Harrow CCG: CVD Primary Care Intelligence Pack

CVD: Primary Care Intelligence Packs NHS Harrow 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 Harrow CCG are: NHS Redbridge CCG NHS Hillingdon CCG NHS Hounslow CCG NHS Barnet CCG NHS Slough CCG NHS Ealing CCG NHS Kingston CCG NHS Luton CCG NHS Sutton CCG NHS Merton 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 Luton CCG 19.2%

NHS Slough CCG 17.6% • prevalence of 12.9% in NHS Harrow CCG NHS Sutton CCG 16.6%

NHS Hillingdon CCG 16.3%

NHS Hounslow CCG 16.2%

NHS Merton CCG 15.5%

NHS Ealing CCG 15.5%

NHS Kingston CCG 15.3% Note: It has been found that the proportion of patients recorded as smokers correlates well NHS Barnet CCG 14.9% with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, NHS Redbridge CCG 13.6% http://bmjopen.bmj.com/content/4/7/e005217.abs tract

NHS Harrow CCG 12.9% 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

SAVITA MEDICAL CENTRE E84681 18.9% ASPRI MEDICAL CENTRE E84658 17.8% ENDERLEY ROAD MEDICAL CENTRE E84009 16.4% THE SHAFTESBURY MEDICAL CENTRE E84062 16.3% • 27,417 people who are recorded as ROXBOURNE MEDICAL CENTRE E84022 16.0% HARNESS HARROW PRACTICE E84075 16.0% smokers in NHS Harrow CCG KENTON BRIDGE MEDICAL CENTRE DR GOLDEN E84601 15.1% • GP practice range: 9.3% to 18.9% BELMONT HEALTH CENTRE E84069 15.0% THE STREATFIELD MEDICAL CENTRE E84646 14.9% THE ENTERPRISE PRACTICE E84713 14.7% SIMPSON HOUSE MEDICAL CENTRE E84008 14.5% HEADSTONE ROAD SURGERY E84680 14.3% GP DIRECT E84058 14.3% ST. PETER'S MEDICAL CENTRE E84693 14.1% THE PINNER ROAD SURGERY E84040 14.0% BACON LANE SURGERY E84014 13.7% THE STANMORE SURGERY E84657 13.5% THE CIRCLE PRACTICE E84004 13.3% ZAIN MEDICAL CENTRE E84653 13.2% FIRST CHOICE MEDICAL CARE Y05080 13.0% THE CIVIC MEDICAL CENTRE E84617 12.9% HONEYPOT MEDICAL CENTRE E84039 12.3% STREATFIELD HEALTH CENTRE E84018 12.0% THE RIDGEWAY SURGERY E84068 11.4% KINGS ROAD SURGERY E84005 10.6% PINNER VIEW MEDICAL CENTRE E84070 10.5% ELLIOTT HALL MEDICAL CTR. E84061 10.3% THE NORTHWICK SURGERY E84044 10.3% THE STANMORE MEDICAL CENTRE E84057 10.3% Note: This method is thought to be a reasonably KENTON BRIDGE MEDICAL CENTRE - DR RAJA E84663 10.1% robust method in estimating smoking prevalence HATCH END MEDICAL CENTRE E84053 9.8% for the majority of GP practices. However, KENTON CLINIC E84647 9.8% caution is advised for extreme estimates of HEADSTONE LANE MEDICAL CENTRE E84676 9.3% smoking prevalence and those with high THE PINN MEDICAL CENTRE E84024 9.3% numbers of smoking status not recorded and 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% 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 Harrow CCG 0.59

NHS Hillingdon CCG 0.58 • the ratio of those diagnosed with hypertension versus those expected NHS Brent CCG 0.58 to have hypertension is 0.59. This compares to 0.59 for England • this suggests that 59% of people with NHS Hounslow CCG 0.57 hypertension have been diagnosed

NHS Ealing CCG 0.57

NHS Hammersmith And Fulham CCG 0.51

NHS West London CCG 0.49

NHS Central London (Westminster) CCG 0.48

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 Harrow CCG 0.59

NHS Hillingdon CCG 0.58

NHS Luton CCG 0.57

NHS Redbridge CCG 0.57

NHS Hounslow CCG 0.57

NHS Ealing CCG 0.57

NHS Sutton CCG 0.57

NHS Barnet CCG 0.57

NHS Slough CCG 0.56

NHS Kingston CCG 0.54

NHS Merton CCG 0.53

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

THE SHAFTESBURY MEDICAL CENTRE E84062 0.72 HEADSTONE LANE MEDICAL CENTRE E84676 0.69 ELLIOTT HALL MEDICAL CTR. E84061 0.68 HEADSTONE ROAD SURGERY E84680 0.66 HONEYPOT MEDICAL CENTRE E84039 0.66 • it is estimated that there are 23,064 BELMONT HEALTH CENTRE E84069 0.65 people with undiagnosed ASPRI MEDICAL CENTRE E84658 0.64 SIMPSON HOUSE MEDICAL CENTRE E84008 0.62 hypertension in NHS Harrow CCG KENTON BRIDGE MEDICAL CENTRE - DR RAJA E84663 0.61 • GP practice range of observed to THE PINN MEDICAL CENTRE E84024 0.60 HARNESS HARROW PRACTICE E84075 0.60 expected hypertension prevalence ZAIN MEDICAL CENTRE E84653 0.59 0.39 to 0.72 ENDERLEY ROAD MEDICAL CENTRE E84009 0.59 BACON LANE SURGERY E84014 0.57 THE ENTERPRISE PRACTICE E84713 0.56 THE STANMORE MEDICAL CENTRE E84057 0.56 THE RIDGEWAY SURGERY E84068 0.56 GP DIRECT E84058 0.56 STREATFIELD HEALTH CENTRE E84018 0.55 SAVITA MEDICAL CENTRE E84681 0.55 KINGS ROAD SURGERY E84005 0.54 ROXBOURNE MEDICAL CENTRE E84022 0.53 KENTON BRIDGE MEDICAL CENTRE DR GOLDEN E84601 0.52 HATCH END MEDICAL CENTRE E84053 0.51 THE CIVIC MEDICAL CENTRE E84617 0.50 THE NORTHWICK SURGERY E84044 0.50 PINNER VIEW MEDICAL CENTRE E84070 0.50 THE STANMORE SURGERY E84657 0.47 ST. PETER'S MEDICAL CENTRE E84693 0.44 KENTON CLINIC E84647 0.44 THE CIRCLE PRACTICE E84004 0.44 THE STREATFIELD MEDICAL CENTRE E84646 0.42 THE PINNER ROAD SURGERY E84040 0.39 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 Harrow CCG 80.3%

NHS Brent CCG 79.8% • 33,536 people with hypertension (diagnosed)* in NHS Harrow CCG NHS Hillingdon CCG 79.7% • 26,933 (80.3%) people whose blood pressure is <= 150/90 • 1,125 (3.4%) people who are NHS Hounslow CCG 78.8% excepted from optimal control • 5,478 (16.3%) additional people NHS Ealing CCG 78.7% whose blood pressure is not <= 150/90

NHS West London CCG 77.6%

NHS Central London (Westminster) CCG 75.3%

NHS Hammersmith And Fulham CCG 74.3%

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 Slough CCG 80.5%

NHS Harrow CCG 80.3%

NHS Hillingdon CCG 79.7%

NHS Kingston CCG 78.9%

NHS Hounslow CCG 78.8%

NHS Ealing CCG 78.7%

NHS Sutton CCG 78.6%

NHS Redbridge CCG 78.3%

NHS Barnet CCG 77.9%

NHS Merton CCG 77.3%

NHS Luton CCG 76.8%

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

ASPRI MEDICAL CENTRE E84658 333 THE STANMORE SURGERY E84657 118 ROXBOURNE MEDICAL CENTRE E84022 224 HEADSTONE LANE MEDICAL CENTRE E84676 141 • in total, including exceptions, there HEADSTONE ROAD SURGERY E84680 150 SAVITA MEDICAL CENTRE E84681 80 are 6,603 people whose blood THE CIRCLE PRACTICE E84004 237 pressure is not <= 150/90 SIMPSON HOUSE MEDICAL CENTRE E84008 413 GP DIRECT E84058 452 • GP practice range: 12.8% to 40.6% KINGS ROAD SURGERY E84005 201 HATCH END MEDICAL CENTRE E84053 115 FIRST CHOICE MEDICAL CARE Y05080 50 THE CIVIC MEDICAL CENTRE E84617 91 ST. PETER'S MEDICAL CENTRE E84693 136 KENTON BRIDGE MEDICAL CENTRE DR GOLDEN E84601 149 ENDERLEY ROAD MEDICAL CENTRE E84009 367 THE STANMORE MEDICAL CENTRE E84057 309 THE RIDGEWAY SURGERY E84068 370 HONEYPOT MEDICAL CENTRE E84039 313 THE PINNER ROAD SURGERY E84040 73 THE PINN MEDICAL CENTRE E84024 503 BELMONT HEALTH CENTRE E84069 280 BACON LANE SURGERY E84014 219 ZAIN MEDICAL CENTRE E84653 44 THE NORTHWICK SURGERY E84044 178 KENTON BRIDGE MEDICAL CENTRE - DR RAJA E84663 131 ELLIOTT HALL MEDICAL CTR. E84061 306 PINNER VIEW MEDICAL CENTRE E84070 80 THE SHAFTESBURY MEDICAL CENTRE E84062 98 THE STREATFIELD MEDICAL CENTRE E84646 68 STREATFIELD HEALTH CENTRE E84018 158 THE ENTERPRISE PRACTICE E84713 76 KENTON CLINIC E84647 53 HARNESS HARROW PRACTICE E84075 87 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 Hammersmith And Fulham CCG 84.4%

NHS Ealing CCG 83.4% • 130 people with a new diagnosis* of hypertension with a CVD risk of 20% NHS Hounslow CCG 78.4% or higher in NHS Harrow CCG • 85 (65.4%) people who are currently treated with statins NHS West London CCG 76.0% • 42 (32.3%) people who are exempted from treatment with statins NHS Central London (Westminster) CCG 73.4% • 3 (2.3%) additional people who are not currently treated with statins

NHS Hillingdon CCG 71.6%

NHS Brent CCG 70.1%

NHS Harrow CCG 65.4%

England 66.5%

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

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

NHS Ealing CCG 83.4%

NHS Redbridge CCG 80.2%

NHS Slough CCG 80.0%

NHS Hounslow CCG 78.4%

NHS Luton CCG 76.9%

NHS Sutton CCG 74.7%

NHS Merton CCG 72.0%

NHS Hillingdon CCG 71.6%

NHS Kingston CCG 69.6%

NHS Barnet CCG 69.2%

NHS Harrow CCG 65.4%

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

ZAIN MEDICAL CENTRE E84653 1 HEADSTONE ROAD SURGERY E84680 2 THE STANMORE MEDICAL CENTRE E84057 4 THE PINN MEDICAL CENTRE E84024 2 • in total, including exceptions, there THE STANMORE SURGERY E84657 2 PINNER VIEW MEDICAL CENTRE E84070 4 are 45 people who are not treated ASPRI MEDICAL CENTRE E84658 4 with statins ROXBOURNE MEDICAL CENTRE E84022 1 THE NORTHWICK SURGERY E84044 2 • GP practice range: 0.0% to 100.0% HATCH END MEDICAL CENTRE E84053 1 ELLIOTT HALL MEDICAL CTR. E84061 1 HARNESS HARROW PRACTICE E84075 1 THE CIVIC MEDICAL CENTRE E84617 1 THE ENTERPRISE PRACTICE E84713 1 FIRST CHOICE MEDICAL CARE Y05080 1 KINGS ROAD SURGERY E84005 3 THE RIDGEWAY SURGERY E84068 6 STREATFIELD HEALTH CENTRE E84018 1 SIMPSON HOUSE MEDICAL CENTRE E84008 2 GP DIRECT E84058 3 KENTON BRIDGE MEDICAL CENTRE - DR RAJA E84663 1 BELMONT HEALTH CENTRE E84069 1 THE CIRCLE PRACTICE E84004 ENDERLEY ROAD MEDICAL CENTRE E84009 BACON LANE SURGERY E84014 HONEYPOT MEDICAL CENTRE E84039 THE SHAFTESBURY MEDICAL CENTRE E84062 KENTON BRIDGE MEDICAL CENTRE DR GOLDEN E84601 THE STREATFIELD MEDICAL CENTRE E84646 KENTON CLINIC E84647 HEADSTONE LANE MEDICAL CENTRE E84676 SAVITA MEDICAL CENTRE E84681 ST. PETER'S MEDICAL CENTRE E84693 THE PINNER ROAD SURGERY E84040 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 Central London (Westminster) CCG 0.65

NHS Hammersmith And Fulham CCG 0.65 • the ratio of those diagnosed with atrial fibrillation versus those expected to NHS Hillingdon CCG 0.64 have atrial fibrillation is 0.58. This compares to 0.7 for England • this suggests that 58% of people with NHS Ealing CCG 0.61 atrial fibrillation have been diagnosed.

NHS Hounslow CCG 0.59

NHS Harrow CCG 0.58

NHS West London CCG 0.58

NHS Brent CCG 0.47 Note: This slide compares the prevalence of atrial fibrillation recorded in QOF in 2015/16 to the estimated prevalence of atrial fibrillation, taken from National Cardiovascular Intelligence Network estimates produced in 2017. The estimates were developed by applying age-sex England 0.70 specific prevalence rates as reported by Norberg et al (2013) to GP population estimates from 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 NHS Digital. Estimates reported are adjusted for age and sex of the local population.

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

NHS Hillingdon CCG 0.64

NHS Sutton CCG 0.63

NHS Barnet CCG 0.61

NHS Ealing CCG 0.61

NHS Kingston CCG 0.60

NHS Hounslow CCG 0.59

NHS Harrow CCG 0.58

NHS Luton CCG 0.58

NHS Merton CCG 0.58

NHS Slough CCG 0.55

NHS Redbridge CCG 0.50

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7

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

GP practice CCG

ELLIOTT HALL MEDICAL CTR. E84061 0.8 THE SHAFTESBURY MEDICAL CENTRE E84062 0.8 SIMPSON HOUSE MEDICAL CENTRE E84008 0.7 ENDERLEY ROAD MEDICAL CENTRE E84009 0.7 THE PINN MEDICAL CENTRE E84024 0.7 • it is estimated that there are 5,479 THE STANMORE MEDICAL CENTRE E84057 0.7 people with undiagnosed atrial THE RIDGEWAY SURGERY E84068 0.7 KENTON BRIDGE MEDICAL CENTRE - DR RAJA E84663 0.7 fibrillation in NHS Harrow CCG BACON LANE SURGERY E84014 0.6 • GP practice range of observed to THE NORTHWICK SURGERY E84044 0.6 GP DIRECT E84058 0.6 expected atrial fibrillation prevalence BELMONT HEALTH CENTRE E84069 0.6 0.1 to 0.8 HEADSTONE ROAD SURGERY E84680 0.6 ST. PETER'S MEDICAL CENTRE E84693 0.6 THE ENTERPRISE PRACTICE E84713 0.6 THE CIRCLE PRACTICE E84004 0.5 KINGS ROAD SURGERY E84005 0.5 STREATFIELD HEALTH CENTRE E84018 0.5 ROXBOURNE MEDICAL CENTRE E84022 0.5 HONEYPOT MEDICAL CENTRE E84039 0.5 PINNER VIEW MEDICAL CENTRE E84070 0.5 KENTON BRIDGE MEDICAL CENTRE DR GOLDEN E84601 0.5 THE CIVIC MEDICAL CENTRE E84617 0.5 THE STANMORE SURGERY E84657 0.5 HATCH END MEDICAL CENTRE E84053 0.4 ASPRI MEDICAL CENTRE E84658 0.4 HEADSTONE LANE MEDICAL CENTRE E84676 0.4 THE PINNER ROAD SURGERY E84040 0.3 HARNESS HARROW PRACTICE E84075 0.3 THE STREATFIELD MEDICAL CENTRE E84646 0.3 KENTON CLINIC E84647 0.3 SAVITA MEDICAL CENTRE E84681 0.2 FIRST CHOICE MEDICAL CARE Y05080 0.2 ZAIN MEDICAL CENTRE E84653 0.1 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 Hounslow CCG 76.9% • 2,676 people with atrial fibrillation* NHS Hammersmith And Fulham CCG 76.4% with a CHA2DS2-VASc score >= 2 in NHS Harrow CCG NHS Central London (Westminster) CCG 76.1% • 1,847 (69%) people treated with anti- coagulation therapy • 361 (13.5%) people who are NHS Ealing CCG 75.9% exceptions • 468 (17.5%) additional people with a NHS West London CCG 75.9% recorded CHA2DS2-VASc score >= 2 who are not treated

NHS Hillingdon CCG 72.2%

NHS Harrow CCG 69.0%

NHS Brent CCG 68.3%

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 Sutton CCG 82.3%

NHS Slough CCG 79.8%

NHS Luton CCG 78.1%

NHS Merton CCG 77.3%

NHS Hounslow CCG 76.9%

NHS Ealing CCG 75.9%

NHS Redbridge CCG 75.5%

NHS Barnet CCG 72.7%

NHS Hillingdon CCG 72.2%

NHS Kingston CCG 71.6%

NHS Harrow CCG 69.0%

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

HATCH END MEDICAL CENTRE E84053 19 THE SHAFTESBURY MEDICAL CENTRE E84062 19 THE CIVIC MEDICAL CENTRE E84617 12 STREATFIELD HEALTH CENTRE E84018 28 • in total, including exceptions, there ASPRI MEDICAL CENTRE E84658 15 ELLIOTT HALL MEDICAL CTR. E84061 87 are 829 people with a recorded THE PINNER ROAD SURGERY E84040 7 CHA2DS2-VASc score >= 2 who are THE PINN MEDICAL CENTRE E84024 105 THE STANMORE MEDICAL CENTRE E84057 62 not treated GP DIRECT E84058 45 • GP practice range: 12.8% to 44.2% ZAIN MEDICAL CENTRE E84653 1 HEADSTONE ROAD SURGERY E84680 11 FIRST CHOICE MEDICAL CARE Y05080 4 ENDERLEY ROAD MEDICAL CENTRE E84009 60 ST. PETER'S MEDICAL CENTRE E84693 14 KENTON CLINIC E84647 6 HONEYPOT MEDICAL CENTRE E84039 30 THE NORTHWICK SURGERY E84044 35 BELMONT HEALTH CENTRE E84069 32 THE CIRCLE PRACTICE E84004 22 SIMPSON HOUSE MEDICAL CENTRE E84008 43 THE ENTERPRISE PRACTICE E84713 12 KENTON BRIDGE MEDICAL CENTRE DR GOLDEN E84601 14 THE RIDGEWAY SURGERY E84068 53 ROXBOURNE MEDICAL CENTRE E84022 15 THE STANMORE SURGERY E84657 7 THE STREATFIELD MEDICAL CENTRE E84646 4 KINGS ROAD SURGERY E84005 21 HARNESS HARROW PRACTICE E84075 5 SAVITA MEDICAL CENTRE E84681 2 BACON LANE SURGERY E84014 23 HEADSTONE LANE MEDICAL CENTRE E84676 2 KENTON BRIDGE MEDICAL CENTRE - DR RAJA E84663 9 PINNER VIEW MEDICAL CENTRE E84070 5 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

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

HATCH END MEDICAL CENTRE 12

THE SHAFTESBURY MEDICAL CENTRE 12

THE CIVIC MEDICAL CENTRE 8 • using the GP cluster method of ASPRI MEDICAL CENTRE 9 calculating potential gains, if each STREATFIELD HEALTH CENTRE 16 practice was to achieve as well as the ELLIOTT HALL MEDICAL CTR. 46 upper quartile of its national cluster, then an additional 377 people would THE PINNER ROAD SURGERY 4 be treated HEADSTONE ROAD SURGERY 6

ZAIN MEDICAL CENTRE 1

THE PINN MEDICAL CENTRE 50

THE STANMORE SURGERY 3

THE STREATFIELD MEDICAL CENTRE 2

KINGS ROAD SURGERY 9

THE RIDGEWAY SURGERY 19

HARNESS HARROW PRACTICE 2

SAVITA MEDICAL CENTRE 1

BACON LANE SURGERY 2

HEADSTONE LANE MEDICAL CENTRE

KENTON BRIDGE MEDICAL CENTRE - DR RAJA

PINNER VIEW MEDICAL 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 Harrow CCG 84.8% • 3,323 people with a history of stroke NHS Hounslow CCG 84.6% or TIA* in NHS Harrow CCG • 2,819 (84.8%) people whose blood NHS Brent CCG 84.2% pressure is <= 150 / 90 • 137 (4.1%) people who are exceptions NHS Hillingdon CCG 83.3% • 367 (11%) additional people whose blood pressure is not <= 150 / 90 NHS Central London (Westminster) CCG 82.9%

NHS Ealing CCG 82.9%

NHS West London CCG 81.3%

NHS Hammersmith And Fulham CCG 80.3%

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 Slough CCG 87.5%

NHS Harrow CCG 84.8%

NHS Redbridge CCG 84.6%

NHS Hounslow CCG 84.6%

NHS Sutton CCG 83.6%

NHS Kingston CCG 83.4%

NHS Hillingdon CCG 83.3%

NHS Barnet CCG 83.0%

NHS Ealing CCG 82.9%

NHS Merton CCG 82.3%

NHS Luton CCG 80.0%

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

HEADSTONE LANE MEDICAL CENTRE E84676 12 ASPRI MEDICAL CENTRE E84658 16 THE STANMORE SURGERY E84657 11 ROXBOURNE MEDICAL CENTRE E84022 21 • in total, including exceptions, there FIRST CHOICE MEDICAL CARE Y05080 4 KENTON BRIDGE MEDICAL CENTRE DR GOLDEN E84601 13 are 504 people whose blood pressure BACON LANE SURGERY E84014 29 is not <= 150 / 90 HONEYPOT MEDICAL CENTRE E84039 27 ENDERLEY ROAD MEDICAL CENTRE E84009 49 • GP practice range: 2.7% to 38.7% KINGS ROAD SURGERY E84005 11 THE CIRCLE PRACTICE E84004 16 HATCH END MEDICAL CENTRE E84053 11 SAVITA MEDICAL CENTRE E84681 3 ST. PETER'S MEDICAL CENTRE E84693 12 SIMPSON HOUSE MEDICAL CENTRE E84008 31 BELMONT HEALTH CENTRE E84069 20 THE PINN MEDICAL CENTRE E84024 40 THE RIDGEWAY SURGERY E84068 31 GP DIRECT E84058 27 STREATFIELD HEALTH CENTRE E84018 13 THE PINNER ROAD SURGERY E84040 7 THE NORTHWICK SURGERY E84044 18 THE STANMORE MEDICAL CENTRE E84057 22 ZAIN MEDICAL CENTRE E84653 1 THE CIVIC MEDICAL CENTRE E84617 5 ELLIOTT HALL MEDICAL CTR. E84061 25 THE STREATFIELD MEDICAL CENTRE E84646 3 PINNER VIEW MEDICAL CENTRE E84070 5 HEADSTONE ROAD SURGERY E84680 5 HARNESS HARROW PRACTICE E84075 3 KENTON BRIDGE MEDICAL CENTRE - DR RAJA E84663 7 THE SHAFTESBURY MEDICAL CENTRE E84062 3 THE ENTERPRISE PRACTICE E84713 2 KENTON CLINIC E84647 1 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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

NHS Ealing CCG 93.0% • 1,991 people with a stroke shown to NHS Hounslow CCG 91.8% be non-haemorrhagic* in NHS Harrow CCG NHS Central London (Westminster) CCG 90.8% • 1,797 (90.3%) people who are taking an anti-platetet agent or anti- coagulant NHS Hillingdon CCG 90.8% • 143 (7.2%) people who are exceptions NHS Brent CCG 90.4% • 51 (2.6%) additional people with no treatment

NHS Harrow CCG 90.3%

NHS Hammersmith And Fulham CCG 90.2%

NHS West London CCG 87.3%

England 91.8%

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

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

NHS Ealing CCG 93.0%

NHS Merton CCG 92.8%

NHS Hounslow CCG 91.8%

NHS Slough CCG 91.5%

NHS Sutton CCG 91.5%

NHS Redbridge CCG 91.0%

NHS Hillingdon CCG 90.8%

NHS Luton CCG 90.8%

NHS Harrow CCG 90.3%

NHS Kingston CCG 89.6%

NHS Barnet CCG 89.1%

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

HATCH END MEDICAL CENTRE E84053 10 THE STANMORE MEDICAL CENTRE E84057 17 THE STANMORE SURGERY E84657 3 KENTON BRIDGE MEDICAL CENTRE DR GOLDEN E84601 8 • in total, including exceptions, there THE CIRCLE PRACTICE E84004 7 ENDERLEY ROAD MEDICAL CENTRE E84009 19 are 194 people who are not taking an SIMPSON HOUSE MEDICAL CENTRE E84008 16 anti-platelet agent or anti-coagulant THE NORTHWICK SURGERY E84044 9 HEADSTONE ROAD SURGERY E84680 3 • GP practice range: 0.0% to 25.0% THE ENTERPRISE PRACTICE E84713 5 STREATFIELD HEALTH CENTRE E84018 6 HONEYPOT MEDICAL CENTRE E84039 10 BELMONT HEALTH CENTRE E84069 8 FIRST CHOICE MEDICAL CARE Y05080 1 THE RIDGEWAY SURGERY E84068 14 PINNER VIEW MEDICAL CENTRE E84070 3 ASPRI MEDICAL CENTRE E84658 3 HEADSTONE LANE MEDICAL CENTRE E84676 1 ST. PETER'S MEDICAL CENTRE E84693 4 THE PINN MEDICAL CENTRE E84024 14 GP DIRECT E84058 8 ROXBOURNE MEDICAL CENTRE E84022 4 THE SHAFTESBURY MEDICAL CENTRE E84062 2 BACON LANE SURGERY E84014 5 KINGS ROAD SURGERY E84005 2 THE PINNER ROAD SURGERY E84040 2 ELLIOTT HALL MEDICAL CTR. E84061 8 HARNESS HARROW PRACTICE E84075 1 KENTON BRIDGE MEDICAL CENTRE - DR RAJA E84663 1 THE CIVIC MEDICAL CENTRE E84617 THE STREATFIELD MEDICAL CENTRE E84646 KENTON CLINIC E84647 ZAIN MEDICAL CENTRE E84653 SAVITA MEDICAL CENTRE E84681 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 Harrow CCG 0.87

• 0.87 ratio of observed to expected NHS Hillingdon CCG 0.81 diabetes prevalence in NHS Harrow CCG, compared to 0.77 in England NHS Hounslow CCG 0.79 • this suggests 87% of people have NHS Brent CCG 0.78 been diagnosed

NHS Ealing CCG 0.76

NHS Hammersmith And Fulham CCG 0.60

NHS Central London (Westminster) CCG 0.57

NHS West London CCG 0.56

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 1.0

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

NHS Harrow CCG 0.87

NHS Slough CCG 0.85

NHS Hillingdon CCG 0.81

NHS Sutton CCG 0.81

NHS Hounslow CCG 0.79

NHS Redbridge CCG 0.77

NHS Ealing CCG 0.76

NHS Kingston CCG 0.75

NHS Merton CCG 0.74

NHS Luton CCG 0.74

NHS Barnet CCG 0.71

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

HEADSTONE LANE MEDICAL CENTRE E84676 14.6% FIRST CHOICE MEDICAL CARE Y05080 14.2% HONEYPOT MEDICAL CENTRE E84039 11.6% HARNESS HARROW PRACTICE E84075 11.2% • GP practice range of observed KENTON CLINIC E84647 11.1% SAVITA MEDICAL CENTRE E84681 10.8% diabetes 5.7% to 14.6% ROXBOURNE MEDICAL CENTRE E84022 10.8% • there are an estimated 2,790 people STREATFIELD HEALTH CENTRE E84018 10.6% BELMONT HEALTH CENTRE E84069 10.5% with undiagnosed diabetes in NHS ASPRI MEDICAL CENTRE E84658 10.3% Harrow CCG SIMPSON HOUSE MEDICAL CENTRE E84008 10.2% THE CIVIC MEDICAL CENTRE E84617 10.0% GP DIRECT E84058 9.9% THE PINNER ROAD SURGERY E84040 9.8% THE SHAFTESBURY MEDICAL CENTRE E84062 9.8% THE RIDGEWAY SURGERY E84068 9.6% THE ENTERPRISE PRACTICE E84713 9.6% ENDERLEY ROAD MEDICAL CENTRE E84009 9.4% HEADSTONE ROAD SURGERY E84680 9.3% THE CIRCLE PRACTICE E84004 8.9% PINNER VIEW MEDICAL CENTRE E84070 8.7% KINGS ROAD SURGERY E84005 8.6% THE STANMORE MEDICAL CENTRE E84057 8.5% ZAIN MEDICAL CENTRE E84653 8.3% ELLIOTT HALL MEDICAL CTR. E84061 8.2% BACON LANE SURGERY E84014 8.0% THE NORTHWICK SURGERY E84044 7.8% HATCH END MEDICAL CENTRE E84053 7.4% THE STANMORE SURGERY E84657 7.3% KENTON BRIDGE MEDICAL CENTRE - DR RAJA E84663 7.2% THE PINN MEDICAL CENTRE E84024 6.8% KENTON BRIDGE MEDICAL CENTRE DR GOLDEN E84601 6.2% Note: The estimated number of undiagnosed THE STREATFIELD MEDICAL CENTRE E84646 5.8% people with diabetes has been calculated by ST. PETER'S MEDICAL CENTRE E84693 5.7% multiplying the estimated prevalence rate to the 0% 2% 4% 6% 8% 10% 12% 14% 16% 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 Harrow CCG 9.1% 1.3% 13.6% • the estimated total prevalence of diabetes in NHS Harrow CCG is 10.4% (diagnosed and undiagnosed) NHS Brent CCG 8.6% 2.5% 12.4%

• in addition, there are an estimated NHS Ealing CCG 7.8% 2.5% 11.9% 13.6% of people in NHS Harrow CCG who are at increased risk of NHS Hounslow CCG 7.3% 1.9% 11.2% developing diabetes (i.e. with non- diabetic hyperglycaemia) NHS Hillingdon CCG 7.0% 1.6% 11.6% • this means that 24.0% of the NHS West London CCG 4.6% 3.7% 9.4% population in NHS Harrow CCG are estimated to have diabetes, or at high NHS Hammersmith And Fulham CCG 4.5% 2.9% 8.7% risk of developing of diabetes

NHS Central London (Westminster) CCG 4.0% 3.1% 8.8%

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% 30% 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 Ealing CCG 62.1%

NHS Hounslow CCG 59.5% • data on care processes and treatment targets are taken from the National Diabetes Audit (NDA) NHS West London CCG 50.5% • overall practice participation in the 2015/16 audit was 81.4% in England NHS Central London (Westminster) CCG 49.5% • in NHS Harrow CCG, 27 out of 34 NHS Hammersmith And Fulham CCG 47.1% practices (79.4%) participated in the NDA. Data is not available for the remaining practices NHS Hillingdon CCG 39.6%

NHS Brent CCG 36.8% • 31.9% of people with diabetes (of practices who participated in the audit) had the eight recommended NHS Harrow CCG 31.9% care processes in NHS Harrow 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

ENDERLEY ROAD MEDICAL CENTRE E84009 59.7% BACON LANE SURGERY E84014 57.9% BELMONT HEALTH CENTRE E84069 52.7% • achievement - 8 care processes: in THE PINN MEDICAL CENTRE E84024 47.8% KENTON CLINIC E84647 44.1% practices who provided data via the ST. PETER'S MEDICAL CENTRE E84693 43.2% NDA, between 5.6% and 59.7% of HATCH END MEDICAL CENTRE E84053 41.2% KENTON BRIDGE MEDICAL CENTRE DR GOLDEN E84601 37.4% patients received all 8 care processes SIMPSON HOUSE MEDICAL CENTRE E84008 37.1% THE STANMORE MEDICAL CENTRE E84057 36.1% KINGS ROAD SURGERY E84005 33.6% • at least 11,038 people did not receive FIRST CHOICE MEDICAL CARE Y05080 33.5% THE NORTHWICK SURGERY E84044 32.9% the eight care processes ELLIOTT HALL MEDICAL CTR. E84061 32.3% STREATFIELD HEALTH CENTRE E84018 28.0% KENTON BRIDGE MEDICAL CENTRE - DR RAJA E84663 26.1% THE RIDGEWAY SURGERY E84068 23.5% GP DIRECT E84058 22.4% PINNER VIEW MEDICAL CENTRE E84070 21.9% HONEYPOT MEDICAL CENTRE E84039 18.5% ZAIN MEDICAL CENTRE E84653 16.1% SAVITA MEDICAL CENTRE E84681 15.9% THE SHAFTESBURY MEDICAL CENTRE E84062 15.8% ROXBOURNE MEDICAL CENTRE E84022 12.1% ASPRI MEDICAL CENTRE E84658 9.1% THE CIRCLE PRACTICE E84004 8.2% THE STREATFIELD MEDICAL CENTRE E84646 5.6% THE ENTERPRISE PRACTICE E84713 HEADSTONE ROAD SURGERY E84680 HEADSTONE LANE MEDICAL CENTRE E84676 THE STANMORE SURGERY E84657 THE CIVIC MEDICAL CENTRE E84617 HARNESS HARROW PRACTICE E84075 THE PINNER ROAD SURGERY E84040 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 Hillingdon CCG 42.8%

NHS Central London (Westminster) CCG 42.2% • 40.4% of people with diabetes (of practices who participated in the audit) met the three treatment targets NHS Harrow CCG 40.4% in NHS Harrow CCG, compared to 39.0% in England

NHS Brent CCG 39.1%

NHS West London CCG 39.1%

NHS Hounslow CCG 38.6%

NHS Ealing CCG 37.2%

NHS Hammersmith And Fulham CCG 37.0%

England 39.0%

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

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

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

THE STREATFIELD MEDICAL CENTRE E84646 50.2% BELMONT HEALTH CENTRE E84069 49.7% KENTON BRIDGE MEDICAL CENTRE - DR RAJA E84663 49.4% • achievement - 3 treatment targets: in PINNER VIEW MEDICAL CENTRE E84070 48.9% KENTON BRIDGE MEDICAL CENTRE DR GOLDEN E84601 48.8% practices who provided data via the THE PINN MEDICAL CENTRE E84024 45.8% NDA, between 27.7% and 50.2% of THE SHAFTESBURY MEDICAL CENTRE E84062 45.4% BACON LANE SURGERY E84014 45.3% patients achieved all 3 treatment GP DIRECT E84058 41.7% targets THE CIRCLE PRACTICE E84004 41.6% ELLIOTT HALL MEDICAL CTR. E84061 41.3% • at least 8,636 people did not meet the THE STANMORE MEDICAL CENTRE E84057 41.3% ENDERLEY ROAD MEDICAL CENTRE E84009 40.7% three treatment targets FIRST CHOICE MEDICAL CARE Y05080 39.9% ZAIN MEDICAL CENTRE E84653 39.2% ST. PETER'S MEDICAL CENTRE E84693 38.2% ROXBOURNE MEDICAL CENTRE E84022 37.5% THE RIDGEWAY SURGERY E84068 37.4% SIMPSON HOUSE MEDICAL CENTRE E84008 37.3% ASPRI MEDICAL CENTRE E84658 37.1% HONEYPOT MEDICAL CENTRE E84039 36.8% KENTON CLINIC E84647 35.8% STREATFIELD HEALTH CENTRE E84018 35.7% THE NORTHWICK SURGERY E84044 33.0% SAVITA MEDICAL CENTRE E84681 30.4% KINGS ROAD SURGERY E84005 29.6% HATCH END MEDICAL CENTRE E84053 27.7% THE ENTERPRISE PRACTICE E84713 HEADSTONE ROAD SURGERY E84680 HEADSTONE LANE MEDICAL CENTRE E84676 THE STANMORE SURGERY E84657 THE CIVIC MEDICAL CENTRE E84617 HARNESS HARROW PRACTICE E84075 THE PINNER ROAD SURGERY E84040 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%

HATCH END MEDICAL CENTRE 41

KINGS ROAD SURGERY 68

SAVITA MEDICAL CENTRE 34 • using the GP cluster method of STREATFIELD HEALTH CENTRE 59 calculating potential gains, if each KENTON CLINIC 27 practice was to achieve as well as the THE NORTHWICK SURGERY 52 upper quartile of its national cluster, then an additional 629 people would HONEYPOT MEDICAL CENTRE 74 be treated SIMPSON HOUSE MEDICAL CENTRE 61

ASPRI MEDICAL CENTRE 23

ROXBOURNE MEDICAL CENTRE 30

THE STANMORE MEDICAL CENTRE 9

GP DIRECT 9

BACON LANE SURGERY

THE SHAFTESBURY MEDICAL CENTRE

THE PINN MEDICAL CENTRE

KENTON BRIDGE MEDICAL CENTRE DR GOLDEN

PINNER VIEW MEDICAL CENTRE

KENTON BRIDGE MEDICAL CENTRE - DR RAJA

THE STREATFIELD MEDICAL CENTRE

BELMONT 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 Hounslow CCG 0.56

NHS Hammersmith And Fulham CCG 0.55 • the ratio of those diagnosed with chronic kidney disease versus those NHS Hillingdon CCG 0.50 expected to have chronic kidney disease is 0.41. This compares to NHS Brent CCG 0.49 0.68 for England • this suggests that 41% of people with chronic kidney disease have been NHS Ealing CCG 0.43 diagnosed

NHS Harrow CCG 0.41

NHS West London CCG 0.40

NHS Central London (Westminster) CCG 0.33 Note: This slide compares the prevalence of CKD recorded in QOF in 2015/16 to the expected prevalence of CKD produced by the University of Southampton in 2011. A small number of CCGs have a ratio greater than 1. It is unlikely that all England 0.68 people with CKD will be diagnosed in any CCG and therefore a ratio greater than 1 suggests that 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 the figures are underestimating the true CKD Ratio prevalence in the area. These ratios should be taken as an indication of the comparative scale of undiagnosed CKD rather than absolute figures.

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

NHS Sutton CCG 0.62

NHS Slough CCG 0.60

NHS Merton CCG 0.60

NHS Hounslow CCG 0.56

NHS Barnet CCG 0.53

NHS Redbridge CCG 0.50

NHS Hillingdon CCG 0.50

NHS Luton CCG 0.48

NHS Ealing CCG 0.43

NHS Kingston CCG 0.42

NHS Harrow CCG 0.41

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 Ratio

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

GP practice CCG

PINNER VIEW MEDICAL CENTRE E84070 4.7% KINGS ROAD SURGERY E84005 4.6% BACON LANE SURGERY E84014 4.3% ELLIOTT HALL MEDICAL CTR. E84061 3.6% • it is estimated that there are 7,349 HONEYPOT MEDICAL CENTRE E84039 3.4% SIMPSON HOUSE MEDICAL CENTRE E84008 3.4% people with undiagnosed chronic KENTON BRIDGE MEDICAL CENTRE - DR RAJA E84663 3.3% kidney disease in NHS Harrow CCG BELMONT HEALTH CENTRE E84069 3.1% THE RIDGEWAY SURGERY E84068 3.1% • GP practice range of observed CKD: THE PINNER ROAD SURGERY E84040 3.1% 0.3% to 4.7% SAVITA MEDICAL CENTRE E84681 2.9% GP DIRECT E84058 2.7% THE CIRCLE PRACTICE E84004 2.6% THE PINN MEDICAL CENTRE E84024 2.6% ROXBOURNE MEDICAL CENTRE E84022 2.6% ENDERLEY ROAD MEDICAL CENTRE E84009 2.5% THE NORTHWICK SURGERY E84044 2.4% THE ENTERPRISE PRACTICE E84713 2.2% THE SHAFTESBURY MEDICAL CENTRE E84062 2.0% HEADSTONE LANE MEDICAL CENTRE E84676 1.9% THE STREATFIELD MEDICAL CENTRE E84646 1.8% FIRST CHOICE MEDICAL CARE Y05080 1.8% THE STANMORE SURGERY E84657 1.8% ST. PETER'S MEDICAL CENTRE E84693 1.7% THE STANMORE MEDICAL CENTRE E84057 1.7% KENTON BRIDGE MEDICAL CENTRE DR GOLDEN E84601 1.3% HATCH END MEDICAL CENTRE E84053 1.2% HARNESS HARROW PRACTICE E84075 1.2% STREATFIELD HEALTH CENTRE E84018 1.0% THE CIVIC MEDICAL CENTRE E84617 0.8% Note: CCG estimates for the estimated KENTON CLINIC E84647 0.7% number of people with CKD are based on HEADSTONE ROAD SURGERY E84680 0.7% applying a proportion from a resident based ZAIN MEDICAL CENTRE E84653 0.6% ASPRI MEDICAL CENTRE E84658 0.3% population estimate to a GP registered population. The characteristics of registered 0% 1% 1% 2% 2% 3% 3% 4% 4% 5% 5% 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 Hillingdon CCG 77.1% • 5,194 people with CKD (diagnosed*) NHS Ealing CCG 75.7% in NHS Harrow CCG • 3,901 (75.1%) people whose blood NHS Brent CCG 75.3% pressure is <= 140 /85 • 371 (7.1%) people who are exceptions NHS Harrow CCG 75.1% • 922 (17.8%) additional people whose blood pressure is not <= 140 / 85 NHS Hounslow CCG 74.9%

NHS West London CCG 73.3%

NHS Central London (Westminster) CCG 73.3%

NHS Hammersmith And Fulham CCG 70.3%

*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 Slough CCG 82.2%

NHS Merton CCG 78.3%

NHS Hillingdon CCG 77.1%

NHS Ealing CCG 75.7%

NHS Redbridge CCG 75.7%

NHS Sutton CCG 75.6%

NHS Kingston CCG 75.4%

NHS Harrow CCG 75.1%

NHS Hounslow CCG 74.9%

NHS Barnet CCG 74.2%

NHS Luton CCG 69.9%

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

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

Not below 140/85 Exceptions reported

THE STANMORE SURGERY E84657 21 ASPRI MEDICAL CENTRE E84658 7 THE NORTHWICK SURGERY E84044 67 ROXBOURNE MEDICAL CENTRE E84022 52 • in total, including exceptions, there CHARLTON ROAD MEDICAL CENTRE E84064 33 STREATFIELD HEALTH CENTRE E84018 21 are 1,293 people whose blood SAVITA MEDICAL CENTRE E84681 23 pressure is not <= 140 / 85 THE CIRCLE PRACTICE E84004 66 THE ENDERLEY MEDICAL CENTRE E84009 86 • GP practice range: 9.1% to 58.3% SIMPSON HOUSE MEDICAL CENTRE E84008 96 KINGS ROAD SURGERY E84005 87 THE PINN MEDICAL CENTRE E84024 118 HEADSTONE ROAD SURGERY E84680 7 KENTON CLINIC E84647 4 THE STANMORE MEDICAL CENTRE E84057 45 THE CIVIC MEDICAL CENTRE E84617 8 THE PINNER ROAD SURGERY E84040 30 GP DIRECT E84058 97 ELLIOTT HALL MEDICAL CTR. E84061 81 HATCH END MEDICAL CENTRE E84053 10 HEADSTONE LANE MEDICAL CENTRE E84676 11 HONEYPOT MEDICAL CENTRE E84039 46 THE RIDGEWAY SURGERY E84068 70 KENTON BRIDGE MEDICAL CENTRE DR GOLDEN E84601 14 HARNESS HARROW PRACTICE E84075 9 BELMONT HEALTH CENTRE E84069 48 PINNER VIEW MEDICAL CENTRE E84070 24 THE SHAFTESBURY MEDICAL CENTRE E84062 11 BACON LANE SURGERY E84014 47 THE ENTERPRISE PRACTICE E84713 11 ST. PETER'S MEDICAL CENTRE E84693 12 THE STREATFIELD MEDICAL CENTRE E84646 11 KENTON BRIDGE MEDICAL CENTRE DR LEVY E84663 19 DR MT SHAHZAD E84653 1 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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

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

THE STANMORE SURGERY 14

ASPRI MEDICAL CENTRE 5

ROXBOURNE MEDICAL CENTRE 29 • using the GP cluster method of STREATFIELD HEALTH CENTRE 12 calculating potential gains, if each SAVITA MEDICAL CENTRE 13 practice was to achieve as well as the THE CIRCLE PRACTICE 36 upper quartile of its national cluster, then an additional 348 people would THE NORTHWICK SURGERY 30 be treated HEADSTONE ROAD SURGERY 3

KENTON CLINIC 2

THE ENDERLEY MEDICAL CENTRE 33

PINNER VIEW MEDICAL CENTRE

THE SHAFTESBURY MEDICAL CENTRE

THE ENTERPRISE PRACTICE

ST. PETER'S MEDICAL CENTRE

THE RIDGEWAY SURGERY

THE STREATFIELD MEDICAL CENTRE

BELMONT HEALTH CENTRE

KENTON BRIDGE MEDICAL CENTRE DR LEVY

BACON LANE SURGERY

DR MT SHAHZAD 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 Hillingdon CCG 78.6% • 5,194 people with CKD (diagnosed*) NHS Harrow CCG 76.0% in NHS Harrow CCG • 3,950 (76%) people who have a NHS Ealing CCG 75.5% record of urine albumin:creatinine ratio test • 239 (4.6%) people who are NHS Brent CCG 74.4% exceptions • 1,005 (19.3%) additional people who NHS Hounslow CCG 74.1% have no record of urine albumin:creatinine ratio test

NHS Central London (Westminster) CCG 73.5%

NHS West London CCG 73.5%

NHS Hammersmith And Fulham CCG 69.6%

*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 Slough CCG 82.9%

NHS Hillingdon CCG 78.6%

NHS Barnet CCG 76.3%

NHS Harrow CCG 76.0%

NHS Ealing CCG 75.5%

NHS Merton CCG 74.4%

NHS Hounslow CCG 74.1%

NHS Sutton CCG 71.8%

NHS Kingston CCG 71.2%

NHS Luton CCG 67.2%

NHS Redbridge CCG 61.6%

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

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

Not recorded Exceptions reported

THE STANMORE SURGERY E84657 26 ASPRI MEDICAL CENTRE E84658 9 HEADSTONE ROAD SURGERY E84680 13 THE PINNER ROAD SURGERY E84040 45 • in total, including exceptions, there THE NORTHWICK SURGERY E84044 72 DR MT SHAHZAD E84653 4 are 1,244 people who have no record THE CIRCLE PRACTICE E84004 69 of urine albumin:creatinine ratio test KINGS ROAD SURGERY E84005 102 SIMPSON HOUSE MEDICAL CENTRE E84008 103 • GP practice range: 7.1% to 72.2% HEADSTONE LANE MEDICAL CENTRE E84676 17 ROXBOURNE MEDICAL CENTRE E84022 48 THE PINN MEDICAL CENTRE E84024 124 THE STANMORE MEDICAL CENTRE E84057 41 THE CIVIC MEDICAL CENTRE E84617 7 THE ENDERLEY MEDICAL CENTRE E84009 63 HONEYPOT MEDICAL CENTRE E84039 52 CHARLTON ROAD MEDICAL CENTRE E84064 20 THE ENTERPRISE PRACTICE E84713 15 ELLIOTT HALL MEDICAL CTR. E84061 69 BELMONT HEALTH CENTRE E84069 57 GP DIRECT E84058 73 SAVITA MEDICAL CENTRE E84681 12 HATCH END MEDICAL CENTRE E84053 8 STREATFIELD HEALTH CENTRE E84018 10 KENTON BRIDGE MEDICAL CENTRE DR GOLDEN E84601 13 THE RIDGEWAY SURGERY E84068 64 KENTON BRIDGE MEDICAL CENTRE DR LEVY E84663 24 BACON LANE SURGERY E84014 37 HARNESS HARROW PRACTICE E84075 6 THE STREATFIELD MEDICAL CENTRE E84646 10 ST. PETER'S MEDICAL CENTRE E84693 10 THE SHAFTESBURY MEDICAL CENTRE E84062 7 PINNER VIEW MEDICAL CENTRE E84070 13 KENTON CLINIC E84647 1 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 Harrow CCG 0.57%

NHS Brent CCG 0.54% • prevalence of 0.57% in NHS Harrow CCG compared to 0.76% in England NHS Hounslow CCG 0.51%

NHS Hillingdon CCG 0.49%

NHS Ealing CCG 0.46%

NHS Central London (Westminster) CCG 0.44%

NHS Hammersmith And Fulham CCG 0.41%

NHS West London CCG 0.40%

England 0.76%

0.0% 0.1% 0.2% 0.3% 0.4% 0.5% 0.6% 0.7% 0.8%

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

NHS Harrow CCG 0.57%

NHS Slough CCG 0.56%

NHS Sutton CCG 0.54%

NHS Hounslow CCG 0.51%

NHS Barnet CCG 0.51%

NHS Luton CCG 0.50%

NHS Hillingdon CCG 0.49%

NHS Merton CCG 0.48%

NHS Ealing CCG 0.46%

NHS Redbridge CCG 0.45%

NHS Kingston CCG 0.45%

0.0% 0.1% 0.2% 0.3% 0.4% 0.5% 0.6%

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

GP practice CCG

THE STANMORE SURGERY E84657 1.0% KENTON BRIDGE MEDICAL CENTRE - DR RAJA E84663 0.8% SIMPSON HOUSE MEDICAL CENTRE E84008 0.8% HEADSTONE ROAD SURGERY E84680 0.8% • 1,478 people with diagnosed heart BELMONT HEALTH CENTRE E84069 0.7% ENDERLEY ROAD MEDICAL CENTRE E84009 0.7% failure in NHS Harrow CCG FIRST CHOICE MEDICAL CARE Y05080 0.7% • GP practice range: 0.2% to 1.0% GP DIRECT E84058 0.7% BACON LANE SURGERY E84014 0.7% THE STANMORE MEDICAL CENTRE E84057 0.7% ELLIOTT HALL MEDICAL CTR. E84061 0.7% PINNER VIEW MEDICAL CENTRE E84070 0.6% THE ENTERPRISE PRACTICE E84713 0.6% HONEYPOT MEDICAL CENTRE E84039 0.6% THE PINN MEDICAL CENTRE E84024 0.6% THE SHAFTESBURY MEDICAL CENTRE E84062 0.6% THE CIVIC MEDICAL CENTRE E84617 0.5% THE NORTHWICK SURGERY E84044 0.5% ASPRI MEDICAL CENTRE E84658 0.5% THE CIRCLE PRACTICE E84004 0.5% ROXBOURNE MEDICAL CENTRE E84022 0.5% KINGS ROAD SURGERY E84005 0.5% SAVITA MEDICAL CENTRE E84681 0.4% HARNESS HARROW PRACTICE E84075 0.4% KENTON BRIDGE MEDICAL CENTRE DR GOLDEN E84601 0.4% THE PINNER ROAD SURGERY E84040 0.4% THE STREATFIELD MEDICAL CENTRE E84646 0.4% THE RIDGEWAY SURGERY E84068 0.4% STREATFIELD HEALTH CENTRE E84018 0.4% ST. PETER'S MEDICAL CENTRE E84693 0.3% KENTON CLINIC E84647 0.3% HEADSTONE LANE MEDICAL CENTRE E84676 0.3% ZAIN MEDICAL CENTRE E84653 0.2% HATCH END MEDICAL CENTRE E84053 0.2% 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2%

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 Hounslow CCG 91.5% • 299 people with heart failure* with NHS Ealing CCG 91.5% LVSD in NHS Harrow CCG • 257 (86%) people treated with ACE-I NHS Brent CCG 88.4% or ARB • 41 (13.7%) people who are exceptions NHS Hillingdon CCG 87.6% • 1 (0.3%) additional people who are not treated with ACE-I or ARB NHS Central London (Westminster) CCG 86.0%

NHS Harrow CCG 86.0%

NHS Hammersmith And Fulham CCG 84.8%

NHS West London CCG 82.7%

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 Hounslow CCG 91.5%

NHS Ealing CCG 91.5%

NHS Redbridge CCG 89.3%

NHS Kingston CCG 88.7%

NHS Sutton CCG 88.1%

NHS Hillingdon CCG 87.6%

NHS Merton CCG 87.3%

NHS Harrow CCG 86.0%

NHS Slough CCG 83.7%

NHS Luton CCG 82.9%

NHS Barnet CCG 79.8%

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

ASPRI MEDICAL CENTRE E84658 1 SAVITA MEDICAL CENTRE E84681 1 PINNER VIEW MEDICAL CENTRE E84070 4 THE CIVIC MEDICAL CENTRE E84617 2 • in total, including exceptions, there ELLIOTT HALL MEDICAL CTR. E84061 7 THE CIRCLE PRACTICE E84004 1 are 42 people who are not treated THE STANMORE MEDICAL CENTRE E84057 2 with ACE-I or ARB THE PINN MEDICAL CENTRE E84024 5 ENDERLEY ROAD MEDICAL CENTRE E84009 5 • GP practice range: 0.0% to 50.0% HONEYPOT MEDICAL CENTRE E84039 3 THE SHAFTESBURY MEDICAL CENTRE E84062 1 THE ENTERPRISE PRACTICE E84713 1 HEADSTONE ROAD SURGERY E84680 1 GP DIRECT E84058 4 KINGS ROAD SURGERY E84005 1 BACON LANE SURGERY E84014 1 SIMPSON HOUSE MEDICAL CENTRE E84008 1 BELMONT HEALTH CENTRE E84069 1 STREATFIELD HEALTH CENTRE E84018 ROXBOURNE MEDICAL CENTRE E84022 THE PINNER ROAD SURGERY E84040 THE NORTHWICK SURGERY E84044 HATCH END MEDICAL CENTRE E84053 THE RIDGEWAY SURGERY E84068 HARNESS HARROW PRACTICE E84075 KENTON BRIDGE MEDICAL CENTRE DR GOLDEN E84601 THE STREATFIELD MEDICAL CENTRE E84646 KENTON CLINIC E84647 ZAIN MEDICAL CENTRE E84653 THE STANMORE SURGERY E84657 KENTON BRIDGE MEDICAL CENTRE - DR RAJA E84663 HEADSTONE LANE MEDICAL CENTRE E84676 ST. PETER'S MEDICAL CENTRE E84693 FIRST CHOICE MEDICAL CARE Y05080 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 Ealing CCG 83.6% • 257 people with heart failure* with NHS Hounslow CCG 82.8% LVSD treated with ACE-I/ARB in NHS Harrow CCG NHS Brent CCG 82.5% • 199 (77.4%) people treated with ACE- I/ARB and BB • 41 (16%) people who are exceptions NHS Harrow CCG 77.4% • 17 (6.6%) additional people who are not treated with ACE-I/ARB and BB NHS Hammersmith And Fulham CCG 74.0%

NHS West London CCG 73.4%

NHS Hillingdon CCG 72.6%

NHS Central London (Westminster) CCG 71.7%

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 Ealing CCG 83.6%

NHS Hounslow CCG 82.8%

NHS Merton CCG 79.9%

NHS Luton CCG 77.5%

NHS Harrow CCG 77.4%

NHS Barnet CCG 76.4%

NHS Slough CCG 75.2%

NHS Sutton CCG 75.0%

NHS Kingston CCG 74.0%

NHS Redbridge CCG 73.5%

NHS Hillingdon CCG 72.6%

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

FIRST CHOICE MEDICAL CARE Y05080 2 THE NORTHWICK SURGERY E84044 7 KENTON CLINIC E84647 1 KENTON BRIDGE MEDICAL CENTRE DR GOLDEN E84601 2 • in total, including exceptions, there THE ENTERPRISE PRACTICE E84713 2 ENDERLEY ROAD MEDICAL CENTRE E84009 5 are 58 people who are not treated THE PINN MEDICAL CENTRE E84024 4 with ACE-I or ARB HARNESS HARROW PRACTICE E84075 1 GP DIRECT E84058 11 • GP practice range: 0.0% to 100.0% ST. PETER'S MEDICAL CENTRE E84693 3 THE STANMORE MEDICAL CENTRE E84057 1 THE STREATFIELD MEDICAL CENTRE E84646 2 HEADSTONE ROAD SURGERY E84680 2 KINGS ROAD SURGERY E84005 2 HONEYPOT MEDICAL CENTRE E84039 2 SIMPSON HOUSE MEDICAL CENTRE E84008 2 KENTON BRIDGE MEDICAL CENTRE - DR RAJA E84663 4 PINNER VIEW MEDICAL CENTRE E84070 1 ELLIOTT HALL MEDICAL CTR. E84061 2 BACON LANE SURGERY E84014 1 STREATFIELD HEALTH CENTRE E84018 1 THE CIRCLE PRACTICE E84004 ROXBOURNE MEDICAL CENTRE E84022 THE PINNER ROAD SURGERY E84040 HATCH END MEDICAL CENTRE E84053 THE SHAFTESBURY MEDICAL CENTRE E84062 THE RIDGEWAY SURGERY E84068 BELMONT HEALTH CENTRE E84069 THE CIVIC MEDICAL CENTRE E84617 ZAIN MEDICAL CENTRE E84653 THE STANMORE SURGERY E84657 ASPRI MEDICAL CENTRE E84658 HEADSTONE LANE MEDICAL CENTRE E84676 SAVITA MEDICAL CENTRE E84681 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 Brent CCG 89.8% • 7,110 people with coronary heart NHS Harrow CCG 89.5% disease* in NHS Harrow CCG • 6,360 (89.5%) people whose blood NHS Hillingdon CCG 89.1% pressure <= 150 / 90 • 245 (3.4%) people who are exceptions NHS Ealing CCG 88.0% • 505 (7.1%) additional people whose blood pressure is not <= 150 / 90 NHS Hounslow CCG 87.9%

NHS West London CCG 86.5%

NHS Central London (Westminster) CCG 86.3%

NHS Hammersmith And Fulham CCG 83.9%

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 Slough CCG 91.1%

NHS Redbridge CCG 90.1%

NHS Merton CCG 89.5%

NHS Harrow CCG 89.5%

NHS Hillingdon CCG 89.1%

NHS Ealing CCG 88.0%

NHS Sutton CCG 87.9%

NHS Barnet CCG 87.9%

NHS Hounslow CCG 87.9%

NHS Kingston CCG 87.7%

NHS Luton CCG 85.4%

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

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

Not below 150/90 Exceptions reported

ASPRI MEDICAL CENTRE E84658 44 THE STANMORE SURGERY E84657 26 HEADSTONE ROAD SURGERY E84680 29 SAVITA MEDICAL CENTRE E84681 16 • in total, including exceptions, there FIRST CHOICE MEDICAL CARE Y05080 12 ROXBOURNE MEDICAL CENTRE E84022 38 are 750 people whose blood pressure HEADSTONE LANE MEDICAL CENTRE E84676 17 is not <= 150 / 90 THE CIRCLE PRACTICE E84004 31 SIMPSON HOUSE MEDICAL CENTRE E84008 49 • GP practice range: 2.0% to 34.4% HATCH END MEDICAL CENTRE E84053 19 THE NORTHWICK SURGERY E84044 31 THE CIVIC MEDICAL CENTRE E84617 11 THE PINNER ROAD SURGERY E84040 15 GP DIRECT E84058 49 STREATFIELD HEALTH CENTRE E84018 24 KENTON BRIDGE MEDICAL CENTRE DR GOLDEN E84601 14 KINGS ROAD SURGERY E84005 23 ENDERLEY ROAD MEDICAL CENTRE E84009 40 BELMONT HEALTH CENTRE E84069 28 HONEYPOT MEDICAL CENTRE E84039 36 BACON LANE SURGERY E84014 29 HARNESS HARROW PRACTICE E84075 10 THE STANMORE MEDICAL CENTRE E84057 33 ST. PETER'S MEDICAL CENTRE E84693 8 THE ENTERPRISE PRACTICE E84713 7 THE SHAFTESBURY MEDICAL CENTRE E84062 8 THE PINN MEDICAL CENTRE E84024 38 KENTON CLINIC E84647 6 ZAIN MEDICAL CENTRE E84653 3 THE RIDGEWAY SURGERY E84068 24 KENTON BRIDGE MEDICAL CENTRE - DR RAJA E84663 9 ELLIOTT HALL MEDICAL CTR. E84061 18 THE STREATFIELD MEDICAL CENTRE E84646 3 PINNER VIEW MEDICAL CENTRE E84070 2 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%

ASPRI MEDICAL CENTRE 36

THE STANMORE SURGERY 20

HEADSTONE ROAD SURGERY 21 • using the GP cluster method of SAVITA MEDICAL CENTRE 11 calculating potential gains, if each ROXBOURNE MEDICAL CENTRE 25 practice was to achieve as well as the HEADSTONE LANE MEDICAL CENTRE 11 upper quartile of its national cluster, then an additional 257 people would THE CIRCLE PRACTICE 19 be treated THE CIVIC MEDICAL CENTRE 5

THE PINNER ROAD SURGERY 7

SIMPSON HOUSE MEDICAL CENTRE 19

KENTON CLINIC 0

THE SHAFTESBURY MEDICAL CENTRE 1

THE STANMORE MEDICAL CENTRE

ZAIN MEDICAL CENTRE

KENTON BRIDGE MEDICAL CENTRE - DR RAJA

THE PINN MEDICAL CENTRE

THE RIDGEWAY SURGERY

THE STREATFIELD MEDICAL CENTRE

PINNER VIEW MEDICAL CENTRE

ELLIOTT HALL MEDICAL CTR. 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 Hillingdon CCG 93.5% • 7,110 people with coronary heart NHS Brent CCG 93.3% disease* in NHS Harrow CCG • 6,571 (92.4%) people who are taking NHS Ealing CCG 92.8% aspirin, an alternative anti-platelet therapy, or an anti-coagulant • 301 (4.2%) people who are NHS Harrow CCG 92.4% exceptions • 238 (3.3%) additional people who are NHS Hounslow CCG 91.8% not taking aspirin, an alternative anti- platelet therapy, or an anti-coagulant

NHS Central London (Westminster) CCG 89.1%

NHS West London CCG 88.4%

NHS Hammersmith And Fulham CCG 87.9%

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 Hillingdon CCG 93.5%

NHS Kingston CCG 92.9%

NHS Merton CCG 92.9%

NHS Ealing CCG 92.8%

NHS Redbridge CCG 92.7%

NHS Harrow CCG 92.4%

NHS Slough CCG 92.3%

NHS Hounslow CCG 91.8%

NHS Sutton CCG 91.4%

NHS Barnet CCG 90.8%

NHS Luton CCG 89.7%

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

HATCH END MEDICAL CENTRE E84053 28 THE STANMORE SURGERY E84657 14 SAVITA MEDICAL CENTRE E84681 9 THE CIVIC MEDICAL CENTRE E84617 10 • in total, including exceptions, there THE PINNER ROAD SURGERY E84040 14 ROXBOURNE MEDICAL CENTRE E84022 21 are 539 people are not taking aspirin, THE STANMORE MEDICAL CENTRE E84057 40 an alternative anti-platelet therapy, or THE CIRCLE PRACTICE E84004 18 ZAIN MEDICAL CENTRE E84653 5 an anti-coagulant HONEYPOT MEDICAL CENTRE E84039 37 • GP practice range: 2.7% to 18.3% SIMPSON HOUSE MEDICAL CENTRE E84008 33 STREATFIELD HEALTH CENTRE E84018 19 KENTON BRIDGE MEDICAL CENTRE DR GOLDEN E84601 11 BELMONT HEALTH CENTRE E84069 25 THE NORTHWICK SURGERY E84044 20 HEADSTONE ROAD SURGERY E84680 9 ENDERLEY ROAD MEDICAL CENTRE E84009 28 ST. PETER'S MEDICAL CENTRE E84693 8 THE ENTERPRISE PRACTICE E84713 7 GP DIRECT E84058 31 ELLIOTT HALL MEDICAL CTR. E84061 30 THE SHAFTESBURY MEDICAL CENTRE E84062 8 THE PINN MEDICAL CENTRE E84024 36 FIRST CHOICE MEDICAL CARE Y05080 4 PINNER VIEW MEDICAL CENTRE E84070 6 BACON LANE SURGERY E84014 18 HEADSTONE LANE MEDICAL CENTRE E84676 5 ASPRI MEDICAL CENTRE E84658 6 KENTON CLINIC E84647 4 THE RIDGEWAY SURGERY E84068 16 KINGS ROAD SURGERY E84005 7 THE STREATFIELD MEDICAL CENTRE E84646 3 KENTON BRIDGE MEDICAL CENTRE - DR RAJA E84663 6 HARNESS HARROW PRACTICE E84075 3 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 Harrow CCG England 900

800 • in NHS Harrow CCG, the hospital admission rate for coronary heart 700 disease in 2015/16 was 506.8 (1,019) 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 Harrow CCG England 200

180 • in NHS Harrow CCG, the hospital admission rate for stroke in 2015/16 160 was 135.2 (275) compared to 172.8 for England 140

120

100

80

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

40

20

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 Harrow CCG England

196.1% Angina 136.8% • The risk of a stroke was 112.5% higher and the risk of a heart attack 132.4% was 132.4% higher compared to Heart Attack 108.6% people without diabetes. The risk of a major amputation was 529.1% higher. 202.8% Heart failure 150.0%

112.5% Stroke 81.3%

529.1% Major amputation 445.8%

1408.3% Minor amputation 753.5%

251.3% RRT 293.0%

0% 200% 400% 600% 800% 1000% 1200% 1400% 1600% 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 Harrow CCG England 90

80 • in NHS Harrow CCG, the early mortality rate for coronary heart 70 disease in 2013-15 was 38.2, 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 Harrow CCG England 30

• in NHS Harrow CCG, the early 25 mortality rate for stroke in 2013-15 was 9.7, 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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