CVD: Primary Care Intelligence Packs NHS North West Surrey 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 North West Surrey CCG are: NHS Surrey Downs CCG NHS Bromley CCG NHS Mid Essex CCG NHS South Gloucestershire CCG NHS Chiltern CCG NHS Basildon and Brentwood CCG NHS Swindon CCG NHS Horsham and Mid Sussex CCG NHS North Hampshire CCG NHS East Surrey 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 Swindon CCG 17.8%
NHS Basildon and Brentwood CCG 17.3% • prevalence of 14.4% in NHS North West Surrey CCG NHS Mid Essex CCG 15.7%
NHS North Hampshire CCG 15.7%
NHS South Gloucestershire CCG 15.3%
NHS Bromley CCG 15.2%
NHS East Surrey CCG 14.7%
NHS North West Surrey CCG 14.4% Note: It has been found that the proportion of patients recorded as smokers correlates well NHS Chiltern CCG 13.9% with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, NHS Horsham and Mid Sussex CCG 12.4% http://bmjopen.bmj.com/content/4/7/e005217.abs tract
NHS Surrey Downs CCG 12.4% Definition: denominator of QOF clinical indicator SMOKE004 ( number of patients 15+ who are 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% 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
ST DAVID'S FAMILY PRACTICE H81087 24.0% ASHFORD HEALTH CENTRE Y02688 22.3% SHEERWATER HEALTH CENTRE H81123 20.1% CROUCH OAK FAMILY PRACTICE H81042 18.9% ABBEY PRACTICE H81033 18.8% • 43,278 people who are recorded as BRIDGE PRACTICE H81054 18.4% SUNBURY GROUP PRACTICE H81003 16.7% smokers in NHS North West Surrey UPPER HALLIFORD MEDICAL CENTRE H81642 16.6% FORDBRIDGE MEDICAL CENTRE H81057 16.4% CCG DR DM NGUYEN H81095 16.4% • GP practice range: 7.0% to 24.0% DR S MORCOS H81131 16.4% SOUTHVIEW MEDICAL PRACTICE H81041 16.2% STANWELL ROAD SURGERY H81104 15.8% HYTHE MEDICAL CENTRE SURGERY H81122 15.3% SHEPPERTON MEDICAL PRACTICE H81004 15.2% STUDHOLME MEDICAL CENTRE H81009 15.2% THE ORCHARD SURGERY H81632 14.9% HERSHAM SURGERY H81065 14.4% THE RED PRACTICE WALTON H81094 14.3% SUNNY MEED SURGERY H81019 14.3% PARISHES BRIDGE MED.PRACT H81036 14.2% GROVE MEDICAL CENTRE H81066 14.0% STAINES HEALTH GROUP H81134 13.9% STAINES THAMESIDE MEDICAL H81079 13.8% THE PRACTICE COLLEGE ROAD H81641 13.8% GOLDSWORTH PARK HEALTH CENTRE H81024 13.7% HILLVIEW MEDICAL CENTRE H81061 13.3% ASHLEY MEDICAL PRACTICE H81663 13.1% KNOWLE GREEN MEDICAL H81002 12.8% MADEIRA MEDICAL H81034 12.6% WEY FAMILY PRACTICE H81050 12.5% CHOBHAM & WEST END MEDICAL PRACTICE H81015 11.7% PIRBRIGHT SURGERY H81129 11.6% HEATHCOT MEDICAL PRACTICE H81032 11.6% MAYBURY SURGERY H81643 11.3% Note: This method is thought to be a reasonably NEW OTTERSHAW SURGERY H81658 11.0% CHURCH STREET PRACTICE H81073 10.7% robust method in estimating smoking prevalence FORT HOUSE SURGERY H81020 10.6% for the majority of GP practices. However, ROWAN TREE PRACTICE H81007 10.2% ST JOHN'S FAMILY PRACTICE H81025 9.8% caution is advised for extreme estimates of VIRGINIA WATER MEDICAL PRACTICE H81111 8.0% smoking prevalence and those with high DR R J POOL H81664 7.0% numbers of smoking status not recorded and 0% 5% 10% 15% 20% 25% 30% 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 Surrey Downs CCG 0.59
• the ratio of those diagnosed with hypertension versus those expected to have hypertension is 0.57. This NHS Guildford And Waverley CCG 0.57 compares to 0.59 for England • this suggests that 57% of people with hypertension have been diagnosed
NHS North West Surrey CCG 0.57
England 0.59 Note: this slide shows Hypertension prevalence 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 Basildon and Brentwood CCG 0.60
NHS Surrey Downs CCG 0.59
NHS Swindon CCG 0.59
NHS South Gloucestershire CCG 0.59
NHS Horsham and Mid Sussex CCG 0.59
NHS Bromley CCG 0.58
NHS Mid Essex CCG 0.58
NHS Chiltern CCG 0.58
NHS North Hampshire CCG 0.57
NHS North West Surrey CCG 0.57
NHS East Surrey CCG 0.56
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
BRIDGE PRACTICE H81054 0.72 DR S MORCOS H81131 0.69 UPPER HALLIFORD MEDICAL CENTRE H81642 0.69 STUDHOLME MEDICAL CENTRE H81009 0.69 ST DAVID'S FAMILY PRACTICE H81087 0.67 DR DM NGUYEN H81095 0.65 • it is estimated that there are 34,895 STANWELL ROAD SURGERY H81104 0.62 ST JOHN'S FAMILY PRACTICE H81025 0.62 people with undiagnosed FORDBRIDGE MEDICAL CENTRE H81057 0.61 HERSHAM SURGERY H81065 0.61 hypertension in NHS North West THE RED PRACTICE WALTON H81094 0.60 SUNBURY GROUP PRACTICE H81003 0.58 Surrey CCG CROUCH OAK FAMILY PRACTICE H81042 0.58 • GP practice range of observed to THE PRACTICE COLLEGE ROAD H81641 0.57 PARISHES BRIDGE MED.PRACT H81036 0.57 expected hypertension prevalence ABBEY PRACTICE H81033 0.57 NEW OTTERSHAW SURGERY H81658 0.57 0.34 to 0.72 STAINES HEALTH GROUP H81134 0.56 SHEPPERTON MEDICAL PRACTICE H81004 0.56 GOLDSWORTH PARK HEALTH CENTRE H81024 0.55 SOUTHVIEW MEDICAL PRACTICE H81041 0.54 KNOWLE GREEN MEDICAL H81002 0.54 SUNNY MEED SURGERY H81019 0.53 PIRBRIGHT SURGERY H81129 0.53 GROVE MEDICAL CENTRE H81066 0.52 MADEIRA MEDICAL H81034 0.50 HEATHCOT MEDICAL PRACTICE H81032 0.50 THE ORCHARD SURGERY H81632 0.50 WEY FAMILY PRACTICE H81050 0.49 CHURCH STREET PRACTICE H81073 0.48 MAYBURY SURGERY H81643 0.48 CHOBHAM & WEST END MEDICAL PRACTICE H81015 0.47 STAINES THAMESIDE MEDICAL H81079 0.47 DR R J POOL H81664 0.46 HYTHE MEDICAL CENTRE SURGERY H81122 0.45 ASHFORD HEALTH CENTRE Y02688 0.45 HILLVIEW MEDICAL CENTRE H81061 0.44 SHEERWATER HEALTH CENTRE H81123 0.43 VIRGINIA WATER MEDICAL PRACTICE H81111 0.42 FORT HOUSE SURGERY H81020 0.41 ROWAN TREE PRACTICE H81007 0.38 ASHLEY MEDICAL PRACTICE H81663 0.34 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 North West Surrey CCG 78.6%
• 46,308 people with hypertension (diagnosed)* in NHS North West Surrey CCG NHS Guildford And Waverley CCG 78.4% • 36,385 (78.6%) people whose blood pressure is <= 150/90 • 1,731 (3.7%) people who are excepted from optimal control • 8,192 (17.7%) additional people NHS Surrey Downs CCG 75.3% whose blood pressure is not <= 150/90
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 Swindon CCG 80.5%
NHS Horsham and Mid Sussex CCG 80.3%
NHS Chiltern CCG 80.0%
NHS Mid Essex CCG 79.3%
NHS South Gloucestershire CCG 79.0%
NHS North Hampshire CCG 78.6%
NHS North West Surrey CCG 78.6%
NHS Basildon and Brentwood CCG 78.2%
NHS Bromley CCG 77.3%
NHS East Surrey CCG 77.2%
NHS Surrey Downs CCG 75.3%
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
ASHLEY MEDICAL PRACTICE H81663 93 STAINES THAMESIDE MEDICAL H81079 169 SUNNY MEED SURGERY H81019 335 VIRGINIA WATER MEDICAL PRACTICE H81111 144 ST DAVID'S FAMILY PRACTICE H81087 464 • in total, including exceptions, there STANWELL ROAD SURGERY H81104 263 MAYBURY SURGERY H81643 44 are 9,923 people whose blood SHEERWATER HEALTH CENTRE H81123 81 THE PRACTICE COLLEGE ROAD H81641 71 pressure is not <= 150/90 SUNBURY GROUP PRACTICE H81003 669 CROUCH OAK FAMILY PRACTICE H81042 552 • GP practice range: 6.3% to 39.1% ASHFORD HEALTH CENTRE Y02688 97 ROWAN TREE PRACTICE H81007 243 UPPER HALLIFORD MEDICAL CENTRE H81642 136 HEATHCOT MEDICAL PRACTICE H81032 442 CHURCH STREET PRACTICE H81073 349 HILLVIEW MEDICAL CENTRE H81061 279 WEY FAMILY PRACTICE H81050 288 STAINES HEALTH GROUP H81134 354 FORDBRIDGE MEDICAL CENTRE H81057 210 GROVE MEDICAL CENTRE H81066 339 KNOWLE GREEN MEDICAL H81002 195 THE RED PRACTICE WALTON H81094 247 SHEPPERTON MEDICAL PRACTICE H81004 422 BRIDGE PRACTICE H81054 288 THE ORCHARD SURGERY H81632 69 STUDHOLME MEDICAL CENTRE H81009 536 NEW OTTERSHAW SURGERY H81658 152 HERSHAM SURGERY H81065 267 ABBEY PRACTICE H81033 290 PARISHES BRIDGE MED.PRACT H81036 296 PIRBRIGHT SURGERY H81129 78 FORT HOUSE SURGERY H81020 206 HYTHE MEDICAL CENTRE SURGERY H81122 82 SOUTHVIEW MEDICAL PRACTICE H81041 192 GOLDSWORTH PARK HEALTH CENTRE H81024 237 CHOBHAM & WEST END MEDICAL PRACTICE H81015 198 DR R J POOL H81664 38 ST JOHN'S FAMILY PRACTICE H81025 298 DR S MORCOS H81131 66 MADEIRA MEDICAL H81034 97 DR DM NGUYEN H81095 47 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 North West Surrey CCG 72.1%
• 140 people with a new diagnosis* of hypertension with a CVD risk of 20% or higher in NHS North West Surrey NHS Surrey Downs CCG 63.4% CCG • 101 (72.1%) people who are currently treated with statins • 37 (26.4%) people who are exempted from treatment with statins NHS Guildford And Waverley CCG 61.7% • 2 (1.4%) additional people who are not currently treated with statins
England 66.5%
0% 10% 20% 30% 40% 50% 60% 70% 80% *Using the QOF clinical indicator CVD-PP001 denominator plus exceptions
23 CVD: Primary Care Intelligence Packs New diagnosis of hypertension who have been given a CVD risk assessment whose CVD risk exceeds 20% and treated with statins by CCG Comparison with demographically similar CCGs
NHS Swindon CCG 76.8%
NHS North West Surrey CCG 72.1%
NHS South Gloucestershire CCG 70.3%
NHS North Hampshire CCG 66.0%
NHS Bromley CCG 66.0%
NHS Chiltern CCG 65.9%
NHS Surrey Downs CCG 63.4%
NHS Mid Essex CCG 63.1%
NHS Horsham and Mid Sussex CCG 61.6%
NHS Basildon and Brentwood CCG 61.6%
NHS East Surrey CCG 59.7%
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
CHOBHAM & WEST END MEDICAL PRACTICE H81015 3 SHEPPERTON MEDICAL PRACTICE H81004 4 WEY FAMILY PRACTICE H81050 2 ASHFORD HEALTH CENTRE Y02688 2 KNOWLE GREEN MEDICAL H81002 2 • in total, including exceptions, there SUNBURY GROUP PRACTICE H81003 4 ROWAN TREE PRACTICE H81007 1 are 39 people who are not treated STUDHOLME MEDICAL CENTRE H81009 7 GROVE MEDICAL CENTRE H81066 2 with statins PIRBRIGHT SURGERY H81129 1 HERSHAM SURGERY H81065 2 • GP practice range: 0.0% to 100.0% ST JOHN'S FAMILY PRACTICE H81025 3 HILLVIEW MEDICAL CENTRE H81061 1 UPPER HALLIFORD MEDICAL CENTRE H81642 1 NEW OTTERSHAW SURGERY H81658 1 ST DAVID'S FAMILY PRACTICE H81087 1 ABBEY PRACTICE H81033 1 CROUCH OAK FAMILY PRACTICE H81042 1 SUNNY MEED SURGERY H81019 FORT HOUSE SURGERY H81020 GOLDSWORTH PARK HEALTH CENTRE H81024 HEATHCOT MEDICAL PRACTICE H81032 MADEIRA MEDICAL H81034 PARISHES BRIDGE MED.PRACT H81036 SOUTHVIEW MEDICAL PRACTICE H81041 BRIDGE PRACTICE H81054 FORDBRIDGE MEDICAL CENTRE H81057 CHURCH STREET PRACTICE H81073 THE RED PRACTICE WALTON H81094 DR DM NGUYEN H81095 STANWELL ROAD SURGERY H81104 VIRGINIA WATER MEDICAL PRACTICE H81111 HYTHE MEDICAL CENTRE SURGERY H81122 SHEERWATER HEALTH CENTRE H81123 DR S MORCOS H81131 STAINES HEALTH GROUP H81134 THE PRACTICE COLLEGE ROAD H81641 MAYBURY SURGERY H81643 ASHLEY MEDICAL PRACTICE H81663 DR R J POOL H81664 THE ORCHARD SURGERY H81632 STAINES THAMESIDE MEDICAL H81079 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 Guildford And Waverley CCG 0.75
• the ratio of those diagnosed with atrial fibrillation versus those expected to have atrial fibrillation is 0.68. This NHS North West Surrey CCG 0.68 compares to 0.7 for England • this suggests that 68% of people with atrial fibrillation have been diagnosed.
NHS Surrey Downs CCG 0.67
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 England 0.70 estimates were developed by applying age-sex 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 East Surrey CCG 0.78
NHS South Gloucestershire CCG 0.76
NHS Chiltern CCG 0.72
NHS Horsham and Mid Sussex CCG 0.70
NHS Bromley CCG 0.70
NHS Swindon CCG 0.68
NHS North West Surrey CCG 0.68
NHS Surrey Downs CCG 0.67
NHS Basildon and Brentwood CCG 0.66
NHS North Hampshire CCG 0.66
NHS Mid Essex CCG 0.65
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
29 CVD: Primary Care Intelligence Packs Atrial fibrillation observed prevalence compared with expected prevalence by GP practice
GP practice CCG
STUDHOLME MEDICAL CENTRE H81009 0.8 FORT HOUSE SURGERY H81020 0.8 BRIDGE PRACTICE H81054 0.8 CHURCH STREET PRACTICE H81073 0.8 ST DAVID'S FAMILY PRACTICE H81087 0.8 PIRBRIGHT SURGERY H81129 0.8 • it is estimated that there are 9,155 SUNBURY GROUP PRACTICE H81003 0.7 SHEPPERTON MEDICAL PRACTICE H81004 0.7 people with undiagnosed atrial CHOBHAM & WEST END MEDICAL PRACTICE H81015 0.7 SUNNY MEED SURGERY H81019 0.7 fibrillation in NHS North West Surrey GOLDSWORTH PARK HEALTH CENTRE H81024 0.7 ST JOHN'S FAMILY PRACTICE H81025 0.7 CCG ABBEY PRACTICE H81033 0.7 • GP practice range of observed to SOUTHVIEW MEDICAL PRACTICE H81041 0.7 CROUCH OAK FAMILY PRACTICE H81042 0.7 expected atrial fibrillation prevalence FORDBRIDGE MEDICAL CENTRE H81057 0.7 HERSHAM SURGERY H81065 0.7 0.3 to 0.8 STANWELL ROAD SURGERY H81104 0.7 NEW OTTERSHAW SURGERY H81658 0.7 DR R J POOL H81664 0.7 KNOWLE GREEN MEDICAL H81002 0.6 ROWAN TREE PRACTICE H81007 0.6 HEATHCOT MEDICAL PRACTICE H81032 0.6 MADEIRA MEDICAL H81034 0.6 PARISHES BRIDGE MED.PRACT H81036 0.6 WEY FAMILY PRACTICE H81050 0.6 HILLVIEW MEDICAL CENTRE H81061 0.6 GROVE MEDICAL CENTRE H81066 0.6 STAINES THAMESIDE MEDICAL H81079 0.6 THE RED PRACTICE WALTON H81094 0.6 DR DM NGUYEN H81095 0.6 VIRGINIA WATER MEDICAL PRACTICE H81111 0.6 HYTHE MEDICAL CENTRE SURGERY H81122 0.6 DR S MORCOS H81131 0.6 STAINES HEALTH GROUP H81134 0.6 ASHFORD HEALTH CENTRE Y02688 0.6 THE ORCHARD SURGERY H81632 0.5 THE PRACTICE COLLEGE ROAD H81641 0.4 UPPER HALLIFORD MEDICAL CENTRE H81642 0.4 MAYBURY SURGERY H81643 0.4 SHEERWATER HEALTH CENTRE H81123 0.3 ASHLEY MEDICAL PRACTICE H81663 0.3 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 Surrey Downs CCG 81.0% • 5,040 people with atrial fibrillation* with a CHA2DS2-VASc score >= 2 in NHS North West Surrey CCG • 3,888 (77.1%) people treated with anti-coagulation therapy NHS Guildford And Waverley CCG 80.4% • 458 (9.1%) people who are exceptions • 694 (13.8%) additional people with a recorded CHA2DS2-VASc score >= 2 NHS North West Surrey CCG 77.1% who are not treated
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 Chiltern CCG 84.9%
NHS Surrey Downs CCG 81.0%
NHS North Hampshire CCG 79.9%
NHS South Gloucestershire CCG 79.7%
NHS Swindon CCG 78.9%
NHS Mid Essex CCG 77.9%
NHS North West Surrey CCG 77.1%
NHS Bromley CCG 76.7%
NHS Basildon and Brentwood CCG 76.6%
NHS East Surrey CCG 76.5%
NHS Horsham and Mid Sussex CCG 75.3%
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
GOLDSWORTH PARK HEALTH CENTRE H81024 59 STANWELL ROAD SURGERY H81104 19 MAYBURY SURGERY H81643 2 HYTHE MEDICAL CENTRE SURGERY H81122 19 ROWAN TREE PRACTICE H81007 37 • in total, including exceptions, there ST DAVID'S FAMILY PRACTICE H81087 52 HEATHCOT MEDICAL PRACTICE H81032 53 are 1,152 people with a recorded ST JOHN'S FAMILY PRACTICE H81025 58 UPPER HALLIFORD MEDICAL CENTRE H81642 10 CHA2DS2-VASc score >= 2 who are DR R J POOL H81664 9 NEW OTTERSHAW SURGERY H81658 23 not treated STAINES THAMESIDE MEDICAL H81079 20 • GP practice range: 0.0% to 34.9% HERSHAM SURGERY H81065 48 KNOWLE GREEN MEDICAL H81002 22 SUNBURY GROUP PRACTICE H81003 81 VIRGINIA WATER MEDICAL PRACTICE H81111 15 FORDBRIDGE MEDICAL CENTRE H81057 27 FORT HOUSE SURGERY H81020 40 CROUCH OAK FAMILY PRACTICE H81042 53 ASHLEY MEDICAL PRACTICE H81663 5 ABBEY PRACTICE H81033 37 STAINES HEALTH GROUP H81134 41 PIRBRIGHT SURGERY H81129 12 HILLVIEW MEDICAL CENTRE H81061 31 PARISHES BRIDGE MED.PRACT H81036 32 SHEERWATER HEALTH CENTRE H81123 3 CHOBHAM & WEST END MEDICAL PRACTICE H81015 31 BRIDGE PRACTICE H81054 29 GROVE MEDICAL CENTRE H81066 29 CHURCH STREET PRACTICE H81073 39 SHEPPERTON MEDICAL PRACTICE H81004 47 THE RED PRACTICE WALTON H81094 21 STUDHOLME MEDICAL CENTRE H81009 51 SUNNY MEED SURGERY H81019 21 WEY FAMILY PRACTICE H81050 28 DR S MORCOS H81131 6 ASHFORD HEALTH CENTRE Y02688 3 MADEIRA MEDICAL H81034 19 THE ORCHARD SURGERY H81632 5 SOUTHVIEW MEDICAL PRACTICE H81041 10 DR DM NGUYEN H81095 5 THE PRACTICE COLLEGE ROAD H81641 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
33 CVD: Primary Care Intelligence Packs In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage treated with anti-coagulation therapy by GP practice – opportunities compared to GP cluster
20% 15% 10% 5% 0% -5% -10% -15% -20%
STANWELL ROAD SURGERY 10
MAYBURY SURGERY 1
GOLDSWORTH PARK HEALTH CENTRE 30 • using the GP cluster method of HYTHE MEDICAL CENTRE SURGERY 10 calculating potential gains, if each ROWAN TREE PRACTICE 17 practice was to achieve as well as the ST DAVID'S FAMILY PRACTICE 22 upper quartile of its national cluster, then an additional 325 people would UPPER HALLIFORD MEDICAL CENTRE 5 be treated DR R J POOL 4
NEW OTTERSHAW SURGERY 11
STAINES THAMESIDE MEDICAL 9
THE RED PRACTICE WALTON 1
DR S MORCOS 0
MADEIRA MEDICAL 0
STUDHOLME MEDICAL CENTRE 0
SUNNY MEED SURGERY
WEY FAMILY PRACTICE
THE ORCHARD SURGERY
DR DM NGUYEN
SOUTHVIEW MEDICAL PRACTICE
THE PRACTICE COLLEGE ROAD 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 North West Surrey CCG 83.1% • 5,507 people with a history of stroke or TIA* in NHS North West Surrey CCG • 4,576 (83.1%) people whose blood pressure is <= 150 / 90 NHS Guildford And Waverley CCG 81.5% • 221 (4%) people who are exceptions • 710 (12.9%) additional people whose blood pressure is not <= 150 / 90
NHS Surrey Downs 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 Chiltern CCG 86.1%
NHS Horsham and Mid Sussex CCG 84.2%
NHS South Gloucestershire CCG 84.1%
NHS Swindon CCG 83.9%
NHS North Hampshire CCG 83.3%
NHS North West Surrey CCG 83.1%
NHS East Surrey CCG 82.8%
NHS Mid Essex CCG 82.3%
NHS Basildon and Brentwood CCG 81.9%
NHS Bromley CCG 81.8%
NHS Surrey Downs CCG 80.3%
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
ASHLEY MEDICAL PRACTICE H81663 11 STAINES THAMESIDE MEDICAL H81079 31 ROWAN TREE PRACTICE H81007 35 SUNNY MEED SURGERY H81019 31 NEW OTTERSHAW SURGERY H81658 19 • in total, including exceptions, there ST DAVID'S FAMILY PRACTICE H81087 44 SHEPPERTON MEDICAL PRACTICE H81004 56 are 931 people whose blood pressure SUNBURY GROUP PRACTICE H81003 67 VIRGINIA WATER MEDICAL PRACTICE H81111 17 is not <= 150 / 90 CHURCH STREET PRACTICE H81073 39 HERSHAM SURGERY H81065 46 • GP practice range: 0.0% to 44.0% CROUCH OAK FAMILY PRACTICE H81042 46 THE ORCHARD SURGERY H81632 12 STANWELL ROAD SURGERY H81104 18 PARISHES BRIDGE MED.PRACT H81036 37 HILLVIEW MEDICAL CENTRE H81061 26 ABBEY PRACTICE H81033 29 CHOBHAM & WEST END MEDICAL PRACTICE H81015 27 KNOWLE GREEN MEDICAL H81002 15 UPPER HALLIFORD MEDICAL CENTRE H81642 8 FORDBRIDGE MEDICAL CENTRE H81057 15 THE RED PRACTICE WALTON H81094 22 HYTHE MEDICAL CENTRE SURGERY H81122 11 SHEERWATER HEALTH CENTRE H81123 4 WEY FAMILY PRACTICE H81050 26 DR R J POOL H81664 5 SOUTHVIEW MEDICAL PRACTICE H81041 26 FORT HOUSE SURGERY H81020 24 STUDHOLME MEDICAL CENTRE H81009 35 MAYBURY SURGERY H81643 1 STAINES HEALTH GROUP H81134 24 HEATHCOT MEDICAL PRACTICE H81032 29 GROVE MEDICAL CENTRE H81066 22 MADEIRA MEDICAL H81034 14 ST JOHN'S FAMILY PRACTICE H81025 21 BRIDGE PRACTICE H81054 14 GOLDSWORTH PARK HEALTH CENTRE H81024 13 PIRBRIGHT SURGERY H81129 4 DR DM NGUYEN H81095 4 ASHFORD HEALTH CENTRE Y02688 2 THE PRACTICE COLLEGE ROAD H81641 1 DR S MORCOS H81131 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 North West Surrey CCG 92.3% • 3,491 people with a stroke shown to be non-haemorrhagic* in NHS North West Surrey CCG • 3,223 (92.3%) people who are taking an anti-platetet agent or anti- NHS Guildford And Waverley CCG 90.5% coagulant • 207 (5.9%) people who are exceptions • 61 (1.7%) additional people with no NHS Surrey Downs CCG 89.9% treatment
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 South Gloucestershire CCG 92.4%
NHS North West Surrey CCG 92.3%
NHS Chiltern CCG 92.3%
NHS Bromley CCG 91.4%
NHS Horsham and Mid Sussex CCG 91.4%
NHS North Hampshire CCG 91.2%
NHS Swindon CCG 91.2%
NHS East Surrey CCG 90.7%
NHS Basildon and Brentwood CCG 90.7%
NHS Mid Essex CCG 90.4%
NHS Surrey Downs CCG 89.9%
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
UPPER HALLIFORD MEDICAL CENTRE H81642 6 FORT HOUSE SURGERY H81020 22 STANWELL ROAD SURGERY H81104 10 GOLDSWORTH PARK HEALTH CENTRE H81024 11 CHURCH STREET PRACTICE H81073 14 • in total, including exceptions, there PIRBRIGHT SURGERY H81129 3 CROUCH OAK FAMILY PRACTICE H81042 18 are 268 people who are not taking an WEY FAMILY PRACTICE H81050 12 ST DAVID'S FAMILY PRACTICE H81087 11 anti-platelet agent or anti-coagulant DR S MORCOS H81131 2 SUNBURY GROUP PRACTICE H81003 16 • GP practice range: 0.0% to 23.1% SHEPPERTON MEDICAL PRACTICE H81004 15 STUDHOLME MEDICAL CENTRE H81009 15 HYTHE MEDICAL CENTRE SURGERY H81122 3 HEATHCOT MEDICAL PRACTICE H81032 11 DR R J POOL H81664 2 PARISHES BRIDGE MED.PRACT H81036 10 STAINES HEALTH GROUP H81134 9 SOUTHVIEW MEDICAL PRACTICE H81041 12 BRIDGE PRACTICE H81054 6 MADEIRA MEDICAL H81034 7 STAINES THAMESIDE MEDICAL H81079 5 KNOWLE GREEN MEDICAL H81002 3 ASHLEY MEDICAL PRACTICE H81663 1 THE RED PRACTICE WALTON H81094 5 HERSHAM SURGERY H81065 6 GROVE MEDICAL CENTRE H81066 5 CHOBHAM & WEST END MEDICAL PRACTICE H81015 5 HILLVIEW MEDICAL CENTRE H81061 4 FORDBRIDGE MEDICAL CENTRE H81057 2 ROWAN TREE PRACTICE H81007 3 ABBEY PRACTICE H81033 5 VIRGINIA WATER MEDICAL PRACTICE H81111 2 DR DM NGUYEN H81095 1 SUNNY MEED SURGERY H81019 2 ST JOHN'S FAMILY PRACTICE H81025 3 NEW OTTERSHAW SURGERY H81658 1 SHEERWATER HEALTH CENTRE H81123 THE ORCHARD SURGERY H81632 THE PRACTICE COLLEGE ROAD H81641 MAYBURY SURGERY H81643 ASHFORD HEALTH CENTRE Y02688 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
40 CVD: Primary Care Intelligence Packs Diabetes
41 CVD: Primary Care Intelligence Packs Diabetes prevention and management
Type 2 Diabetes in numbers Diabetes costs the NHS • diagnosed prevalence – 3.0 million £9.8 billion per year – and the • undiagnosed diabetes – 900,000 • non-diabetic hyperglycaemia (high risk of diabetes) – 5 million prevalence is rising What questions should we ask in our CCG? 1. for each indicator how wide is the variation in achievement and exception reporting? Type 2 diabetes is often preventable 2. how many people would benefit if all practices performed as well People at high risk of developing type 2 diabetes as the best? can be identified through the NHS Health Check, 3. how can we support practices who are average and below and the disease can be prevented or delayed in average to perform as well as the best in: many through intensive behaviour change support. • detection of diabetes • delivery of the 8 care processes and achievement of the 3 treatment targets Complications of diabetes are preventable • identification and management of Non-diabetic hyperglycaemia Diabetes is a major cause of premature death and disability and greatly increases the risk of heart disease and stroke, kidney failure, amputations and What might help blindness. 80% of NHS spending on diabetes goes • ensure universal participation by practices in the National on managing these complications, most of which Diabetes Audit (NDA) could be prevented. There are 8 essential care • benchmark practice level data from the NDA – and support processes, in addition to retinal screening, that practices to explore variation together substantially reduce complication rates. • increase support for patient education and shared Despite this, around a half of people with diabetes management do not receive all 8 care processes, and there is • maximise uptake of the NHS Health Check to aid detection of widespread variation between CCGs and practices diabetes and Non Diabetic Hyperglycaemia in levels of achievement • maximise uptake of the NHS Diabetes Prevention Programme
42 CVD: Primary Care Intelligence Packs Diabetes observed prevalence compared with expected prevalence by CCG Comparison with CCGs in the STP
NHS North West Surrey CCG 0.75 • 0.75 ratio of observed to expected diabetes prevalence in NHS North West Surrey CCG, compared to 0.77 in England
NHS Surrey Downs CCG 0.67 • this suggests 75% of people have been diagnosed
NHS Guildford And Waverley CCG 0.63
Note: This slide compares the prevalence of Diabetes recorded in QOF in 2015/16 to the England 0.77 expected prevalence of Diabetes in 2016 taken from the NCVIN diabetes prevalence model produced in 2015.
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
43 CVD: Primary Care Intelligence Packs Diabetes observed prevalence compared with expected prevalence by CCG Comparison with demographically similar CCGs
NHS Swindon CCG 0.94
NHS North Hampshire CCG 0.78
NHS South Gloucestershire CCG 0.78
NHS Mid Essex CCG 0.77
NHS North West Surrey CCG 0.75
NHS Basildon and Brentwood CCG 0.75
NHS Chiltern CCG 0.72
NHS East Surrey CCG 0.70
NHS Horsham and Mid Sussex CCG 0.69
NHS Surrey Downs CCG 0.67
NHS Bromley CCG 0.67
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
THE PRACTICE COLLEGE ROAD H81641 12.2% ST DAVID'S FAMILY PRACTICE H81087 8.4% THE ORCHARD SURGERY H81632 7.9% SHEERWATER HEALTH CENTRE H81123 7.8% MAYBURY SURGERY H81643 7.8% • GP practice range of observed FORDBRIDGE MEDICAL CENTRE H81057 7.1% STUDHOLME MEDICAL CENTRE H81009 7.0% diabetes 3.7% to 12.2% STANWELL ROAD SURGERY H81104 6.9% UPPER HALLIFORD MEDICAL CENTRE H81642 6.5% • there are an estimated 5,616 people BRIDGE PRACTICE H81054 6.5% SUNNY MEED SURGERY H81019 6.4% with undiagnosed diabetes in NHS ABBEY PRACTICE H81033 6.3% NEW OTTERSHAW SURGERY H81658 6.3% North West Surrey CCG THE RED PRACTICE WALTON H81094 6.2% SUNBURY GROUP PRACTICE H81003 6.2% STAINES HEALTH GROUP H81134 6.1% CROUCH OAK FAMILY PRACTICE H81042 6.0% DR S MORCOS H81131 6.0% STAINES THAMESIDE MEDICAL H81079 5.8% GOLDSWORTH PARK HEALTH CENTRE H81024 5.8% DR DM NGUYEN H81095 5.7% SHEPPERTON MEDICAL PRACTICE H81004 5.6% HERSHAM SURGERY H81065 5.5% MADEIRA MEDICAL H81034 5.4% SOUTHVIEW MEDICAL PRACTICE H81041 5.4% ST JOHN'S FAMILY PRACTICE H81025 5.3% WEY FAMILY PRACTICE H81050 5.3% GROVE MEDICAL CENTRE H81066 5.3% KNOWLE GREEN MEDICAL H81002 5.2% PARISHES BRIDGE MED.PRACT H81036 5.1% HYTHE MEDICAL CENTRE SURGERY H81122 5.1% HEATHCOT MEDICAL PRACTICE H81032 5.0% CHOBHAM & WEST END MEDICAL PRACTICE H81015 5.0% HILLVIEW MEDICAL CENTRE H81061 4.8% CHURCH STREET PRACTICE H81073 4.3% ASHLEY MEDICAL PRACTICE H81663 4.3% FORT HOUSE SURGERY H81020 4.1% VIRGINIA WATER MEDICAL PRACTICE H81111 4.0% PIRBRIGHT SURGERY H81129 4.0% ASHFORD HEALTH CENTRE Y02688 3.9% Note: The estimated number of undiagnosed DR R J POOL H81664 3.7% people with diabetes has been calculated by ROWAN TREE PRACTICE H81007 3.7% multiplying the estimated prevalence rate to the 0% 2% 4% 6% 8% 10% 12% 14% 2015/16 QOF list size and subtracting the number of people on the diabetes register.
45 CVD: Primary Care Intelligence Packs Expected total prevalence of diabetes and non-diabetic hyperglycaemia
Diabetes prevalence Undiagnosed diabetes prevalence Expected non-diabetic hyperglycaemia prevalence
• the estimated total prevalence of NHS Surrey Downs CCG 5.1% 2.5% 11.5% diabetes in NHS North West Surrey CCG is 7.6% (diagnosed and undiagnosed) • in addition, there are an estimated 11.0% of people in NHS North West NHS North West Surrey CCG 5.7% 1.9% 11.0% Surrey CCG who are at increased risk of developing diabetes (i.e. with non- diabetic hyperglycaemia)
NHS Guildford And Waverley CCG 4.5% 2.6% 10.8% • this means that 18.6% of the population in NHS North West Surrey CCG are estimated to have diabetes, or at high risk of developing of diabetes
Note: Prevalence estimates of non-diabetic hyperglycaemia were developed using Health England 6.5% 1.9% 11.2% Survey for England (HSE) data. Five years of HSE data were combined, 2009- 2013. The estimates take into account the age, ethnic group and estimated body mass index of the population. 0% 5% 10% 15% 20% 25% These estimates were produced using the GP registered population.
46 CVD: Primary Care Intelligence Packs People with diabetes who had eight care processes by CCG 2015/16
NHS Guildford And Waverley CCG 36.6% • data on care processes and treatment targets are taken from the National Diabetes Audit (NDA) • overall practice participation in the NHS Surrey Downs CCG 35.6% 2015/16 audit was 81.4% in England
• in NHS North West Surrey CCG, 32 out of 42 practices (76.2%) participated in the NDA. Data is not NHS North West Surrey CCG 32.1% available for the remaining practices
• 32.1% of people with diabetes (of practices who participated in the audit) had the eight recommended care processes in NHS North West Surrey CCG, compared to 52.6% in England
England 52.6%
0% 10% 20% 30% 40% 50% 60%
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
PARISHES BRIDGE MED.PRACT H81036 70.4% STANWELL ROAD SURGERY H81104 67.5% MADEIRA MEDICAL H81034 63.5% ABBEY PRACTICE H81033 61.3% • achievement - 8 care processes: in STAINES THAMESIDE MEDICAL H81079 56.5% STAINES HEALTH GROUP H81134 54.1% practices who provided data via the DR DM NGUYEN H81095 48.6% SOUTHVIEW MEDICAL PRACTICE H81041 42.5% NDA, between 4.4% and 70.4% of ST JOHN'S FAMILY PRACTICE H81025 40.1% patients received all 8 care processes CHURCH STREET PRACTICE H81073 38.2% THE RED PRACTICE WALTON H81094 37.3% WEY FAMILY PRACTICE H81050 37.3% HILLVIEW MEDICAL CENTRE H81061 36.6% HERSHAM SURGERY H81065 34.4% • at least 8,552 people did not receive THE ORCHARD SURGERY H81632 32.0% FORT HOUSE SURGERY H81020 28.7% the eight care processes BRIDGE PRACTICE H81054 26.5% ASHFORD HEALTH CENTRE Y02688 24.9% SHEERWATER HEALTH CENTRE H81123 23.4% SHEPPERTON MEDICAL PRACTICE H81004 21.9% FORDBRIDGE MEDICAL CENTRE H81057 19.8% STUDHOLME MEDICAL CENTRE H81009 19.4% NEW OTTERSHAW SURGERY H81658 19.2% KNOWLE GREEN MEDICAL H81002 18.0% PIRBRIGHT SURGERY H81129 15.6% THE PRACTICE COLLEGE ROAD H81641 15.3% SUNBURY GROUP PRACTICE H81003 14.7% DR S MORCOS H81131 13.9% HEATHCOT MEDICAL PRACTICE H81032 13.7% MAYBURY SURGERY H81643 6.6% DR R J POOL H81664 4.8% ST DAVID'S FAMILY PRACTICE H81087 4.4% ASHLEY MEDICAL PRACTICE H81663 UPPER HALLIFORD MEDICAL CENTRE H81642 HYTHE MEDICAL CENTRE SURGERY H81122 VIRGINIA WATER MEDICAL PRACTICE H81111 GROVE MEDICAL CENTRE H81066 CROUCH OAK FAMILY PRACTICE H81042 GOLDSWORTH PARK HEALTH CENTRE H81024 SUNNY MEED SURGERY H81019 CHOBHAM & WEST END MEDICAL PRACTICE H81015 ROWAN TREE PRACTICE H81007 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 North West Surrey CCG 43.7% • 43.7% of people with diabetes (of practices who participated in the audit) met the three treatment targets in NHS North West Surrey CCG, NHS Guildford And Waverley CCG 39.1% compared to 39.0% in England
NHS Surrey Downs CCG 38.8%
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
DR DM NGUYEN H81095 68.5% SOUTHVIEW MEDICAL PRACTICE H81041 56.9% CHURCH STREET PRACTICE H81073 55.6% MADEIRA MEDICAL H81034 51.4% • achievement - 3 treatment targets: in ABBEY PRACTICE H81033 49.1% DR S MORCOS H81131 48.8% practices who provided data via the FORDBRIDGE MEDICAL CENTRE H81057 47.4% ST JOHN'S FAMILY PRACTICE H81025 47.3% NDA, between 22.2% and 68.5% of PARISHES BRIDGE MED.PRACT H81036 47.1% patients achieved all 3 treatment THE RED PRACTICE WALTON H81094 47.0% DR R J POOL H81664 46.3% targets BRIDGE PRACTICE H81054 45.0% STANWELL ROAD SURGERY H81104 44.5% FORT HOUSE SURGERY H81020 44.3% • at least 6,201 people did not meet the NEW OTTERSHAW SURGERY H81658 44.3% SHEERWATER HEALTH CENTRE H81123 44.3% three treatment targets HEATHCOT MEDICAL PRACTICE H81032 43.8% STUDHOLME MEDICAL CENTRE H81009 43.6% HILLVIEW MEDICAL CENTRE H81061 43.5% WEY FAMILY PRACTICE H81050 42.9% PIRBRIGHT SURGERY H81129 41.2% STAINES THAMESIDE MEDICAL H81079 39.7% SUNBURY GROUP PRACTICE H81003 39.7% STAINES HEALTH GROUP H81134 39.4% HERSHAM SURGERY H81065 39.2% KNOWLE GREEN MEDICAL H81002 39.0% SHEPPERTON MEDICAL PRACTICE H81004 38.2% MAYBURY SURGERY H81643 37.7% THE ORCHARD SURGERY H81632 35.9% ST DAVID'S FAMILY PRACTICE H81087 34.8% THE PRACTICE COLLEGE ROAD H81641 26.4% ASHFORD HEALTH CENTRE Y02688 22.2% ASHLEY MEDICAL PRACTICE H81663 UPPER HALLIFORD MEDICAL CENTRE H81642 HYTHE MEDICAL CENTRE SURGERY H81122 VIRGINIA WATER MEDICAL PRACTICE H81111 GROVE MEDICAL CENTRE H81066 CROUCH OAK FAMILY PRACTICE H81042 GOLDSWORTH PARK HEALTH CENTRE H81024 SUNNY MEED SURGERY H81019 CHOBHAM & WEST END MEDICAL PRACTICE H81015 ROWAN TREE PRACTICE H81007 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
25% 20% 15% 10% 5% 0% -5% -10% -15% -20% -25%
ASHFORD HEALTH CENTRE 28
THE PRACTICE COLLEGE ROAD 49
THE ORCHARD SURGERY 12 • using the GP cluster method of ST DAVID'S FAMILY PRACTICE 47 calculating potential gains, if each KNOWLE GREEN MEDICAL 18 practice was to achieve as well as the MAYBURY SURGERY 7 upper quartile of its national cluster, then an additional 294 people would SHEPPERTON MEDICAL PRACTICE 30 be treated STAINES THAMESIDE MEDICAL 9
STAINES HEALTH GROUP 26
HERSHAM SURGERY 15
FORT HOUSE SURGERY
THE RED PRACTICE WALTON
ST JOHN'S FAMILY PRACTICE
PARISHES BRIDGE MED.PRACT
DR S MORCOS
ABBEY PRACTICE
MADEIRA MEDICAL
CHURCH STREET PRACTICE
SOUTHVIEW MEDICAL PRACTICE
DR DM NGUYEN 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 North West Surrey CCG 0.56
• the ratio of those diagnosed with chronic kidney disease versus those expected to have chronic kidney NHS Surrey Downs CCG 0.55 disease is 0.56. This compares to 0.68 for England • this suggests that 56% of people with chronic kidney disease have been diagnosed NHS Guildford And Waverley CCG 0.51
Note: This slide compares the prevalence of CKD recorded in QOF in 2015/16 to the expected prevalence of CKD produced by the University of Southampton in 2011. A small number of CCGs England 0.68 have a ratio greater than 1. It is unlikely that all people with CKD will be diagnosed in any CCG and therefore a ratio greater than 1 suggests that 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 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 Basildon and Brentwood CCG 0.89
NHS South Gloucestershire CCG 0.86
NHS East Surrey CCG 0.66
NHS Mid Essex CCG 0.66
NHS Horsham and Mid Sussex CCG 0.65
NHS North West Surrey CCG 0.56
NHS Swindon CCG 0.56
NHS North Hampshire CCG 0.56
NHS Bromley CCG 0.55
NHS Surrey Downs CCG 0.55
NHS Chiltern CCG 0.51
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Ratio
55 CVD: Primary Care Intelligence Packs CKD prevalence by GP practice, 2015/16
GP practice CCG
DR DM NGUYEN H81095 8.2% STUDHOLME MEDICAL CENTRE H81009 7.7% STAINES HEALTH GROUP H81134 5.5% DR S MORCOS H81131 5.4% THE RED PRACTICE WALTON H81094 4.7% • it is estimated that there are 8,040 WEY FAMILY PRACTICE H81050 4.6% STANWELL ROAD SURGERY H81104 4.6% people with undiagnosed chronic ST DAVID'S FAMILY PRACTICE H81087 4.5% MADEIRA MEDICAL H81034 4.5% kidney disease in NHS North West ST JOHN'S FAMILY PRACTICE H81025 4.5% CROUCH OAK FAMILY PRACTICE H81042 4.1% Surrey CCG PIRBRIGHT SURGERY H81129 4.1% HEATHCOT MEDICAL PRACTICE H81032 4.0% • GP practice range of observed CKD: CHURCH STREET PRACTICE H81073 3.9% 0.4% to 8.2% SHEPPERTON MEDICAL PRACTICE H81004 3.7% GROVE MEDICAL CENTRE H81066 3.6% SOUTHVIEW MEDICAL PRACTICE H81041 3.6% KNOWLE GREEN MEDICAL H81002 3.3% GOLDSWORTH PARK HEALTH CENTRE H81024 3.3% BRIDGE PRACTICE H81054 3.2% ABBEY PRACTICE H81033 3.1% CHOBHAM & WEST END MEDICAL PRACTICE H81015 3.0% PARISHES BRIDGE MED.PRACT H81036 2.9% ROWAN TREE PRACTICE H81007 2.9% HERSHAM SURGERY H81065 2.9% DR R J POOL H81664 2.8% HILLVIEW MEDICAL CENTRE H81061 2.8% SUNBURY GROUP PRACTICE H81003 2.7% VIRGINIA WATER MEDICAL PRACTICE H81111 2.6% FORDBRIDGE MEDICAL CENTRE H81057 2.6% THE ORCHARD SURGERY H81632 2.5% HYTHE MEDICAL CENTRE SURGERY H81122 2.5% NEW OTTERSHAW SURGERY H81658 2.3% FORT HOUSE SURGERY H81020 2.2% STAINES THAMESIDE MEDICAL H81079 1.9% THE PRACTICE COLLEGE ROAD H81641 1.8% SUNNY MEED SURGERY H81019 1.4% Note: CCG estimates for the estimated SHEERWATER HEALTH CENTRE H81123 1.1% UPPER HALLIFORD MEDICAL CENTRE H81642 1.1% number of people with CKD are based on ASHLEY MEDICAL PRACTICE H81663 0.7% applying a proportion from a resident based ASHFORD HEALTH CENTRE Y02688 0.5% MAYBURY SURGERY H81643 0.4% population estimate to a GP registered population. The characteristics of registered 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% and resident populations may vary in some CCGs, and local interpretation is required.
56 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding 12 months) is 140/85 mmHg or less by CCG, 2014/15 Comparison with CCGs in the STP Below 140/85 Not below 140/85 Exceptions reported
NHS North West Surrey CCG 77.7% • 10,258 people with CKD (diagnosed*) in NHS North West Surrey CCG • 7,975 (77.7%) people whose blood pressure is <= 140 /85 • 489 (4.8%) people who are NHS Surrey Downs CCG 71.9% exceptions • 1,794 (17.5%) additional people whose blood pressure is not <= 140 / 85 NHS Guildford And Waverley CCG 71.6%
England 74.4% *Using the QOF clinical indicator CKD002 denominator plus exceptions. Note: as the CKD002 indicator was removed from 0% 20% 40% 60% 80% 100% the QOF in 15/16 this is historic data taken from the 2014/15 QOF.
57 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding 12 months) is 140/85 mmHg or less by CCG, 2014/15 Comparison with demographically similar CCGs Below 140/85 Not below 140/85 Exceptions reported
NHS North West Surrey CCG 77.7%
NHS South Gloucestershire CCG 76.6%
NHS Swindon CCG 76.3%
NHS Chiltern CCG 75.9%
NHS East Surrey CCG 73.9%
NHS Basildon and Brentwood CCG 73.3%
NHS Horsham and Mid Sussex CCG 72.2%
NHS Mid Essex CCG 72.0%
NHS Surrey Downs CCG 71.9%
NHS North Hampshire CCG 71.2%
NHS Bromley CCG 70.8%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
58 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding 12 months) is not 140/85 mmHg or less by GP practice, 2014/15
Not below 140/85 Exceptions reported
ASHLEY MEDICAL PRACTICE H81663 14 KNOWLE GREEN MEDICAL H81002 80 SUNNY MEED SURGERY H81019 40 OLD VICARAGE H81129 41 SHEPPERTON MEDICAL PRACTICE H81004 124 • in total, including exceptions, there STAINES THAMESIDE MEDICAL H81079 21 STANWELL ROAD SURGERY H81104 74 are 2,283 people whose blood HILLVIEW MEDICAL CENTRE H81061 89 THE PRACTICE COLLEGE ROAD H81641 14 pressure is not <= 140 / 85 GROVE MEDICAL CENTRE H81066 120 FORDBRIDGE MEDICAL CENTRE H81057 39 • GP practice range: 6.4% to 73.7% THE ORCHARD SURGERY H81632 15 SUNBURY HEALTH CENTRE H81003 100 ST DAVID'S FAMILY PRACTICE H81087 103 HERSHAM SURGERY H81065 40 STAINES HEALTH GROUP H81134 132 THE RED PRACTICE WALTON H81094 79 PARISHES BRIDGE MED.PRACT H81036 59 HEATHCOT MEDICAL PRACTICE H81032 126 CHURCH STREET PRACTICE H81073 90 SHEERWATER HEALTH CENTRE H81123 6 NEW OTTERSHAW SURGERY H81658 22 CROUCH OAK FAMILY PRACTICE H81042 70 WEY FAMILY PRACTICE H81050 79 BRIDGE PRACTICE H81054 45 HYTHE MEDICAL CENTRE SURGERY H81122 19 DR R J POOL H81664 10 STUDHOLME MEDICAL CENTRE H81009 199 GOLDSWORTH PARK HEALTH CENTRE H81024 64 VIRGINIA WATER MEDICAL PRACTICE H81111 17 ROWAN TREE PRACTICE H81007 47 ASHFORD HEALTH CENTRE Y02688 4 THE ABBEY PRACTICE H81033 49 MAYBURY SURGERY H81643 1 CHOBHAM & WEST END MEDICAL PRACTICE H81015 46 LYNCH MEDICAL CENTRE H81034 51 THE FORT HOUSE SURGERY H81020 35 ST JOHNS FAMILY PRACTICE H81025 71 SOUTHVIEW MEDICAL PRACTICE H81041 24 UPPER HALLIFORD MEDICAL CENTRE H81642 4 DR DM NGUYEN H81095 12 DR S MORCOS H81131 8 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
20% 10% 0% -10% -20% -30% -40% -50% -60% -70%
ASHLEY MEDICAL PRACTICE 11
KNOWLE GREEN MEDICAL 43
OLD VICARAGE 22 • using the GP cluster method of SUNNY MEED SURGERY 17 calculating potential gains, if each THE PRACTICE COLLEGE ROAD 6 practice was to achieve as well as the STAINES THAMESIDE MEDICAL 8 upper quartile of its national cluster, then an additional 350 people would STANWELL ROAD SURGERY 27 be treated SHEPPERTON MEDICAL PRACTICE 37
THE ORCHARD SURGERY 5
FORDBRIDGE MEDICAL CENTRE 13
LYNCH MEDICAL CENTRE
ROWAN TREE PRACTICE
THE ABBEY PRACTICE
CHOBHAM & WEST END MEDICAL PRACTICE
UPPER HALLIFORD MEDICAL CENTRE
THE FORT HOUSE SURGERY
ST JOHNS FAMILY PRACTICE
SOUTHVIEW MEDICAL PRACTICE
DR DM NGUYEN
DR S MORCOS 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 Guildford And Waverley CCG 74.7% • 10,258 people with CKD (diagnosed*) in NHS North West Surrey CCG • 7,655 (74.6%) people who have a record of urine albumin:creatinine ratio test NHS North West Surrey CCG 74.6% • 445 (4.3%) people who are exceptions • 2,158 (21%) additional people who have no record of urine NHS Surrey Downs CCG 66.6% albumin:creatinine ratio test
England 75.4% *Using the QOF clinical indicator CKD004 denominator plus exceptions. Note: as the CKD004 indicator was removed from the QOF in 15/16 this is historic data 0% 20% 40% 60% 80% 100% taken from the 2014/15 QOF.
61 CVD: Primary Care Intelligence Packs Percentage of patients on the CKD register whose notes have a record of a urine albumin: creatinine ratio test in the preceding 12 months by CCG, 2014/15 Comparison with demographically similar CCGs Recorded Not recorded Exceptions reported
NHS South Gloucestershire CCG 80.2%
NHS North Hampshire CCG 77.2%
NHS Swindon CCG 75.3%
NHS North West Surrey CCG 74.6%
NHS Chiltern CCG 73.9%
NHS East Surrey CCG 73.2%
NHS Horsham and Mid Sussex CCG 71.4%
NHS Bromley CCG 69.5%
NHS Basildon and Brentwood CCG 67.5%
NHS Surrey Downs CCG 66.6%
NHS Mid Essex CCG 61.3%
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
ASHLEY MEDICAL PRACTICE H81663 19 THE ORCHARD SURGERY H81632 33 STAINES THAMESIDE MEDICAL H81079 37 HILLVIEW MEDICAL CENTRE H81061 141 CHOBHAM & WEST END MEDICAL PRACTICE H81015 120 • in total, including exceptions, there BRIDGE PRACTICE H81054 91 ST DAVID'S FAMILY PRACTICE H81087 150 are 2,603 people who have no record KNOWLE GREEN MEDICAL H81002 80 ASHFORD HEALTH CENTRE Y02688 8 of urine albumin:creatinine ratio test UPPER HALLIFORD MEDICAL CENTRE H81642 10 STANWELL ROAD SURGERY H81104 83 • GP practice range: 0.0% to 100.0% DR R J POOL H81664 16 FORDBRIDGE MEDICAL CENTRE H81057 43 SHEPPERTON MEDICAL PRACTICE H81004 122 SUNNY MEED SURGERY H81019 33 CHURCH STREET PRACTICE H81073 118 STUDHOLME MEDICAL CENTRE H81009 292 HEATHCOT MEDICAL PRACTICE H81032 154 THE PRACTICE COLLEGE ROAD H81641 13 GROVE MEDICAL CENTRE H81066 110 SHEERWATER HEALTH CENTRE H81123 7 THE RED PRACTICE WALTON H81094 78 THE ABBEY PRACTICE H81033 65 THE FORT HOUSE SURGERY H81020 49 STAINES HEALTH GROUP H81134 120 HERSHAM SURGERY H81065 36 SOUTHVIEW MEDICAL PRACTICE H81041 35 GOLDSWORTH PARK HEALTH CENTRE H81024 70 CROUCH OAK FAMILY PRACTICE H81042 66 SUNBURY HEALTH CENTRE H81003 69 NEW OTTERSHAW SURGERY H81658 18 PARISHES BRIDGE MED.PRACT H81036 46 VIRGINIA WATER MEDICAL PRACTICE H81111 16 LYNCH MEDICAL CENTRE H81034 50 ST JOHNS FAMILY PRACTICE H81025 67 WEY FAMILY PRACTICE H81050 51 ROWAN TREE PRACTICE H81007 35 OLD VICARAGE H81129 14 HYTHE MEDICAL CENTRE SURGERY H81122 11 DR DM NGUYEN H81095 14 DR S MORCOS H81131 13 MAYBURY SURGERY H81643 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 Guildford And Waverley CCG 0.55%
• prevalence of 0.53% in NHS North West Surrey CCG compared to 0.76% in England
NHS North West Surrey CCG 0.53%
NHS Surrey Downs CCG 0.52%
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 Basildon and Brentwood CCG 0.77%
NHS Horsham and Mid Sussex CCG 0.72%
NHS South Gloucestershire CCG 0.70%
NHS Bromley CCG 0.66%
NHS Mid Essex CCG 0.62%
NHS East Surrey CCG 0.61%
NHS Swindon CCG 0.61%
NHS Chiltern CCG 0.56%
NHS North West Surrey CCG 0.53%
NHS Surrey Downs CCG 0.52%
NHS North Hampshire CCG 0.46%
0.0% 0.1% 0.2% 0.3% 0.4% 0.5% 0.6% 0.7% 0.8% 0.9%
67 CVD: Primary Care Intelligence Packs Heart failure prevalence by GP practice
GP practice CCG
SOUTHVIEW MEDICAL PRACTICE H81041 1.0% SHEPPERTON MEDICAL PRACTICE H81004 0.8% WEY FAMILY PRACTICE H81050 0.8% STUDHOLME MEDICAL CENTRE H81009 0.7% HERSHAM SURGERY H81065 0.7% • 1,947 people with diagnosed heart ST DAVID'S FAMILY PRACTICE H81087 0.7% STAINES THAMESIDE MEDICAL H81079 0.6% failure in NHS North West Surrey SUNBURY GROUP PRACTICE H81003 0.6% GROVE MEDICAL CENTRE H81066 0.6% CCG THE ORCHARD SURGERY H81632 0.6% STAINES HEALTH GROUP H81134 0.6% • GP practice range: 0.2% to 1.0% SUNNY MEED SURGERY H81019 0.6% VIRGINIA WATER MEDICAL PRACTICE H81111 0.6% ABBEY PRACTICE H81033 0.5% ST JOHN'S FAMILY PRACTICE H81025 0.5% CHURCH STREET PRACTICE H81073 0.5% CROUCH OAK FAMILY PRACTICE H81042 0.5% DR S MORCOS H81131 0.5% BRIDGE PRACTICE H81054 0.5% UPPER HALLIFORD MEDICAL CENTRE H81642 0.5% GOLDSWORTH PARK HEALTH CENTRE H81024 0.5% HEATHCOT MEDICAL PRACTICE H81032 0.5% FORDBRIDGE MEDICAL CENTRE H81057 0.5% PARISHES BRIDGE MED.PRACT H81036 0.5% FORT HOUSE SURGERY H81020 0.5% PIRBRIGHT SURGERY H81129 0.5% MADEIRA MEDICAL H81034 0.5% STANWELL ROAD SURGERY H81104 0.4% HILLVIEW MEDICAL CENTRE H81061 0.4% ROWAN TREE PRACTICE H81007 0.4% ASHLEY MEDICAL PRACTICE H81663 0.4% DR DM NGUYEN H81095 0.4% KNOWLE GREEN MEDICAL H81002 0.4% HYTHE MEDICAL CENTRE SURGERY H81122 0.4% THE RED PRACTICE WALTON H81094 0.3% NEW OTTERSHAW SURGERY H81658 0.3% CHOBHAM & WEST END MEDICAL PRACTICE H81015 0.3% DR R J POOL H81664 0.3% MAYBURY SURGERY H81643 0.3% THE PRACTICE COLLEGE ROAD H81641 0.3% SHEERWATER HEALTH CENTRE H81123 0.2% ASHFORD HEALTH CENTRE Y02688 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 Guildford And Waverley CCG 88.8% • 392 people with heart failure* with LVSD in NHS North West Surrey CCG • 333 (84.9%) people treated with ACE- I or ARB NHS North West Surrey CCG 84.9% • 59 (15.1%) people who are exceptions • 0 (0%) additional people who are not treated with ACE-I or ARB NHS Surrey Downs CCG 82.1%
England 84.7%
0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator HF003 denominator plus exceptions
69 CVD: Primary Care Intelligence Packs Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who are treated with ACE-I / ARB by CCG Comparison with demographically similar CCGs Treatment No treatment Exceptions reported
NHS Bromley CCG 90.7%
NHS Chiltern CCG 87.7%
NHS Basildon and Brentwood CCG 86.9%
NHS North Hampshire CCG 85.3%
NHS Swindon CCG 85.3%
NHS South Gloucestershire CCG 85.3%
NHS North West Surrey CCG 84.9%
NHS Mid Essex CCG 82.9%
NHS Horsham and Mid Sussex CCG 82.6%
NHS Surrey Downs CCG 82.1%
NHS East Surrey CCG 81.5%
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
ST JOHN'S FAMILY PRACTICE H81025 2 SHEPPERTON MEDICAL PRACTICE H81004 3 DR S MORCOS H81131 4 FORT HOUSE SURGERY H81020 2 CHURCH STREET PRACTICE H81073 2 • in total, including exceptions, there ST DAVID'S FAMILY PRACTICE H81087 2 ABBEY PRACTICE H81033 5 are 59 people who are not treated HILLVIEW MEDICAL CENTRE H81061 3 STAINES HEALTH GROUP H81134 11 with ACE-I or ARB FORDBRIDGE MEDICAL CENTRE H81057 1 THE PRACTICE COLLEGE ROAD H81641 1 • GP practice range: 0.0% to 40.0% THE RED PRACTICE WALTON H81094 2 BRIDGE PRACTICE H81054 3 STUDHOLME MEDICAL CENTRE H81009 5 WEY FAMILY PRACTICE H81050 2 UPPER HALLIFORD MEDICAL CENTRE H81642 1 SOUTHVIEW MEDICAL PRACTICE H81041 8 MADEIRA MEDICAL H81034 1 HEATHCOT MEDICAL PRACTICE H81032 1 KNOWLE GREEN MEDICAL H81002 SUNBURY GROUP PRACTICE H81003 ROWAN TREE PRACTICE H81007 CHOBHAM & WEST END MEDICAL PRACTICE H81015 SUNNY MEED SURGERY H81019 GOLDSWORTH PARK HEALTH CENTRE H81024 PARISHES BRIDGE MED.PRACT H81036 CROUCH OAK FAMILY PRACTICE H81042 HERSHAM SURGERY H81065 GROVE MEDICAL CENTRE H81066 STAINES THAMESIDE MEDICAL H81079 DR DM NGUYEN H81095 STANWELL ROAD SURGERY H81104 VIRGINIA WATER MEDICAL PRACTICE H81111 HYTHE MEDICAL CENTRE SURGERY H81122 SHEERWATER HEALTH CENTRE H81123 PIRBRIGHT SURGERY H81129 MAYBURY SURGERY H81643 NEW OTTERSHAW SURGERY H81658 ASHLEY MEDICAL PRACTICE H81663 DR R J POOL H81664 ASHFORD HEALTH CENTRE Y02688 THE ORCHARD SURGERY H81632 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
71 CVD: Primary Care Intelligence Packs Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who are treated with ACE-I / ARB and BB by CCG Comparison with CCGs in the STP Treatment No treatment Exceptions reported
NHS North West Surrey CCG 82.9% • 333 people with heart failure* with LVSD treated with ACE-I/ARB in NHS North West Surrey CCG • 276 (82.9%) people treated with ACE- I/ARB and BB NHS Guildford And Waverley CCG 75.9% • 46 (13.8%) people who are exceptions • 11 (3.3%) additional people who are not treated with ACE-I/ARB and BB NHS Surrey Downs CCG 71.2%
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 Bromley CCG 87.9%
NHS North West Surrey CCG 82.9%
NHS Basildon and Brentwood CCG 82.3%
NHS South Gloucestershire CCG 81.3%
NHS East Surrey CCG 77.8%
NHS Chiltern CCG 77.3%
NHS Horsham and Mid Sussex CCG 76.9%
NHS North Hampshire CCG 74.2%
NHS Mid Essex CCG 72.9%
NHS Swindon CCG 71.2%
NHS Surrey Downs CCG 71.2%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
73 CVD: Primary Care Intelligence Packs Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who are not treated with ACE-I / ARB and BB by GP practice
No treatment Exceptions reported
ROWAN TREE PRACTICE H81007 2 FORT HOUSE SURGERY H81020 2 SHEERWATER HEALTH CENTRE H81123 2 THE PRACTICE COLLEGE ROAD H81641 2 ASHFORD HEALTH CENTRE Y02688 1 • in total, including exceptions, there DR S MORCOS H81131 3 ST JOHN'S FAMILY PRACTICE H81025 1 are 57 people who are not treated HERSHAM SURGERY H81065 2 UPPER HALLIFORD MEDICAL CENTRE H81642 2 with ACE-I or ARB SUNNY MEED SURGERY H81019 1 GOLDSWORTH PARK HEALTH CENTRE H81024 1 • GP practice range: 0.0% to 66.7% PARISHES BRIDGE MED.PRACT H81036 2 DR DM NGUYEN H81095 1 PIRBRIGHT SURGERY H81129 1 DR R J POOL H81664 1 ABBEY PRACTICE H81033 3 MADEIRA MEDICAL H81034 2 GROVE MEDICAL CENTRE H81066 1 STAINES HEALTH GROUP H81134 7 STUDHOLME MEDICAL CENTRE H81009 5 SOUTHVIEW MEDICAL PRACTICE H81041 9 BRIDGE PRACTICE H81054 2 SUNBURY GROUP PRACTICE H81003 1 THE RED PRACTICE WALTON H81094 1 CROUCH OAK FAMILY PRACTICE H81042 1 WEY FAMILY PRACTICE H81050 1 KNOWLE GREEN MEDICAL H81002 SHEPPERTON MEDICAL PRACTICE H81004 CHOBHAM & WEST END MEDICAL PRACTICE H81015 HEATHCOT MEDICAL PRACTICE H81032 FORDBRIDGE MEDICAL CENTRE H81057 HILLVIEW MEDICAL CENTRE H81061 CHURCH STREET PRACTICE H81073 STAINES THAMESIDE MEDICAL H81079 ST DAVID'S FAMILY PRACTICE H81087 STANWELL ROAD SURGERY H81104 VIRGINIA WATER MEDICAL PRACTICE H81111 HYTHE MEDICAL CENTRE SURGERY H81122 MAYBURY SURGERY H81643 NEW OTTERSHAW SURGERY H81658 ASHLEY MEDICAL PRACTICE H81663 THE ORCHARD SURGERY H81632 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 North West Surrey CCG 88.5% • 9,266 people with coronary heart disease* in NHS North West Surrey CCG • 8,203 (88.5%) people whose blood pressure <= 150 / 90 NHS Guildford And Waverley CCG 85.9% • 361 (3.9%) people who are exceptions • 702 (7.6%) additional people whose blood pressure is not <= 150 / 90 NHS Surrey Downs CCG 84.8%
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 Chiltern CCG 90.0%
NHS Horsham and Mid Sussex CCG 89.3%
NHS North West Surrey CCG 88.5%
NHS Swindon CCG 88.0%
NHS North Hampshire CCG 88.0%
NHS South Gloucestershire CCG 87.8%
NHS Bromley CCG 87.4%
NHS Mid Essex CCG 87.0%
NHS Basildon and Brentwood CCG 86.9%
NHS East Surrey CCG 86.6%
NHS Surrey Downs CCG 84.8%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
76 CVD: Primary Care Intelligence Packs Percentage of patients with CHD whose blood pressure reading (measured in the preceding 12 months) is not 150/90 mmHg or less by GP practice
Not below 150/90 Exceptions reported
STAINES THAMESIDE MEDICAL H81079 41 STANWELL ROAD SURGERY H81104 42 SUNBURY GROUP PRACTICE H81003 83 SHEPPERTON MEDICAL PRACTICE H81004 72 SUNNY MEED SURGERY H81019 35 • in total, including exceptions, there THE PRACTICE COLLEGE ROAD H81641 13 ASHFORD HEALTH CENTRE Y02688 13 are 1,063 people whose blood ASHLEY MEDICAL PRACTICE H81663 8 CROUCH OAK FAMILY PRACTICE H81042 58 pressure is not <= 150 / 90 ST DAVID'S FAMILY PRACTICE H81087 50 VIRGINIA WATER MEDICAL PRACTICE H81111 18 • GP practice range: 3.1% to 27.2% THE ORCHARD SURGERY H81632 15 ROWAN TREE PRACTICE H81007 28 CHOBHAM & WEST END MEDICAL PRACTICE H81015 32 GROVE MEDICAL CENTRE H81066 39 WEY FAMILY PRACTICE H81050 34 KNOWLE GREEN MEDICAL H81002 18 MAYBURY SURGERY H81643 5 DR S MORCOS H81131 9 SOUTHVIEW MEDICAL PRACTICE H81041 24 CHURCH STREET PRACTICE H81073 31 STAINES HEALTH GROUP H81134 38 UPPER HALLIFORD MEDICAL CENTRE H81642 10 FORDBRIDGE MEDICAL CENTRE H81057 19 HERSHAM SURGERY H81065 28 BRIDGE PRACTICE H81054 24 HEATHCOT MEDICAL PRACTICE H81032 36 THE RED PRACTICE WALTON H81094 17 HILLVIEW MEDICAL CENTRE H81061 24 GOLDSWORTH PARK HEALTH CENTRE H81024 24 ABBEY PRACTICE H81033 24 ST JOHN'S FAMILY PRACTICE H81025 27 PIRBRIGHT SURGERY H81129 6 STUDHOLME MEDICAL CENTRE H81009 40 SHEERWATER HEALTH CENTRE H81123 4 NEW OTTERSHAW SURGERY H81658 11 PARISHES BRIDGE MED.PRACT H81036 22 MADEIRA MEDICAL H81034 15 FORT HOUSE SURGERY H81020 16 DR R J POOL H81664 3 HYTHE MEDICAL CENTRE SURGERY H81122 3 DR DM NGUYEN H81095 4 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%
STAINES THAMESIDE MEDICAL 30
STANWELL ROAD SURGERY 28
THE PRACTICE COLLEGE ROAD 8 • using the GP cluster method of ASHLEY MEDICAL PRACTICE 5 calculating potential gains, if each ASHFORD HEALTH CENTRE 7 practice was to achieve as well as the SHEPPERTON MEDICAL PRACTICE 36 upper quartile of its national cluster, then an additional 336 people would SUNNY MEED SURGERY 17 be treated SUNBURY GROUP PRACTICE 37
THE ORCHARD SURGERY 8
VIRGINIA WATER MEDICAL PRACTICE 9
HEATHCOT MEDICAL PRACTICE 0
ST JOHN'S FAMILY PRACTICE
NEW OTTERSHAW SURGERY
MADEIRA MEDICAL
STUDHOLME MEDICAL CENTRE
PARISHES BRIDGE MED.PRACT
DR R J POOL
FORT HOUSE SURGERY
HYTHE MEDICAL CENTRE SURGERY
DR DM NGUYEN 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 North West Surrey CCG 92.9% • 9,266 people with coronary heart disease* in NHS North West Surrey CCG • 8,605 (92.9%) people who are taking aspirin, an alternative anti-platelet NHS Guildford And Waverley CCG 91.5% therapy, or an anti-coagulant • 357 (3.9%) people who are exceptions • 304 (3.3%) additional people who are NHS Surrey Downs CCG 90.8% not taking aspirin, an alternative anti- platelet therapy, or an anti-coagulant
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 Chiltern CCG 93.1%
NHS Bromley CCG 93.0%
NHS North West Surrey CCG 92.9%
NHS South Gloucestershire CCG 92.8%
NHS North Hampshire CCG 92.1%
NHS Horsham and Mid Sussex CCG 91.7%
NHS East Surrey CCG 91.1%
NHS Swindon CCG 90.9%
NHS Surrey Downs CCG 90.8%
NHS Basildon and Brentwood CCG 90.3%
NHS Mid Essex CCG 90.0%
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
CROUCH OAK FAMILY PRACTICE H81042 49 UPPER HALLIFORD MEDICAL CENTRE H81642 11 STAINES THAMESIDE MEDICAL H81079 18 CHOBHAM & WEST END MEDICAL PRACTICE H81015 30 SHEPPERTON MEDICAL PRACTICE H81004 48 • in total, including exceptions, there KNOWLE GREEN MEDICAL H81002 17 ST DAVID'S FAMILY PRACTICE H81087 37 are 661 people are not taking aspirin, HILLVIEW MEDICAL CENTRE H81061 28 GOLDSWORTH PARK HEALTH CENTRE H81024 26 an alternative anti-platelet therapy, or PARISHES BRIDGE MED.PRACT H81036 27 WEY FAMILY PRACTICE H81050 23 an anti-coagulant STANWELL ROAD SURGERY H81104 16 • GP practice range: 0.0% to 12.0% FORT HOUSE SURGERY H81020 20 HEATHCOT MEDICAL PRACTICE H81032 30 STAINES HEALTH GROUP H81134 26 SHEERWATER HEALTH CENTRE H81123 4 HERSHAM SURGERY H81065 19 BRIDGE PRACTICE H81054 18 VIRGINIA WATER MEDICAL PRACTICE H81111 9 ABBEY PRACTICE H81033 19 THE ORCHARD SURGERY H81632 7 FORDBRIDGE MEDICAL CENTRE H81057 11 SUNBURY GROUP PRACTICE H81003 30 CHURCH STREET PRACTICE H81073 15 THE RED PRACTICE WALTON H81094 10 MADEIRA MEDICAL H81034 12 DR S MORCOS H81131 4 ROWAN TREE PRACTICE H81007 11 DR DM NGUYEN H81095 6 STUDHOLME MEDICAL CENTRE H81009 23 ST JOHN'S FAMILY PRACTICE H81025 14 SUNNY MEED SURGERY H81019 9 NEW OTTERSHAW SURGERY H81658 6 GROVE MEDICAL CENTRE H81066 12 DR R J POOL H81664 2 HYTHE MEDICAL CENTRE SURGERY H81122 3 PIRBRIGHT SURGERY H81129 2 ASHFORD HEALTH CENTRE Y02688 2 SOUTHVIEW MEDICAL PRACTICE H81041 5 MAYBURY SURGERY H81643 1 ASHLEY MEDICAL PRACTICE H81663 1 THE PRACTICE COLLEGE ROAD H81641 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 North West Surrey CCG England 800
700 • in NHS North West Surrey CCG, the hospital admission rate for coronary heart disease in 2015/16 was 524.3 600 (1,666) 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 North West Surrey CCG England 250
• in NHS North West Surrey CCG, the hospital admission rate for stroke in 200 2015/16 was 155.3 (509) 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 North West Surrey CCG England
159.8% Angina 136.8% • The risk of a stroke was 68.4% higher and the risk of a heart attack was 111.2% 111.2% higher compared to people Heart Attack 108.6% without diabetes. The risk of a major amputation was 522.9% higher. 183.3% Heart failure 150.0%
68.4% Stroke 81.3%
522.9% Major amputation 445.8%
1026.7% Minor amputation 753.5%
375.1% RRT 293.0%
0% 200% 400% 600% 800% 1000% 1200% Note: This slide uses data from the National Diabetes Audit (NDA)
85 CVD: Primary Care Intelligence Packs Deaths from coronary heart disease, under 75s
NHS North West Surrey CCG England 90
80 • in NHS North West Surrey CCG, the early mortality rate for coronary heart 70 disease in 2013-15 was 29.8, compared to 40.6 for England
60
50
40
30 Age Age standardised (per rate 1000,000) 20
10
0 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11 2010-12 2011-13 2012-14 2013-15
Source: Office for National Statistics (ONS) mortality data 2002 - 2015
86 CVD: Primary Care Intelligence Packs Deaths from stroke, under 75s
NHS North West Surrey CCG England 30
• in NHS North West Surrey CCG, the 25 early mortality rate for stroke in 2013- 15 was 10.1, 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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