Sheffield CCG England 250

• in NHS Sheffield CCG, the hospital admission rate for stroke in 2015/16 200 was 173 (832) 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 Sheffield CCG England

125.3% Angina 136.8% • The risk of a stroke was 110.4% higher and the risk of a heart attack 115.2% was 115.2% higher compared to Heart Attack 108.6% people without diabetes. The risk of a major amputation was 475.1% higher. 165.8% Heart failure 150.0%

110.4% Stroke 81.3%

475.1% Major amputation 445.8%

845.6% Minor amputation 753.5%

368.9% RRT 293.0%

0% 100% 200% 300% 400% 500% 600% 700% 800% 900% Note: This slide uses data from the National Diabetes Audit (NDA)

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

NHS Sheffield CCG England 90

80 • in NHS Sheffield CCG, the early mortality rate for coronary heart 70 disease in 2013-15 was 46.8, compared to 40.6 for England

60

50

40

30 Age Age standardised (per rate 1000,000) 20

10

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

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

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

NHS Sheffield CCG England 30

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

20

15

10 Age Age standardised (per rate 100,000)

5

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

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

87 CVD: Primary Care Intelligence Packs Appendix Data sources

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

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

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

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

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

• NHS Stop smoking services Copyright © 2014, NHS Digital

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

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

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

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

88 CVD: Primary Care Intelligence Packs About Public Health England

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Published June 2017 Gateway number 2017095

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