CVD: Primary Care Intelligence Packs NHS West Lancashire CCG

June 2017 Version 1 Contents

1. Introduction 3

2. CVD prevention • The narrative 11 • The data 13 3. Hypertension • The narrative 16 • The data 17 4. Stroke • The narrative 27 • The data 28 5. Diabetes • The narrative 42 • The data 43 6. Kidney • The narrative 53 • The data 54 7. Heart • The narrative 65 • The data 66 8. Outcomes 82

9. Appendix 88 This document is valid only when viewed via the internet. If it is printed into hard copy or saved to another location, you must first check that the version number on your copy matches that of the one online. Printed copies are uncontrolled copies.

2 CVD: Primary Care Intelligence Packs Introduction

3 CVD: Primary Care Intelligence Packs This intelligence pack has been compiled by GPs and nurses and pharmacists in the Primary Care CVD Leadership Forum in collaboration with the National Cardiovascular Intelligence Network

Matt Kearney Sarit Ghosh Kathryn Griffith George Kassianos Jo Whitmore Matthew Fay Chris Harris Jan Procter-King Yassir Javaid Ivan Benett Ruth Chambers Ahmet Fuat Mike Kirby Peter Green Kamlesh Khunti Helen Williams Quincy Chuhka Sheila McCorkindale Nigel Rowell Ali Morgan Stephen Kirk Sally Christie Clare Hawley Paul Wright Bruce Taylor Mike Knapton John Robson Richard Mendelsohn Chris Arden David Fitzmaurice

4 CVD: Primary Care Intelligence Packs Local intelligence as a tool for clinicians and commissioners to improve outcomes for our patients Why should we use this CVD Intelligence Pack The high risk conditions for cardiovascular disease (CVD) - such as hypertension, atrial fibrillation, high cholesterol, diabetes, non-diabetic hyperglycaemia and chronic kidney disease - are the low hanging fruit for prevention in the NHS because in each case late diagnosis and suboptimal treatment is common and there is substantial variation. High quality primary care is central to improving outcomes in CVD because primary care is where much prevention and most diagnosis and treatment is delivered. This cardiovascular intelligence pack is a powerful resource for stimulating local conversations about quality improvement in primary care. Across a number of vascular conditions, looking at prevention, diagnosis, care and outcomes, the data allows comparison between clinical commissioning groups (CCGs) and between practices. This is not about performance management because we know that variation can have more than one interpretation. But patients have a right to expect that we will ask challenging questions about how the best practices are achieving the best, what average or below average performers could do differently, and how they could be supported to perform as well as the best.

How to use the CVD intelligence pack The intelligence pack has several sections – CVD prevention, hypertension, stroke and atrial fibrillation (AF), diabetes, kidney disease, heart disease and heart failure. Each section has one slide of narrative that makes the case and asks some questions. This is followed by data for a number of indicators, each with benchmarked comparison between CCGs and between practices. Use the pack to identify where there is variation that needs exploring and to start asking challenging questions about where and how quality could be improved. We suggest you then develop a local action plan for quality improvement – this might include establishing communities of practice to build clinical leadership, systematic local audit to get a better understanding of the gaps in care and outcomes, and developing new models of care that mobilise the wider primary care team to reduce burden on general practice.

5 CVD: Primary Care Intelligence Packs Data and methods

This slide pack compares the clinical commissioning group (CCG) with CCGs in its strategic transformation plan (STP) and England. Where a CCG is in more than one STP, it has been allocated to the STP with the greatest geographical or population coverage. The slide pack also compares the CCG to its 10 most similar CCGs in terms of demography, ethnicity and deprivation. For information on the methodology used to calculate the 10 most similar CCGs please go to: http://www.england.nhs.uk/resources/resources-for-ccgs/comm-for-value/

The 10 most similar CCGs to NHS West Lancashire CCG are: NHS Warwickshire North CCG NHS Vale Royal CCG NHS North East Lincolnshire CCG NHS Newark & Sherwood CCG NHS Bassetlaw CCG NHS South Cheshire CCG NHS West Cheshire CCG NHS Thanet CCG NHS St Helens CCG NHS South Sefton 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 North East Lincolnshire CCG 23.5%

NHS Thanet CCG 22.6% • prevalence of 15.7% in NHS West Lancashire CCG NHS South Sefton CCG 19.4%

NHS St Helens CCG 18.9%

NHS Warwickshire North CCG 18.7%

NHS Bassetlaw CCG 18.0%

NHS Newark & Sherwood CCG 17.4%

NHS Vale Royal CCG 17.1% Note: It has been found that the proportion of patients recorded as smokers correlates well NHS South Cheshire CCG 16.9% with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, NHS West Lancashire CCG 15.7% http://bmjopen.bmj.com/content/4/7/e005217.abs tract

NHS West Cheshire CCG 15.3% Definition: denominator of QOF clinical indicator SMOKE004 ( number of patients 15+ who are 0% 5% 10% 15% 20% 25% recorded as current smokers) divided by GP practice’s estimated number of patients 15+

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

GP Practice CCG

SKELMERSDALE PRACTICE P81208 30.1%

BIRLEYWOOD HEALTH CENTRE P81121 28.7%

MANOR PRIMARY CARE P81039 26.5% • 14,812 people who are recorded as

BEACON PRIMARY CARE P81112 22.7% smokers in NHS West Lancashire

COUNTY ROAD SURGERY P81727 22.6% CCG • GP practice range: 7.6% to 30.1% ASHURST PRIMARY CARE P81201 20.8%

SKELMERSDALE FAMILY PRACTICE P81764 18.4%

NORTH MEOLS MEDICAL CENTRE P81772 18.0%

DR A LITTLER P81774 16.9%

DR A BISARYA P81136 15.3%

VIRAN MEDICAL CENTRE P81177 14.2%

TARLETON GROUP PRACTICE P81710 12.9%

BURSCOUGH FAMILY PRACTICE P81138 12.7%

STANLEY COURT SURGERY P81674 12.4%

MATTHEW RYDER CLINIC P81758 12.2%

LATHOM HOUSE SURGERY P81646 11.6%

ORMSKIRK MEDICAL PRACTICE P81014 11.4%

THE ELMS PRACTICE P81045 10.9% Note: This method is thought to be a reasonably HALL GREEN SURGERY P81084 10.5% robust method in estimating smoking prevalence PARKGATE SURGERY P81041 9.8% for the majority of GP practices. However, PARBOLD SURGERY P81096 8.0% caution is advised for extreme estimates of smoking prevalence and those with high AUGHTON SURGERY P81695 7.6% numbers of smoking status not recorded and 0% 5% 10% 15% 20% 25% 30% 35% 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 Blackpool CCG 0.62

NHS Fylde & Wyre CCG 0.62 • the ratio of those diagnosed with hypertension versus those expected NHS West Lancashire CCG 0.61 to have hypertension is 0.61. This compares to 0.59 for England • this suggests that 61% of people with NHS Chorley And South Ribble CCG 0.60 hypertension have been diagnosed

NHS East Lancashire CCG 0.59

NHS Greater Preston CCG 0.59

NHS Lancashire North CCG 0.58

NHS Blackburn With Darwen CCG 0.57

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

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

NHS St Helens CCG 0.64

NHS South Sefton CCG 0.63

NHS Thanet CCG 0.62

NHS Warwickshire North CCG 0.62

NHS Vale Royal CCG 0.61

NHS West Lancashire CCG 0.61

NHS South Cheshire CCG 0.61

NHS North East Lincolnshire CCG 0.61

NHS Newark & Sherwood CCG 0.60

NHS Bassetlaw CCG 0.59

NHS West Cheshire CCG 0.59

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

18 CVD: Primary Care Intelligence Packs Hypertension observed prevalence compared with expected prevalence by GP practice

GP practice CCG

VIRAN MEDICAL CENTRE P81177 0.76

DR A LITTLER P81774 0.75 DR A BISARYA P81136 0.70 • it is estimated that there are 11,283 PARBOLD SURGERY P81096 0.68 people with undiagnosed BIRLEYWOOD HEALTH CENTRE P81121 0.66 hypertension in NHS West TARLETON GROUP PRACTICE P81710 0.66 Lancashire CCG BEACON PRIMARY CARE P81112 0.65 • GP practice range of observed to BURSCOUGH FAMILY PRACTICE P81138 0.64 expected hypertension prevalence SKELMERSDALE FAMILY PRACTICE P81764 0.62 0.47 to 0.76 ORMSKIRK MEDICAL PRACTICE P81014 0.60

MANOR PRIMARY CARE P81039 0.60

ASHURST PRIMARY CARE P81201 0.59

HALL GREEN SURGERY P81084 0.59

LATHOM HOUSE SURGERY P81646 0.58

AUGHTON SURGERY P81695 0.58

STANLEY COURT SURGERY P81674 0.58

COUNTY ROAD SURGERY P81727 0.57

SKELMERSDALE PRACTICE P81208 0.56

NORTH MEOLS MEDICAL CENTRE P81772 0.56

MATTHEW RYDER CLINIC P81758 0.52

PARKGATE SURGERY P81041 0.50

THE ELMS PRACTICE P81045 0.47

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

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 West Lancashire CCG 82.5%

NHS Fylde & Wyre CCG 81.4% • 17,712 people with hypertension (diagnosed)* in NHS West Lancashire NHS Blackpool CCG 80.9% CCG • 14,607 (82.5%) people whose blood pressure is <= 150/90 NHS Blackburn With Darwen CCG 80.7% • 383 (2.2%) people who are excepted from optimal control NHS Chorley And South Ribble CCG 80.6% • 2,722 (15.4%) additional people whose blood pressure is not <= 150/90 NHS Greater Preston CCG 80.5%

NHS East Lancashire CCG 80.5%

NHS Lancashire North CCG 76.8%

England 79.6%

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

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

NHS West Lancashire CCG 82.5%

NHS Warwickshire North CCG 82.3%

NHS North East Lincolnshire CCG 82.2%

NHS Vale Royal CCG 82.1%

NHS West Cheshire CCG 81.6%

NHS Bassetlaw CCG 80.9%

NHS St Helens CCG 80.5%

NHS South Cheshire CCG 80.3%

NHS Newark & Sherwood CCG 80.2%

NHS South Sefton CCG 77.5%

NHS Thanet CCG 77.0%

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

ORMSKIRK MEDICAL PRACTICE P81014 621

PARKGATE SURGERY P81041 202 HALL GREEN SURGERY P81084 248 • in total, including exceptions, there MATTHEW RYDER CLINIC P81758 72 are 3,105 people whose blood

NORTH MEOLS MEDICAL CENTRE P81772 102 pressure is not <= 150/90

PARBOLD SURGERY P81096 236 • GP practice range: 10.1% to 41.6%

VIRAN MEDICAL CENTRE P81177 89

THE ELMS PRACTICE P81045 130

BEACON PRIMARY CARE P81112 276

AUGHTON SURGERY P81695 138

COUNTY ROAD SURGERY P81727 45

ASHURST PRIMARY CARE P81201 95

LATHOM HOUSE SURGERY P81646 101

DR A BISARYA P81136 71

BURSCOUGH FAMILY PRACTICE P81138 76

SKELMERSDALE PRACTICE P81208 140

TARLETON GROUP PRACTICE P81710 167

MANOR PRIMARY CARE P81039 80

SKELMERSDALE FAMILY PRACTICE P81764 46

BIRLEYWOOD HEALTH CENTRE P81121 33

STANLEY COURT SURGERY P81674 89

DR A LITTLER P81774 48

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 West Lancashire CCG 75.0%

NHS Blackburn With Darwen CCG 70.9% • 68 people with a new diagnosis* of hypertension with a CVD risk of 20% NHS Fylde & Wyre CCG 64.5% or higher in NHS West Lancashire CCG • 51 (75%) people who are currently NHS East Lancashire CCG 64.3% treated with statins • 17 (25%) people who are exempted NHS Chorley And South Ribble CCG 62.9% from treatment with statins • 0 (0%) additional people who are not currently treated with statins NHS Greater Preston CCG 59.7%

NHS Blackpool CCG 57.7%

NHS Lancashire North CCG 55.6%

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 North East Lincolnshire CCG 82.5%

NHS Warwickshire North CCG 80.8%

NHS West Lancashire CCG 75.0%

NHS Thanet CCG 72.2%

NHS South Sefton CCG 71.1%

NHS Newark & Sherwood CCG 70.9%

NHS St Helens CCG 70.2%

NHS Bassetlaw CCG 63.3%

NHS West Cheshire CCG 61.0%

NHS South Cheshire CCG 60.8%

NHS Vale Royal CCG 60.0%

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

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

No treatment Exceptions reported

HALL GREEN SURGERY P81084 2

PARBOLD SURGERY P81096 1 LATHOM HOUSE SURGERY P81646 1 • in total, including exceptions, there AUGHTON SURGERY P81695 1 are 17 people who are not treated

COUNTY ROAD SURGERY P81727 1 with statins

PARKGATE SURGERY P81041 2 • GP practice range: 0.0% to 66.7%

TARLETON GROUP PRACTICE P81710 1

SKELMERSDALE FAMILY PRACTICE P81764 1

NORTH MEOLS MEDICAL CENTRE P81772 1

STANLEY COURT SURGERY P81674 2

MANOR PRIMARY CARE P81039 2

BEACON PRIMARY CARE P81112 2

ORMSKIRK MEDICAL PRACTICE P81014

THE ELMS PRACTICE P81045

BIRLEYWOOD HEALTH CENTRE P81121

DR A BISARYA P81136

BURSCOUGH FAMILY PRACTICE P81138

ASHURST PRIMARY CARE P81201

SKELMERSDALE PRACTICE P81208

MATTHEW RYDER CLINIC P81758

DR A LITTLER P81774

VIRAN MEDICAL CENTRE P81177

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 Blackpool CCG 0.77

NHS Lancashire North CCG 0.75 • the ratio of those diagnosed with atrial fibrillation versus those expected to NHS Chorley And South Ribble CCG 0.73 have atrial fibrillation is 0.71. This compares to 0.7 for England • this suggests that 71% of people with NHS Fylde & Wyre CCG 0.72 atrial fibrillation have been diagnosed.

NHS West Lancashire CCG 0.71

NHS Greater Preston CCG 0.70

NHS East Lancashire CCG 0.68

NHS Blackburn With Darwen CCG 0.65 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 Vale Royal CCG 0.82

NHS South Cheshire CCG 0.80

NHS West Cheshire CCG 0.80

NHS South Sefton CCG 0.80

NHS Bassetlaw CCG 0.78

NHS St Helens CCG 0.76

NHS North East Lincolnshire CCG 0.75

NHS Newark & Sherwood CCG 0.75

NHS Thanet CCG 0.72

NHS West Lancashire CCG 0.71

NHS Warwickshire North CCG 0.65

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

HALL GREEN SURGERY P81084 0.9

MATTHEW RYDER CLINIC P81758 0.9

THE ELMS PRACTICE P81045 0.8 • it is estimated that there are 3,195

PARBOLD SURGERY P81096 0.8 people with undiagnosed atrial

BEACON PRIMARY CARE P81112 0.8 fibrillation in NHS West Lancashire CCG PARKGATE SURGERY P81041 0.7 • GP practice range of observed to BURSCOUGH FAMILY PRACTICE P81138 0.7 expected atrial fibrillation prevalence VIRAN MEDICAL CENTRE P81177 0.7 0.4 to 0.9 ASHURST PRIMARY CARE P81201 0.7

LATHOM HOUSE SURGERY P81646 0.7

STANLEY COURT SURGERY P81674 0.7

TARLETON GROUP PRACTICE P81710 0.7

NORTH MEOLS MEDICAL CENTRE P81772 0.7

ORMSKIRK MEDICAL PRACTICE P81014 0.6

MANOR PRIMARY CARE P81039 0.6

BIRLEYWOOD HEALTH CENTRE P81121 0.6

DR A BISARYA P81136 0.6

AUGHTON SURGERY P81695 0.6

COUNTY ROAD SURGERY P81727 0.6

SKELMERSDALE PRACTICE P81208 0.4

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 Fylde & Wyre CCG 76.5% • 1,871 people with atrial fibrillation* NHS Blackpool CCG 75.3% with a CHA2DS2-VASc score >= 2 in NHS West Lancashire CCG NHS Blackburn With Darwen CCG 74.9% • 1,392 (74.4%) people treated with anti-coagulation therapy • 214 (11.4%) people who are NHS West Lancashire CCG 74.4% exceptions • 265 (14.2%) additional people with a NHS Greater Preston CCG 74.1% recorded CHA2DS2-VASc score >= 2 who are not treated

NHS Lancashire North CCG 73.4%

NHS Chorley And South Ribble CCG 72.5%

NHS East Lancashire CCG 72.3%

England 77.9%

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

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

NHS Bassetlaw CCG 83.3%

NHS Newark & Sherwood CCG 80.8%

NHS North East Lincolnshire CCG 80.3%

NHS Vale Royal CCG 79.8%

NHS St Helens CCG 77.8%

NHS Warwickshire North CCG 77.5%

NHS South Cheshire CCG 77.3%

NHS West Cheshire CCG 77.3%

NHS South Sefton CCG 76.2%

NHS Thanet CCG 76.2%

NHS West Lancashire CCG 74.4%

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

VIRAN MEDICAL CENTRE P81177 19

ASHURST PRIMARY CARE P81201 14 STANLEY COURT SURGERY P81674 30 • in total, including exceptions, there THE ELMS PRACTICE P81045 35 are 479 people with a recorded

AUGHTON SURGERY P81695 32 CHA2DS2-VASc score >= 2 who are

MANOR PRIMARY CARE P81039 13 not treated

BEACON PRIMARY CARE P81112 51 • GP practice range: 11.1% to 38.8%

COUNTY ROAD SURGERY P81727 7

TARLETON GROUP PRACTICE P81710 37

PARKGATE SURGERY P81041 38

NORTH MEOLS MEDICAL CENTRE P81772 16

SKELMERSDALE FAMILY PRACTICE P81764 10

ORMSKIRK MEDICAL PRACTICE P81014 40

BURSCOUGH FAMILY PRACTICE P81138 14

PARBOLD SURGERY P81096 37

DR A BISARYA P81136 8

DR A LITTLER P81774 9

BIRLEYWOOD HEALTH CENTRE P81121 3

HALL GREEN SURGERY P81084 35

LATHOM HOUSE SURGERY P81646 15

SKELMERSDALE PRACTICE P81208 10

MATTHEW RYDER CLINIC P81758 6

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

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

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

VIRAN MEDICAL CENTRE 12

ASHURST PRIMARY CARE 7

STANLEY COURT SURGERY 15 • using the GP cluster method of THE ELMS PRACTICE 17 calculating potential gains, if each AUGHTON SURGERY 16 practice was to achieve as well as the MANOR PRIMARY CARE 6 upper quartile of its national cluster, then an additional 195 people would COUNTY ROAD SURGERY 3 be treated TARLETON GROUP PRACTICE 18

PARKGATE SURGERY 18

BEACON PRIMARY CARE 21

ORMSKIRK MEDICAL PRACTICE 17

BURSCOUGH FAMILY PRACTICE 5

PARBOLD SURGERY 13

DR A BISARYA 3

DR A LITTLER 2

BIRLEYWOOD HEALTH CENTRE 1

HALL GREEN SURGERY 7

LATHOM HOUSE SURGERY 2

SKELMERSDALE PRACTICE

MATTHEW RYDER CLINIC 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 West Lancashire CCG 87.2% • 2,250 people with a history of stroke NHS Blackburn With Darwen CCG 86.6% or TIA* in NHS West Lancashire CCG • 1,962 (87.2%) people whose blood NHS Fylde & Wyre CCG 86.0% pressure is <= 150 / 90 • 49 (2.2%) people who are exceptions • 239 (10.6%) additional people whose NHS East Lancashire CCG 85.7% blood pressure is not <= 150 / 90

NHS Greater Preston CCG 85.4%

NHS Blackpool CCG 84.0%

NHS Chorley And South Ribble CCG 83.9%

NHS Lancashire North CCG 81.0%

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 North East Lincolnshire CCG 87.4%

NHS West Lancashire CCG 87.2%

NHS Warwickshire North CCG 85.1%

NHS St Helens CCG 85.1%

NHS Vale Royal CCG 84.5%

NHS West Cheshire CCG 84.4%

NHS South Cheshire CCG 84.0%

NHS Newark & Sherwood CCG 83.9%

NHS Thanet CCG 83.5%

NHS Bassetlaw CCG 83.4%

NHS South Sefton CCG 82.4%

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

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

No treatment Exceptions reported

ORMSKIRK MEDICAL PRACTICE P81014 58

PARKGATE SURGERY P81041 25 MATTHEW RYDER CLINIC P81758 9 • in total, including exceptions, there COUNTY ROAD SURGERY P81727 6 are 288 people whose blood pressure

VIRAN MEDICAL CENTRE P81177 8 is not <= 150 / 90

AUGHTON SURGERY P81695 16 • GP practice range: 4.5% to 32.8%

BURSCOUGH FAMILY PRACTICE P81138 7

PARBOLD SURGERY P81096 17

ASHURST PRIMARY CARE P81201 9

THE ELMS PRACTICE P81045 15

DR A BISARYA P81136 6

SKELMERSDALE PRACTICE P81208 15

TARLETON GROUP PRACTICE P81710 20

HALL GREEN SURGERY P81084 18

STANLEY COURT SURGERY P81674 10

BEACON PRIMARY CARE P81112 25

NORTH MEOLS MEDICAL CENTRE P81772 8

MANOR PRIMARY CARE P81039 4

SKELMERSDALE FAMILY PRACTICE P81764 3

LATHOM HOUSE SURGERY P81646 5

BIRLEYWOOD HEALTH CENTRE P81121 2

DR A LITTLER P81774 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 Greater Preston CCG 93.5% • 1,447 people with a stroke shown to NHS West Lancashire CCG 92.2% be non-haemorrhagic* in NHS West Lancashire CCG NHS Blackburn With Darwen CCG 91.7% • 1,334 (92.2%) people who are taking an anti-platetet agent or anti- coagulant NHS East Lancashire CCG 90.9% • 60 (4.1%) people who are exceptions • 53 (3.7%) additional people with no NHS Chorley And South Ribble CCG 90.6% treatment

NHS Fylde & Wyre CCG 90.1%

NHS Lancashire North CCG 90.1%

NHS Blackpool CCG 89.6%

England 91.8%

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

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

NHS Newark & Sherwood CCG 93.0%

NHS Thanet CCG 92.9%

NHS North East Lincolnshire CCG 92.9%

NHS South Sefton CCG 92.6%

NHS Warwickshire North CCG 92.4%

NHS West Lancashire CCG 92.2%

NHS West Cheshire CCG 90.8%

NHS Bassetlaw CCG 90.2%

NHS St Helens CCG 90.0%

NHS South Cheshire CCG 88.9%

NHS Vale Royal CCG 88.8%

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

VIRAN MEDICAL CENTRE P81177 8

ORMSKIRK MEDICAL PRACTICE P81014 18 TARLETON GROUP PRACTICE P81710 15 • in total, including exceptions, there NORTH MEOLS MEDICAL CENTRE P81772 6 are 113 people who are not taking an

PARBOLD SURGERY P81096 11 anti-platelet agent or anti-coagulant

MATTHEW RYDER CLINIC P81758 4 • GP practice range: 0.0% to 19.0%

COUNTY ROAD SURGERY P81727 3

DR A BISARYA P81136 3

SKELMERSDALE PRACTICE P81208 7

ASHURST PRIMARY CARE P81201 4

PARKGATE SURGERY P81041 7

AUGHTON SURGERY P81695 5

THE ELMS PRACTICE P81045 5

BIRLEYWOOD HEALTH CENTRE P81121 1

SKELMERSDALE FAMILY PRACTICE P81764 1

LATHOM HOUSE SURGERY P81646 2

BEACON PRIMARY CARE P81112 6

MANOR PRIMARY CARE P81039 1

STANLEY COURT SURGERY P81674 2

BURSCOUGH FAMILY PRACTICE P81138 1

HALL GREEN SURGERY P81084 3

DR A LITTLER P81774

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 Blackburn With Darwen CCG 0.85

• 0.81 ratio of observed to expected NHS Lancashire North CCG 0.85 diabetes prevalence in NHS West Lancashire CCG, compared to 0.77 in NHS Chorley And South Ribble CCG 0.83 England • this suggests 81% of people have NHS West Lancashire CCG 0.81 been diagnosed

NHS Blackpool CCG 0.80

NHS East Lancashire CCG 0.78

NHS Greater Preston CCG 0.77

NHS Fylde & Wyre CCG 0.75

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

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

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

NHS Bassetlaw CCG 0.90

NHS Warwickshire North CCG 0.84

NHS St Helens CCG 0.83

NHS North East Lincolnshire CCG 0.82

NHS Vale Royal CCG 0.81

NHS West Lancashire CCG 0.81

NHS Newark & Sherwood CCG 0.80

NHS West Cheshire CCG 0.80

NHS South Cheshire CCG 0.80

NHS Thanet CCG 0.78

NHS South Sefton CCG 0.76

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

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

GP practice CCG

COUNTY ROAD SURGERY P81727 10.0%

DR A LITTLER P81774 8.9% SKELMERSDALE PRACTICE P81208 8.3% • GP practice range of observed BIRLEYWOOD HEALTH CENTRE P81121 7.6% diabetes 4.7% to 10.0%

BEACON PRIMARY CARE P81112 7.6% • there are an estimated 1,492 people

SKELMERSDALE FAMILY PRACTICE P81764 7.5% with undiagnosed diabetes in NHS

BURSCOUGH FAMILY PRACTICE P81138 7.3% West Lancashire CCG

ASHURST PRIMARY CARE P81201 7.3%

DR A BISARYA P81136 7.2%

NORTH MEOLS MEDICAL CENTRE P81772 7.2%

TARLETON GROUP PRACTICE P81710 7.1%

MATTHEW RYDER CLINIC P81758 7.0%

HALL GREEN SURGERY P81084 6.8%

MANOR PRIMARY CARE P81039 6.7%

LATHOM HOUSE SURGERY P81646 6.7%

STANLEY COURT SURGERY P81674 6.5%

PARBOLD SURGERY P81096 6.4%

ORMSKIRK MEDICAL PRACTICE P81014 6.3%

VIRAN MEDICAL CENTRE P81177 6.0%

PARKGATE SURGERY P81041 5.9%

AUGHTON SURGERY P81695 5.4% Note: The estimated number of undiagnosed

THE ELMS PRACTICE P81045 4.7% people with diabetes has been calculated by multiplying the estimated prevalence rate to the 0% 2% 4% 6% 8% 10% 12% 2015/16 QOF list size and subtracting the number of people on the diabetes register.

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

Diabetes prevalence Undiagnosed diabetes prevalence Expected non-diabetic hyperglycaemia prevalence

NHS Fylde & Wyre CCG 7.1% 2.4% 12.8% • the estimated total prevalence of diabetes in NHS West Lancashire CCG is 8.4% (diagnosed and NHS Blackpool CCG 7.6% 1.9% 11.9% undiagnosed) • in addition, there are an estimated NHS Blackburn With Darwen CCG 8.2% 1.4% 11.7% 11.3% of people in NHS West Lancashire CCG who are at NHS East Lancashire CCG 7.1% 2.0% 11.4% increased risk of developing diabetes (i.e. with non-diabetic NHS West Lancashire CCG 6.8% 1.6% 11.3% hyperglycaemia) • this means that 19.8% of the NHS Greater Preston CCG 6.5% 1.9% 11.1% population in NHS West Lancashire CCG are estimated to have diabetes, NHS Chorley And South Ribble CCG 6.9% 1.4% 11.0% or at high risk of developing of diabetes

NHS Lancashire North CCG 6.8% 1.2% 10.8%

Note: Prevalence estimates of non-diabetic hyperglycaemia were developed using Health Survey for England (HSE) data. Five years of HSE data were combined, 2009- 2013. The England 6.5% 1.9% 11.2% 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 Blackburn With Darwen CCG 61.3%

NHS Fylde & Wyre CCG 61.1% • data on care processes and treatment targets are taken from the National Diabetes Audit (NDA) NHS Lancashire North CCG 56.5% • overall practice participation in the 2015/16 audit was 81.4% in England NHS Blackpool CCG 53.3% • in NHS West Lancashire CCG, 21 out NHS East Lancashire CCG 50.2% of 21 practices (100.0%) participated in the NDA

NHS Chorley And South Ribble CCG 49.6%

NHS Greater Preston CCG 45.4% • 34.2% of people with diabetes (of practices who participated in the audit) had the eight recommended NHS West Lancashire CCG 34.2% care processes in NHS West Lancashire 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

STANLEY COURT SURGERY P81674 72.3% DR A LITTLER P81774 72.1% • achievement - 8 care processes: in PARBOLD SURGERY P81096 53.2% practices who provided data via the THE ELMS PRACTICE P81045 52.1% NDA, between 13.0% and 72.3% of TARLETON GROUP PRACTICE P81710 50.8% patients received all 8 care processes PARKGATE SURGERY P81041 45.7%

COUNTY ROAD SURGERY P81727 44.5% • at least 3,837 people did not receive ASHURST PRIMARY CARE P81201 43.3% the eight care processes VIRAN MEDICAL CENTRE P81177 38.0%

ORMSKIRK MEDICAL PRACTICE P81014 37.1%

LATHOM HOUSE SURGERY P81646 35.3%

DR A BISARYA P81136 34.8%

NORTH MEOLS MEDICAL CENTRE P81772 34.0%

BIRLEYWOOD HEALTH CENTRE P81121 32.2%

BURSCOUGH FAMILY PRACTICE P81138 32.0%

MATTHEW RYDER CLINIC P81758 28.2%

SKELMERSDALE PRACTICE P81208 18.7%

AUGHTON SURGERY P81695 18.7%

MANOR PRIMARY CARE P81039 17.6%

HALL GREEN SURGERY P81084 15.9%

BEACON PRIMARY CARE P81112 13.0%

SKELMERSDALE FAMILY PRACTICE P81764

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 Chorley And South Ribble CCG 44.8%

NHS Blackpool CCG 44.0% • 43.2% of people with diabetes (of practices who participated in the audit) met the three treatment targets NHS Greater Preston CCG 43.2% in NHS West Lancashire CCG, compared to 39.0% in England

NHS West Lancashire CCG 43.2%

NHS Fylde & Wyre CCG 41.6%

NHS Lancashire North CCG 41.6%

NHS Blackburn With Darwen CCG 39.9%

NHS East Lancashire CCG 39.5%

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

BIRLEYWOOD HEALTH CENTRE P81121 54.5% COUNTY ROAD SURGERY P81727 52.3% • achievement - 3 treatment targets: in DR A BISARYA P81136 52.3% practices who provided data via the HALL GREEN SURGERY P81084 52.1% NDA, between 30.9% and 54.5% of DR A LITTLER P81774 51.5% patients achieved all 3 treatment BURSCOUGH FAMILY PRACTICE P81138 50.5% targets MATTHEW RYDER CLINIC P81758 47.0% • at least 2,983 people did not meet the THE ELMS PRACTICE P81045 46.0% three treatment targets VIRAN MEDICAL CENTRE P81177 45.8%

PARBOLD SURGERY P81096 44.5%

SKELMERSDALE PRACTICE P81208 44.1%

STANLEY COURT SURGERY P81674 43.5%

BEACON PRIMARY CARE P81112 43.4%

MANOR PRIMARY CARE P81039 42.8%

ASHURST PRIMARY CARE P81201 42.4%

TARLETON GROUP PRACTICE P81710 41.0%

AUGHTON SURGERY P81695 39.6%

LATHOM HOUSE SURGERY P81646 36.9%

PARKGATE SURGERY P81041 35.3%

NORTH MEOLS MEDICAL CENTRE P81772 32.4%

ORMSKIRK MEDICAL PRACTICE P81014 30.9%

SKELMERSDALE FAMILY PRACTICE P81764

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

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

ORMSKIRK MEDICAL PRACTICE 52

NORTH MEOLS MEDICAL CENTRE 18

PARKGATE SURGERY 26 • using the GP cluster method of LATHOM HOUSE SURGERY 18 calculating potential gains, if each AUGHTON SURGERY 13 practice was to achieve as well as the TARLETON GROUP PRACTICE 19 upper quartile of its national cluster, then an additional 176 people would ASHURST PRIMARY CARE 7 be treated MANOR PRIMARY CARE 7

STANLEY COURT SURGERY 6

PARBOLD SURGERY 4

THE ELMS PRACTICE

VIRAN MEDICAL CENTRE

SKELMERSDALE PRACTICE

MATTHEW RYDER CLINIC

BURSCOUGH FAMILY PRACTICE

DR A LITTLER

COUNTY ROAD SURGERY

HALL GREEN SURGERY

DR A BISARYA

BIRLEYWOOD HEALTH 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 Blackpool CCG 1.17

NHS Chorley And South Ribble CCG 1.02 • the ratio of those diagnosed with chronic kidney disease versus those NHS Fylde & Wyre CCG 0.85 expected to have chronic kidney disease is 0.7. This compares to 0.68 NHS Greater Preston CCG 0.84 for England • this suggests that 70% of people with chronic kidney disease have been NHS Lancashire North CCG 0.79 diagnosed

NHS West Lancashire CCG 0.70

NHS Blackburn With Darwen CCG 0.65

NHS East Lancashire CCG 0.59 Note: This slide compares the prevalence of CKD recorded in QOF in 2015/16 to the expected prevalence of CKD produced by the University of Southampton in 2011. A small number of CCGs have a ratio greater than 1. It is unlikely that all England 0.68 people with CKD will be diagnosed in any CCG and therefore a ratio greater than 1 suggests that 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 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 Bassetlaw CCG 1.09

NHS Warwickshire North CCG 1.05

NHS North East Lincolnshire CCG 0.92

NHS South Sefton CCG 0.90

NHS Thanet CCG 0.83

NHS Newark & Sherwood CCG 0.82

NHS Vale Royal CCG 0.79

NHS South Cheshire CCG 0.75

NHS West Lancashire CCG 0.70

NHS St Helens CCG 0.68

NHS West Cheshire CCG 0.55

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

DR A BISARYA P81136 8.4%

HALL GREEN SURGERY P81084 6.5% TARLETON GROUP PRACTICE P81710 6.2% • it is estimated that there are 1,813 SKELMERSDALE FAMILY PRACTICE P81764 6.0% people with undiagnosed chronic

MATTHEW RYDER CLINIC P81758 5.9% kidney disease in NHS West

DR A LITTLER P81774 5.3% Lancashire CCG

PARBOLD SURGERY P81096 5.0% • GP practice range of observed CKD:

PARKGATE SURGERY P81041 4.7% 2.4% to 8.4%

STANLEY COURT SURGERY P81674 4.7%

BEACON PRIMARY CARE P81112 4.7%

LATHOM HOUSE SURGERY P81646 4.5%

ORMSKIRK MEDICAL PRACTICE P81014 4.3%

VIRAN MEDICAL CENTRE P81177 4.3%

BIRLEYWOOD HEALTH CENTRE P81121 4.0%

THE ELMS PRACTICE P81045 3.8%

SKELMERSDALE PRACTICE P81208 3.8%

COUNTY ROAD SURGERY P81727 3.7%

ASHURST PRIMARY CARE P81201 3.7%

BURSCOUGH FAMILY PRACTICE P81138 3.5% Note: CCG estimates for the estimated MANOR PRIMARY CARE P81039 3.5% number of people with CKD are based on AUGHTON SURGERY P81695 3.4% applying a proportion from a resident based NORTH MEOLS MEDICAL CENTRE P81772 2.4% population estimate to a GP registered population. The characteristics of registered 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 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 Blackburn With Darwen CCG 78.4% • 3,691 people with CKD (diagnosed*) NHS West Lancashire CCG 77.9% in NHS West Lancashire CCG • 2,876 (77.9%) people whose blood NHS Chorley And South Ribble CCG 77.4% pressure is <= 140 /85 • 171 (4.6%) people who are exceptions NHS East Lancashire CCG 77.2% • 644 (17.4%) additional people whose blood pressure is not <= 140 / 85 NHS Blackpool CCG 77.1%

NHS Greater Preston CCG 76.8%

NHS Fylde & Wyre CCG 74.9%

NHS Lancashire North CCG 74.4%

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

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

NHS North East Lincolnshire CCG 79.4%

NHS St Helens CCG 78.9%

NHS Vale Royal CCG 78.5%

NHS South Sefton CCG 78.4%

NHS West Lancashire CCG 77.9%

NHS West Cheshire CCG 77.8%

NHS Warwickshire North CCG 75.5%

NHS South Cheshire CCG 75.0%

NHS Thanet CCG 74.7%

NHS Bassetlaw CCG 72.9%

NHS Newark & Sherwood CCG 71.5%

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

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

Not below 140/85 Exceptions reported

SKELMERSDALE FAMILY PRACTICE P81764 27

ORMSKIRK MEDICAL PRACTICE P81014 117 AUGHTON SURGERY P81695 52 • in total, including exceptions, there DR M J HINDLE P81177 29 are 815 people whose blood pressure

PARBOLD SURGERY P81096 68 is not <= 140 / 85

TARLETON GROUP PRACTICE P81710 89 • GP practice range: 8.8% to 44.3%

COUNTY ROAD SURGERY P81727 10

MATTHEW RYDER CLINIC P81758 26

DR S DONTULA P81772 15

HALL GREEN SURGERY P81084 86

BEACON PRIMARY CARE P81112 55

MANOR PRIMARY CARE P81039 15

BURSCOUGH FAMILY PRACTICE P81138 18

DR A BISARYA P81136 32

STANLEY COURT SURGERY P81674 27

DR A LITTLER P81774 16

LATHOM HOUSE SURGERY P81646 22

PARKGATE SURGERY P81041 30

DR SK SUR P81208 36

ASHURST PRIMARY CARE P81201 14

THE ELMS SURGERY P81045 26

DR JL JAIN P81121 5

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

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

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

SKELMERSDALE FAMILY PRACTICE 17

ORMSKIRK MEDICAL PRACTICE 66

AUGHTON SURGERY 22 • using the GP cluster method of DR M J HINDLE 12 calculating potential gains, if each PARBOLD SURGERY 16 practice was to achieve as well as the TARLETON GROUP PRACTICE 17 upper quartile of its national cluster, then an additional 181 people would COUNTY ROAD SURGERY 2 be treated DR S DONTULA 3

HALL GREEN SURGERY 14

MANOR PRIMARY CARE 3

BEACON PRIMARY CARE 3

DR A BISARYA 2

STANLEY COURT SURGERY 0

DR A LITTLER

LATHOM HOUSE SURGERY

DR SK SUR

PARKGATE SURGERY

ASHURST PRIMARY CARE

THE ELMS SURGERY

DR JL JAIN 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 Chorley And South Ribble CCG 81.0% • 3,691 people with CKD (diagnosed*) NHS West Lancashire CCG 77.7% in NHS West Lancashire CCG • 2,868 (77.7%) people who have a NHS Blackpool CCG 77.1% record of urine albumin:creatinine ratio test • 140 (3.8%) people who are NHS Blackburn With Darwen CCG 77.0% exceptions • 683 (18.5%) additional people who NHS Fylde & Wyre CCG 76.4% have no record of urine albumin:creatinine ratio test

NHS Greater Preston CCG 75.7%

NHS East Lancashire CCG 75.7%

NHS Lancashire North CCG 74.1%

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

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

NHS North East Lincolnshire CCG 83.6%

NHS South Sefton CCG 78.6%

NHS St Helens CCG 77.8%

NHS West Lancashire CCG 77.7%

NHS Vale Royal CCG 77.5%

NHS West Cheshire CCG 76.9%

NHS Warwickshire North CCG 76.8%

NHS Newark & Sherwood CCG 76.8%

NHS Thanet CCG 75.5%

NHS South Cheshire CCG 75.3%

NHS Bassetlaw CCG 74.9%

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

ORMSKIRK MEDICAL PRACTICE P81014 118

HALL GREEN SURGERY P81084 162 BURSCOUGH FAMILY PRACTICE P81138 28 • in total, including exceptions, there DR S DONTULA P81772 19 are 823 people who have no record of

STANLEY COURT SURGERY P81674 36 urine albumin:creatinine ratio test

LATHOM HOUSE SURGERY P81646 31 • GP practice range: 7.1% to 42.0%

DR M J HINDLE P81177 23

PARBOLD SURGERY P81096 61

TARLETON GROUP PRACTICE P81710 84

MANOR PRIMARY CARE P81039 16

AUGHTON SURGERY P81695 35

ASHURST PRIMARY CARE P81201 23

BEACON PRIMARY CARE P81112 44

THE ELMS SURGERY P81045 38

MATTHEW RYDER CLINIC P81758 19

DR SK SUR P81208 31

SKELMERSDALE FAMILY PRACTICE P81764 7

DR A LITTLER P81774 10

PARKGATE SURGERY P81041 17

COUNTY ROAD SURGERY P81727 4

DR JL JAIN P81121 5

DR A BISARYA P81136 12

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 Fylde & Wyre CCG 1.49%

NHS Blackpool CCG 1.45% • prevalence of 1.05% in NHS West Lancashire CCG compared to 0.76% NHS West Lancashire CCG 1.05% in England

NHS Chorley And South Ribble CCG 0.96%

NHS Greater Preston CCG 0.92%

NHS East Lancashire CCG 0.88%

NHS Blackburn With Darwen CCG 0.82%

NHS Lancashire North CCG 0.80%

England 0.76%

0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6%

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

NHS South Sefton CCG 1.28%

NHS St Helens CCG 1.12%

NHS West Lancashire CCG 1.05%

NHS Bassetlaw CCG 1.01%

NHS South Cheshire CCG 0.98%

NHS Vale Royal CCG 0.96%

NHS Newark & Sherwood CCG 0.94%

NHS West Cheshire CCG 0.90%

NHS Thanet CCG 0.86%

NHS Warwickshire North CCG 0.82%

NHS North East Lincolnshire CCG 0.67%

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

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

GP practice CCG

COUNTY ROAD SURGERY P81727 2.0%

BEACON PRIMARY CARE P81112 1.6% HALL GREEN SURGERY P81084 1.6% • 1,181 people with diagnosed heart DR A LITTLER P81774 1.5% failure in NHS West Lancashire CCG

LATHOM HOUSE SURGERY P81646 1.3% • GP practice range: 0.5% to 2.0%

NORTH MEOLS MEDICAL CENTRE P81772 1.2%

PARBOLD SURGERY P81096 1.2%

STANLEY COURT SURGERY P81674 1.1%

TARLETON GROUP PRACTICE P81710 1.1%

BIRLEYWOOD HEALTH CENTRE P81121 1.0%

DR A BISARYA P81136 1.0%

ASHURST PRIMARY CARE P81201 1.0%

ORMSKIRK MEDICAL PRACTICE P81014 1.0%

THE ELMS PRACTICE P81045 0.9%

PARKGATE SURGERY P81041 0.9%

MATTHEW RYDER CLINIC P81758 0.8%

BURSCOUGH FAMILY PRACTICE P81138 0.8%

VIRAN MEDICAL CENTRE P81177 0.8%

SKELMERSDALE FAMILY PRACTICE P81764 0.8%

MANOR PRIMARY CARE P81039 0.7%

AUGHTON SURGERY P81695 0.7%

SKELMERSDALE PRACTICE P81208 0.5%

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 Blackpool CCG 88.2% • 393 people with heart failure* with NHS Lancashire North CCG 87.6% LVSD in NHS West Lancashire CCG • 322 (81.9%) people treated with ACE- NHS East Lancashire CCG 87.5% I or ARB • 63 (16%) people who are exceptions • 8 (2%) additional people who are not NHS Fylde & Wyre CCG 86.9% treated with ACE-I or ARB

NHS Greater Preston CCG 86.2%

NHS Chorley And South Ribble CCG 85.3%

NHS Blackburn With Darwen CCG 85.1%

NHS West Lancashire CCG 81.9%

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 Vale Royal CCG 89.8%

NHS Warwickshire North CCG 87.6%

NHS South Cheshire CCG 87.5%

NHS West Cheshire CCG 85.8%

NHS North East Lincolnshire CCG 85.1%

NHS St Helens CCG 84.6%

NHS Newark & Sherwood CCG 84.6%

NHS Bassetlaw CCG 84.3%

NHS Thanet CCG 83.4%

NHS West Lancashire CCG 81.9%

NHS South Sefton CCG 78.9%

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

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

No treatment Exceptions reported

THE ELMS PRACTICE P81045 13

BURSCOUGH FAMILY PRACTICE P81138 3 SKELMERSDALE FAMILY PRACTICE P81764 3 • in total, including exceptions, there AUGHTON SURGERY P81695 3 are 71 people who are not treated

STANLEY COURT SURGERY P81674 3 with ACE-I or ARB

ORMSKIRK MEDICAL PRACTICE P81014 4 • GP practice range: 0.0% to 33.3%

PARKGATE SURGERY P81041 4

SKELMERSDALE PRACTICE P81208 2

LATHOM HOUSE SURGERY P81646 6

BEACON PRIMARY CARE P81112 7

MATTHEW RYDER CLINIC P81758 1

TARLETON GROUP PRACTICE P81710 9

PARBOLD SURGERY P81096 4

COUNTY ROAD SURGERY P81727 3

BIRLEYWOOD HEALTH CENTRE P81121 1

DR A BISARYA P81136 1

NORTH MEOLS MEDICAL CENTRE P81772 2

HALL GREEN SURGERY P81084 2

MANOR PRIMARY CARE P81039

VIRAN MEDICAL CENTRE P81177

ASHURST PRIMARY CARE P81201

DR A LITTLER P81774

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 Blackpool CCG 88.1% • 322 people with heart failure* with NHS Fylde & Wyre CCG 84.9% LVSD treated with ACE-I/ARB in NHS West Lancashire CCG NHS Greater Preston CCG 84.6% • 220 (68.3%) people treated with ACE- I/ARB and BB • 67 (20.8%) people who are NHS Lancashire North CCG 82.1% exceptions • 35 (10.9%) additional people who are NHS Chorley And South Ribble CCG 81.0% not treated with ACE-I/ARB and BB

NHS Blackburn With Darwen CCG 78.7%

NHS East Lancashire CCG 75.5%

NHS West Lancashire CCG 68.3%

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 West Cheshire CCG 85.3%

NHS Vale Royal CCG 84.2%

NHS North East Lincolnshire CCG 83.6%

NHS Warwickshire North CCG 83.0%

NHS Bassetlaw CCG 81.8%

NHS Newark & Sherwood CCG 78.9%

NHS Thanet CCG 76.1%

NHS St Helens CCG 74.1%

NHS South Cheshire CCG 72.0%

NHS South Sefton CCG 71.5%

NHS West Lancashire CCG 68.3%

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

STANLEY COURT SURGERY P81674 6

DR A BISARYA P81136 4 ASHURST PRIMARY CARE P81201 1 • in total, including exceptions, there MATTHEW RYDER CLINIC P81758 2 are 102 people who are not treated

TARLETON GROUP PRACTICE P81710 18 with ACE-I or ARB

SKELMERSDALE FAMILY PRACTICE P81764 3 • GP practice range: 10.0% to 60.0%

COUNTY ROAD SURGERY P81727 8

NORTH MEOLS MEDICAL CENTRE P81772 7

AUGHTON SURGERY P81695 3

THE ELMS PRACTICE P81045 9

VIRAN MEDICAL CENTRE P81177 1

PARBOLD SURGERY P81096 7

ORMSKIRK MEDICAL PRACTICE P81014 4

BURSCOUGH FAMILY PRACTICE P81138 2

SKELMERSDALE PRACTICE P81208 2

LATHOM HOUSE SURGERY P81646 6

PARKGATE SURGERY P81041 3

BEACON PRIMARY CARE P81112 6

MANOR PRIMARY CARE P81039 5

HALL GREEN SURGERY P81084 3

BIRLEYWOOD HEALTH CENTRE P81121 1

DR A LITTLER P81774 1

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 Blackburn With Darwen CCG 89.4% • 4,278 people with coronary heart NHS West Lancashire CCG 89.1% disease* in NHS West Lancashire CCG NHS Fylde & Wyre CCG 88.8% • 3,811 (89.1%) people whose blood pressure <= 150 / 90 • 67 (1.6%) people who are exceptions NHS Greater Preston CCG 88.8% • 400 (9.4%) additional people whose blood pressure is not <= 150 / 90 NHS Chorley And South Ribble CCG 88.8%

NHS East Lancashire CCG 88.7%

NHS Blackpool CCG 88.6%

NHS Lancashire North CCG 85.4%

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 West Cheshire CCG 90.1%

NHS Warwickshire North CCG 90.1%

NHS North East Lincolnshire CCG 90.0%

NHS St Helens CCG 89.9%

NHS West Lancashire CCG 89.1%

NHS South Cheshire CCG 88.5%

NHS Thanet CCG 88.0%

NHS Vale Royal CCG 87.9%

NHS Newark & Sherwood CCG 87.8%

NHS South Sefton CCG 86.8%

NHS Bassetlaw CCG 85.5%

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

ORMSKIRK MEDICAL PRACTICE P81014 148

NORTH MEOLS MEDICAL CENTRE P81772 21 BURSCOUGH FAMILY PRACTICE P81138 16 • in total, including exceptions, there HALL GREEN SURGERY P81084 42 are 467 people whose blood pressure

LATHOM HOUSE SURGERY P81646 17 is not <= 150 / 90

PARKGATE SURGERY P81041 25 • GP practice range: 3.0% to 36.1%

PARBOLD SURGERY P81096 23

COUNTY ROAD SURGERY P81727 10

ASHURST PRIMARY CARE P81201 15

VIRAN MEDICAL CENTRE P81177 10

BEACON PRIMARY CARE P81112 36

TARLETON GROUP PRACTICE P81710 22

BIRLEYWOOD HEALTH CENTRE P81121 5

DR A BISARYA P81136 7

MANOR PRIMARY CARE P81039 10

STANLEY COURT SURGERY P81674 14

MATTHEW RYDER CLINIC P81758 7

SKELMERSDALE FAMILY PRACTICE P81764 7

SKELMERSDALE PRACTICE P81208 13

AUGHTON SURGERY P81695 8

THE ELMS PRACTICE P81045 8

DR A LITTLER P81774 3

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

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

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

ORMSKIRK MEDICAL PRACTICE 119

NORTH MEOLS MEDICAL CENTRE 13

BURSCOUGH FAMILY PRACTICE 7 • using the GP cluster method of HALL GREEN SURGERY 18 calculating potential gains, if each LATHOM HOUSE SURGERY 6 practice was to achieve as well as the PARKGATE SURGERY 8 upper quartile of its national cluster, then an additional 189 people would PARBOLD SURGERY 7 be treated COUNTY ROAD SURGERY 3

ASHURST PRIMARY CARE 4

VIRAN MEDICAL CENTRE 2

DR A BISARYA

BEACON PRIMARY CARE

MANOR PRIMARY CARE

STANLEY COURT SURGERY

MATTHEW RYDER CLINIC

SKELMERSDALE FAMILY PRACTICE

SKELMERSDALE PRACTICE

AUGHTON SURGERY

THE ELMS PRACTICE

DR A LITTLER 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 Greater Preston CCG 93.1% • 4,278 people with coronary heart NHS Blackburn With Darwen CCG 92.5% disease* in NHS West Lancashire CCG NHS East Lancashire CCG 92.2% • 3,940 (92.1%) people who are taking aspirin, an alternative anti-platelet therapy, or an anti-coagulant NHS West Lancashire CCG 92.1% • 149 (3.5%) people who are exceptions NHS Fylde & Wyre CCG 91.5% • 189 (4.4%) additional people who are not taking aspirin, an alternative anti- platelet therapy, or an anti-coagulant NHS Chorley And South Ribble CCG 91.3%

NHS Blackpool CCG 91.0%

NHS Lancashire North CCG 90.7%

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 Warwickshire North CCG 93.7%

NHS Thanet CCG 92.5%

NHS South Sefton CCG 92.4%

NHS West Lancashire CCG 92.1%

NHS Newark & Sherwood CCG 92.1%

NHS South Cheshire CCG 91.6%

NHS West Cheshire CCG 91.5%

NHS North East Lincolnshire CCG 91.3%

NHS Vale Royal CCG 91.2%

NHS St Helens CCG 91.1%

NHS Bassetlaw CCG 91.1%

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

COUNTY ROAD SURGERY P81727 14

ORMSKIRK MEDICAL PRACTICE P81014 57 BURSCOUGH FAMILY PRACTICE P81138 17 • in total, including exceptions, there NORTH MEOLS MEDICAL CENTRE P81772 13 are 338 people are not taking aspirin,

TARLETON GROUP PRACTICE P81710 30 an alternative anti-platelet therapy, or

MANOR PRIMARY CARE P81039 16 an anti-coagulant

PARKGATE SURGERY P81041 25 • GP practice range: 2.5% to 14.1%

VIRAN MEDICAL CENTRE P81177 11

ASHURST PRIMARY CARE P81201 16

LATHOM HOUSE SURGERY P81646 16

SKELMERSDALE FAMILY PRACTICE P81764 11

STANLEY COURT SURGERY P81674 19

THE ELMS PRACTICE P81045 18

PARBOLD SURGERY P81096 16

AUGHTON SURGERY P81695 11

DR A BISARYA P81136 5

DR A LITTLER P81774 5

BIRLEYWOOD HEALTH CENTRE P81121 3

SKELMERSDALE PRACTICE P81208 10

HALL GREEN SURGERY P81084 11

MATTHEW RYDER CLINIC P81758 3

BEACON PRIMARY CARE P81112 11

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 West Lancashire CCG England 900

800 • in NHS West Lancashire CCG, the hospital admission rate for coronary 700 heart disease in 2015/16 was 545 (643) compared to 527.9 for England

600

500

400

300 Age Age standardised (per rate 100,000) 200

100

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

83 CVD: Primary Care Intelligence Packs Hospital admissions for stroke for all ages 2002/03 – 2015/16

NHS West Lancashire CCG England 300

• in NHS West Lancashire CCG, the 250 hospital admission rate for stroke in 2015/16 was 146.8 (171) compared to 172.8 for England

200

150

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

50

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

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

NHS West Lancashire CCG England

126.7% Angina 136.8% • The risk of a stroke was 84% higher and the risk of a heart attack was 81.2% 81.2% higher compared to people Heart Attack 108.6% without diabetes. The risk of a major amputation was 268.5% higher. 144.4% Heart failure 150.0%

84.0% Stroke 81.3%

268.5% Major amputation 445.8%

1112.0% Minor amputation 753.5%

216.9% RRT 293.0%

0% 200% 400% 600% 800% 1000% 1200% Note: This slide uses data from the National Diabetes Audit (NDA)

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

NHS West Lancashire CCG England 90

80 • in NHS West Lancashire CCG, the early mortality rate for coronary heart 70 disease in 2013-15 was 39.5, 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 West Lancashire CCG England 30

• in NHS West Lancashire CCG, the 25 early mortality rate for stroke in 2013- 15 was 14.6, 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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