CVD: Primary Care Intelligence Packs NHS Greater Huddersfield 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 Greater Huddersfield CCG are: NHS Telford and Wrekin CCG NHS Dartford, Gravesham and Swanley CCG NHS Warwickshire North CCG NHS Medway CCG NHS Calderdale CCG NHS Hartlepool and Stockton-on-Tees CCG NHS Warrington CCG NHS Redditch and Bromsgrove CCG NHS Tameside and Glossop CCG NHS Doncaster 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 Doncaster CCG 22.1%

NHS Tameside and Glossop CCG 21.9% • prevalence of 18.7% in NHS Greater Huddersfield CCG NHS Calderdale CCG 20.4%

NHS Medway CCG 20.1%

NHS Telford and Wrekin CCG 20.1%

NHS Hartlepool and Stockton-on-Tees CCG 19.3%

NHS Warwickshire North CCG 18.7%

NHS Greater Huddersfield CCG 18.7% Note: It has been found that the proportion of patients recorded as smokers correlates well NHS Dartford, Gravesham and Swanley CCG 17.2% with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, NHS Redditch and Bromsgrove CCG 17.2% http://bmjopen.bmj.com/content/4/7/e005217.abs tract

NHS Warrington CCG 16.7% Definition: denominator of QOF clinical indicator SMOKE004 ( number of patients 15+ who are 0% 5% 10% 15% 20% 25% recorded as current smokers) divided by GP practice’s estimated number of patients 15+

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

GP Practice CCG

THE WHITEHOUSE CENTRE B85659 40.9% WOODHOUSE HILL SURGERY B85048 31.0% NEWSOME SURGERY B85037 27.3% DR GLENCROSS B85058 26.0% PADDOCK AND LONGWOOD FAMILY PRACTICE B85042 25.6% • 37,662 people who are recorded as DR BOULTON AND PARTNERS B85036 24.6% smokers in NHS Greater Huddersfield THE GRANGE GROUP PRACTICE B85028 24.4% THE JUNCTION SURGERY B85660 23.7% CCG THE WATERLOO PRACTICE B85024 22.4% LOCKWOOD SURGERY B85641 22.2% • GP practice range: 10.3% to 40.9% CROSLAND MOOR SURGERY Y04266 22.1% THE ALMONDBURY SURGERY B85023 21.3% DALTON SURGERY B85010 20.5% MARSH SURGERY B85623 20.4% FIELDHEAD SURGERY B85051 20.4% MELTHAM ROAD SURGERY B85016 20.2% DR GILKAR B85638 20.2% COLNE VALLEY FAMILY DOCTORS B85011 19.5% SLAITHWAITE HEALTH CENTRE B85059 19.1% COLNE VALLEY GROUP PRACTICE B85054 19.0% DR KHALIQ B85634 18.3% DR HANDA & PARTNER B85611 17.4% THORNTON LODGE SURGERY B85044 16.4% UNIVERSITY HEALTH CENTRE B85062 16.4% MELTHAM GROUP PRACTICE B85032 16.3% MELTHAM VILLAGE SURGERY B85644 16.3% LEPTON AND KIRKHEATON SURGERIES B85031 16.2% DR AHMED & PARTNERS B85614 15.8% DR EDARA & PARTNER B85060 15.3% THE LINDLEY VILLAGE SURG. B85033 15.3% HONLEY SURGERY B85022 14.8% THE LINDLEY GROUP PRACT. B85027 14.8% WESTBOURNE SURGERY B85636 14.2% Note: This method is thought to be a reasonably ELMWOOD FAMILY DOCTORS B85006 13.8% robust method in estimating smoking prevalence DEARNE VALLEY HEALTH CENTRE B85002 13.7% for the majority of GP practices. However, SKELMANTHORPE FAMILY DOCTORS B85061 13.3% OAKLANDS HEALTH CENTRE B85610 12.5% caution is advised for extreme estimates of KIRKBURTON HEALTH CENTRE B85026 12.2% smoking prevalence and those with high SHEPLEY HEALTH CENTRE B85005 10.3% numbers of smoking status not recorded and 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 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 Bradford Districts CCG 0.62

NHS North Kirklees CCG 0.61 • the ratio of those diagnosed with NHS Wakefield CCG 0.60 hypertension versus those expected to have hypertension is 0.57. This NHS Airedale, Wharfedale and Craven CCG 0.59 compares to 0.59 for England

NHS Harrogate And Rural District CCG 0.59 • this suggests that 57% of people with hypertension have been diagnosed NHS Leeds South And East CCG 0.58

NHS Calderdale CCG 0.58

NHS Leeds North CCG 0.57

NHS Greater Huddersfield CCG 0.57

NHS Bradford City CCG 0.56

NHS Leeds West CCG 0.55

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

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

NHS Warwickshire North CCG 0.62

NHS Hartlepool and Stockton-on-Tees CCG 0.61

NHS Tameside and Glossop CCG 0.61

NHS Dartford, Gravesham and Swanley CCG 0.60

NHS Redditch and Bromsgrove CCG 0.60

NHS Medway CCG 0.60

NHS Warrington CCG 0.59

NHS Doncaster CCG 0.59

NHS Telford and Wrekin CCG 0.58

NHS Calderdale CCG 0.58

NHS Greater Huddersfield CCG 0.57

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

THORNTON LODGE SURGERY B85044 0.73 THE WATERLOO PRACTICE B85024 0.67 DR HANDA & PARTNER B85611 0.65 DR BOULTON AND PARTNERS B85036 0.65 KIRKBURTON HEALTH CENTRE B85026 0.61 • it is estimated that there are 23,413 FIELDHEAD SURGERY B85051 0.61 ELMWOOD FAMILY DOCTORS B85006 0.61 people with undiagnosed SKELMANTHORPE FAMILY DOCTORS B85061 0.60 PADDOCK AND LONGWOOD FAMILY PRACTICE B85042 0.59 hypertension in NHS Greater MELTHAM GROUP PRACTICE B85032 0.58 Huddersfield CCG LEPTON AND KIRKHEATON SURGERIES B85031 0.57 DR AHMED & PARTNERS B85614 0.57 • GP practice range of observed to LOCKWOOD SURGERY B85641 0.56 THE LINDLEY GROUP PRACT. B85027 0.56 expected hypertension prevalence COLNE VALLEY GROUP PRACTICE B85054 0.56 THE ALMONDBURY SURGERY B85023 0.55 0.1 to 0.73 THE LINDLEY VILLAGE SURG. B85033 0.54 THE JUNCTION SURGERY B85660 0.53 HONLEY SURGERY B85022 0.53 SHEPLEY HEALTH CENTRE B85005 0.53 DR KHALIQ B85634 0.53 DEARNE VALLEY HEALTH CENTRE B85002 0.52 THE GRANGE GROUP PRACTICE B85028 0.52 DR GILKAR B85638 0.51 OAKLANDS HEALTH CENTRE B85610 0.50 MELTHAM VILLAGE SURGERY B85644 0.50 NEWSOME SURGERY B85037 0.50 SLAITHWAITE HEALTH CENTRE B85059 0.49 COLNE VALLEY FAMILY DOCTORS B85011 0.48 DR EDARA & PARTNER B85060 0.47 WOODHOUSE HILL SURGERY B85048 0.47 MARSH SURGERY B85623 0.47 WESTBOURNE SURGERY B85636 0.45 DALTON SURGERY B85010 0.44 MELTHAM ROAD SURGERY B85016 0.43 DR GLENCROSS B85058 0.42 THE WHITEHOUSE CENTRE B85659 0.26 UNIVERSITY HEALTH CENTRE B85062 0.10 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 Harrogate And Rural District CCG 82.4%

NHS Wakefield CCG 81.7% • 31,873 people with hypertension NHS North Kirklees CCG 81.3% (diagnosed)* in NHS Greater Huddersfield CCG NHS Calderdale CCG 81.2% • 25,766 (80.8%) people whose blood pressure is <= 150/90 NHS Greater Huddersfield CCG 80.8% • 1,076 (3.4%) people who are

NHS Leeds West CCG 80.4% excepted from optimal control • 5,031 (15.8%) additional people NHS Leeds South And East CCG 79.7% whose blood pressure is not <= 150/90 NHS Bradford Districts CCG 79.4%

NHS Airedale, Wharfedale and Craven CCG 78.9%

NHS Leeds North CCG 78.4%

NHS Bradford City CCG 76.2%

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 Doncaster CCG 83.5%

NHS Warwickshire North CCG 82.3%

NHS Hartlepool and Stockton-on-Tees CCG 82.2%

NHS Redditch and Bromsgrove CCG 81.9%

NHS Tameside and Glossop CCG 81.4%

NHS Calderdale CCG 81.2%

NHS Greater Huddersfield CCG 80.8%

NHS Dartford, Gravesham and Swanley CCG 80.0%

NHS Warrington CCG 79.1%

NHS Telford and Wrekin CCG 78.8%

NHS Medway CCG 78.0%

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

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

No treatment Exceptions reported

THE WHITEHOUSE CENTRE B85659 21 THE LINDLEY VILLAGE SURG. B85033 259 COLNE VALLEY FAMILY DOCTORS B85011 225 CROSLAND MOOR SURGERY Y04266 173 MARSH SURGERY B85623 89 • in total, including exceptions, there THORNTON LODGE SURGERY B85044 68 THE GRANGE GROUP PRACTICE B85028 519 are 6,107 people whose blood WOODHOUSE HILL SURGERY B85048 92 pressure is not <= 150/90 UNIVERSITY HEALTH CENTRE B85062 23 DR GLENCROSS B85058 72 • GP practice range: 3.4% to 44.7% DR KHALIQ B85634 83 NEWSOME SURGERY B85037 200 DALTON SURGERY B85010 175 DR GILKAR B85638 141 DR BOULTON AND PARTNERS B85036 248 FIELDHEAD SURGERY B85051 242 SHEPLEY HEALTH CENTRE B85005 182 THE ALMONDBURY SURGERY B85023 177 OAKLANDS HEALTH CENTRE B85610 208 MELTHAM GROUP PRACTICE B85032 191 THE LINDLEY GROUP PRACT. B85027 267 LOCKWOOD SURGERY B85641 137 MELTHAM ROAD SURGERY B85016 171 THE WATERLOO PRACTICE B85024 291 THE JUNCTION SURGERY B85660 128 DR AHMED & PARTNERS B85614 79 KIRKBURTON HEALTH CENTRE B85026 199 SLAITHWAITE HEALTH CENTRE B85059 85 LEPTON AND KIRKHEATON SURGERIES B85031 185 PADDOCK AND LONGWOOD FAMILY PRACTICE B85042 182 SKELMANTHORPE FAMILY DOCTORS B85061 223 DR EDARA & PARTNER B85060 85 WESTBOURNE SURGERY B85636 68 HONLEY SURGERY B85022 170 DEARNE VALLEY HEALTH CENTRE B85002 71 COLNE VALLEY GROUP PRACTICE B85054 87 ELMWOOD FAMILY DOCTORS B85006 240 MELTHAM VILLAGE SURGERY B85644 34 DR HANDA & PARTNER B85611 17 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 Bradford City CCG 87.0%

NHS Wakefield CCG 78.4% • 110 people with a new diagnosis* of NHS Bradford Districts CCG 76.4% hypertension with a CVD risk of 20% or higher in NHS Greater NHS Leeds West CCG 75.2% Huddersfield CCG • 64 (58.2%) people who are currently NHS Leeds South And East CCG 73.2% treated with statins

NHS Calderdale CCG 71.7% • 43 (39.1%) people who are exempted from treatment with statins NHS North Kirklees CCG 68.8% • 3 (2.7%) additional people who are not currently treated with statins NHS Leeds North CCG 67.9%

NHS Harrogate And Rural District CCG 65.3%

NHS Airedale, Wharfedale and Craven CCG 61.8%

NHS Greater Huddersfield CCG 58.2%

England 66.5%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% *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 Warwickshire North CCG 80.8%

NHS Telford and Wrekin CCG 78.3%

NHS Hartlepool and Stockton-on-Tees CCG 75.9%

NHS Doncaster CCG 74.6%

NHS Tameside and Glossop CCG 74.4%

NHS Dartford, Gravesham and Swanley CCG 74.1%

NHS Calderdale CCG 71.7%

NHS Medway CCG 67.1%

NHS Redditch and Bromsgrove CCG 64.8%

NHS Warrington CCG 61.5%

NHS Greater Huddersfield CCG 58.2%

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

DR BOULTON AND PARTNERS B85036 1 THE LINDLEY VILLAGE SURG. B85033 3 SHEPLEY HEALTH CENTRE B85005 2 DALTON SURGERY B85010 2 MELTHAM GROUP PRACTICE B85032 2 • in total, including exceptions, there MARSH SURGERY B85623 2 THE JUNCTION SURGERY B85660 2 are 46 people who are not treated FIELDHEAD SURGERY B85051 7 with statins THE ALMONDBURY SURGERY B85023 3 MELTHAM VILLAGE SURGERY B85644 3 • GP practice range: 0.0% to 100.0% THE GRANGE GROUP PRACTICE B85028 5 THE LINDLEY GROUP PRACT. B85027 2 LEPTON AND KIRKHEATON SURGERIES B85031 1 NEWSOME SURGERY B85037 1 DR AHMED & PARTNERS B85614 1 LOCKWOOD SURGERY B85641 1 SKELMANTHORPE FAMILY DOCTORS B85061 3 KIRKBURTON HEALTH CENTRE B85026 1 ELMWOOD FAMILY DOCTORS B85006 1 MELTHAM ROAD SURGERY B85016 1 PADDOCK AND LONGWOOD FAMILY PRACTICE B85042 1 OAKLANDS HEALTH CENTRE B85610 1 DEARNE VALLEY HEALTH CENTRE B85002 COLNE VALLEY FAMILY DOCTORS B85011 HONLEY SURGERY B85022 THE WATERLOO PRACTICE B85024 THORNTON LODGE SURGERY B85044 WOODHOUSE HILL SURGERY B85048 COLNE VALLEY GROUP PRACTICE B85054 DR GLENCROSS B85058 SLAITHWAITE HEALTH CENTRE B85059 DR EDARA & PARTNER B85060 DR HANDA & PARTNER B85611 WESTBOURNE SURGERY B85636 DR GILKAR B85638 CROSLAND MOOR SURGERY Y04266 THE WHITEHOUSE CENTRE B85659 DR KHALIQ B85634 UNIVERSITY HEALTH CENTRE B85062 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 Airedale, Wharfedale and Craven CCG 0.77

NHS Harrogate And Rural District CCG 0.76 • the ratio of those diagnosed with atrial NHS Wakefield CCG 0.74 fibrillation versus those expected to have atrial fibrillation is 0.66. This NHS Leeds South And East CCG 0.70 compares to 0.7 for England • this suggests that 66% of people with NHS Leeds West CCG 0.69 atrial fibrillation have been diagnosed.

NHS Leeds North CCG 0.69

NHS Bradford Districts CCG 0.68

NHS Greater Huddersfield CCG 0.66

NHS North Kirklees CCG 0.66

NHS Calderdale CCG 0.65 Note: This slide compares the prevalence of atrial fibrillation recorded in QOF in 2015/16 to NHS Bradford City CCG 0.41 the estimated prevalence of atrial fibrillation, taken from National Cardiovascular Intelligence Network estimates produced in 2017. The estimates were developed by applying age-sex specific prevalence rates as reported by Norberg England 0.70 et al (2013) to GP population estimates from 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 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 Hartlepool and Stockton-on-Tees CCG 0.78

NHS Doncaster CCG 0.77

NHS Tameside and Glossop CCG 0.70

NHS Redditch and Bromsgrove CCG 0.69

NHS Telford and Wrekin CCG 0.69

NHS Dartford, Gravesham and Swanley CCG 0.68

NHS Warrington CCG 0.67

NHS Greater Huddersfield CCG 0.66

NHS Medway CCG 0.66

NHS Warwickshire North CCG 0.65

NHS Calderdale 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

MELTHAM VILLAGE SURGERY B85644 0.9 DEARNE VALLEY HEALTH CENTRE B85002 0.8 SHEPLEY HEALTH CENTRE B85005 0.8 HONLEY SURGERY B85022 0.8 THE ALMONDBURY SURGERY B85023 0.8 • it is estimated that there are 5,793 THE WATERLOO PRACTICE B85024 0.8 KIRKBURTON HEALTH CENTRE B85026 0.8 people with undiagnosed atrial MELTHAM GROUP PRACTICE B85032 0.8 SKELMANTHORPE FAMILY DOCTORS B85061 0.8 fibrillation in NHS Greater ELMWOOD FAMILY DOCTORS B85006 0.7 Huddersfield CCG THE LINDLEY GROUP PRACT. B85027 0.7 DR BOULTON AND PARTNERS B85036 0.7 • GP practice range of observed to WOODHOUSE HILL SURGERY B85048 0.7 FIELDHEAD SURGERY B85051 0.7 expected atrial fibrillation prevalence SLAITHWAITE HEALTH CENTRE B85059 0.7 DR EDARA & PARTNER B85060 0.7 0.2 to 0.9 OAKLANDS HEALTH CENTRE B85610 0.7 LOCKWOOD SURGERY B85641 0.7 DALTON SURGERY B85010 0.6 MELTHAM ROAD SURGERY B85016 0.6 THE GRANGE GROUP PRACTICE B85028 0.6 LEPTON AND KIRKHEATON SURGERIES B85031 0.6 THE LINDLEY VILLAGE SURG. B85033 0.6 NEWSOME SURGERY B85037 0.6 DR GLENCROSS B85058 0.6 WESTBOURNE SURGERY B85636 0.6 DR GILKAR B85638 0.6 THE JUNCTION SURGERY B85660 0.6 PADDOCK AND LONGWOOD FAMILY PRACTICE B85042 0.5 CROSLAND MOOR SURGERY Y04266 0.5 DR HANDA & PARTNER B85611 0.4 DR KHALIQ B85634 0.4 COLNE VALLEY GROUP PRACTICE B85054 0.3 UNIVERSITY HEALTH CENTRE B85062 0.3 MARSH SURGERY B85623 0.3 THE WHITEHOUSE CENTRE B85659 0.3 THORNTON LODGE SURGERY B85044 0.2 DR AHMED & PARTNERS B85614 0.2 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Ratio

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

NHS Wakefield CCG 79.7%

NHS Bradford Districts CCG 79.5% • 3,097 people with atrial fibrillation* with a CHA2DS2-VASc score >= 2 in NHS Harrogate And Rural District CCG 77.0% NHS Greater Huddersfield CCG • 2,305 (74.4%) people treated with NHS Calderdale CCG 76.7% anti-coagulation therapy • 320 (10.3%) people who are NHS Leeds North CCG 76.6% exceptions • 472 (15.2%) additional people with a NHS Leeds West CCG 76.3% recorded CHA2DS2-VASc score >= 2 NHS North Kirklees CCG 75.5% who are not treated

NHS Greater Huddersfield CCG 74.4%

NHS Leeds South And East CCG 74.3%

NHS Airedale, Wharfedale and Craven CCG 74.1%

NHS Bradford City CCG 72.2%

England 77.9%

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

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

NHS Doncaster CCG 83.2%

NHS Medway CCG 82.0%

NHS Dartford, Gravesham and Swanley CCG 81.2%

NHS Tameside and Glossop CCG 80.9%

NHS Telford and Wrekin CCG 78.9%

NHS Warwickshire North CCG 77.5%

NHS Calderdale CCG 76.7%

NHS Hartlepool and Stockton-on-Tees CCG 76.6%

NHS Warrington CCG 76.5%

NHS Redditch and Bromsgrove CCG 75.6%

NHS Greater Huddersfield CCG 74.4%

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

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

No treatment Exceptions reported

THE WHITEHOUSE CENTRE B85659 1 SLAITHWAITE HEALTH CENTRE B85059 21 DEARNE VALLEY HEALTH CENTRE B85002 25 THE ALMONDBURY SURGERY B85023 41 CROSLAND MOOR SURGERY Y04266 17 • in total, including exceptions, there MARSH SURGERY B85623 5 LOCKWOOD SURGERY B85641 23 are 792 people with a recorded OAKLANDS HEALTH CENTRE B85610 32 CHA2DS2-VASc score >= 2 who are MELTHAM VILLAGE SURGERY B85644 18 DR GILKAR B85638 20 not treated COLNE VALLEY FAMILY DOCTORS B85011 19 PADDOCK AND LONGWOOD FAMILY PRACTICE B85042 21 • GP practice range: 0.0% to 50.0% DR EDARA & PARTNER B85060 24 THE GRANGE GROUP PRACTICE B85028 48 WOODHOUSE HILL SURGERY B85048 8 DR HANDA & PARTNER B85611 5 HONLEY SURGERY B85022 43 SKELMANTHORPE FAMILY DOCTORS B85061 46 DR GLENCROSS B85058 6 MELTHAM GROUP PRACTICE B85032 32 ELMWOOD FAMILY DOCTORS B85006 43 DR AHMED & PARTNERS B85614 3 WESTBOURNE SURGERY B85636 13 KIRKBURTON HEALTH CENTRE B85026 32 NEWSOME SURGERY B85037 18 THE WATERLOO PRACTICE B85024 42 THE JUNCTION SURGERY B85660 14 DR BOULTON AND PARTNERS B85036 23 COLNE VALLEY GROUP PRACTICE B85054 15 SHEPLEY HEALTH CENTRE B85005 26 THE LINDLEY GROUP PRACT. B85027 27 LEPTON AND KIRKHEATON SURGERIES B85031 23 FIELDHEAD SURGERY B85051 19 THE LINDLEY VILLAGE SURG. B85033 12 DALTON SURGERY B85010 13 MELTHAM ROAD SURGERY B85016 13 DR KHALIQ B85634 1 THORNTON LODGE SURGERY B85044 UNIVERSITY HEALTH CENTRE B85062 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% 0% -20% -40% -60% -80% -100%

UNIVERSITY HEALTH CENTRE

THE WHITEHOUSE CENTRE 1

SLAITHWAITE HEALTH CENTRE 13 • using the GP cluster method of DEARNE VALLEY HEALTH CENTRE 15 calculating potential gains, if each THE ALMONDBURY SURGERY 24 practice was to achieve as well as the CROSLAND MOOR SURGERY 10 upper quartile of its national cluster, then an additional 299 people would MARSH SURGERY 3 be treated LOCKWOOD SURGERY 12

OAKLANDS HEALTH CENTRE 17

MELTHAM VILLAGE SURGERY 9

SHEPLEY HEALTH CENTRE 7

THE WATERLOO PRACTICE 9

LEPTON AND KIRKHEATON SURGERIES 5

THE LINDLEY VILLAGE SURG. 2

THE LINDLEY GROUP PRACT. 4

FIELDHEAD SURGERY 2

DALTON SURGERY 1

MELTHAM ROAD SURGERY

DR KHALIQ

THORNTON LODGE SURGERY 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 Harrogate And Rural District CCG 87.6%

NHS Wakefield CCG 86.9% • 4,281 people with a history of stroke or TIA* in NHS Greater Huddersfield NHS Greater Huddersfield CCG 86.2% CCG • 3,691 (86.2%) people whose blood NHS Calderdale CCG 86.0% pressure is <= 150 / 90 • 141 (3.3%) people who are NHS Leeds South And East CCG 84.5% exceptions • 449 (10.5%) additional people whose NHS North Kirklees CCG 83.9% blood pressure is not <= 150 / 90 NHS Bradford Districts CCG 83.3%

NHS Leeds West CCG 83.2%

NHS Leeds North CCG 82.6%

NHS Bradford City CCG 82.1%

NHS Airedale, Wharfedale and Craven CCG 81.9%

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 Doncaster CCG 86.8%

NHS Redditch and Bromsgrove CCG 86.4%

NHS Tameside and Glossop CCG 86.4%

NHS Greater Huddersfield CCG 86.2%

NHS Calderdale CCG 86.0%

NHS Warwickshire North CCG 85.1%

NHS Hartlepool and Stockton-on-Tees CCG 84.5%

NHS Warrington CCG 83.3%

NHS Telford and Wrekin CCG 82.7%

NHS Medway CCG 82.4%

NHS Dartford, Gravesham and Swanley CCG 82.3%

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

THE WHITEHOUSE CENTRE B85659 3 THE LINDLEY VILLAGE SURG. B85033 25 MARSH SURGERY B85623 11 DALTON SURGERY B85010 25 UNIVERSITY HEALTH CENTRE B85062 1 • in total, including exceptions, there NEWSOME SURGERY B85037 26 DR AHMED & PARTNERS B85614 11 are 590 people whose blood pressure CROSLAND MOOR SURGERY Y04266 20 is not <= 150 / 90 FIELDHEAD SURGERY B85051 33 WOODHOUSE HILL SURGERY B85048 8 • GP practice range: 1.3% to 60.0% MELTHAM GROUP PRACTICE B85032 24 MELTHAM ROAD SURGERY B85016 26 COLNE VALLEY FAMILY DOCTORS B85011 19 THE JUNCTION SURGERY B85660 16 DR GILKAR B85638 13 LOCKWOOD SURGERY B85641 19 DR EDARA & PARTNER B85060 21 THE GRANGE GROUP PRACTICE B85028 34 THORNTON LODGE SURGERY B85044 3 LEPTON AND KIRKHEATON SURGERIES B85031 20 THE ALMONDBURY SURGERY B85023 17 SHEPLEY HEALTH CENTRE B85005 14 THE LINDLEY GROUP PRACT. B85027 20 DR KHALIQ B85634 4 WESTBOURNE SURGERY B85636 9 KIRKBURTON HEALTH CENTRE B85026 21 SKELMANTHORPE FAMILY DOCTORS B85061 23 OAKLANDS HEALTH CENTRE B85610 17 DEARNE VALLEY HEALTH CENTRE B85002 11 DR BOULTON AND PARTNERS B85036 13 HONLEY SURGERY B85022 20 SLAITHWAITE HEALTH CENTRE B85059 7 THE WATERLOO PRACTICE B85024 20 DR GLENCROSS B85058 4 COLNE VALLEY GROUP PRACTICE B85054 8 PADDOCK AND LONGWOOD FAMILY PRACTICE B85042 8 ELMWOOD FAMILY DOCTORS B85006 14 DR HANDA & PARTNER B85611 1 MELTHAM VILLAGE SURGERY B85644 1 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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

NHS North Kirklees CCG 93.6%

NHS Wakefield CCG 93.2% • 2,731 people with a stroke shown to be non-haemorrhagic* in NHS NHS Bradford City CCG 92.8% Greater Huddersfield CCG • 2,513 (92%) people who are taking NHS Leeds South And East CCG 92.7% an anti-platetet agent or anti- coagulant NHS Calderdale CCG 92.6% • 123 (4.5%) people who are exceptions NHS Leeds West CCG 92.2% • 95 (3.5%) additional people with no NHS Greater Huddersfield CCG 92.0% treatment

NHS Bradford Districts CCG 91.8%

NHS Leeds North CCG 91.8%

NHS Airedale, Wharfedale and Craven CCG 91.4%

NHS Harrogate And Rural District CCG 91.4%

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 Doncaster CCG 93.7%

NHS Hartlepool and Stockton-on-Tees CCG 93.7%

NHS Redditch and Bromsgrove CCG 93.2%

NHS Calderdale CCG 92.6%

NHS Tameside and Glossop CCG 92.5%

NHS Warwickshire North CCG 92.4%

NHS Warrington CCG 92.3%

NHS Greater Huddersfield CCG 92.0%

NHS Telford and Wrekin CCG 92.0%

NHS Dartford, Gravesham and Swanley CCG 91.8%

NHS Medway CCG 91.2%

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

DR KHALIQ B85634 4 DR EDARA & PARTNER B85060 19 THORNTON LODGE SURGERY B85044 2 WOODHOUSE HILL SURGERY B85048 5 THE LINDLEY GROUP PRACT. B85027 13 • in total, including exceptions, there MELTHAM ROAD SURGERY B85016 15 LEPTON AND KIRKHEATON SURGERIES B85031 13 are 218 people who are not taking an WESTBOURNE SURGERY B85636 6 anti-platelet agent or anti-coagulant COLNE VALLEY FAMILY DOCTORS B85011 8 DR GILKAR B85638 6 • GP practice range: 0.0% to 22.2% FIELDHEAD SURGERY B85051 12 MARSH SURGERY B85623 2 PADDOCK AND LONGWOOD FAMILY PRACTICE B85042 7 LOCKWOOD SURGERY B85641 7 DR BOULTON AND PARTNERS B85036 8 HONLEY SURGERY B85022 12 MELTHAM GROUP PRACTICE B85032 7 ELMWOOD FAMILY DOCTORS B85006 10 SKELMANTHORPE FAMILY DOCTORS B85061 9 THE LINDLEY VILLAGE SURG. B85033 4 THE GRANGE GROUP PRACTICE B85028 10 CROSLAND MOOR SURGERY Y04266 4 THE ALMONDBURY SURGERY B85023 5 THE WATERLOO PRACTICE B85024 10 SLAITHWAITE HEALTH CENTRE B85059 3 COLNE VALLEY GROUP PRACTICE B85054 4 SHEPLEY HEALTH CENTRE B85005 3 KIRKBURTON HEALTH CENTRE B85026 4 NEWSOME SURGERY B85037 2 DEARNE VALLEY HEALTH CENTRE B85002 2 THE JUNCTION SURGERY B85660 1 OAKLANDS HEALTH CENTRE B85610 1 DALTON SURGERY B85010 DR GLENCROSS B85058 UNIVERSITY HEALTH CENTRE B85062 DR HANDA & PARTNER B85611 DR AHMED & PARTNERS B85614 MELTHAM VILLAGE SURGERY B85644 THE WHITEHOUSE CENTRE B85659 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 Bradford City CCG 0.86

NHS Bradford Districts CCG 0.84 • 0.70 ratio of observed to expected diabetes prevalence in NHS Greater NHS Wakefield CCG 0.83 Huddersfield CCG, compared to 0.77 in England NHS North Kirklees CCG 0.83 • this suggests 70% of people have NHS Leeds South And East CCG 0.82 been diagnosed

NHS Airedale, Wharfedale and Craven CCG 0.75

NHS Leeds West CCG 0.74

NHS Leeds North CCG 0.73

NHS Calderdale CCG 0.71

NHS Harrogate And Rural District CCG 0.70

NHS Greater Huddersfield CCG 0.70 Note: This slide compares the prevalence of Diabetes recorded in QOF in 2015/16 to the expected prevalence of Diabetes in 2016 taken from the NCVIN diabetes prevalence model England 0.77 produced in 2015.

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

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

NHS Doncaster CCG 0.88

NHS Warrington CCG 0.85

NHS Medway CCG 0.85

NHS Tameside and Glossop CCG 0.85

NHS Warwickshire North CCG 0.84

NHS Telford and Wrekin CCG 0.84

NHS Redditch and Bromsgrove CCG 0.83

NHS Dartford, Gravesham and Swanley CCG 0.78

NHS Hartlepool and Stockton-on-Tees CCG 0.78

NHS Calderdale CCG 0.71

NHS Greater Huddersfield CCG 0.70

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

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

GP practice CCG

DR AHMED & PARTNERS B85614 14.1% DR KHALIQ B85634 12.9% THORNTON LODGE SURGERY B85044 12.9% DR HANDA & PARTNER B85611 10.0% MARSH SURGERY B85623 9.1% • GP practice range of observed CROSLAND MOOR SURGERY Y04266 8.7% LOCKWOOD SURGERY B85641 8.2% diabetes 0.7% to 14.1% DR EDARA & PARTNER B85060 8.2% • there are an estimated 5,145 people THE GRANGE GROUP PRACTICE B85028 8.0% MELTHAM ROAD SURGERY B85016 8.0% with undiagnosed diabetes in NHS WOODHOUSE HILL SURGERY B85048 7.5% DR GLENCROSS B85058 7.4% Greater Huddersfield CCG PADDOCK AND LONGWOOD FAMILY PRACTICE B85042 7.3% DR BOULTON AND PARTNERS B85036 7.2% NEWSOME SURGERY B85037 6.9% THE WATERLOO PRACTICE B85024 6.9% DR GILKAR B85638 6.7% DALTON SURGERY B85010 6.6% THE JUNCTION SURGERY B85660 6.3% LEPTON AND KIRKHEATON SURGERIES B85031 6.0% SHEPLEY HEALTH CENTRE B85005 5.7% THE LINDLEY GROUP PRACT. B85027 5.6% MELTHAM GROUP PRACTICE B85032 5.6% SKELMANTHORPE FAMILY DOCTORS B85061 5.6% THE LINDLEY VILLAGE SURG. B85033 5.6% COLNE VALLEY GROUP PRACTICE B85054 5.6% MELTHAM VILLAGE SURGERY B85644 5.5% FIELDHEAD SURGERY B85051 5.4% DEARNE VALLEY HEALTH CENTRE B85002 5.3% HONLEY SURGERY B85022 5.1% SLAITHWAITE HEALTH CENTRE B85059 5.1% WESTBOURNE SURGERY B85636 5.0% THE ALMONDBURY SURGERY B85023 4.9% ELMWOOD FAMILY DOCTORS B85006 4.8% COLNE VALLEY FAMILY DOCTORS B85011 4.7% OAKLANDS HEALTH CENTRE B85610 4.7% KIRKBURTON HEALTH CENTRE B85026 4.5% Note: The estimated number of undiagnosed THE WHITEHOUSE CENTRE B85659 2.7% people with diabetes has been calculated by UNIVERSITY HEALTH CENTRE B85062 0.7% multiplying the estimated prevalence rate to the 0% 2% 4% 6% 8% 10% 12% 14% 16% 2015/16 QOF list size and subtracting the number of people on the diabetes register.

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

Diabetes prevalence Undiagnosed diabetes prevalence Expected non-diabetic hyperglycaemia prevalence

NHS Bradford City CCG 10.3% 1.6% 12.6% • the estimated total prevalence of diabetes in NHS Greater Huddersfield NHS Airedale, Wharfedale and Craven CCG 6.9% 2.3% 12.6% CCG is 8.8% (diagnosed and undiagnosed) NHS Bradford Districts CCG 8.1% 1.6% 11.7% • in addition, there are an estimated NHS North Kirklees CCG 8.1% 1.6% 11.5% 11.2% of people in NHS Greater Huddersfield CCG who are at NHS Calderdale CCG 6.2% 2.5% 11.4% increased risk of developing diabetes

NHS Harrogate And Rural District CCG 5.7% 2.4% 11.9% (i.e. with non-diabetic hyperglycaemia) NHS Greater Huddersfield CCG 6.2% 2.6% 11.2% • this means that 20.0% of the population in NHS Greater NHS Wakefield CCG 7.1% 1.4% 11.1% Huddersfield CCG are estimated to NHS Leeds North CCG 6.2% 2.2% 11.2% have diabetes, or at high risk of developing of diabetes NHS Leeds South And East CCG 7.0% 1.5% 10.3%

NHS Leeds West CCG 5.1% 1.8% 9.1% Note: Prevalence estimates of non-diabetic hyperglycaemia were developed using Health Survey for England (HSE) data. Five years of HSE data were combined, 2009- 2013. The England 6.5% 1.9% 11.2% estimates take into account the age, ethnic group and estimated body mass index of the population. 0% 5% 10% 15% 20% 25% 30% These estimates were produced using the GP registered population.

46 CVD: Primary Care Intelligence Packs People with diabetes who had eight care processes by CCG 2015/16

NHS Bradford City CCG 76.9%

NHS Leeds South And East CCG 66.2% • data on care processes and treatment targets are taken from the National NHS Harrogate And Rural District CCG 65.3% Diabetes Audit (NDA) NHS Calderdale CCG 62.5% • overall practice participation in the 2015/16 audit was 81.4% in England NHS Bradford Districts CCG 60.2% • in NHS Greater Huddersfield CCG, NHS Leeds West CCG 59.8% 29 out of 40 practices (72.5%) participated in the NDA. Data is not NHS Leeds North CCG 58.6% available for the remaining practices

NHS Wakefield CCG 58.4%

NHS Airedale, Wharfedale and Craven CCG 57.3% • 48.5% of people with diabetes (of practices who participated in the NHS North Kirklees CCG 51.2% audit) had the eight recommended care processes in NHS Greater NHS Greater Huddersfield CCG 48.5% Huddersfield CCG, compared to 52.6% in England

England 52.6%

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

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

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

MELTHAM GROUP PRACTICE B85032 82.7% SKELMANTHORPE FAMILY DOCTORS B85061 79.4% DEARNE VALLEY HEALTH CENTRE B85002 78.1% LOCKWOOD SURGERY B85641 70.4% • achievement - 8 care processes: in DR BOULTON AND PARTNERS B85036 66.6% practices who provided data via the UNIVERSITY HEALTH CENTRE B85062 65.3% THE GRANGE GROUP PRACTICE B85028 64.7% NDA, between 9.0% and 82.7% of THE WATERLOO PRACTICE B85024 63.2% FIELDHEAD SURGERY B85051 62.7% patients received all 8 care processes MARSH SURGERY B85623 60.5% DR KHALIQ B85634 60.5% KIRKBURTON HEALTH CENTRE B85026 59.6% COLNE VALLEY GROUP PRACTICE B85054 54.1% • at least 4,961 people did not receive DALTON SURGERY B85010 53.6% CROSLAND MOOR SURGERY Y04266 53.3% the eight care processes SHEPLEY HEALTH CENTRE B85005 51.5% DR GLENCROSS B85058 46.6% LEPTON AND KIRKHEATON SURGERIES B85031 45.5% THE LINDLEY VILLAGE SURG. B85033 42.0% PADDOCK AND LONGWOOD FAMILY PRACTICE B85042 36.6% MELTHAM ROAD SURGERY B85016 30.5% DR AHMED & PARTNERS B85614 30.2% THE WHITEHOUSE CENTRE B85659 25.8% WOODHOUSE HILL SURGERY B85048 23.3% NEWSOME SURGERY B85037 17.6% THE LINDLEY GROUP PRACT. B85027 15.1% THORNTON LODGE SURGERY B85044 13.5% DR EDARA & PARTNER B85060 10.7% OAKLANDS HEALTH CENTRE B85610 9.0% THE JUNCTION SURGERY B85660 MELTHAM VILLAGE SURGERY B85644 DR GILKAR B85638 WESTBOURNE SURGERY B85636 DR HANDA & PARTNER B85611 SLAITHWAITE HEALTH CENTRE B85059 THE ALMONDBURY SURGERY B85023 HONLEY SURGERY B85022 COLNE VALLEY FAMILY DOCTORS B85011 ELMWOOD FAMILY DOCTORS B85006 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 Harrogate And Rural District CCG 43.0%

NHS Wakefield CCG 41.9% • 38.3% of people with diabetes (of practices who participated in the NHS Calderdale CCG 40.9% audit) met the three treatment targets

NHS Leeds West CCG 39.1% in NHS Greater Huddersfield CCG, compared to 39.0% in England NHS Bradford Districts CCG 38.4%

NHS Greater Huddersfield CCG 38.3%

NHS Leeds South And East CCG 38.2%

NHS Leeds North CCG 37.5%

NHS North Kirklees CCG 36.8%

NHS Airedale, Wharfedale and Craven CCG 34.8%

NHS Bradford City CCG 34.3%

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 AHMED & PARTNERS B85614 49.4% DR EDARA & PARTNER B85060 48.8% CROSLAND MOOR SURGERY Y04266 45.4% LEPTON AND KIRKHEATON SURGERIES B85031 44.7% • achievement - 3 treatment targets: in LOCKWOOD SURGERY B85641 44.4% practices who provided data via the MELTHAM ROAD SURGERY B85016 43.9% DR BOULTON AND PARTNERS B85036 42.5% NDA, between 15.4% and 49.4% of SKELMANTHORPE FAMILY DOCTORS B85061 42.0% SHEPLEY HEALTH CENTRE B85005 41.4% patients achieved all 3 treatment DEARNE VALLEY HEALTH CENTRE B85002 40.6% targets DALTON SURGERY B85010 40.6% THE LINDLEY GROUP PRACT. B85027 39.8% KIRKBURTON HEALTH CENTRE B85026 39.3% • at least 5,242 people did not meet the OAKLANDS HEALTH CENTRE B85610 38.2% COLNE VALLEY GROUP PRACTICE B85054 38.1% three treatment targets MELTHAM GROUP PRACTICE B85032 37.4% MARSH SURGERY B85623 36.6% FIELDHEAD SURGERY B85051 36.5% THE LINDLEY VILLAGE SURG. B85033 36.3% THE WATERLOO PRACTICE B85024 35.6% WOODHOUSE HILL SURGERY B85048 34.9% DR KHALIQ B85634 34.5% THE GRANGE GROUP PRACTICE B85028 31.9% PADDOCK AND LONGWOOD FAMILY PRACTICE B85042 31.8% THORNTON LODGE SURGERY B85044 31.5% NEWSOME SURGERY B85037 29.1% DR GLENCROSS B85058 25.4% UNIVERSITY HEALTH CENTRE B85062 21.2% THE WHITEHOUSE CENTRE B85659 15.4% THE JUNCTION SURGERY B85660 MELTHAM VILLAGE SURGERY B85644 DR GILKAR B85638 WESTBOURNE SURGERY B85636 DR HANDA & PARTNER B85611 SLAITHWAITE HEALTH CENTRE B85059 THE ALMONDBURY SURGERY B85023 HONLEY SURGERY B85022 COLNE VALLEY FAMILY DOCTORS B85011 ELMWOOD FAMILY DOCTORS B85006 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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

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

THE WHITEHOUSE CENTRE 8

UNIVERSITY HEALTH CENTRE 14

DR GLENCROSS 27 • using the GP cluster method of NEWSOME SURGERY 60 calculating potential gains, if each THORNTON LODGE SURGERY 20 practice was to achieve as well as the PADDOCK AND LONGWOOD FAMILY PRACTICE 48 upper quartile of its national cluster, then an additional 583 people would THE GRANGE GROUP PRACTICE 85 be treated THE LINDLEY VILLAGE SURG. 16

MARSH SURGERY 16

THE WATERLOO PRACTICE 41

THE LINDLEY GROUP PRACT. 19

SHEPLEY HEALTH CENTRE 12

SKELMANTHORPE FAMILY DOCTORS 16

DR BOULTON AND PARTNERS 11

LOCKWOOD SURGERY 8

CROSLAND MOOR SURGERY 5

LEPTON AND KIRKHEATON SURGERIES 4

MELTHAM ROAD SURGERY

DR EDARA & PARTNER

DR AHMED & PARTNERS 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 Kirklees CCG 0.80

NHS Wakefield CCG 0.75

NHS Harrogate And Rural District CCG 0.70 • the ratio of those diagnosed with chronic kidney disease versus those NHS Bradford Districts CCG 0.70 expected to have chronic kidney disease is 0.57. This compares to NHS Leeds South And East CCG 0.67 0.68 for England • this suggests that 57% of people with NHS Calderdale CCG 0.64 chronic kidney disease have been diagnosed NHS Bradford City CCG 0.62

NHS Greater Huddersfield CCG 0.57

NHS Leeds North CCG 0.57

NHS Airedale, Wharfedale and Craven CCG 0.56 Note: This slide compares the prevalence of CKD NHS Leeds West CCG 0.55 recorded in QOF in 2015/16 to the expected prevalence of CKD produced by the University of Southampton in 2011. A small number of CCGs have a ratio greater than 1. It is unlikely that all England 0.68 people with CKD will be diagnosed in any CCG and therefore a ratio greater than 1 suggests that 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 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 Warwickshire North CCG 1.05

NHS Doncaster CCG 0.97

NHS Dartford, Gravesham and Swanley CCG 0.84

NHS Telford and Wrekin CCG 0.79

NHS Redditch and Bromsgrove CCG 0.74

NHS Medway CCG 0.71

NHS Calderdale CCG 0.64

NHS Hartlepool and Stockton-on-Tees CCG 0.64

NHS Warrington CCG 0.62

NHS Greater Huddersfield CCG 0.57

NHS Tameside and Glossop CCG 0.52

0.0 0.2 0.4 0.6 0.8 1.0 1.2 Ratio

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

GP practice CCG

LOCKWOOD SURGERY B85641 7.1% MELTHAM VILLAGE SURGERY B85644 6.3% NEWSOME SURGERY B85037 6.2% CROSLAND MOOR SURGERY Y04266 5.5% THE JUNCTION SURGERY B85660 5.2% • it is estimated that there are 4,993 DEARNE VALLEY HEALTH CENTRE B85002 5.1% THE WATERLOO PRACTICE B85024 4.8% people with undiagnosed chronic WESTBOURNE SURGERY B85636 4.5% kidney disease in NHS Greater DR BOULTON AND PARTNERS B85036 4.5% DR EDARA & PARTNER B85060 4.5% Huddersfield CCG KIRKBURTON HEALTH CENTRE B85026 4.3% HONLEY SURGERY B85022 4.2% • GP practice range of observed CKD: SKELMANTHORPE FAMILY DOCTORS B85061 4.0% 0.0% to 7.1% FIELDHEAD SURGERY B85051 3.9% ELMWOOD FAMILY DOCTORS B85006 3.9% COLNE VALLEY FAMILY DOCTORS B85011 3.8% THE LINDLEY GROUP PRACT. B85027 3.8% SHEPLEY HEALTH CENTRE B85005 3.7% LEPTON AND KIRKHEATON SURGERIES B85031 3.7% MELTHAM ROAD SURGERY B85016 3.6% DR GILKAR B85638 3.5% THORNTON LODGE SURGERY B85044 3.4% THE LINDLEY VILLAGE SURG. B85033 3.4% MARSH SURGERY B85623 3.2% WOODHOUSE HILL SURGERY B85048 3.2% THE ALMONDBURY SURGERY B85023 3.0% DALTON SURGERY B85010 3.0% MELTHAM GROUP PRACTICE B85032 2.8% OAKLANDS HEALTH CENTRE B85610 2.7% SLAITHWAITE HEALTH CENTRE B85059 2.6% PADDOCK AND LONGWOOD FAMILY PRACTICE B85042 2.6% THE GRANGE GROUP PRACTICE B85028 2.4% DR KHALIQ B85634 2.4% DR GLENCROSS B85058 2.4% Note: CCG estimates for the estimated DR AHMED & PARTNERS B85614 1.5% COLNE VALLEY GROUP PRACTICE B85054 1.3% number of people with CKD are based on DR HANDA & PARTNER B85611 0.6% applying a proportion from a resident based THE WHITEHOUSE CENTRE B85659 0.5% UNIVERSITY HEALTH CENTRE B85062 population estimate to a GP registered population. The characteristics of registered 0% 1% 2% 3% 4% 5% 6% 7% 8% 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 Wakefield CCG 78.0%

NHS Leeds South And East CCG 75.6% • 6,712 people with CKD (diagnosed*) in NHS Greater Huddersfield CCG NHS Harrogate And Rural District CCG 75.4% • 4,969 (74%) people whose blood pressure is <= 140 /85 NHS Calderdale CCG 74.7% • 507 (7.6%) people who are exceptions NHS Greater Huddersfield CCG 74.0% • 1,236 (18.4%) additional people whose blood pressure is not <= 140 / NHS North Kirklees CCG 73.9% 85 NHS Bradford Districts CCG 73.6%

NHS Leeds West CCG 73.6%

NHS Bradford City CCG 72.5%

NHS Leeds North CCG 71.9%

NHS Airedale, Wharfedale and Craven CCG 70.7%

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

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

NHS Doncaster CCG 79.3%

NHS Hartlepool and Stockton-on-Tees CCG 78.1%

NHS Tameside and Glossop CCG 78.1%

NHS Medway CCG 76.3%

NHS Warwickshire North CCG 75.5%

NHS Redditch and Bromsgrove CCG 75.2%

NHS Warrington CCG 74.7%

NHS Calderdale CCG 74.7%

NHS Telford and Wrekin CCG 74.5%

NHS Greater Huddersfield CCG 74.0%

NHS Dartford, Gravesham and Swanley CCG 73.5%

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

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

Not below 140/85 Exceptions reported

THE WHITEHOUSE CENTRE B85659 5 UNIVERSITY HEALTH CENTRE B85062 2 THE LINDLEY VILLAGE SURG. B85033 52 DR V J IVES & PARTNERS B85010 65 CROSLAND MOOR SURGERY Y04266 68 • in total, including exceptions, there FIELDHEAD SURGERY B85051 94 DR GLENCROSS B85058 18 are 1,743 people whose blood THE GRANGE GROUP PRACTICE B85028 109 pressure is not <= 140 / 85 DEARNE VALLEY HEALTH CENTRE B85002 50 DR P RICHARDSON & PARTNERS B85037 46 • GP practice range: 14.3% to 62.5% DR I A GILKAR B85638 41 LEPTON & KIRKHEATON SURGERIES B85031 74 THE LINDLEY GROUP PRACT. B85027 97 PADDOCK AND LONGWOOD FAMILY PRACTICE B85042 52 THE WATERLOO PRACTICE B85024 108 DR BOULTON AND PARTNERS B85036 70 DR K M L DEAN & PARTNERS B85026 74 MELTHAM GROUP PRACTICE B85032 38 SKELMANTHORPE FAMILY DOCTORS B85061 79 MELTHAM ROAD SURGERY B85016 45 DR SINGH B85634 16 LOCKWOOD & CROSLAND MOOR GROUP PRACTICE B85641 64 THORNTON LODGE SURGERY B85044 13 WOODHOUSE HILL SURGERY B85048 16 ELMWOOD FAMILY DOCTORS B85006 89 DR D A CASHIN PARTNERS B85022 61 THE ALMONDBURY SURGERY B85023 31 SLAITHWAITE HEALTH CENTRE B85059 22 OAKLANDS HEALTH CENTRE B85610 37 DR D C SHAW & PARTNERS B85005 40 COLNE VALLEY FAMILY DOCTORS B85011 38 WESTBOURNE SURGERY B85636 26 THE JUNCTION SURGERY B85660 39 DR BUTT & PARTNER B85614 8 MARSDEN HEALTH CENTRE B85054 7 DR WYBREW & PARTNER B85060 19 MARSH SURGERY B85623 11 MELTHAM VILLAGE SURGERY B85644 17 DR HANDA & PARTNER B85611 2 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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

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

THE WHITEHOUSE CENTRE 4

UNIVERSITY HEALTH CENTRE 1

DR V J IVES & PARTNERS 37 • using the GP cluster method of THE LINDLEY VILLAGE SURG. 28 calculating potential gains, if each CROSLAND MOOR SURGERY 35 practice was to achieve as well as the DR GLENCROSS 9 upper quartile of its national cluster, then an additional 514 people would FIELDHEAD SURGERY 39 be treated DR P RICHARDSON & PARTNERS 21

DEARNE VALLEY HEALTH CENTRE 21

DR I A GILKAR 17

DR D C SHAW & PARTNERS 2

THE JUNCTION SURGERY 1

COLNE VALLEY FAMILY DOCTORS 0

DR BUTT & PARTNER

WESTBOURNE SURGERY

DR HANDA & PARTNER

MARSH SURGERY

MARSDEN HEALTH CENTRE

MELTHAM VILLAGE SURGERY

DR WYBREW & PARTNER 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 Greater Huddersfield CCG 80.8%

NHS Harrogate And Rural District CCG 80.7% • 6,712 people with CKD (diagnosed*) in NHS Greater Huddersfield CCG NHS Wakefield CCG 80.1% • 5,426 (80.8%) people who have a record of urine albumin:creatinine NHS Calderdale CCG 79.1% ratio test • 217 (3.2%) people who are NHS Bradford City CCG 77.8% exceptions • 1,069 (15.9%) additional people who NHS Leeds West CCG 76.2% have no record of urine NHS Leeds South And East CCG 75.8% albumin:creatinine ratio test

NHS Bradford Districts CCG 75.5%

NHS North Kirklees CCG 74.5%

NHS Airedale, Wharfedale and Craven CCG 74.0%

NHS Leeds North CCG 73.8%

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

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

NHS Greater Huddersfield CCG 80.8%

NHS Telford and Wrekin CCG 80.6%

NHS Tameside and Glossop CCG 79.8%

NHS Doncaster CCG 79.7%

NHS Calderdale CCG 79.1%

NHS Hartlepool and Stockton-on-Tees CCG 78.0%

NHS Warwickshire North CCG 76.8%

NHS Redditch and Bromsgrove CCG 76.5%

NHS Medway CCG 75.7%

NHS Warrington CCG 71.2%

NHS Dartford, Gravesham and Swanley CCG 66.9%

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

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

Not recorded Exceptions reported

DR WYBREW & PARTNER B85060 56 THE LINDLEY VILLAGE SURG. B85033 46 THE LINDLEY GROUP PRACT. B85027 108 MELTHAM VILLAGE SURGERY B85644 38 THE WATERLOO PRACTICE B85024 101 • in total, including exceptions, there DR BOULTON AND PARTNERS B85036 65 DR I A GILKAR B85638 33 are 1,286 people who have no record THE WHITEHOUSE CENTRE B85659 2 of urine albumin:creatinine ratio test THE JUNCTION SURGERY B85660 54 LEPTON & KIRKHEATON SURGERIES B85031 57 • GP practice range: 0.0% to 44.4% UNIVERSITY HEALTH CENTRE B85062 1 DR SINGH B85634 13 THE ALMONDBURY SURGERY B85023 29 DR D C SHAW & PARTNERS B85005 40 WOODHOUSE HILL SURGERY B85048 14 THORNTON LODGE SURGERY B85044 11 FIELDHEAD SURGERY B85051 52 THE GRANGE GROUP PRACTICE B85028 64 DR GLENCROSS B85058 10 DR K M L DEAN & PARTNERS B85026 52 DR P RICHARDSON & PARTNERS B85037 25 MELTHAM ROAD SURGERY B85016 30 DR V J IVES & PARTNERS B85010 28 ELMWOOD FAMILY DOCTORS B85006 65 SKELMANTHORPE FAMILY DOCTORS B85061 44 OAKLANDS HEALTH CENTRE B85610 26 SLAITHWAITE HEALTH CENTRE B85059 15 WESTBOURNE SURGERY B85636 20 COLNE VALLEY FAMILY DOCTORS B85011 28 DR D A CASHIN PARTNERS B85022 38 MARSH SURGERY B85623 9 DEARNE VALLEY HEALTH CENTRE B85002 19 PADDOCK AND LONGWOOD FAMILY PRACTICE B85042 21 LOCKWOOD & CROSLAND MOOR GROUP PRACTICE B85641 31 MELTHAM GROUP PRACTICE B85032 16 CROSLAND MOOR SURGERY Y04266 20 MARSDEN HEALTH CENTRE B85054 4 DR HANDA & PARTNER B85611 1 DR BUTT & PARTNER B85614 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 Airedale, Wharfedale and Craven CCG 0.98%

NHS Harrogate And Rural District CCG 0.92% • prevalence of 0.74% in NHS Greater NHS Bradford Districts CCG 0.82% Huddersfield CCG compared to 0.76% in England NHS Leeds South And East CCG 0.80%

NHS North Kirklees CCG 0.79%

NHS Greater Huddersfield CCG 0.74%

NHS Wakefield CCG 0.74%

NHS Calderdale CCG 0.71%

NHS Leeds North CCG 0.71%

NHS Leeds West CCG 0.61%

NHS Bradford City CCG 0.48%

England 0.76%

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

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

NHS Doncaster CCG 0.92%

NHS Redditch and Bromsgrove CCG 0.92%

NHS Hartlepool and Stockton-on-Tees CCG 0.90%

NHS Tameside and Glossop CCG 0.83%

NHS Warwickshire North CCG 0.82%

NHS Warrington CCG 0.80%

NHS Medway CCG 0.75%

NHS Telford and Wrekin CCG 0.75%

NHS Greater Huddersfield CCG 0.74%

NHS Calderdale CCG 0.71%

NHS Dartford, Gravesham and Swanley CCG 0.58%

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

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

GP practice CCG

DR EDARA & PARTNER B85060 1.9% THE WATERLOO PRACTICE B85024 1.5% DEARNE VALLEY HEALTH CENTRE B85002 1.1% MARSH SURGERY B85623 1.0% LOCKWOOD SURGERY B85641 1.0% • 1,821 people with diagnosed heart COLNE VALLEY GROUP PRACTICE B85054 1.0% SKELMANTHORPE FAMILY DOCTORS B85061 1.0% failure in NHS Greater Huddersfield MELTHAM GROUP PRACTICE B85032 1.0% CCG MELTHAM VILLAGE SURGERY B85644 1.0% HONLEY SURGERY B85022 1.0% • GP practice range: 0.0% to 1.9% KIRKBURTON HEALTH CENTRE B85026 1.0% LEPTON AND KIRKHEATON SURGERIES B85031 1.0% THE LINDLEY VILLAGE SURG. B85033 0.9% ELMWOOD FAMILY DOCTORS B85006 0.9% COLNE VALLEY FAMILY DOCTORS B85011 0.8% THE ALMONDBURY SURGERY B85023 0.8% NEWSOME SURGERY B85037 0.8% CROSLAND MOOR SURGERY Y04266 0.8% DR BOULTON AND PARTNERS B85036 0.7% THE GRANGE GROUP PRACTICE B85028 0.7% SHEPLEY HEALTH CENTRE B85005 0.7% PADDOCK AND LONGWOOD FAMILY PRACTICE B85042 0.7% DR GILKAR B85638 0.7% MELTHAM ROAD SURGERY B85016 0.6% FIELDHEAD SURGERY B85051 0.6% THE JUNCTION SURGERY B85660 0.6% DR GLENCROSS B85058 0.6% DALTON SURGERY B85010 0.6% DR AHMED & PARTNERS B85614 0.5% WESTBOURNE SURGERY B85636 0.5% THE LINDLEY GROUP PRACT. B85027 0.5% WOODHOUSE HILL SURGERY B85048 0.5% DR HANDA & PARTNER B85611 0.5% DR KHALIQ B85634 0.5% SLAITHWAITE HEALTH CENTRE B85059 0.4% OAKLANDS HEALTH CENTRE B85610 0.3% THORNTON LODGE SURGERY B85044 0.3% THE WHITEHOUSE CENTRE B85659 0.1% UNIVERSITY HEALTH CENTRE B85062 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6% 1.8% 2.0%

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 North Kirklees CCG 91.0%

NHS Calderdale CCG 88.3% • 425 people with heart failure* with LVSD in NHS Greater Huddersfield NHS Wakefield CCG 88.0% CCG • 367 (86.4%) people treated with ACE- NHS Greater Huddersfield CCG 86.4% I or ARB • 57 (13.4%) people who are NHS Bradford City CCG 85.9% exceptions • 1 (0.2%) additional people who are NHS Harrogate And Rural District CCG 85.9% not treated with ACE-I or ARB NHS Leeds South And East CCG 82.6%

NHS Leeds West CCG 82.3%

NHS Bradford Districts CCG 81.4%

NHS Leeds North CCG 76.3%

NHS Airedale, Wharfedale and Craven CCG 72.5%

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 Redditch and Bromsgrove CCG 88.9%

NHS Calderdale CCG 88.3%

NHS Hartlepool and Stockton-on-Tees CCG 88.1%

NHS Warwickshire North CCG 87.6%

NHS Medway CCG 87.5%

NHS Greater Huddersfield CCG 86.4%

NHS Telford and Wrekin CCG 85.6%

NHS Tameside and Glossop CCG 85.6%

NHS Doncaster CCG 85.4%

NHS Warrington CCG 85.2%

NHS Dartford, Gravesham and Swanley CCG 84.6%

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

SLAITHWAITE HEALTH CENTRE B85059 2 MELTHAM VILLAGE SURGERY B85644 3 DALTON SURGERY B85010 1 ELMWOOD FAMILY DOCTORS B85006 6 MELTHAM ROAD SURGERY B85016 4 • in total, including exceptions, there MELTHAM GROUP PRACTICE B85032 3 DR KHALIQ B85634 1 are 58 people who are not treated WESTBOURNE SURGERY B85636 1 with ACE-I or ARB THE LINDLEY GROUP PRACT. B85027 1 DR BOULTON AND PARTNERS B85036 2 • GP practice range: 0.0% to 50.0% SKELMANTHORPE FAMILY DOCTORS B85061 6 DR GILKAR B85638 1 KIRKBURTON HEALTH CENTRE B85026 2 SHEPLEY HEALTH CENTRE B85005 3 COLNE VALLEY FAMILY DOCTORS B85011 2 THE LINDLEY VILLAGE SURG. B85033 1 DR GLENCROSS B85058 1 THE WATERLOO PRACTICE B85024 9 HONLEY SURGERY B85022 1 THE GRANGE GROUP PRACTICE B85028 2 DEARNE VALLEY HEALTH CENTRE B85002 1 COLNE VALLEY GROUP PRACTICE B85054 2 LEPTON AND KIRKHEATON SURGERIES B85031 2 PADDOCK AND LONGWOOD FAMILY PRACTICE B85042 1 THE ALMONDBURY SURGERY B85023 NEWSOME SURGERY B85037 THORNTON LODGE SURGERY B85044 WOODHOUSE HILL SURGERY B85048 FIELDHEAD SURGERY B85051 DR EDARA & PARTNER B85060 OAKLANDS HEALTH CENTRE B85610 DR HANDA & PARTNER B85611 DR AHMED & PARTNERS B85614 MARSH SURGERY B85623 LOCKWOOD SURGERY B85641 THE JUNCTION SURGERY B85660 CROSLAND MOOR SURGERY Y04266 THE WHITEHOUSE CENTRE B85659 UNIVERSITY HEALTH CENTRE B85062 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 Wakefield CCG 85.6%

NHS Leeds South And East CCG 84.7% • 367 people with heart failure* with LVSD treated with ACE-I/ARB in NHS NHS Leeds West CCG 82.8% Greater Huddersfield CCG • 282 (76.8%) people treated with ACE- NHS Leeds North CCG 82.4% I/ARB and BB • 59 (16.1%) people who are NHS Calderdale CCG 77.2% exceptions • 26 (7.1%) additional people who are NHS Greater Huddersfield CCG 76.8% not treated with ACE-I/ARB and BB NHS Harrogate And Rural District CCG 75.9%

NHS North Kirklees CCG 75.1%

NHS Bradford Districts CCG 73.3%

NHS Bradford City CCG 71.8%

NHS Airedale, Wharfedale and Craven CCG 70.0%

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 Warwickshire North CCG 83.0%

NHS Dartford, Gravesham and Swanley CCG 83.0%

NHS Medway CCG 81.5%

NHS Doncaster CCG 80.4%

NHS Tameside and Glossop CCG 79.8%

NHS Redditch and Bromsgrove CCG 78.1%

NHS Warrington CCG 77.9%

NHS Calderdale CCG 77.2%

NHS Greater Huddersfield CCG 76.8%

NHS Hartlepool and Stockton-on-Tees CCG 75.4%

NHS Telford and Wrekin CCG 73.6%

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

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

No treatment Exceptions reported

CROSLAND MOOR SURGERY Y04266 4 OAKLANDS HEALTH CENTRE B85610 3 DALTON SURGERY B85010 1 THE ALMONDBURY SURGERY B85023 3 DR GLENCROSS B85058 3 • in total, including exceptions, there DR EDARA & PARTNER B85060 2 THE JUNCTION SURGERY B85660 4 are 85 people who are not treated SHEPLEY HEALTH CENTRE B85005 8 with ACE-I or ARB HONLEY SURGERY B85022 3 COLNE VALLEY FAMILY DOCTORS B85011 5 • GP practice range: 0.0% to 66.7% DR GILKAR B85638 2 MELTHAM GROUP PRACTICE B85032 3 DR BOULTON AND PARTNERS B85036 3 FIELDHEAD SURGERY B85051 1 LOCKWOOD SURGERY B85641 2 THE WATERLOO PRACTICE B85024 15 MARSH SURGERY B85623 2 LEPTON AND KIRKHEATON SURGERIES B85031 6 DR AHMED & PARTNERS B85614 2 MELTHAM VILLAGE SURGERY B85644 1 THE GRANGE GROUP PRACTICE B85028 3 THE LINDLEY VILLAGE SURG. B85033 1 PADDOCK AND LONGWOOD FAMILY PRACTICE B85042 2 DEARNE VALLEY HEALTH CENTRE B85002 1 WOODHOUSE HILL SURGERY B85048 1 KIRKBURTON HEALTH CENTRE B85026 1 SKELMANTHORPE FAMILY DOCTORS B85061 2 COLNE VALLEY GROUP PRACTICE B85054 1 ELMWOOD FAMILY DOCTORS B85006 MELTHAM ROAD SURGERY B85016 THE LINDLEY GROUP PRACT. B85027 NEWSOME SURGERY B85037 THORNTON LODGE SURGERY B85044 SLAITHWAITE HEALTH CENTRE B85059 DR HANDA & PARTNER B85611 DR KHALIQ B85634 WESTBOURNE SURGERY B85636 THE WHITEHOUSE CENTRE B85659 UNIVERSITY HEALTH CENTRE B85062 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 Harrogate And Rural District CCG 90.4%

NHS Wakefield CCG 89.3% • 8,422 people with coronary heart disease* in NHS Greater Huddersfield NHS North Kirklees CCG 89.3% CCG • 7,491 (88.9%) people whose blood NHS Calderdale CCG 89.1% pressure <= 150 / 90 • 248 (2.9%) people who are NHS Greater Huddersfield CCG 88.9% exceptions • 683 (8.1%) additional people whose NHS Leeds West CCG 88.7% blood pressure is not <= 150 / 90 NHS Bradford Districts CCG 88.2%

NHS Leeds South And East CCG 87.6%

NHS Leeds North CCG 87.2%

NHS Airedale, Wharfedale and Craven CCG 86.5%

NHS Bradford City CCG 85.6%

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 Redditch and Bromsgrove CCG 91.0%

NHS Doncaster CCG 90.8%

NHS Warwickshire North CCG 90.1%

NHS Tameside and Glossop CCG 90.1%

NHS Dartford, Gravesham and Swanley CCG 89.1%

NHS Calderdale CCG 89.1%

NHS Hartlepool and Stockton-on-Tees CCG 89.0%

NHS Greater Huddersfield CCG 88.9%

NHS Medway CCG 87.9%

NHS Telford and Wrekin CCG 87.8%

NHS Warrington CCG 87.4%

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

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

Not below 150/90 Exceptions reported

THE WHITEHOUSE CENTRE B85659 3 THE LINDLEY VILLAGE SURG. B85033 38 CROSLAND MOOR SURGERY Y04266 34 THORNTON LODGE SURGERY B85044 11 NEWSOME SURGERY B85037 46 • in total, including exceptions, there DALTON SURGERY B85010 40 DR KHALIQ B85634 21 are 931 people whose blood pressure THE LINDLEY GROUP PRACT. B85027 49 is not <= 150 / 90 DR GLENCROSS B85058 13 WOODHOUSE HILL SURGERY B85048 11 • GP practice range: 2.1% to 30.0% LOCKWOOD SURGERY B85641 28 THE GRANGE GROUP PRACTICE B85028 89 DR GILKAR B85638 28 MARSH SURGERY B85623 12 COLNE VALLEY FAMILY DOCTORS B85011 28 DR BOULTON AND PARTNERS B85036 32 THE ALMONDBURY SURGERY B85023 24 OAKLANDS HEALTH CENTRE B85610 31 MELTHAM ROAD SURGERY B85016 34 SKELMANTHORPE FAMILY DOCTORS B85061 40 SHEPLEY HEALTH CENTRE B85005 25 KIRKBURTON HEALTH CENTRE B85026 30 COLNE VALLEY GROUP PRACTICE B85054 17 FIELDHEAD SURGERY B85051 26 MELTHAM GROUP PRACTICE B85032 21 LEPTON AND KIRKHEATON SURGERIES B85031 28 DR EDARA & PARTNER B85060 18 ELMWOOD FAMILY DOCTORS B85006 37 HONLEY SURGERY B85022 25 WESTBOURNE SURGERY B85636 11 THE WATERLOO PRACTICE B85024 29 UNIVERSITY HEALTH CENTRE B85062 1 DEARNE VALLEY HEALTH CENTRE B85002 9 PADDOCK AND LONGWOOD FAMILY PRACTICE B85042 17 THE JUNCTION SURGERY B85660 7 DR AHMED & PARTNERS B85614 7 SLAITHWAITE HEALTH CENTRE B85059 5 DR HANDA & PARTNER B85611 4 MELTHAM VILLAGE SURGERY B85644 2 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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

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

THE WHITEHOUSE CENTRE 2

THE LINDLEY VILLAGE SURG. 28

THORNTON LODGE SURGERY 8 • using the GP cluster method of CROSLAND MOOR SURGERY 22 calculating potential gains, if each NEWSOME SURGERY 30 practice was to achieve as well as the DALTON SURGERY 26 upper quartile of its national cluster, then an additional 345 people would DR KHALIQ 13 be treated DR GLENCROSS 8

WOODHOUSE HILL SURGERY 6

LOCKWOOD SURGERY 14

DR EDARA & PARTNER 1

ELMWOOD FAMILY DOCTORS 1

DEARNE VALLEY HEALTH CENTRE

THE WATERLOO PRACTICE

PADDOCK AND LONGWOOD FAMILY PRACTICE

DR AHMED & PARTNERS

SLAITHWAITE HEALTH CENTRE

THE JUNCTION SURGERY

DR HANDA & PARTNER

MELTHAM VILLAGE SURGERY Details of this methodology are available on slide 9. Click here to view them.

78 CVD: Primary Care Intelligence Packs Percentage of patients with CHD with a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken by CCG Comparison with CCGs in the STP Optimal management No treatment Exceptions reported

NHS Bradford Districts CCG 92.9%

NHS Leeds South And East CCG 92.5% • 8,422 people with coronary heart disease* in NHS Greater Huddersfield NHS Wakefield CCG 92.5% CCG • 7,622 (90.5%) people who are taking NHS Bradford City CCG 92.1% aspirin, an alternative anti-platelet therapy, or an anti-coagulant NHS Leeds West CCG 92.1% • 370 (4.4%) people who are exceptions NHS Calderdale CCG 91.7% • 430 (5.1%) additional people who are NHS Harrogate And Rural District CCG 91.5% not taking aspirin, an alternative anti- platelet therapy, or an anti-coagulant NHS Leeds North CCG 91.3%

NHS North Kirklees CCG 91.2%

NHS Greater Huddersfield CCG 90.5%

NHS Airedale, Wharfedale and Craven CCG 90.0%

England 91.8%

0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator CHD005 denominator plus exceptions

79 CVD: Primary Care Intelligence Packs Percentage of patients with CHD with a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken by CCG Comparison with demographically similar CCGs Optimal management No treatment Exceptions reported

NHS Warwickshire North CCG 93.7%

NHS Redditch and Bromsgrove CCG 93.4%

NHS Telford and Wrekin CCG 93.1%

NHS Dartford, Gravesham and Swanley CCG 92.7%

NHS Doncaster CCG 92.5%

NHS Tameside and Glossop CCG 92.4%

NHS Hartlepool and Stockton-on-Tees CCG 92.4%

NHS Medway CCG 92.1%

NHS Calderdale CCG 91.7%

NHS Warrington CCG 90.9%

NHS Greater Huddersfield CCG 90.5%

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

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

No treatment Exceptions reported

DR KHALIQ B85634 27 DR EDARA & PARTNER B85060 36 DR BOULTON AND PARTNERS B85036 44 DR GILKAR B85638 33 LOCKWOOD SURGERY B85641 31 • in total, including exceptions, there CROSLAND MOOR SURGERY Y04266 25 THE LINDLEY GROUP PRACT. B85027 49 are 800 people are not taking aspirin, FIELDHEAD SURGERY B85051 41 an alternative anti-platelet therapy, or LEPTON AND KIRKHEATON SURGERIES B85031 42 WOODHOUSE HILL SURGERY B85048 10 an anti-coagulant THE JUNCTION SURGERY B85660 24 THE LINDLEY VILLAGE SURG. B85033 16 • GP practice range: 0.0% to 22.9% DALTON SURGERY B85010 25 COLNE VALLEY FAMILY DOCTORS B85011 24 MELTHAM ROAD SURGERY B85016 28 PADDOCK AND LONGWOOD FAMILY PRACTICE B85042 25 THE ALMONDBURY SURGERY B85023 18 SKELMANTHORPE FAMILY DOCTORS B85061 35 THE GRANGE GROUP PRACTICE B85028 54 WESTBOURNE SURGERY B85636 12 THE WATERLOO PRACTICE B85024 32 DR GLENCROSS B85058 7 MARSH SURGERY B85623 7 UNIVERSITY HEALTH CENTRE B85062 1 ELMWOOD FAMILY DOCTORS B85006 30 MELTHAM GROUP PRACTICE B85032 16 KIRKBURTON HEALTH CENTRE B85026 19 COLNE VALLEY GROUP PRACTICE B85054 11 HONLEY SURGERY B85022 20 DR AHMED & PARTNERS B85614 11 SHEPLEY HEALTH CENTRE B85005 14 THORNTON LODGE SURGERY B85044 3 NEWSOME SURGERY B85037 12 DEARNE VALLEY HEALTH CENTRE B85002 7 MELTHAM VILLAGE SURGERY B85644 4 SLAITHWAITE HEALTH CENTRE B85059 3 DR HANDA & PARTNER B85611 2 OAKLANDS HEALTH CENTRE B85610 2 THE WHITEHOUSE CENTRE B85659 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 Greater Huddersfield CCG England 800

700 • in NHS Greater Huddersfield CCG, the hospital admission rate for coronary heart disease in 2015/16 600 was 461.5 (1,032) 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 Greater Huddersfield CCG England 300

• in NHS Greater Huddersfield CCG, 250 the hospital admission rate for stroke in 2015/16 was 154.1 (329) compared to 172.8 for England

200

150

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

50

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

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

NHS Greater Huddersfield CCG England

107.1% Angina 136.8% • The risk of a stroke was 43.7% higher and the risk of a heart attack was 127.5% 127.5% higher compared to people Heart Attack 108.6% without diabetes. The risk of a major amputation was 219.6% higher. 131.9% Heart failure 150.0%

43.7% Stroke 81.3%

219.6% Major amputation 445.8%

978.9% Minor amputation 753.5%

223.2% 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 Greater Huddersfield CCG England 100

90 • in NHS Greater Huddersfield CCG, the early mortality rate for coronary 80 heart disease in 2013-15 was 42.7, compared to 40.6 for England 70

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 Greater Huddersfield CCG England 35

• in NHS Greater Huddersfield CCG, 30 the early mortality rate for stroke in 2013-15 was 13.9, compared to 13.6 for England 25

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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