CVD: Primary Care Intelligence Packs NHS Southport and Formby 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 Southport and Formby CCG are: NHS Fylde & Wyre CCG NHS Nottingham West CCG NHS Castle Point and Rochford CCG NHS Nottingham North and East CCG NHS Wyre Forest CCG NHS North Tyneside CCG NHS Eastbourne, Hailsham and Seaford CCG NHS South Tyneside CCG NHS South Devon and Torbay CCG NHS Erewash 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 South Tyneside CCG 21.1%

NHS Erewash CCG 18.8% • prevalence of 15.6% in NHS Southport and Formby CCG NHS Wyre Forest CCG 18.4%

NHS North Tyneside CCG 17.8%

NHS Fylde & Wyre CCG 17.7%

NHS South Devon and Torbay CCG 17.6%

NHS Nottingham North and East CCG 17.6%

NHS Nottingham West CCG 16.4% Note: It has been found that the proportion of patients recorded as smokers correlates well NHS Eastbourne, Hailsham and Seaford CCG 16.2% with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, NHS Castle Point and Rochford CCG 15.9% http://bmjopen.bmj.com/content/4/7/e005217.abs tract

NHS Southport and Formby CCG 15.6% 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

TRINITY PRACTICE Y02610 32.4%

ST MARKS MEDICAL CENTRE N84021 25.1% • 16,484 people who are recorded as LINCOLN HOUSE SURGERY N84037 20.2% smokers in NHS Southport and KEW SURGERY N84617 20.1% Formby CCG

CURZON ROAD MEDICAL PRACTICE N84013 19.9% • GP practice range: 8.0% to 32.4%

AINSDALE VILLAGE SURGERY N84014 18.4%

THE FAMILY SURGERY N84625 17.2%

ROE LANE SURGERY N84611 16.3%

CUMBERLAND HOUSE SURGERY N84005 15.6%

NORWOOD SURGERY N84008 15.4%

CHURCHTOWN MEDICAL CENTRE N84017 14.7%

THE CORNER SURGERY (DR MULLA) N84613 13.7%

THE MARSHSIDE SURGERY (DR WAINWRIGHT) N84614 13.5%

GRANGE SURGERY N84024 12.7%

AINSDALE MEDICAL CENTRE N84012 12.3%

FRESHFIELD SURGERY N84036 9.5% Note: This method is thought to be a reasonably

THE VILLAGE SURGERY FORMBY N84018 8.6% robust method in estimating smoking prevalence for the majority of GP practices. However, THE HOLLIES SURGERY N84618 8.3% caution is advised for extreme estimates of

CHAPEL LANE SURGERY N84006 8.0% smoking prevalence and those with high 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 St Helens CCG 0.64

NHS South Sefton CCG 0.63

NHS Knowsley CCG 0.61 • the ratio of those diagnosed with hypertension versus those expected NHS Vale Royal CCG 0.61 to have hypertension is 0.6. This compares to 0.59 for England NHS South Cheshire CCG 0.61 • this suggests that 60% of people with hypertension have been diagnosed NHS Halton CCG 0.61

NHS Wirral CCG 0.60

NHS Southport And Formby CCG 0.60

NHS Eastern Cheshire CCG 0.59

NHS Warrington CCG 0.59

NHS West Cheshire CCG 0.59

NHS Liverpool CCG 0.58

Note: this slide shows Hypertension prevalence estimates created using data from QOF England 0.59 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 South Devon and Torbay CCG 0.62

NHS Fylde & Wyre CCG 0.62

NHS Wyre Forest CCG 0.61

NHS Castle Point and Rochford CCG 0.61

NHS Eastbourne, Hailsham and Seaford CCG 0.61

NHS South Tyneside CCG 0.60

NHS North Tyneside CCG 0.60

NHS Erewash CCG 0.60

NHS Nottingham West CCG 0.60

NHS Southport and Formby CCG 0.60

NHS Nottingham North and East CCG 0.58

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 HOLLIES SURGERY N84618 0.69

LINCOLN HOUSE SURGERY N84037 0.64

THE CORNER SURGERY (DR MULLA) N84613 0.64 • it is estimated that there are 13,826 people with undiagnosed GRANGE SURGERY N84024 0.61 hypertension in NHS Southport and CHURCHTOWN MEDICAL CENTRE N84017 0.60 Formby CCG CHAPEL LANE SURGERY N84006 0.60 • GP practice range of observed to AINSDALE MEDICAL CENTRE N84012 0.58 expected hypertension prevalence NORWOOD SURGERY N84008 0.58 0.38 to 0.69

THE VILLAGE SURGERY FORMBY N84018 0.56

AINSDALE VILLAGE SURGERY N84014 0.56

KEW SURGERY N84617 0.54

CURZON ROAD MEDICAL PRACTICE N84013 0.53

THE MARSHSIDE SURGERY (DR WAINWRIGHT) N84614 0.53

ST MARKS MEDICAL CENTRE N84021 0.53

FRESHFIELD SURGERY N84036 0.52

ROE LANE SURGERY N84611 0.52

CUMBERLAND HOUSE SURGERY N84005 0.51

TRINITY PRACTICE Y02610 0.44

THE FAMILY SURGERY N84625 0.38

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

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

NHS Knowsley CCG 82.4%

NHS Vale Royal CCG 82.1%

NHS West Cheshire CCG 81.6% • 20,520 people with hypertension (diagnosed)* in NHS Southport and NHS Southport And Formby CCG 81.6% Formby CCG • 16,736 (81.6%) people whose blood NHS St Helens CCG 80.5% pressure is <= 150/90 • 455 (2.2%) people who are excepted NHS South Cheshire CCG 80.3% from optimal control

NHS Halton CCG 80.3% • 3,329 (16.2%) additional people whose blood pressure is not <= NHS Liverpool CCG 80.3% 150/90

NHS Eastern Cheshire CCG 79.8%

NHS Wirral CCG 79.4%

NHS Warrington CCG 79.1%

NHS South Sefton CCG 77.5%

England 79.6%

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

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

NHS Nottingham West CCG 82.3%

NHS Erewash CCG 82.0%

NHS Southport and Formby CCG 81.6%

NHS North Tyneside CCG 81.5%

NHS Fylde & Wyre CCG 81.4%

NHS Wyre Forest CCG 81.2%

NHS Nottingham North and East CCG 81.1%

NHS South Tyneside CCG 80.0%

NHS Eastbourne, Hailsham and Seaford CCG 77.3%

NHS South Devon and Torbay CCG 77.1%

NHS Castle Point and Rochford CCG 74.6%

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

KEW SURGERY N84617 144

THE VILLAGE SURGERY FORMBY N84018 461 • in total, including exceptions, there THE HOLLIES SURGERY N84618 178 are 3,784 people whose blood GRANGE SURGERY N84024 412 pressure is not <= 150/90 FRESHFIELD SURGERY N84036 75 • GP practice range: 10.1% to 32.1%

CHURCHTOWN MEDICAL CENTRE N84017 418

TRINITY PRACTICE Y02610 103

ST MARKS MEDICAL CENTRE N84021 424

THE CORNER SURGERY (DR MULLA) N84613 134

NORWOOD SURGERY N84008 263

AINSDALE MEDICAL CENTRE N84012 387

CURZON ROAD MEDICAL PRACTICE N84013 129

THE MARSHSIDE SURGERY (DR WAINWRIGHT) N84614 66

CUMBERLAND HOUSE SURGERY N84005 203

LINCOLN HOUSE SURGERY N84037 56

AINSDALE VILLAGE SURGERY N84014 74

ROE LANE SURGERY N84611 63

CHAPEL LANE SURGERY N84006 161

THE FAMILY SURGERY N84625 33

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 Knowsley CCG 83.5%

NHS South Sefton CCG 71.1%

NHS Liverpool CCG 70.9% • 82 people with a new diagnosis* of hypertension with a CVD risk of 20% NHS St Helens CCG 70.2% or higher in NHS Southport and Formby CCG NHS Wirral CCG 69.2% • 39 (47.6%) people who are currently treated with statins NHS Eastern Cheshire CCG 62.9% • 35 (42.7%) people who are exempted

NHS Warrington CCG 61.5% from treatment with statins • 8 (9.8%) additional people who are NHS West Cheshire CCG 61.0% not currently treated with statins

NHS South Cheshire CCG 60.8%

NHS Vale Royal CCG 60.0%

NHS Halton CCG 58.0%

NHS Southport And Formby CCG 47.6%

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 Erewash CCG 72.2%

NHS Castle Point and Rochford CCG 68.3%

NHS Nottingham North and East CCG 67.2%

NHS South Devon and Torbay CCG 66.7%

NHS Fylde & Wyre CCG 64.5%

NHS North Tyneside CCG 64.3%

NHS Nottingham West CCG 60.4%

NHS Wyre Forest CCG 58.3%

NHS South Tyneside CCG 58.2%

NHS Eastbourne, Hailsham and Seaford CCG 54.9%

NHS Southport and Formby CCG 47.6%

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

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

No treatment Exceptions reported

NORWOOD SURGERY N84008 2

CHURCHTOWN MEDICAL CENTRE N84017 4 • in total, including exceptions, there THE VILLAGE SURGERY FORMBY N84018 8 are 43 people who are not treated ROE LANE SURGERY N84611 2 with statins CHAPEL LANE SURGERY N84006 3 • GP practice range: 0.0% to 66.7%

AINSDALE VILLAGE SURGERY N84014 3

KEW SURGERY N84617 3

ST MARKS MEDICAL CENTRE N84021 7

GRANGE SURGERY N84024 4

THE CORNER SURGERY (DR MULLA) N84613 1

TRINITY PRACTICE Y02610 2

CUMBERLAND HOUSE SURGERY N84005 1

CURZON ROAD MEDICAL PRACTICE N84013 1

AINSDALE MEDICAL CENTRE N84012 2

FRESHFIELD SURGERY N84036

THE MARSHSIDE SURGERY (DR WAINWRIGHT) N84614

THE HOLLIES SURGERY N84618

THE FAMILY SURGERY N84625

LINCOLN HOUSE SURGERY N84037

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 Wirral CCG 0.86

NHS Halton CCG 0.85

NHS Vale Royal CCG 0.82 • the ratio of those diagnosed with atrial fibrillation versus those expected to NHS South Cheshire CCG 0.80 have atrial fibrillation is 0.72. This compares to 0.7 for England NHS West Cheshire CCG 0.80 • this suggests that 72% of people with atrial fibrillation have been diagnosed. NHS South Sefton CCG 0.80

NHS Liverpool CCG 0.79

NHS Knowsley CCG 0.77

NHS St Helens CCG 0.76

NHS Eastern Cheshire CCG 0.75

NHS Southport And Formby CCG 0.72 Note: This slide compares the prevalence of atrial fibrillation recorded in QOF in 2015/16 to NHS Warrington CCG 0.67 the estimated prevalence of atrial fibrillation, taken from National Cardiovascular Intelligence Network estimates produced in 2017. The estimates were developed by applying age-sex specific prevalence rates as reported by Norberg England 0.70 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 1.0 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 Eastbourne, Hailsham and Seaford CCG 0.84

NHS South Devon and Torbay CCG 0.78

NHS South Tyneside CCG 0.73

NHS Fylde & Wyre CCG 0.72

NHS Southport and Formby CCG 0.72

NHS Nottingham West CCG 0.72

NHS Wyre Forest CCG 0.71

NHS Erewash CCG 0.71

NHS North Tyneside CCG 0.70

NHS Nottingham North and East CCG 0.65

NHS Castle Point and Rochford CCG 0.64

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

AINSDALE VILLAGE SURGERY N84014 0.9

KEW SURGERY N84617 0.9

CHAPEL LANE SURGERY N84006 0.8 • it is estimated that there are 4,314 people with undiagnosed atrial ST MARKS MEDICAL CENTRE N84021 0.8 fibrillation in NHS Southport and GRANGE SURGERY N84024 0.8 Formby CCG ROE LANE SURGERY N84611 0.8 • GP practice range of observed to CUMBERLAND HOUSE SURGERY N84005 0.7 expected atrial fibrillation prevalence NORWOOD SURGERY N84008 0.7 0.5 to 0.9

AINSDALE MEDICAL CENTRE N84012 0.7

CHURCHTOWN MEDICAL CENTRE N84017 0.7

THE VILLAGE SURGERY FORMBY N84018 0.7

THE HOLLIES SURGERY N84618 0.7

CURZON ROAD MEDICAL PRACTICE N84013 0.6

LINCOLN HOUSE SURGERY N84037 0.6

THE CORNER SURGERY (DR MULLA) N84613 0.6

THE FAMILY SURGERY N84625 0.6

TRINITY PRACTICE Y02610 0.6

FRESHFIELD SURGERY N84036 0.5

THE MARSHSIDE SURGERY (DR WAINWRIGHT) N84614 0.5

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

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

NHS Knowsley CCG 79.9%

NHS Vale Royal CCG 79.8% • 2,596 people with atrial fibrillation* with a CHA2DS2-VASc score >= 2 in NHS Wirral CCG 79.3% NHS Southport and Formby CCG NHS Liverpool CCG 79.0% • 1,997 (76.9%) people treated with anti-coagulation therapy NHS Halton CCG 78.5% • 230 (8.9%) people who are exceptions NHS St Helens CCG 77.8% • 369 (14.2%) additional people with a

NHS Eastern Cheshire CCG 77.7% recorded CHA2DS2-VASc score >= 2 who are not treated NHS South Cheshire CCG 77.3%

NHS West Cheshire CCG 77.3%

NHS Southport And Formby CCG 76.9%

NHS Warrington CCG 76.5%

NHS South Sefton CCG 76.2%

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 Castle Point and Rochford CCG 82.5%

NHS Erewash CCG 81.7%

NHS South Tyneside CCG 80.0%

NHS South Devon and Torbay CCG 79.9%

NHS Eastbourne, Hailsham and Seaford CCG 78.1%

NHS Wyre Forest CCG 77.5%

NHS Southport and Formby CCG 76.9%

NHS Fylde & Wyre CCG 76.5%

NHS Nottingham North and East CCG 74.8%

NHS Nottingham West CCG 73.9%

NHS North Tyneside CCG 73.8%

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

TRINITY PRACTICE Y02610 33

GRANGE SURGERY N84024 92 • in total, including exceptions, there THE FAMILY SURGERY N84625 12 are 599 people with a recorded THE VILLAGE SURGERY FORMBY N84018 85 CHA2DS2-VASc score >= 2 who are CURZON ROAD MEDICAL PRACTICE N84013 24 not treated

ROE LANE SURGERY N84611 19 • GP practice range: 10.9% to 57.9%

CHURCHTOWN MEDICAL CENTRE N84017 62

CUMBERLAND HOUSE SURGERY N84005 37

THE CORNER SURGERY (DR MULLA) N84613 13

ST MARKS MEDICAL CENTRE N84021 60

THE HOLLIES SURGERY N84618 16

NORWOOD SURGERY N84008 30

CHAPEL LANE SURGERY N84006 45

KEW SURGERY N84617 10

THE MARSHSIDE SURGERY (DR WAINWRIGHT) N84614 7

LINCOLN HOUSE SURGERY N84037 6

AINSDALE VILLAGE SURGERY N84014 11

FRESHFIELD SURGERY N84036 3

AINSDALE MEDICAL CENTRE N84012 34

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

TRINITY PRACTICE 24

THE FAMILY SURGERY 6 CURZON ROAD MEDICAL PRACTICE 12 • using the GP cluster method of GRANGE SURGERY 40 calculating potential gains, if each

THE VILLAGE SURGERY FORMBY 32 practice was to achieve as well as the upper quartile of its national cluster, ROE LANE SURGERY 8 then an additional 171 people would THE CORNER SURGERY (DR MULLA) 4 be treated CUMBERLAND HOUSE SURGERY 10

CHURCHTOWN MEDICAL CENTRE 14

THE HOLLIES SURGERY 4

ST MARKS MEDICAL CENTRE 10

KEW SURGERY 2

THE MARSHSIDE SURGERY (DR WAINWRIGHT) 1

LINCOLN HOUSE SURGERY 1

NORWOOD SURGERY 2

AINSDALE VILLAGE SURGERY 0

CHAPEL LANE SURGERY

FRESHFIELD SURGERY

AINSDALE 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 Knowsley CCG 86.3%

NHS St Helens CCG 85.1% • 2,896 people with a history of stroke or TIA* in NHS Southport and Formby NHS Liverpool CCG 84.9% CCG NHS Southport And Formby CCG 84.9% • 2,458 (84.9%) people whose blood pressure is <= 150 / 90 NHS Vale Royal CCG 84.5% • 90 (3.1%) people who are exceptions • 348 (12%) additional people whose NHS West Cheshire CCG 84.4% blood pressure is not <= 150 / 90

NHS Wirral CCG 84.3%

NHS Halton CCG 84.2%

NHS South Cheshire CCG 84.0%

NHS Warrington CCG 83.3%

NHS Eastern Cheshire CCG 82.5%

NHS South Sefton CCG 82.4%

England 83.8%

0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator STIA003 denominator plus exceptions

35 CVD: Primary Care Intelligence Packs Percentage of patients with a history of stroke whose last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less by CCG Comparison with demographically similar CCGs Below 150/90 Not below 150/90 Exceptions reported

NHS Nottingham West CCG 87.7%

NHS Fylde & Wyre CCG 86.0%

NHS Wyre Forest CCG 85.5%

NHS Erewash CCG 85.5%

NHS Nottingham North and East CCG 85.0%

NHS Southport and Formby CCG 84.9%

NHS North Tyneside CCG 84.5%

NHS South Tyneside CCG 84.2%

NHS Eastbourne, Hailsham and Seaford CCG 82.6%

NHS South Devon and Torbay CCG 80.6%

NHS Castle Point and Rochford CCG 78.7%

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

KEW SURGERY N84617 16

THE VILLAGE SURGERY FORMBY N84018 60 • in total, including exceptions, there THE CORNER SURGERY (DR MULLA) N84613 21 are 438 people whose blood pressure CHURCHTOWN MEDICAL CENTRE N84017 54 is not <= 150 / 90 CURZON ROAD MEDICAL PRACTICE N84013 18 • GP practice range: 2.4% to 27.1%

NORWOOD SURGERY N84008 33

FRESHFIELD SURGERY N84036 8

THE HOLLIES SURGERY N84618 18

ST MARKS MEDICAL CENTRE N84021 52

THE FAMILY SURGERY N84625 5

CUMBERLAND HOUSE SURGERY N84005 26

AINSDALE MEDICAL CENTRE N84012 41

TRINITY PRACTICE Y02610 17

GRANGE SURGERY N84024 35

ROE LANE SURGERY N84611 7

CHAPEL LANE SURGERY N84006 17

AINSDALE VILLAGE SURGERY N84014 7

THE MARSHSIDE SURGERY (DR WAINWRIGHT) N84614 2

LINCOLN HOUSE SURGERY N84037 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 Liverpool CCG 93.4%

NHS Knowsley CCG 92.9% • 2,023 people with a stroke shown to be non-haemorrhagic* in NHS NHS South Sefton CCG 92.6% Southport and Formby CCG NHS Warrington CCG 92.3% • 1,862 (92%) people who are taking an anti-platetet agent or anti- NHS Southport And Formby CCG 92.0% coagulant • 94 (4.6%) people who are exceptions NHS Halton CCG 92.0% • 67 (3.3%) additional people with no

NHS West Cheshire CCG 90.8% treatment

NHS St Helens CCG 90.0%

NHS Wirral CCG 89.7%

NHS Eastern Cheshire CCG 89.3%

NHS South Cheshire CCG 88.9%

NHS Vale Royal CCG 88.8%

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 Nottingham West CCG 93.9%

NHS South Tyneside CCG 93.5%

NHS Wyre Forest CCG 93.3%

NHS Nottingham North and East CCG 92.9%

NHS Castle Point and Rochford CCG 92.9%

NHS North Tyneside CCG 92.8%

NHS Eastbourne, Hailsham and Seaford CCG 92.1%

NHS Southport and Formby CCG 92.0%

NHS South Devon and Torbay CCG 92.0%

NHS Erewash CCG 91.6%

NHS Fylde & Wyre CCG 90.1%

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

TRINITY PRACTICE Y02610 18

ROE LANE SURGERY N84611 5 • in total, including exceptions, there CHURCHTOWN MEDICAL CENTRE N84017 21 are 161 people who are not taking an ST MARKS MEDICAL CENTRE N84021 27 anti-platelet agent or anti-coagulant THE MARSHSIDE SURGERY (DR WAINWRIGHT) N84614 4 • GP practice range: 0.0% to 25.4%

CUMBERLAND HOUSE SURGERY N84005 11

CURZON ROAD MEDICAL PRACTICE N84013 6

CHAPEL LANE SURGERY N84006 10

AINSDALE MEDICAL CENTRE N84012 15

KEW SURGERY N84617 3

THE FAMILY SURGERY N84625 2

THE CORNER SURGERY (DR MULLA) N84613 4

THE VILLAGE SURGERY FORMBY N84018 12

THE HOLLIES SURGERY N84618 5

NORWOOD SURGERY N84008 7

GRANGE SURGERY N84024 7

AINSDALE VILLAGE SURGERY N84014 3

LINCOLN HOUSE SURGERY N84037 1

FRESHFIELD SURGERY N84036

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 Halton CCG 0.97

NHS Warrington CCG 0.85 • 0.72 ratio of observed to expected diabetes prevalence in NHS NHS Knowsley CCG 0.85 Southport and Formby CCG, NHS St Helens CCG 0.83 compared to 0.77 in England

NHS Vale Royal CCG 0.81 • this suggests 72% of people have been diagnosed NHS West Cheshire CCG 0.80

NHS South Cheshire CCG 0.80

NHS Wirral CCG 0.79

NHS South Sefton CCG 0.76

NHS Liverpool CCG 0.76

NHS Southport And Formby CCG 0.72

NHS Eastern Cheshire CCG 0.72 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 0.2 0.4 0.6 0.8 1.0 1.2

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

NHS North Tyneside CCG 0.84

NHS Castle Point and Rochford CCG 0.82

NHS Erewash CCG 0.81

NHS Wyre Forest CCG 0.80

NHS Nottingham West CCG 0.80

NHS South Tyneside CCG 0.79

NHS Nottingham North and East CCG 0.78

NHS Fylde & Wyre CCG 0.75

NHS Southport and Formby CCG 0.72

NHS South Devon and Torbay CCG 0.69

NHS Eastbourne, Hailsham and Seaford CCG 0.67

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

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

GP practice CCG

AINSDALE VILLAGE SURGERY N84014 8.5%

THE CORNER SURGERY (DR MULLA) N84613 7.6% • GP practice range of observed CHURCHTOWN MEDICAL CENTRE N84017 7.5% diabetes 4.3% to 8.5% CURZON ROAD MEDICAL PRACTICE N84013 7.4% • there are an estimated 2,690 people ROE LANE SURGERY N84611 7.4% with undiagnosed diabetes in NHS

AINSDALE MEDICAL CENTRE N84012 7.3% Southport and Formby CCG

GRANGE SURGERY N84024 7.3%

CHAPEL LANE SURGERY N84006 7.2%

LINCOLN HOUSE SURGERY N84037 7.1%

CUMBERLAND HOUSE SURGERY N84005 7.0%

ST MARKS MEDICAL CENTRE N84021 7.0%

THE VILLAGE SURGERY FORMBY N84018 6.7%

TRINITY PRACTICE Y02610 6.6%

KEW SURGERY N84617 6.3%

NORWOOD SURGERY N84008 5.9%

THE MARSHSIDE SURGERY (DR WAINWRIGHT) N84614 5.8%

THE HOLLIES SURGERY N84618 5.0%

FRESHFIELD SURGERY N84036 4.5% Note: The estimated number of undiagnosed THE FAMILY SURGERY N84625 4.3% people with diabetes has been calculated by multiplying the estimated prevalence rate to the 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 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 Southport And Formby CCG 6.8% 2.6% 12.8% • the estimated total prevalence of diabetes in NHS Southport and NHS Eastern Cheshire CCG 6.1% 2.4% 12.0% Formby CCG is 9.4% (diagnosed and NHS St Helens CCG 7.4% 1.5% 11.5% undiagnosed) • in addition, there are an estimated NHS Wirral CCG 7.0% 1.8% 11.2% 12.8% of people in NHS Southport NHS South Sefton CCG 6.7% 2.1% 11.2% and Formby CCG who are at increased risk of developing diabetes NHS West Cheshire CCG 6.5% 1.6% 11.5% (i.e. with non-diabetic NHS Vale Royal CCG 6.7% 1.6% 11.1% hyperglycaemia) • this means that 22.3% of the NHS South Cheshire CCG 6.5% 1.7% 11.1% population in NHS Southport and NHS Halton CCG 8.0% 0.3% 11.1% Formby CCG are estimated to have diabetes, or at high risk of developing NHS Knowsley CCG 7.3% 1.3% 10.3% of diabetes

NHS Warrington CCG 6.7% 1.1% 10.7%

NHS Liverpool CCG 6.1% 1.9% 10.0% 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 Liverpool CCG 77.8%

NHS Southport And Formby CCG 64.7% • data on care processes and treatment NHS West Cheshire CCG 58.3% targets are taken from the National Diabetes Audit (NDA) NHS South Sefton CCG 56.5% • overall practice participation in the NHS Vale Royal CCG 56.1% 2015/16 audit was 81.4% in England

NHS Eastern Cheshire CCG 52.8% • in NHS Southport and Formby CCG, 16 out of 19 practices (84.2%) NHS Warrington CCG 51.6% participated in the NDA. Data is not available for the remaining practices NHS Halton CCG 46.5%

NHS South Cheshire CCG 46.1% • 64.7% of people with diabetes (of NHS Wirral CCG 42.3% practices who participated in the audit) had the eight recommended NHS St Helens CCG 38.1% care processes in NHS Southport and

NHS Knowsley CCG 37.4% Formby CCG, compared to 52.6% in England

England 52.6%

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

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

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

ROE LANE SURGERY N84611 82.4%

CURZON ROAD MEDICAL PRACTICE N84013 79.5% • achievement - 8 care processes: in

CHAPEL LANE SURGERY N84006 75.2% practices who provided data via the NDA, between 12.4% and 82.4% of GRANGE SURGERY N84024 74.2% patients received all 8 care processes CHURCHTOWN MEDICAL CENTRE N84017 71.8%

AINSDALE MEDICAL CENTRE N84012 71.2% • at least 1,813 people did not receive FRESHFIELD SURGERY N84036 69.9% the eight care processes THE CORNER SURGERY (DR MULLA) N84613 66.4%

CUMBERLAND HOUSE SURGERY N84005 63.4%

NORWOOD SURGERY N84008 60.2%

LINCOLN HOUSE SURGERY N84037 59.1%

AINSDALE VILLAGE SURGERY N84014 57.1%

KEW SURGERY N84617 44.9%

THE MARSHSIDE SURGERY (DR WAINWRIGHT) N84614 37.1%

THE FAMILY SURGERY N84625 26.1%

TRINITY PRACTICE Y02610 12.4%

THE HOLLIES SURGERY N84618

ST MARKS MEDICAL CENTRE N84021

THE VILLAGE SURGERY FORMBY N84018

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 West Cheshire CCG 46.4%

NHS Wirral CCG 44.0% • 43.2% of people with diabetes (of NHS Knowsley CCG 44.0% practices who participated in the audit) met the three treatment targets NHS Liverpool CCG 43.7% in NHS Southport and Formby CCG, compared to 39.0% in England NHS Southport And Formby CCG 43.2%

NHS St Helens CCG 41.9%

NHS Warrington CCG 40.6%

NHS South Sefton CCG 39.3%

NHS Vale Royal CCG 39.0%

NHS Eastern Cheshire CCG 38.7%

NHS Halton CCG 37.5%

NHS South Cheshire CCG 36.6%

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

CHAPEL LANE SURGERY N84006 58.1%

FRESHFIELD SURGERY N84036 52.6% • achievement - 3 treatment targets: in

THE MARSHSIDE SURGERY (DR WAINWRIGHT) N84614 50.0% practices who provided data via the NDA, between 31.6% and 58.1% of THE FAMILY SURGERY N84625 47.2% patients achieved all 3 treatment GRANGE SURGERY N84024 47.0% targets AINSDALE MEDICAL CENTRE N84012 46.7% • at least 2,669 people did not meet the THE CORNER SURGERY (DR MULLA) N84613 44.2% three treatment targets CUMBERLAND HOUSE SURGERY N84005 43.3%

AINSDALE VILLAGE SURGERY N84014 43.0%

LINCOLN HOUSE SURGERY N84037 40.0%

CHURCHTOWN MEDICAL CENTRE N84017 37.8%

CURZON ROAD MEDICAL PRACTICE N84013 36.8%

TRINITY PRACTICE Y02610 36.2%

NORWOOD SURGERY N84008 35.7%

ROE LANE SURGERY N84611 31.8%

KEW SURGERY N84617 31.6%

THE HOLLIES SURGERY N84618

ST MARKS MEDICAL CENTRE N84021

THE VILLAGE SURGERY FORMBY N84018

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

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

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

KEW SURGERY 22

ROE LANE SURGERY 21

TRINITY PRACTICE 21 • using the GP cluster method of calculating potential gains, if each CURZON ROAD MEDICAL PRACTICE 24 practice was to achieve as well as the

NORWOOD SURGERY 31 upper quartile of its national cluster, then an additional 174 people would CHURCHTOWN MEDICAL CENTRE 38 be treated LINCOLN HOUSE SURGERY 6

AINSDALE VILLAGE SURGERY 5

THE CORNER SURGERY (DR MULLA) 2

CUMBERLAND HOUSE SURGERY 5

THE FAMILY SURGERY

AINSDALE MEDICAL CENTRE

GRANGE SURGERY

THE MARSHSIDE SURGERY (DR WAINWRIGHT)

FRESHFIELD SURGERY

CHAPEL LANE SURGERY 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 Liverpool CCG 1.05

NHS South Sefton CCG 0.90

NHS Vale Royal CCG 0.79 • the ratio of those diagnosed with chronic kidney disease versus those NHS Knowsley CCG 0.78 expected to have chronic kidney disease is 0.65. This compares to NHS South Cheshire CCG 0.75 0.68 for England NHS Halton CCG 0.73 • this suggests that 65% of people with chronic kidney disease have been NHS Wirral CCG 0.71 diagnosed

NHS St Helens CCG 0.68

NHS Southport And Formby CCG 0.65

NHS Warrington CCG 0.62

NHS Eastern Cheshire CCG 0.62 Note: This slide compares the prevalence of CKD NHS West Cheshire CCG 0.55 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 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 Erewash CCG 1.07

NHS Nottingham North and East CCG 1.00

NHS Nottingham West CCG 0.90

NHS North Tyneside CCG 0.86

NHS Fylde & Wyre CCG 0.85

NHS Wyre Forest CCG 0.79

NHS Eastbourne, Hailsham and Seaford CCG 0.75

NHS South Devon and Torbay CCG 0.69

NHS Southport and Formby CCG 0.65

NHS South Tyneside CCG 0.58

NHS Castle Point and Rochford CCG 0.52

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

ROE LANE SURGERY N84611 8.0%

GRANGE SURGERY N84024 7.5% • it is estimated that there are 2,915 AINSDALE VILLAGE SURGERY N84014 7.4% people with undiagnosed chronic CHAPEL LANE SURGERY N84006 7.0% kidney disease in NHS Southport and AINSDALE MEDICAL CENTRE N84012 6.8% Formby CCG

THE CORNER SURGERY (DR MULLA) N84613 6.3% • GP practice range of observed CKD: 2.3% to 8.0% CURZON ROAD MEDICAL PRACTICE N84013 5.9%

CUMBERLAND HOUSE SURGERY N84005 5.5%

ST MARKS MEDICAL CENTRE N84021 5.2%

TRINITY PRACTICE Y02610 4.8%

CHURCHTOWN MEDICAL CENTRE N84017 4.6%

THE HOLLIES SURGERY N84618 4.4%

THE MARSHSIDE SURGERY (DR WAINWRIGHT) N84614 4.2%

THE VILLAGE SURGERY FORMBY N84018 4.1%

NORWOOD SURGERY N84008 4.0%

LINCOLN HOUSE SURGERY N84037 3.9%

THE FAMILY SURGERY N84625 3.0% Note: CCG estimates for the estimated number of people with CKD are based on KEW SURGERY N84617 2.6% applying a proportion from a resident based FRESHFIELD SURGERY N84036 2.3% 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 Knowsley CCG 79.6%

NHS St Helens CCG 78.9% • 5,306 people with CKD (diagnosed*) in NHS Southport and Formby CCG NHS Vale Royal CCG 78.5% • 4,097 (77.2%) people whose blood NHS South Sefton CCG 78.4% pressure is <= 140 /85 • 303 (5.7%) people who are NHS West Cheshire CCG 77.8% exceptions • 906 (17.1%) additional people whose NHS Liverpool CCG 77.7% blood pressure is not <= 140 / 85

NHS Southport And Formby CCG 77.2%

NHS Wirral CCG 75.6%

NHS South Cheshire CCG 75.0%

NHS Halton CCG 74.9%

NHS Warrington CCG 74.7%

NHS Eastern Cheshire CCG 73.0%

*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 South Tyneside CCG 78.2%

NHS Southport and Formby CCG 77.2%

NHS Nottingham West CCG 76.5%

NHS Fylde & Wyre CCG 74.9%

NHS Eastbourne, Hailsham and Seaford CCG 74.7%

NHS Nottingham North and East CCG 74.0%

NHS Erewash CCG 73.9%

NHS North Tyneside CCG 73.7%

NHS Wyre Forest CCG 72.9%

NHS Castle Point and Rochford CCG 69.5%

NHS South Devon and Torbay CCG 69.3%

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

KEW SURGERY N84617 29

ST MARKS MEDICAL CENTRE N84021 209 • in total, including exceptions, there THE VILLAGE SURGERY FORMBY N84018 90 are 1,209 people whose blood NORWOOD SURGERY N84008 78 pressure is not <= 140 / 85 NUGENT & PARTNERS N84012 172 • GP practice range: 9.6% to 33.7%

MCCLELLAND & PARTNER N84014 35

TRINITY PRACTICE Y02610 41

THE HOLLIES N84618 42

FIRTH & PTNRS N84017 90

THE CORNER SURGERY (DR MULLA) N84613 37

GRANGE SURGERY N84024 136

CUMBERLAND HOUSE SURGERY N84005 84

JACKSON & PARTNERS N84006 76

BOND & PARTNER N84013 25

ROE LANE SURGERY N84611 29

GANA & PARTNER N84037 11

FRESHFIELD SURGERY N84036 9

THE MARSHSIDE SURGERY (DR WAINWRIGHT) N84614 9

THE FAMILY SURGERY N84625 7

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%

KEW SURGERY 15

ST MARKS MEDICAL CENTRE 66 THE VILLAGE SURGERY FORMBY 25 • using the GP cluster method of TRINITY PRACTICE 11 calculating potential gains, if each

MCCLELLAND & PARTNER 9 practice was to achieve as well as the upper quartile of its national cluster, NORWOOD SURGERY 13 then an additional 177 people would THE HOLLIES 8 be treated NUGENT & PARTNERS 26

THE CORNER SURGERY (DR MULLA) 4

FIRTH & PTNRS

BOND & PARTNER

GRANGE SURGERY

ROE LANE SURGERY

GANA & PARTNER

CUMBERLAND HOUSE SURGERY

JACKSON & PARTNERS

FRESHFIELD SURGERY

THE FAMILY SURGERY

THE MARSHSIDE SURGERY (DR WAINWRIGHT) 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 Liverpool CCG 81.2%

NHS Southport And Formby CCG 79.2% • 5,306 people with CKD (diagnosed*) in NHS Southport and Formby CCG NHS South Sefton CCG 78.6% • 4,203 (79.2%) people who have a NHS St Helens CCG 77.8% record of urine albumin:creatinine ratio test NHS Eastern Cheshire CCG 77.6% • 180 (3.4%) people who are exceptions NHS Vale Royal CCG 77.5% • 923 (17.4%) additional people who

NHS Halton CCG 77.0% have no record of urine albumin:creatinine ratio test NHS West Cheshire CCG 76.9%

NHS Knowsley CCG 76.7%

NHS South Cheshire CCG 75.3%

NHS Warrington CCG 71.2%

NHS Wirral CCG 71.1%

*Using the QOF clinical indicator CKD004 denominator plus exceptions. Note: as England 75.4% 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 Nottingham West CCG 81.6%

NHS South Tyneside CCG 80.9%

NHS Wyre Forest CCG 79.6%

NHS Southport and Formby CCG 79.2%

NHS Erewash CCG 77.6%

NHS Fylde & Wyre CCG 76.4%

NHS North Tyneside CCG 76.4%

NHS Nottingham North and East CCG 75.3%

NHS Eastbourne, Hailsham and Seaford CCG 74.9%

NHS South Devon and Torbay CCG 68.1%

NHS Castle Point and Rochford CCG 68.0%

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

TRINITY PRACTICE Y02610 114

ST MARKS MEDICAL CENTRE N84021 173 • in total, including exceptions, there FIRTH & PTNRS N84017 104 are 1,103 people who have no record KEW SURGERY N84617 20 of urine albumin:creatinine ratio test CUMBERLAND HOUSE SURGERY N84005 97 • GP practice range: 8.7% to 65.5%

GRANGE SURGERY N84024 140

THE VILLAGE SURGERY FORMBY N84018 64

THE HOLLIES N84618 36

THE FAMILY SURGERY N84625 14

NUGENT & PARTNERS N84012 124

NORWOOD SURGERY N84008 54

BOND & PARTNER N84013 25

MCCLELLAND & PARTNER N84014 24

GANA & PARTNER N84037 11

FRESHFIELD SURGERY N84036 10

THE CORNER SURGERY (DR MULLA) N84613 26

ROE LANE SURGERY N84611 22

THE MARSHSIDE SURGERY (DR WAINWRIGHT) N84614 8

JACKSON & PARTNERS N84006 37

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 South Sefton CCG 1.28%

NHS St Helens CCG 1.12%

NHS Southport And Formby CCG 1.07% • prevalence of 1.07% in NHS Southport and Formby CCG NHS Halton CCG 0.98% compared to 0.76% in England

NHS South Cheshire CCG 0.98%

NHS Vale Royal CCG 0.96%

NHS Wirral CCG 0.94%

NHS Knowsley CCG 0.91%

NHS West Cheshire CCG 0.90%

NHS Liverpool CCG 0.84%

NHS Warrington CCG 0.80%

NHS Eastern Cheshire CCG 0.79%

England 0.76%

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

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

NHS Fylde & Wyre CCG 1.49%

NHS North Tyneside CCG 1.18%

NHS South Tyneside CCG 1.16%

NHS Eastbourne, Hailsham and Seaford CCG 1.13%

NHS Wyre Forest CCG 1.10%

NHS Southport and Formby CCG 1.07%

NHS Nottingham West CCG 0.96%

NHS Castle Point and Rochford CCG 0.90%

NHS South Devon and Torbay CCG 0.81%

NHS Erewash CCG 0.75%

NHS Nottingham North and East CCG 0.63%

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

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

GP practice CCG

ROE LANE SURGERY N84611 1.6%

AINSDALE VILLAGE SURGERY N84014 1.5% • 1,323 people with diagnosed heart LINCOLN HOUSE SURGERY N84037 1.4% failure in NHS Southport and Formby THE CORNER SURGERY (DR MULLA) N84613 1.3% CCG CHURCHTOWN MEDICAL CENTRE N84017 1.3% • GP practice range: 0.5% to 1.6%

CURZON ROAD MEDICAL PRACTICE N84013 1.2%

GRANGE SURGERY N84024 1.2%

CUMBERLAND HOUSE SURGERY N84005 1.2%

CHAPEL LANE SURGERY N84006 1.2%

THE MARSHSIDE SURGERY (DR WAINWRIGHT) N84614 1.1%

NORWOOD SURGERY N84008 1.0%

TRINITY PRACTICE Y02610 1.0%

ST MARKS MEDICAL CENTRE N84021 1.0%

AINSDALE MEDICAL CENTRE N84012 0.9%

THE VILLAGE SURGERY FORMBY N84018 0.9%

THE HOLLIES SURGERY N84618 0.9%

KEW SURGERY N84617 0.8%

FRESHFIELD SURGERY N84036 0.8%

THE FAMILY SURGERY N84625 0.5%

0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6% 1.8%

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 Vale Royal CCG 89.8%

NHS South Cheshire CCG 87.5% • 542 people with heart failure* with LVSD in NHS Southport and Formby NHS West Cheshire CCG 85.8% CCG NHS Warrington CCG 85.2% • 434 (80.1%) people treated with ACE- I or ARB NHS St Helens CCG 84.6% • 98 (18.1%) people who are exceptions NHS Wirral CCG 82.4% • 10 (1.8%) additional people who are

NHS Halton CCG 81.5% not treated with ACE-I or ARB

NHS Liverpool CCG 81.2%

NHS Eastern Cheshire CCG 80.3%

NHS Southport And Formby CCG 80.1%

NHS Knowsley CCG 79.1%

NHS South Sefton CCG 78.9%

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 Nottingham West CCG 89.6%

NHS Nottingham North and East CCG 89.5%

NHS Castle Point and Rochford CCG 87.5%

NHS North Tyneside CCG 87.4%

NHS Fylde & Wyre CCG 86.9%

NHS South Tyneside CCG 84.1%

NHS Erewash CCG 83.9%

NHS Eastbourne, Hailsham and Seaford CCG 83.4%

NHS Wyre Forest CCG 82.8%

NHS South Devon and Torbay CCG 81.9%

NHS Southport and Formby CCG 80.1%

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

TRINITY PRACTICE Y02610 4

THE FAMILY SURGERY N84625 2 • in total, including exceptions, there ST MARKS MEDICAL CENTRE N84021 16 are 108 people who are not treated GRANGE SURGERY N84024 4 with ACE-I or ARB FRESHFIELD SURGERY N84036 2 • GP practice range: 0.0% to 36.4%

CHAPEL LANE SURGERY N84006 16

CUMBERLAND HOUSE SURGERY N84005 9

NORWOOD SURGERY N84008 13

CHURCHTOWN MEDICAL CENTRE N84017 20

LINCOLN HOUSE SURGERY N84037 3

CURZON ROAD MEDICAL PRACTICE N84013 3

THE HOLLIES SURGERY N84618 2

ROE LANE SURGERY N84611 5

THE CORNER SURGERY (DR MULLA) N84613 2

AINSDALE VILLAGE SURGERY N84014 3

THE VILLAGE SURGERY FORMBY N84018 1

AINSDALE MEDICAL CENTRE N84012 3

THE MARSHSIDE SURGERY (DR WAINWRIGHT) N84614

KEW SURGERY N84617

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 West Cheshire CCG 85.3%

NHS Vale Royal CCG 84.2% • 434 people with heart failure* with LVSD treated with ACE-I/ARB in NHS NHS Liverpool CCG 80.5% Southport and Formby CCG NHS Halton CCG 79.1% • 316 (72.8%) people treated with ACE- I/ARB and BB NHS Warrington CCG 77.9% • 84 (19.4%) people who are exceptions NHS Wirral CCG 77.1% • 34 (7.8%) additional people who are

NHS St Helens CCG 74.1% not treated with ACE-I/ARB and BB

NHS Eastern Cheshire CCG 73.0%

NHS Southport And Formby CCG 72.8%

NHS South Cheshire CCG 72.0%

NHS South Sefton CCG 71.5%

NHS Knowsley CCG 71.4%

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 Castle Point and Rochford CCG 85.6%

NHS Fylde & Wyre CCG 84.9%

NHS North Tyneside CCG 79.8%

NHS Nottingham North and East CCG 75.0%

NHS Eastbourne, Hailsham and Seaford CCG 74.9%

NHS Erewash CCG 74.1%

NHS Wyre Forest CCG 73.6%

NHS Nottingham West CCG 73.4%

NHS Southport and Formby CCG 72.8%

NHS South Tyneside CCG 72.5%

NHS South Devon and Torbay CCG 65.0%

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

TRINITY PRACTICE Y02610 3

CHURCHTOWN MEDICAL CENTRE N84017 34 • in total, including exceptions, there THE HOLLIES SURGERY N84618 5 are 118 people who are not treated AINSDALE VILLAGE SURGERY N84014 9 with ACE-I or ARB LINCOLN HOUSE SURGERY N84037 4 • GP practice range: 0.0% to 42.9%

ST MARKS MEDICAL CENTRE N84021 10

ROE LANE SURGERY N84611 9

CURZON ROAD MEDICAL PRACTICE N84013 4

CHAPEL LANE SURGERY N84006 12

GRANGE SURGERY N84024 2

THE CORNER SURGERY (DR MULLA) N84613 3

AINSDALE MEDICAL CENTRE N84012 8

FRESHFIELD SURGERY N84036 1

CUMBERLAND HOUSE SURGERY N84005 6

THE MARSHSIDE SURGERY (DR WAINWRIGHT) N84614 1

NORWOOD SURGERY N84008 7

THE VILLAGE SURGERY FORMBY N84018

KEW SURGERY N84617

THE FAMILY SURGERY N84625

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 West Cheshire CCG 90.1%

NHS St Helens CCG 89.9% • 5,117 people with coronary heart disease* in NHS Southport and NHS Knowsley CCG 89.7% Formby CCG NHS Southport And Formby CCG 89.6% • 4,584 (89.6%) people whose blood pressure <= 150 / 90 NHS Halton CCG 89.1% • 131 (2.6%) people who are exceptions NHS Liverpool CCG 88.9% • 402 (7.9%) additional people whose

NHS Eastern Cheshire CCG 88.5% blood pressure is not <= 150 / 90

NHS South Cheshire CCG 88.5%

NHS Wirral CCG 88.2%

NHS Vale Royal CCG 87.9%

NHS Warrington CCG 87.4%

NHS South Sefton CCG 86.8%

England 88.2%

0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator CHD002 denominator plus exceptions

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

NHS Nottingham West CCG 89.8%

NHS Southport and Formby CCG 89.6%

NHS Wyre Forest CCG 89.4%

NHS Fylde & Wyre CCG 88.8%

NHS South Tyneside CCG 88.3%

NHS Nottingham North and East CCG 88.3%

NHS Erewash CCG 88.2%

NHS North Tyneside CCG 88.1%

NHS Eastbourne, Hailsham and Seaford CCG 86.5%

NHS South Devon and Torbay CCG 85.6%

NHS Castle Point and Rochford CCG 83.5%

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

THE VILLAGE SURGERY FORMBY N84018 89

KEW SURGERY N84617 20 • in total, including exceptions, there TRINITY PRACTICE Y02610 20 are 533 people whose blood pressure THE HOLLIES SURGERY N84618 25 is not <= 150 / 90 CURZON ROAD MEDICAL PRACTICE N84013 26 • GP practice range: 2.8% to 17.4%

ST MARKS MEDICAL CENTRE N84021 77

THE CORNER SURGERY (DR MULLA) N84613 20

CUMBERLAND HOUSE SURGERY N84005 35

CHAPEL LANE SURGERY N84006 36

CHURCHTOWN MEDICAL CENTRE N84017 51

THE MARSHSIDE SURGERY (DR WAINWRIGHT) N84614 9

NORWOOD SURGERY N84008 27

GRANGE SURGERY N84024 34

AINSDALE MEDICAL CENTRE N84012 39

ROE LANE SURGERY N84611 8

AINSDALE VILLAGE SURGERY N84014 8

FRESHFIELD SURGERY N84036 3

THE FAMILY SURGERY N84625 4

LINCOLN HOUSE SURGERY N84037 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

6% 4% 2% 0% -2% -4% -6% -8% -10% -12%

KEW SURGERY 12

THE VILLAGE SURGERY FORMBY 46 TRINITY PRACTICE 10 • using the GP cluster method of THE HOLLIES SURGERY 13 calculating potential gains, if each

CURZON ROAD MEDICAL PRACTICE 12 practice was to achieve as well as the upper quartile of its national cluster, THE CORNER SURGERY (DR MULLA) 8 then an additional 143 people would ST MARKS MEDICAL CENTRE 23 be treated THE MARSHSIDE SURGERY (DR WAINWRIGHT) 2

CUMBERLAND HOUSE SURGERY 6

CHAPEL LANE SURGERY 5

CHURCHTOWN MEDICAL CENTRE 5

NORWOOD SURGERY

ROE LANE SURGERY

GRANGE SURGERY

AINSDALE VILLAGE SURGERY

AINSDALE MEDICAL CENTRE

FRESHFIELD SURGERY

THE FAMILY SURGERY

LINCOLN HOUSE SURGERY 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 Knowsley CCG 93.5%

NHS Liverpool CCG 93.2% • 5,117 people with coronary heart disease* in NHS Southport and NHS Halton CCG 92.8% Formby CCG NHS South Sefton CCG 92.4% • 4,713 (92.1%) people who are taking aspirin, an alternative anti-platelet NHS Southport And Formby CCG 92.1% therapy, or an anti-coagulant • 204 (4%) people who are exceptions NHS South Cheshire CCG 91.6% • 200 (3.9%) additional people who are

NHS West Cheshire CCG 91.5% not taking aspirin, an alternative anti- platelet therapy, or an anti-coagulant NHS Eastern Cheshire CCG 91.2%

NHS Vale Royal CCG 91.2%

NHS St Helens CCG 91.1%

NHS Warrington CCG 90.9%

NHS Wirral CCG 89.6%

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 Wyre Forest CCG 94.3%

NHS South Tyneside CCG 93.6%

NHS Nottingham West CCG 92.5%

NHS Eastbourne, Hailsham and Seaford CCG 92.4%

NHS North Tyneside CCG 92.2%

NHS Southport and Formby CCG 92.1%

NHS Nottingham North and East CCG 91.8%

NHS Fylde & Wyre CCG 91.5%

NHS South Devon and Torbay CCG 90.9%

NHS Erewash CCG 90.5%

NHS Castle Point and Rochford CCG 90.4%

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

TRINITY PRACTICE Y02610 26

THE MARSHSIDE SURGERY (DR WAINWRIGHT) N84614 12 • in total, including exceptions, there KEW SURGERY N84617 14 are 404 people are not taking aspirin, ST MARKS MEDICAL CENTRE N84021 60 an alternative anti-platelet therapy, or THE HOLLIES SURGERY N84618 15 an anti-coagulant

CUMBERLAND HOUSE SURGERY N84005 30 • GP practice range: 1.4% to 19.3%

CHURCHTOWN MEDICAL CENTRE N84017 46

THE VILLAGE SURGERY FORMBY N84018 42

AINSDALE MEDICAL CENTRE N84012 44

THE CORNER SURGERY (DR MULLA) N84613 13

CHAPEL LANE SURGERY N84006 28

NORWOOD SURGERY N84008 23

ROE LANE SURGERY N84611 7

AINSDALE VILLAGE SURGERY N84014 8

GRANGE SURGERY N84024 24

FRESHFIELD SURGERY N84036 2

CURZON ROAD MEDICAL PRACTICE N84013 7

THE FAMILY SURGERY N84625 2

LINCOLN HOUSE SURGERY N84037 1

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

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

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

NHS Southport and Formby CCG England 800

700 • in NHS Southport and Formby CCG, the hospital admission rate for coronary heart disease in 2015/16 600 was 506.3 (736) compared to 527.9 for England

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 Southport and Formby CCG England 250

• in NHS Southport and Formby CCG, the hospital admission rate for stroke 200 in 2015/16 was 132.7 (205) compared to 172.8 for England

150

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

50

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

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

NHS Southport and Formby CCG England

116.9% Angina 136.8% • The risk of a stroke was 27.8% higher and the risk of a heart attack was 47.4% 47.4% higher compared to people Heart Attack 108.6% without diabetes. The risk of a major amputation was 422.9% higher. 110.3% Heart failure 150.0%

27.8% Stroke 81.3%

422.9% Major amputation 445.8%

576.7% Minor amputation 753.5%

260.8% RRT 293.0%

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

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

NHS Southport and Formby CCG England 90

80 • in NHS Southport and Formby CCG, the early mortality rate for coronary 70 heart disease in 2013-15 was 40, 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 Southport and Formby CCG England 30

• in NHS Southport and Formby CCG, 25 the early mortality rate for stroke in 2013-15 was 10.6, 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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