CVD: Primary Care Intelligence Packs NHS Southampton 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 Southampton CCG are: NHS Portsmouth CCG NHS Leeds West CCG NHS Norwich CCG NHS Bristol CCG NHS Newcastle Gateshead CCG NHS South Manchester CCG NHS Brighton and Hove CCG NHS Hull CCG NHS Nottingham City CCG NHS Canterbury and Coastal 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 Hull CCG 25.1%

NHS South Manchester CCG 22.4% • prevalence of 21.3% in NHS Southampton CCG NHS Nottingham City CCG 21.7%

NHS Brighton and Hove CCG 21.6%

NHS Portsmouth CCG 21.6%

NHS Southampton CCG 21.3%

NHS Bristol CCG 20.9%

NHS Norwich CCG 20.0% Note: It has been found that the proportion of patients recorded as smokers correlates well NHS Newcastle Gateshead CCG 19.6% with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, NHS Leeds West CCG 19.2% http://bmjopen.bmj.com/content/4/7/e005217.abs tract

NHS Canterbury and Coastal CCG 16.9% Definition: denominator of QOF clinical indicator SMOKE004 ( number of patients 15+ who are 0% 5% 10% 15% 20% 25% 30% 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

HOMELESS HEALTHCARE TEAM J82217 92.7% WESTON LANE SURGERY J82187 29.3% ADELAIDE GP SURGERY Y02838 28.8% WEST END ROAD SURGERY J82040 28.6% • 49,128 people who are recorded as CHEVIOT ROAD SURGERY J82062 28.0% smokers in NHS Southampton CCG BROOK HOUSE SURGERY J82213 25.3% PORTSWOOD SOLENT SURGERY J82619 24.4% • GP practice range: 6.6% to 92.7% ST.MARY'S SURGERY J82081 24.0% ALMA ROAD SURGERY J82122 23.9% GROVE MEDICAL PRACTICE J82088 23.4% ATHERLEY HOUSE SURGERY J82115 23.2% LORDSHILL HEALTH CENTRE J82002 23.2% BURGESS ROAD SURGERY J82001 22.6% WOOLSTON LODGE SURGERY J82076 22.5% CHESSEL PRACTICE J82101 22.5% ST.PETERS SURGERY J82208 22.4% NICHOLS TOWN SURGERY J82024 22.3% STONEHAM LANE SURGERY J82087 21.9% VICTOR STREET SURGERY J82022 21.0% OLD FIRE STATION SURGERY J82128 20.9% WALNUT TREE SURGERY J82605 20.2% ALDERMOOR SURGERY J82092 19.8% BATH LODGE PRACTICE J82141 19.4% REGENTS PARK SURGERY J82203 19.1% LADIES WALK PRACTICE J82622 19.1% BITTERNE PARK SURGERY J82171 18.0% TOWNHILL SURGERY J82180 17.8% Note: This method is thought to be a reasonably HILL LANE SURGERY J82207 17.5% robust method in estimating smoking prevalence MULBERRY HOUSE SURGERY J82183 16.0% for the majority of GP practices. However, RAYMOND ROAD SURGERY J82126 15.7% caution is advised for extreme estimates of HIGHFIELD HEALTH J82663 8.5% smoking prevalence and those with high UNIVERSITY HEALTH SERVICE J82080 6.6% numbers of smoking status not recorded and 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 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 Isle Of Wight CCG 0.61

NHS Fareham And Gosport CCG 0.60 • the ratio of those diagnosed with hypertension versus those expected to have hypertension is 0.53. This NHS South Eastern Hampshire CCG 0.60 compares to 0.59 for England • this suggests that 53% of people with hypertension have been diagnosed NHS West Hampshire CCG 0.59

NHS North Hampshire CCG 0.57

NHS Portsmouth CCG 0.56

NHS Southampton CCG 0.53

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

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

NHS Hull CCG 0.59

NHS Canterbury and Coastal CCG 0.59

NHS Newcastle Gateshead CCG 0.59

NHS Portsmouth CCG 0.56

NHS Nottingham City CCG 0.55

NHS South Manchester CCG 0.55

NHS Norwich CCG 0.55

NHS Leeds West CCG 0.55

NHS Bristol CCG 0.54

NHS Southampton CCG 0.53

NHS Brighton and Hove CCG 0.52

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

LADIES WALK PRACTICE J82622 0.59 CHEVIOT ROAD SURGERY J82062 0.57 ALDERMOOR SURGERY J82092 0.56 ALMA ROAD SURGERY J82122 0.55 • it is estimated that there are 25,173 BURGESS ROAD SURGERY J82001 0.55 WESTON LANE SURGERY J82187 0.55 people with undiagnosed GROVE MEDICAL PRACTICE J82088 0.54 hypertension in NHS Southampton ST.PETERS SURGERY J82208 0.53 CCG TOWNHILL SURGERY J82180 0.53 BROOK HOUSE SURGERY J82213 0.53 • GP practice range of observed to LORDSHILL HEALTH CENTRE J82002 0.53 expected hypertension prevalence CHESSEL PRACTICE J82101 0.53 WOOLSTON LODGE SURGERY J82076 0.52 0.17 to 0.59 BATH LODGE PRACTICE J82141 0.52 OLD FIRE STATION SURGERY J82128 0.50 VICTOR STREET SURGERY J82022 0.50 PORTSWOOD SOLENT SURGERY J82619 0.50 REGENTS PARK SURGERY J82203 0.49 HIGHFIELD HEALTH J82663 0.48 STONEHAM LANE SURGERY J82087 0.48 HILL LANE SURGERY J82207 0.48 RAYMOND ROAD SURGERY J82126 0.46 ST.MARY'S SURGERY J82081 0.46 ADELAIDE GP SURGERY Y02838 0.45 MULBERRY HOUSE SURGERY J82183 0.44 WEST END ROAD SURGERY J82040 0.43 ATHERLEY HOUSE SURGERY J82115 0.42 BITTERNE PARK SURGERY J82171 0.42 NICHOLS TOWN SURGERY J82024 0.35 WALNUT TREE SURGERY J82605 0.26 UNIVERSITY HEALTH SERVICE J82080 0.17 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 Isle Of Wight CCG 82.8%

NHS South Eastern Hampshire CCG 80.6% • 29,613 people with hypertension (diagnosed)* in NHS Southampton CCG NHS Portsmouth CCG 80.0% • 22,747 (76.8%) people whose blood pressure is <= 150/90 • 1,343 (4.5%) people who are NHS North Hampshire CCG 78.6% excepted from optimal control • 5,523 (18.7%) additional people NHS West Hampshire CCG 78.3% whose blood pressure is not <= 150/90

NHS Southampton CCG 76.8%

NHS Fareham And Gosport CCG 75.7%

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 Norwich CCG 81.5%

NHS Newcastle Gateshead CCG 81.3%

NHS Leeds West CCG 80.4%

NHS Canterbury and Coastal CCG 80.1%

NHS Nottingham City CCG 80.0%

NHS Portsmouth CCG 80.0%

NHS Hull CCG 78.1%

NHS Bristol CCG 77.8%

NHS Southampton CCG 76.8%

NHS South Manchester CCG 75.0%

NHS Brighton and Hove CCG 73.3%

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

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

No treatment Exceptions reported

HOMELESS HEALTHCARE TEAM J82217 11 BURGESS ROAD SURGERY J82001 303 ADELAIDE GP SURGERY Y02838 112 WOOLSTON LODGE SURGERY J82076 664 • in total, including exceptions, there MULBERRY HOUSE SURGERY J82183 225 are 6,866 people whose blood BATH LODGE PRACTICE J82141 507 NICHOLS TOWN SURGERY J82024 90 pressure is not <= 150/90 ALDERMOOR SURGERY J82092 297 • GP practice range: 14.3% to 61.1% BROOK HOUSE SURGERY J82213 151 REGENTS PARK SURGERY J82203 165 CHESSEL PRACTICE J82101 461 UNIVERSITY HEALTH SERVICE J82080 55 STONEHAM LANE SURGERY J82087 225 PORTSWOOD SOLENT SURGERY J82619 159 TOWNHILL SURGERY J82180 163 HILL LANE SURGERY J82207 216 ALMA ROAD SURGERY J82122 293 GROVE MEDICAL PRACTICE J82088 270 ATHERLEY HOUSE SURGERY J82115 86 CHEVIOT ROAD SURGERY J82062 374 VICTOR STREET SURGERY J82022 316 ST.MARY'S SURGERY J82081 257 WESTON LANE SURGERY J82187 210 ST.PETERS SURGERY J82208 129 BITTERNE PARK SURGERY J82171 162 LORDSHILL HEALTH CENTRE J82002 260 RAYMOND ROAD SURGERY J82126 78 WALNUT TREE SURGERY J82605 45 HIGHFIELD HEALTH J82663 41 LADIES WALK PRACTICE J82622 206 OLD FIRE STATION SURGERY J82128 167 WEST END ROAD SURGERY J82040 168 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 South Eastern Hampshire CCG 77.7%

NHS Southampton CCG 71.7% • 92 people with a new diagnosis* of hypertension with a CVD risk of 20% or higher in NHS Southampton CCG NHS Portsmouth CCG 71.6% • 66 (71.7%) people who are currently treated with statins • 24 (26.1%) people who are exempted NHS North Hampshire CCG 66.0% from treatment with statins • 2 (2.2%) additional people who are NHS Fareham And Gosport CCG 64.7% not currently treated with statins

NHS West Hampshire CCG 55.9%

NHS Isle Of Wight CCG 54.8%

England 66.5%

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

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

NHS Leeds West CCG 75.2%

NHS Nottingham City CCG 74.1%

NHS Newcastle Gateshead CCG 73.6%

NHS Southampton CCG 71.7%

NHS Portsmouth CCG 71.6%

NHS South Manchester CCG 70.4%

NHS Bristol CCG 68.1%

NHS Canterbury and Coastal CCG 67.2%

NHS Hull CCG 67.2%

NHS Norwich CCG 64.2%

NHS Brighton and Hove CCG 60.5%

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

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

No treatment Exceptions reported

BROOK HOUSE SURGERY J82213 3 ALMA ROAD SURGERY J82122 2 RAYMOND ROAD SURGERY J82126 2 WOOLSTON LODGE SURGERY J82076 1 • in total, including exceptions, there UNIVERSITY HEALTH SERVICE J82080 1 are 26 people who are not treated ATHERLEY HOUSE SURGERY J82115 2 OLD FIRE STATION SURGERY J82128 3 with statins BITTERNE PARK SURGERY J82171 2 • GP practice range: 0.0% to 75.0% PORTSWOOD SOLENT SURGERY J82619 2 LORDSHILL HEALTH CENTRE J82002 2 VICTOR STREET SURGERY J82022 1 NICHOLS TOWN SURGERY J82024 1 LADIES WALK PRACTICE J82622 1 CHEVIOT ROAD SURGERY J82062 2 CHESSEL PRACTICE J82101 1 BURGESS ROAD SURGERY J82001 WEST END ROAD SURGERY J82040 ST.MARY'S SURGERY J82081 STONEHAM LANE SURGERY J82087 ALDERMOOR SURGERY J82092 BATH LODGE PRACTICE J82141 TOWNHILL SURGERY J82180 MULBERRY HOUSE SURGERY J82183 WESTON LANE SURGERY J82187 REGENTS PARK SURGERY J82203 HILL LANE SURGERY J82207 ST.PETERS SURGERY J82208 WALNUT TREE SURGERY J82605 HIGHFIELD HEALTH J82663 ADELAIDE GP SURGERY Y02838 HOMELESS HEALTHCARE TEAM J82217 GROVE MEDICAL PRACTICE J82088 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 Portsmouth CCG 0.74

NHS South Eastern Hampshire CCG 0.74 • the ratio of those diagnosed with atrial fibrillation versus those expected to have atrial fibrillation is 0.68. This NHS Fareham And Gosport CCG 0.71 compares to 0.7 for England • this suggests that 68% of people with atrial fibrillation have been diagnosed. NHS West Hampshire CCG 0.70

NHS Southampton CCG 0.68

NHS North Hampshire CCG 0.66

NHS Isle Of Wight CCG 0.63 Note: This slide compares the prevalence of atrial fibrillation recorded in QOF in 2015/16 to the estimated prevalence of atrial fibrillation, taken from National Cardiovascular Intelligence Network estimates produced in 2017. The estimates were developed by applying age-sex England 0.70 specific prevalence rates as reported by Norberg et al (2013) to GP population estimates from 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 NHS Digital. Estimates reported are adjusted for age and sex of the local population.

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

NHS Canterbury and Coastal CCG 0.79

NHS Portsmouth CCG 0.74

NHS Bristol CCG 0.74

NHS South Manchester CCG 0.72

NHS Newcastle Gateshead CCG 0.70

NHS Leeds West CCG 0.69

NHS Southampton CCG 0.68

NHS Brighton and Hove CCG 0.66

NHS Nottingham City CCG 0.65

NHS Norwich CCG 0.65

NHS Hull CCG 0.63

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

WALNUT TREE SURGERY J82605 0.9 HIGHFIELD HEALTH J82663 0.9 ADELAIDE GP SURGERY Y02838 0.9 BURGESS ROAD SURGERY J82001 0.8 • it is estimated that there are 5,368 WOOLSTON LODGE SURGERY J82076 0.8 GROVE MEDICAL PRACTICE J82088 0.8 people with undiagnosed atrial CHESSEL PRACTICE J82101 0.8 fibrillation in NHS Southampton CCG BITTERNE PARK SURGERY J82171 0.8 • GP practice range of observed to WESTON LANE SURGERY J82187 0.8 VICTOR STREET SURGERY J82022 0.7 expected atrial fibrillation prevalence CHEVIOT ROAD SURGERY J82062 0.7 0.3 to 0.9 ALMA ROAD SURGERY J82122 0.7 OLD FIRE STATION SURGERY J82128 0.7 BATH LODGE PRACTICE J82141 0.7 HILL LANE SURGERY J82207 0.7 ST.PETERS SURGERY J82208 0.7 LADIES WALK PRACTICE J82622 0.7 LORDSHILL HEALTH CENTRE J82002 0.6 ST.MARY'S SURGERY J82081 0.6 STONEHAM LANE SURGERY J82087 0.6 ALDERMOOR SURGERY J82092 0.6 MULBERRY HOUSE SURGERY J82183 0.6 REGENTS PARK SURGERY J82203 0.6 BROOK HOUSE SURGERY J82213 0.6 PORTSWOOD SOLENT SURGERY J82619 0.6 WEST END ROAD SURGERY J82040 0.5 ATHERLEY HOUSE SURGERY J82115 0.5 RAYMOND ROAD SURGERY J82126 0.5 TOWNHILL SURGERY J82180 0.5 NICHOLS TOWN SURGERY J82024 0.4 UNIVERSITY HEALTH SERVICE J82080 0.3 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Ratio

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

NHS West Hampshire CCG 81.0% • 2,919 people with atrial fibrillation* NHS North Hampshire CCG 79.9% with a CHA2DS2-VASc score >= 2 in NHS Southampton CCG • 2,271 (77.8%) people treated with NHS Southampton CCG 77.8% anti-coagulation therapy • 322 (11%) people who are exceptions • 326 (11.2%) additional people with a NHS South Eastern Hampshire CCG 76.2% recorded CHA2DS2-VASc score >= 2 who are not treated NHS Fareham And Gosport CCG 75.2%

NHS Portsmouth CCG 74.2%

NHS Isle Of Wight CCG 73.5%

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 Bristol CCG 79.1%

NHS Norwich CCG 78.7%

NHS Newcastle Gateshead CCG 78.4%

NHS Southampton CCG 77.8%

NHS South Manchester CCG 77.4%

NHS Canterbury and Coastal CCG 77.4%

NHS Hull CCG 77.0%

NHS Leeds West CCG 76.3%

NHS Portsmouth CCG 74.2%

NHS Nottingham City CCG 73.1%

NHS Brighton and Hove CCG 70.4%

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

RAYMOND ROAD SURGERY J82126 17 HIGHFIELD HEALTH J82663 14 NICHOLS TOWN SURGERY J82024 5 ADELAIDE GP SURGERY Y02838 7 • in total, including exceptions, there BITTERNE PARK SURGERY J82171 37 are 648 people with a recorded REGENTS PARK SURGERY J82203 15 WEST END ROAD SURGERY J82040 30 CHA2DS2-VASc score >= 2 who are WOOLSTON LODGE SURGERY J82076 51 not treated CHESSEL PRACTICE J82101 59 CHEVIOT ROAD SURGERY J82062 42 • GP practice range: 4.5% to 38.6% WALNUT TREE SURGERY J82605 11 GROVE MEDICAL PRACTICE J82088 30 TOWNHILL SURGERY J82180 11 BATH LODGE PRACTICE J82141 44 WESTON LANE SURGERY J82187 24 LADIES WALK PRACTICE J82622 26 LORDSHILL HEALTH CENTRE J82002 28 BURGESS ROAD SURGERY J82001 19 HILL LANE SURGERY J82207 19 ALDERMOOR SURGERY J82092 16 ST.PETERS SURGERY J82208 13 ALMA ROAD SURGERY J82122 24 OLD FIRE STATION SURGERY J82128 19 VICTOR STREET SURGERY J82022 32 STONEHAM LANE SURGERY J82087 16 PORTSWOOD SOLENT SURGERY J82619 11 MULBERRY HOUSE SURGERY J82183 10 UNIVERSITY HEALTH SERVICE J82080 1 ST.MARY'S SURGERY J82081 12 ATHERLEY HOUSE SURGERY J82115 3 BROOK HOUSE SURGERY J82213 2 HOMELESS HEALTHCARE TEAM J82217 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

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

RAYMOND ROAD SURGERY 10

HIGHFIELD HEALTH 8

ADELAIDE GP SURGERY 4 • using the GP cluster method of NICHOLS TOWN SURGERY 3 calculating potential gains, if each BITTERNE PARK SURGERY 20 practice was to achieve as well as the REGENTS PARK SURGERY 7 upper quartile of its national cluster, then an additional 183 people would WOOLSTON LODGE SURGERY 20 be treated WEST END ROAD SURGERY 11

CHESSEL PRACTICE 21

WESTON LANE SURGERY 9

ALMA ROAD SURGERY 2

STONEHAM LANE SURGERY 1

PORTSWOOD SOLENT SURGERY 0

OLD FIRE STATION SURGERY

VICTOR STREET SURGERY

MULBERRY HOUSE SURGERY

ATHERLEY HOUSE SURGERY

UNIVERSITY HEALTH SERVICE

ST.MARY'S SURGERY

BROOK HOUSE 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 South Eastern Hampshire CCG 84.7% • 4,056 people with a history of stroke NHS Portsmouth CCG 84.4% or TIA* in NHS Southampton CCG • 3,362 (82.9%) people whose blood pressure is <= 150 / 90 NHS Isle Of Wight CCG 84.3% • 176 (4.3%) people who are exceptions • 518 (12.8%) additional people whose NHS North Hampshire CCG 83.3% blood pressure is not <= 150 / 90

NHS Southampton CCG 82.9%

NHS West Hampshire CCG 82.3%

NHS Fareham And Gosport CCG 82.2%

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 Newcastle Gateshead CCG 85.7%

NHS Canterbury and Coastal CCG 84.5%

NHS Portsmouth CCG 84.4%

NHS Nottingham City CCG 84.4%

NHS Norwich CCG 83.4%

NHS Leeds West CCG 83.2%

NHS Southampton CCG 82.9%

NHS Hull CCG 82.5%

NHS Bristol CCG 81.9%

NHS South Manchester CCG 78.8%

NHS Brighton and Hove CCG 78.6%

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

HOMELESS HEALTHCARE TEAM J82217 2 REGENTS PARK SURGERY J82203 26 ADELAIDE GP SURGERY Y02838 9 BURGESS ROAD SURGERY J82001 25 • in total, including exceptions, there MULBERRY HOUSE SURGERY J82183 31 are 694 people whose blood pressure BATH LODGE PRACTICE J82141 60 WOOLSTON LODGE SURGERY J82076 56 is not <= 150 / 90 PORTSWOOD SOLENT SURGERY J82619 19 • GP practice range: 8.3% to 66.7% ALDERMOOR SURGERY J82092 26 HILL LANE SURGERY J82207 22 CHESSEL PRACTICE J82101 50 NICHOLS TOWN SURGERY J82024 7 TOWNHILL SURGERY J82180 13 WESTON LANE SURGERY J82187 25 LORDSHILL HEALTH CENTRE J82002 39 CHEVIOT ROAD SURGERY J82062 39 ATHERLEY HOUSE SURGERY J82115 7 STONEHAM LANE SURGERY J82087 24 BROOK HOUSE SURGERY J82213 11 WEST END ROAD SURGERY J82040 20 UNIVERSITY HEALTH SERVICE J82080 3 ALMA ROAD SURGERY J82122 23 LADIES WALK PRACTICE J82622 23 VICTOR STREET SURGERY J82022 34 BITTERNE PARK SURGERY J82171 21 HIGHFIELD HEALTH J82663 6 GROVE MEDICAL PRACTICE J82088 19 ST.MARY'S SURGERY J82081 17 OLD FIRE STATION SURGERY J82128 14 WALNUT TREE SURGERY J82605 8 ST.PETERS SURGERY J82208 8 RAYMOND ROAD SURGERY J82126 7 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 Southampton CCG 92.3% • 2,839 people with a stroke shown to NHS West Hampshire CCG 91.9% be non-haemorrhagic* in NHS Southampton CCG • 2,621 (92.3%) people who are taking NHS Isle Of Wight CCG 91.7% an anti-platetet agent or anti- coagulant • 130 (4.6%) people who are NHS Fareham And Gosport CCG 91.6% exceptions • 88 (3.1%) additional people with no NHS South Eastern Hampshire CCG 91.5% treatment

NHS North Hampshire CCG 91.2%

NHS Portsmouth CCG 90.6%

England 91.8%

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

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

NHS Newcastle Gateshead CCG 93.4%

NHS Norwich CCG 92.7%

NHS Canterbury and Coastal CCG 92.4%

NHS Southampton CCG 92.3%

NHS Leeds West CCG 92.2%

NHS Nottingham City CCG 91.8%

NHS South Manchester CCG 91.0%

NHS Hull CCG 91.0%

NHS Bristol CCG 90.8%

NHS Portsmouth CCG 90.6%

NHS Brighton and Hove CCG 90.2%

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

HOMELESS HEALTHCARE TEAM J82217 1 ADELAIDE GP SURGERY Y02838 6 WOOLSTON LODGE SURGERY J82076 25 WALNUT TREE SURGERY J82605 5 • in total, including exceptions, there REGENTS PARK SURGERY J82203 8 are 218 people who are not taking an CHESSEL PRACTICE J82101 22 MULBERRY HOUSE SURGERY J82183 10 anti-platelet agent or anti-coagulant HIGHFIELD HEALTH J82663 3 • GP practice range: 0.0% to 50.0% OLD FIRE STATION SURGERY J82128 9 HILL LANE SURGERY J82207 7 STONEHAM LANE SURGERY J82087 12 LADIES WALK PRACTICE J82622 11 ST.MARY'S SURGERY J82081 10 BITTERNE PARK SURGERY J82171 9 BROOK HOUSE SURGERY J82213 3 WESTON LANE SURGERY J82187 8 PORTSWOOD SOLENT SURGERY J82619 5 GROVE MEDICAL PRACTICE J82088 7 ATHERLEY HOUSE SURGERY J82115 2 ALMA ROAD SURGERY J82122 6 ST.PETERS SURGERY J82208 4 LORDSHILL HEALTH CENTRE J82002 11 CHEVIOT ROAD SURGERY J82062 7 VICTOR STREET SURGERY J82022 10 BURGESS ROAD SURGERY J82001 3 ALDERMOOR SURGERY J82092 4 WEST END ROAD SURGERY J82040 3 BATH LODGE PRACTICE J82141 5 TOWNHILL SURGERY J82180 1 RAYMOND ROAD SURGERY J82126 1 NICHOLS TOWN SURGERY J82024 UNIVERSITY HEALTH SERVICE J82080 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 Fareham And Gosport CCG 0.81

• 0.76 ratio of observed to expected NHS South Eastern Hampshire CCG 0.80 diabetes prevalence in NHS Southampton CCG, compared to 0.77 in England NHS North Hampshire CCG 0.78 • this suggests 76% of people have been diagnosed NHS Portsmouth CCG 0.78

NHS Southampton CCG 0.76

NHS Isle Of Wight CCG 0.67

NHS West Hampshire CCG 0.66

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

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

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

NHS Hull CCG 0.81

NHS Newcastle Gateshead CCG 0.81

NHS South Manchester CCG 0.80

NHS Portsmouth CCG 0.78

NHS Southampton CCG 0.76

NHS Nottingham City CCG 0.74

NHS Leeds West CCG 0.74

NHS Canterbury and Coastal CCG 0.73

NHS Bristol CCG 0.71

NHS Norwich CCG 0.67

NHS Brighton and Hove CCG 0.60

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

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

GP practice CCG

CHESSEL PRACTICE J82101 7.6% LADIES WALK PRACTICE J82622 7.5% LORDSHILL HEALTH CENTRE J82002 7.3% BATH LODGE PRACTICE J82141 7.3% • GP practice range of observed VICTOR STREET SURGERY J82022 7.0% ALMA ROAD SURGERY J82122 6.9% diabetes 0.7% to 7.6% WESTON LANE SURGERY J82187 6.9% • there are an estimated 4,015 people BROOK HOUSE SURGERY J82213 6.8% with undiagnosed diabetes in NHS STONEHAM LANE SURGERY J82087 6.8% ALDERMOOR SURGERY J82092 6.7% Southampton CCG WOOLSTON LODGE SURGERY J82076 6.5% WEST END ROAD SURGERY J82040 6.5% PORTSWOOD SOLENT SURGERY J82619 6.3% OLD FIRE STATION SURGERY J82128 6.3% GROVE MEDICAL PRACTICE J82088 6.2% RAYMOND ROAD SURGERY J82126 6.2% ST.PETERS SURGERY J82208 6.0% CHEVIOT ROAD SURGERY J82062 5.9% TOWNHILL SURGERY J82180 5.9% NICHOLS TOWN SURGERY J82024 5.8% ATHERLEY HOUSE SURGERY J82115 5.7% BURGESS ROAD SURGERY J82001 5.7% REGENTS PARK SURGERY J82203 5.5% BITTERNE PARK SURGERY J82171 5.2% ADELAIDE GP SURGERY Y02838 4.6% MULBERRY HOUSE SURGERY J82183 4.3% HILL LANE SURGERY J82207 4.1% ST.MARY'S SURGERY J82081 3.5% HIGHFIELD HEALTH J82663 2.3% WALNUT TREE SURGERY J82605 2.3% Note: The estimated number of undiagnosed HOMELESS HEALTHCARE TEAM J82217 1.8% people with diabetes has been calculated by UNIVERSITY HEALTH SERVICE J82080 0.7% multiplying the estimated prevalence rate to the 0% 1% 2% 3% 4% 5% 6% 7% 8% 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 Isle Of Wight CCG 6.8% 3.4% 12.7% • the estimated total prevalence of diabetes in NHS Southampton CCG is 7.3% (diagnosed and undiagnosed) NHS South Eastern Hampshire CCG 6.9% 1.7% 12.0% • in addition, there are an estimated NHS West Hampshire CCG 5.5% 2.8% 12.0% 9.7% of people in NHS Southampton CCG who are at increased risk of developing diabetes (i.e. with non- NHS Fareham And Gosport CCG 6.7% 1.6% 11.7% diabetic hyperglycaemia)

NHS North Hampshire CCG 5.7% 1.6% 10.7% • this means that 17.0% of the population in NHS Southampton CCG NHS Portsmouth CCG 5.8% 1.6% 9.6% are estimated to have diabetes, or at high risk of developing of diabetes

NHS Southampton CCG 5.5% 1.8% 9.7%

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

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

NHS Southampton CCG 65.5%

• data on care processes and treatment NHS North Hampshire CCG 59.2% targets are taken from the National Diabetes Audit (NDA)

NHS Isle Of Wight CCG 55.3% • overall practice participation in the 2015/16 audit was 81.4% in England

NHS West Hampshire CCG 54.6% • in NHS Southampton CCG, 28 out of 32 practices (87.5%) participated in the NDA. Data is not available for the NHS South Eastern Hampshire CCG 45.4% remaining practices

NHS Portsmouth CCG 43.6% • 65.5% of people with diabetes (of practices who participated in the NHS Fareham And Gosport CCG 40.8% audit) had the eight recommended care processes in NHS Southampton CCG, compared to 52.6% in England

England 52.6%

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

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

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

UNIVERSITY HEALTH SERVICE J82080 79.1% REGENTS PARK SURGERY J82203 78.5% VICTOR STREET SURGERY J82022 78.3% • achievement - 8 care processes: in ATHERLEY HOUSE SURGERY J82115 72.5% practices who provided data via the NICHOLS TOWN SURGERY J82024 71.6% LADIES WALK PRACTICE J82622 71.5% NDA, between 24.0% and 79.1% of ST.PETERS SURGERY J82208 71.4% patients received all 8 care processes CHEVIOT ROAD SURGERY J82062 70.6% BROOK HOUSE SURGERY J82213 70.4% PORTSWOOD SOLENT SURGERY J82619 69.4% BURGESS ROAD SURGERY J82001 69.3% • at least 3,522 people did not receive ALDERMOOR SURGERY J82092 69.0% the eight care processes GROVE MEDICAL PRACTICE J82088 68.9% OLD FIRE STATION SURGERY J82128 67.6% HILL LANE SURGERY J82207 66.9% ST.MARY'S SURGERY J82081 65.5% WESTON LANE SURGERY J82187 65.0% ALMA ROAD SURGERY J82122 62.8% BITTERNE PARK SURGERY J82171 62.5% WALNUT TREE SURGERY J82605 61.7% WOOLSTON LODGE SURGERY J82076 60.7% STONEHAM LANE SURGERY J82087 57.4% MULBERRY HOUSE SURGERY J82183 54.9% BATH LODGE PRACTICE J82141 49.9% ADELAIDE GP SURGERY Y02838 31.3% HIGHFIELD HEALTH J82663 24.0% HOMELESS HEALTHCARE TEAM J82217 TOWNHILL SURGERY J82180 RAYMOND ROAD SURGERY J82126 CHESSEL PRACTICE J82101 WEST END ROAD SURGERY J82040 LORDSHILL HEALTH CENTRE J82002 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 South Eastern Hampshire CCG 37.9%

• 37.8% of people with diabetes (of NHS Southampton CCG 37.8% practices who participated in the audit) met the three treatment targets in NHS Southampton CCG, NHS Portsmouth CCG 37.7% compared to 39.0% in England

NHS Isle Of Wight CCG 37.6%

NHS Fareham And Gosport CCG 36.4%

NHS West Hampshire CCG 36.1%

NHS North Hampshire CCG 35.4%

England 39.0%

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

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

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

ST.PETERS SURGERY J82208 51.3% REGENTS PARK SURGERY J82203 44.7% PORTSWOOD SOLENT SURGERY J82619 44.1% • achievement - 3 treatment targets: in OLD FIRE STATION SURGERY J82128 43.8% practices who provided data via the CHEVIOT ROAD SURGERY J82062 43.3% BITTERNE PARK SURGERY J82171 41.5% NDA, between 25.4% and 51.3% of UNIVERSITY HEALTH SERVICE J82080 40.4% patients achieved all 3 treatment BURGESS ROAD SURGERY J82001 40.2% ATHERLEY HOUSE SURGERY J82115 39.4% targets HILL LANE SURGERY J82207 38.7% LADIES WALK PRACTICE J82622 37.7% • at least 5,559 people did not meet the VICTOR STREET SURGERY J82022 37.4% three treatment targets GROVE MEDICAL PRACTICE J82088 37.4% ST.MARY'S SURGERY J82081 37.2% MULBERRY HOUSE SURGERY J82183 37.2% BATH LODGE PRACTICE J82141 36.4% WESTON LANE SURGERY J82187 35.7% STONEHAM LANE SURGERY J82087 34.6% HIGHFIELD HEALTH J82663 34.6% NICHOLS TOWN SURGERY J82024 34.3% WOOLSTON LODGE SURGERY J82076 33.1% ALMA ROAD SURGERY J82122 32.9% ALDERMOOR SURGERY J82092 31.6% ADELAIDE GP SURGERY Y02838 27.4% BROOK HOUSE SURGERY J82213 27.2% WALNUT TREE SURGERY J82605 25.4% HOMELESS HEALTHCARE TEAM J82217 TOWNHILL SURGERY J82180 RAYMOND ROAD SURGERY J82126 CHESSEL PRACTICE J82101 WEST END ROAD SURGERY J82040 LORDSHILL HEALTH CENTRE J82002 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%

BROOK HOUSE SURGERY 41

WALNUT TREE SURGERY 13

ADELAIDE GP SURGERY 18 • using the GP cluster method of ALDERMOOR SURGERY 53 calculating potential gains, if each STONEHAM LANE SURGERY 40 practice was to achieve as well as the ALMA ROAD SURGERY 54 upper quartile of its national cluster, then an additional 637 people would WOOLSTON LODGE SURGERY 69 be treated HIGHFIELD HEALTH 8

LADIES WALK PRACTICE 45

NICHOLS TOWN SURGERY 24

ATHERLEY HOUSE SURGERY 12

ST.MARY'S SURGERY 36

BITTERNE PARK SURGERY 14

PORTSWOOD SOLENT SURGERY 8

UNIVERSITY HEALTH SERVICE 3

BURGESS ROAD SURGERY 8

REGENTS PARK SURGERY 2

OLD FIRE STATION SURGERY 3

CHEVIOT ROAD SURGERY

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

51 CVD: Primary Care Intelligence Packs Kidney

52 CVD: Primary Care Intelligence Packs Management of chronic kidney disease

Chronic Kidney Disease can progress to kidney failure and it Late diagnosis of CKD is common. substantially increases the risk Around a third of people with CKD are undiagnosed. More of heart attack and stroke. opportunistic testing and improved uptake of the NHS Health Check will increase detection rates.

Chronic Kidney Disease (CKD) is common. What questions should we ask in our CCG? It is one of the commonest co-morbidities and affects a third 1. for each indicator how wide is the variation in of people over 75. In 2010 it was estimated to cost the NHS achievement and exception reporting? around £1.5bn. Average length of stay in hospital tends to 2. how many people would benefit if all practices be longer and outcomes are considerably worse: performed as well as the best? approximately 7,000 excess strokes and 12,000 excess 3. how can we support practices who are average and heart attacks occur each year in people with CKD below average to perform as well as the best in: compared to those without. • detection of CKD Individuals with CKD are also at much higher risk of • more systematic delivery of evidence based care developing acute kidney injury when they have an intercurrent illness such as pneumonia What might help • Support practices to share audit data and systematically Evidence based guidance from NICE highlights CVD identify gaps and opportunities for improved detection risk reduction, good blood pressure control and and management of CKD. management of proteinuria as essential steps to reduce the • Promote uptake of and follow up from the NHS Health risk of cardiovascular events and progression to kidney Check to aid detection and management of CKD failure. Despite this there is often significant variation • Offer local training and education in the detection and between practices in achievement and exception reporting. management of CKD

53 CVD: Primary Care Intelligence Packs Chronic kidney disease (CKD) observed prevalence (2015/16) compared with expected prevalence (2011) by CCG Comparison with CCGs in the STP

NHS South Eastern Hampshire CCG 0.64

NHS Southampton CCG 0.62 • the ratio of those diagnosed with chronic kidney disease versus those

NHS Portsmouth CCG 0.60 expected to have chronic kidney disease is 0.62. This compares to 0.68 for England NHS Fareham And Gosport CCG 0.57 • this suggests that 62% of people with chronic kidney disease have been diagnosed NHS North Hampshire CCG 0.56

NHS Isle Of Wight CCG 0.53

NHS West Hampshire CCG 0.50

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

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

NHS Newcastle Gateshead CCG 0.89

NHS Bristol CCG 0.87

NHS Nottingham City CCG 0.74

NHS Hull CCG 0.73

NHS Canterbury and Coastal CCG 0.73

NHS Brighton and Hove CCG 0.66

NHS Southampton CCG 0.62

NHS South Manchester CCG 0.60

NHS Portsmouth CCG 0.60

NHS Norwich CCG 0.58

NHS Leeds West CCG 0.55

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

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

GP practice CCG

RAYMOND ROAD SURGERY J82126 5.5% LORDSHILL HEALTH CENTRE J82002 5.3% GROVE MEDICAL PRACTICE J82088 5.2% OLD FIRE STATION SURGERY J82128 5.1% • it is estimated that there are 4,109 MULBERRY HOUSE SURGERY J82183 5.0% people with undiagnosed chronic WOOLSTON LODGE SURGERY J82076 4.6% VICTOR STREET SURGERY J82022 4.2% kidney disease in NHS Southampton LADIES WALK PRACTICE J82622 4.0% CCG ALDERMOOR SURGERY J82092 3.8% STONEHAM LANE SURGERY J82087 3.7% • GP practice range of observed CKD: CHEVIOT ROAD SURGERY J82062 3.6% 0.0% to 5.5% ALMA ROAD SURGERY J82122 3.6% CHESSEL PRACTICE J82101 3.6% TOWNHILL SURGERY J82180 3.5% BATH LODGE PRACTICE J82141 3.3% PORTSWOOD SOLENT SURGERY J82619 3.2% BURGESS ROAD SURGERY J82001 3.1% BROOK HOUSE SURGERY J82213 2.8% WEST END ROAD SURGERY J82040 2.7% ST.PETERS SURGERY J82208 2.7% WESTON LANE SURGERY J82187 2.6% REGENTS PARK SURGERY J82203 2.5% ATHERLEY HOUSE SURGERY J82115 2.2% BITTERNE PARK SURGERY J82171 2.2% WALNUT TREE SURGERY J82605 2.0% HIGHFIELD HEALTH J82663 1.6% HILL LANE SURGERY J82207 1.5% ADELAIDE GP SURGERY Y02838 1.4% Note: CCG estimates for the estimated ST.MARY'S SURGERY J82081 1.4% number of people with CKD are based on NICHOLS TOWN SURGERY J82024 1.1% applying a proportion from a resident based UNIVERSITY HEALTH SERVICE J82080 0.2% HOMELESS HEALTHCARE TEAM J82217 population estimate to a GP registered population. The characteristics of registered 0% 1% 2% 3% 4% 5% 6% 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 Portsmouth CCG 78.8% • 7,054 people with CKD (diagnosed*) NHS Isle Of Wight CCG 76.0% in NHS Southampton CCG • 5,222 (74%) people whose blood pressure is <= 140 /85 NHS South Eastern Hampshire CCG 75.2% • 488 (6.9%) people who are exceptions • 1,344 (19.1%) additional people NHS Fareham And Gosport CCG 74.6% whose blood pressure is not <= 140 / 85 NHS Southampton CCG 74.0%

NHS North Hampshire CCG 71.2%

NHS West Hampshire CCG 69.6%

*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 Portsmouth CCG 78.8%

NHS Canterbury and Coastal CCG 76.6%

NHS Newcastle Gateshead CCG 74.9%

NHS Bristol CCG 74.4%

NHS Hull CCG 74.1%

NHS Southampton CCG 74.0%

NHS Nottingham City CCG 73.7%

NHS Leeds West CCG 73.6%

NHS South Manchester CCG 72.5%

NHS Brighton and Hove CCG 72.3%

NHS Norwich CCG 71.5%

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

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

Not below 140/85 Exceptions reported

ALMA ROAD SURGERY J82122 116 VICTOR STREET SURGERY J82022 165 BROOK HOUSE SURGERY J82213 37 WOOLSTON LODGE SURGERY J82076 140 • in total, including exceptions, there MULBERRY HOUSE SURGERY J82183 39 BURGESS ROAD SURGERY J82001 71 are 1,832 people whose blood CHESSEL PRACTICE J82101 127 pressure is not <= 140 / 85 STONEHAM LANE SURGERY J82087 69 • GP practice range: 11.6% to 37.4% HILL LANE SURGERY J82207 40 ADELAIDE GP SURGERY Y02838 13 BATH LODGE PRACTICE J82141 99 PORTSWOOD SOLENT SURGERY J82619 42 BITTERNE PARK SURGERY J82171 44 ALDERMOOR SURGERY J82092 65 UNIVERSITY HEALTH SERVICE J82080 8 ST.MARY'S SURGERY J82081 50 REGENTS PARK SURGERY J82203 29 TOWNHILL SURGERY J82180 39 NICHOLS TOWN SURGERY J82024 10 OLD FIRE STATION SURGERY J82128 82 THE GROVE MEDICAL PRACTICE J82088 101 LORDSHILL HEALTH CENTRE J82002 103 CHEVIOT ROAD SURGERY J82062 97 WALNUT TREE SURGERY J82605 14 THE WESTON LANE AND HAREFIELD SURGERIES J82187 35 DR SUNAK AND PARTNERS J82126 33 ST.PETERS SURGERY J82208 22 ATHERLEY HOUSE SURGERY J82115 16 CANUTE SURGERY J82182 28 BARGATE MEDICAL CENTRE J82631 14 HIGHFIELD HEALTH J82663 13 WEST END ROAD SURGERY J82040 41 LADIES WALK PRACTICE J82622 30 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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

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

BROOK HOUSE SURGERY 19

ALMA ROAD SURGERY 53

VICTOR STREET SURGERY 73 • using the GP cluster method of HILL LANE SURGERY 20 calculating potential gains, if each ADELAIDE GP SURGERY 6 practice was to achieve as well as the MULBERRY HOUSE SURGERY 17 upper quartile of its national cluster, then an additional 529 people would WOOLSTON LODGE SURGERY 58 be treated STONEHAM LANE SURGERY 32

BURGESS ROAD SURGERY 27

CHESSEL PRACTICE 47

OLD FIRE STATION SURGERY 9

THE GROVE MEDICAL PRACTICE 11

ST.PETERS SURGERY 3

ATHERLEY HOUSE SURGERY 2

LORDSHILL HEALTH CENTRE 7

CHEVIOT ROAD SURGERY 4

DR SUNAK AND PARTNERS 1

HIGHFIELD HEALTH 0

WEST END ROAD SURGERY

LADIES WALK PRACTICE 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 North Hampshire CCG 77.2% • 7,054 people with CKD (diagnosed*) NHS Southampton CCG 77.1% in NHS Southampton CCG • 5,437 (77.1%) people who have a record of urine albumin:creatinine NHS Fareham And Gosport CCG 76.6% ratio test • 383 (5.4%) people who are exceptions NHS Portsmouth CCG 75.3% • 1,234 (17.5%) additional people who have no record of urine NHS Isle Of Wight CCG 74.9% albumin:creatinine ratio test

NHS West Hampshire CCG 71.2%

NHS South Eastern Hampshire CCG 70.8%

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

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

NHS Canterbury and Coastal CCG 79.2%

NHS Southampton CCG 77.1%

NHS Bristol CCG 76.8%

NHS Nottingham City CCG 76.2%

NHS Leeds West CCG 76.2%

NHS Newcastle Gateshead CCG 76.1%

NHS Portsmouth CCG 75.3%

NHS Hull CCG 75.0%

NHS Norwich CCG 74.8%

NHS Brighton and Hove CCG 73.8%

NHS South Manchester CCG 71.9%

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

STONEHAM LANE SURGERY J82087 105 MULBERRY HOUSE SURGERY J82183 51 ALMA ROAD SURGERY J82122 135 ADELAIDE GP SURGERY Y02838 16 • in total, including exceptions, there ALDERMOOR SURGERY J82092 81 VICTOR STREET SURGERY J82022 142 are 1,617 people who have no record BITTERNE PARK SURGERY J82171 51 of urine albumin:creatinine ratio test HIGHFIELD HEALTH J82663 23 • GP practice range: 9.0% to 47.9% CANUTE SURGERY J82182 45 THE WESTON LANE AND HAREFIELD SURGERIES J82187 45 WEST END ROAD SURGERY J82040 64 CHEVIOT ROAD SURGERY J82062 112 WOOLSTON LODGE SURGERY J82076 97 BATH LODGE PRACTICE J82141 80 REGENTS PARK SURGERY J82203 27 DR SUNAK AND PARTNERS J82126 37 NICHOLS TOWN SURGERY J82024 9 PORTSWOOD SOLENT SURGERY J82619 31 UNIVERSITY HEALTH SERVICE J82080 6 TOWNHILL SURGERY J82180 30 LORDSHILL HEALTH CENTRE J82002 86 THE GROVE MEDICAL PRACTICE J82088 76 HILL LANE SURGERY J82207 21 ST.PETERS SURGERY J82208 18 BARGATE MEDICAL CENTRE J82631 12 LADIES WALK PRACTICE J82622 38 WALNUT TREE SURGERY J82605 10 CHESSEL PRACTICE J82101 57 BROOK HOUSE SURGERY J82213 15 BURGESS ROAD SURGERY J82001 29 ATHERLEY HOUSE SURGERY J82115 11 OLD FIRE STATION SURGERY J82128 39 ST.MARY'S SURGERY J82081 18 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 Isle Of Wight CCG 0.98%

NHS South Eastern Hampshire CCG 0.83% • prevalence of 0.59% in NHS Southampton CCG compared to 0.76% in England NHS Fareham And Gosport CCG 0.80%

NHS West Hampshire CCG 0.78%

NHS Portsmouth CCG 0.64%

NHS Southampton CCG 0.59%

NHS North Hampshire CCG 0.46%

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 Newcastle Gateshead CCG 0.82%

NHS Norwich CCG 0.75%

NHS Hull CCG 0.67%

NHS Canterbury and Coastal CCG 0.66%

NHS South Manchester CCG 0.65%

NHS Bristol CCG 0.64%

NHS Portsmouth CCG 0.64%

NHS Leeds West CCG 0.61%

NHS Southampton CCG 0.59%

NHS Nottingham City CCG 0.54%

NHS Brighton and Hove CCG 0.53%

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

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

GP practice CCG

LADIES WALK PRACTICE J82622 1.3% BURGESS ROAD SURGERY J82001 0.9% LORDSHILL HEALTH CENTRE J82002 0.9% BITTERNE PARK SURGERY J82171 0.8% • 1,627 people with diagnosed heart ALMA ROAD SURGERY J82122 0.8% failure in NHS Southampton CCG STONEHAM LANE SURGERY J82087 0.8% BATH LODGE PRACTICE J82141 0.8% • GP practice range: 0.0% to 1.3% TOWNHILL SURGERY J82180 0.7% PORTSWOOD SOLENT SURGERY J82619 0.7% MULBERRY HOUSE SURGERY J82183 0.7% OLD FIRE STATION SURGERY J82128 0.7% BROOK HOUSE SURGERY J82213 0.7% GROVE MEDICAL PRACTICE J82088 0.7% VICTOR STREET SURGERY J82022 0.7% WOOLSTON LODGE SURGERY J82076 0.7% WALNUT TREE SURGERY J82605 0.7% CHEVIOT ROAD SURGERY J82062 0.6% CHESSEL PRACTICE J82101 0.6% WESTON LANE SURGERY J82187 0.6% HILL LANE SURGERY J82207 0.5% ST.PETERS SURGERY J82208 0.5% HIGHFIELD HEALTH J82663 0.5% ALDERMOOR SURGERY J82092 0.4% ADELAIDE GP SURGERY Y02838 0.3% WEST END ROAD SURGERY J82040 0.3% RAYMOND ROAD SURGERY J82126 0.3% ST.MARY'S SURGERY J82081 0.3% REGENTS PARK SURGERY J82203 0.3% ATHERLEY HOUSE SURGERY J82115 0.3% NICHOLS TOWN SURGERY J82024 0.2% UNIVERSITY HEALTH SERVICE J82080 HOMELESS HEALTHCARE TEAM J82217 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6%

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 Isle Of Wight CCG 87.9% • 529 people with heart failure* with NHS South Eastern Hampshire CCG 86.8% LVSD in NHS Southampton CCG • 439 (83%) people treated with ACE-I or ARB NHS Portsmouth CCG 86.6% • 88 (16.6%) people who are exceptions • 2 (0.4%) additional people who are NHS North Hampshire CCG 85.3% not treated with ACE-I or ARB

NHS Fareham And Gosport CCG 84.8%

NHS West Hampshire CCG 84.0%

NHS Southampton CCG 83.0%

England 84.7%

0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator HF003 denominator plus exceptions

69 CVD: Primary Care Intelligence Packs Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who are treated with ACE-I / ARB by CCG Comparison with demographically similar CCGs Treatment No treatment Exceptions reported

NHS Nottingham City CCG 89.1%

NHS Hull CCG 87.9%

NHS Newcastle Gateshead CCG 87.0%

NHS South Manchester CCG 86.9%

NHS Portsmouth CCG 86.6%

NHS Bristol CCG 83.6%

NHS Southampton CCG 83.0%

NHS Canterbury and Coastal CCG 82.4%

NHS Leeds West CCG 82.3%

NHS Norwich CCG 81.7%

NHS Brighton and Hove CCG 81.3%

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

UNIVERSITY HEALTH SERVICE J82080 2 OLD FIRE STATION SURGERY J82128 5 VICTOR STREET SURGERY J82022 3 BATH LODGE PRACTICE J82141 9 • in total, including exceptions, there ALMA ROAD SURGERY J82122 11 are 90 people who are not treated ATHERLEY HOUSE SURGERY J82115 1 TOWNHILL SURGERY J82180 7 with ACE-I or ARB BITTERNE PARK SURGERY J82171 6 • GP practice range: 0.0% to 50.0% STONEHAM LANE SURGERY J82087 2 MULBERRY HOUSE SURGERY J82183 1 CHEVIOT ROAD SURGERY J82062 7 LADIES WALK PRACTICE J82622 7 GROVE MEDICAL PRACTICE J82088 4 WEST END ROAD SURGERY J82040 1 CHESSEL PRACTICE J82101 6 BURGESS ROAD SURGERY J82001 6 LORDSHILL HEALTH CENTRE J82002 6 WOOLSTON LODGE SURGERY J82076 2 ST.PETERS SURGERY J82208 1 ST.MARY'S SURGERY J82081 1 HILL LANE SURGERY J82207 1 WESTON LANE SURGERY J82187 1 NICHOLS TOWN SURGERY J82024 ALDERMOOR SURGERY J82092 RAYMOND ROAD SURGERY J82126 REGENTS PARK SURGERY J82203 BROOK HOUSE SURGERY J82213 WALNUT TREE SURGERY J82605 PORTSWOOD SOLENT SURGERY J82619 HIGHFIELD HEALTH J82663 ADELAIDE GP SURGERY Y02838 HOMELESS HEALTHCARE TEAM J82217 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 Portsmouth CCG 85.5% • 439 people with heart failure* with NHS South Eastern Hampshire CCG 82.0% LVSD treated with ACE-I/ARB in NHS Southampton CCG • 345 (78.6%) people treated with ACE- NHS Fareham And Gosport CCG 81.2% I/ARB and BB • 68 (15.5%) people who are exceptions NHS Southampton CCG 78.6% • 26 (5.9%) additional people who are not treated with ACE-I/ARB and BB NHS West Hampshire CCG 77.4%

NHS North Hampshire CCG 74.2%

NHS Isle Of Wight CCG 69.3%

England 77.7%

0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator HF004 denominator plus exceptions

72 CVD: Primary Care Intelligence Packs Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who are treated with ACE-I / ARB and BB by CCG Comparison with demographically similar CCGs Treatment No treatment Exceptions reported

NHS South Manchester CCG 88.4%

NHS Hull CCG 87.6%

NHS Portsmouth CCG 85.5%

NHS Leeds West CCG 82.8%

NHS Bristol CCG 81.2%

NHS Newcastle Gateshead CCG 78.7%

NHS Southampton CCG 78.6%

NHS Canterbury and Coastal CCG 76.0%

NHS Brighton and Hove CCG 75.6%

NHS Nottingham City CCG 71.9%

NHS Norwich CCG 66.6%

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

ALDERMOOR SURGERY J82092 5 REGENTS PARK SURGERY J82203 1 TOWNHILL SURGERY J82180 8 HILL LANE SURGERY J82207 5 • in total, including exceptions, there LADIES WALK PRACTICE J82622 9 are 94 people who are not treated BURGESS ROAD SURGERY J82001 12 GROVE MEDICAL PRACTICE J82088 5 with ACE-I or ARB CHESSEL PRACTICE J82101 9 • GP practice range: 0.0% to 55.6% MULBERRY HOUSE SURGERY J82183 1 WALNUT TREE SURGERY J82605 1 LORDSHILL HEALTH CENTRE J82002 10 CHEVIOT ROAD SURGERY J82062 6 ALMA ROAD SURGERY J82122 6 BATH LODGE PRACTICE J82141 4 WOOLSTON LODGE SURGERY J82076 3 BROOK HOUSE SURGERY J82213 1 WESTON LANE SURGERY J82187 3 STONEHAM LANE SURGERY J82087 1 OLD FIRE STATION SURGERY J82128 1 PORTSWOOD SOLENT SURGERY J82619 1 BITTERNE PARK SURGERY J82171 2 VICTOR STREET SURGERY J82022 NICHOLS TOWN SURGERY J82024 WEST END ROAD SURGERY J82040 UNIVERSITY HEALTH SERVICE J82080 ST.MARY'S SURGERY J82081 ATHERLEY HOUSE SURGERY J82115 RAYMOND ROAD SURGERY J82126 ST.PETERS SURGERY J82208 HIGHFIELD HEALTH J82663 ADELAIDE GP SURGERY Y02838 HOMELESS HEALTHCARE TEAM J82217 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 South Eastern Hampshire CCG 89.5% • 6,607 people with coronary heart NHS Portsmouth CCG 88.5% disease* in NHS Southampton CCG • 5,847 (88.5%) people whose blood pressure <= 150 / 90 NHS Southampton CCG 88.5% • 289 (4.4%) people who are exceptions • 471 (7.1%) additional people whose NHS North Hampshire CCG 88.0% blood pressure is not <= 150 / 90

NHS Isle Of Wight CCG 87.6%

NHS West Hampshire CCG 86.8%

NHS Fareham And Gosport CCG 86.6%

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 Newcastle Gateshead CCG 89.2%

NHS Canterbury and Coastal CCG 89.1%

NHS Leeds West CCG 88.7%

NHS Portsmouth CCG 88.5%

NHS Southampton CCG 88.5%

NHS Norwich CCG 88.1%

NHS Nottingham City CCG 88.0%

NHS Bristol CCG 86.9%

NHS Hull CCG 86.4%

NHS South Manchester CCG 83.5%

NHS Brighton and Hove CCG 83.0%

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

HOMELESS HEALTHCARE TEAM J82217 2 ADELAIDE GP SURGERY Y02838 18 BURGESS ROAD SURGERY J82001 46 CHESSEL PRACTICE J82101 81 • in total, including exceptions, there ATHERLEY HOUSE SURGERY J82115 17 are 760 people whose blood pressure MULBERRY HOUSE SURGERY J82183 26 BROOK HOUSE SURGERY J82213 18 is not <= 150 / 90 NICHOLS TOWN SURGERY J82024 10 • GP practice range: 0.0% to 66.7% BATH LODGE PRACTICE J82141 58 STONEHAM LANE SURGERY J82087 31 REGENTS PARK SURGERY J82203 18 PORTSWOOD SOLENT SURGERY J82619 19 WALNUT TREE SURGERY J82605 8 WOOLSTON LODGE SURGERY J82076 49 VICTOR STREET SURGERY J82022 45 RAYMOND ROAD SURGERY J82126 10 GROVE MEDICAL PRACTICE J82088 31 LORDSHILL HEALTH CENTRE J82002 37 ALMA ROAD SURGERY J82122 24 TOWNHILL SURGERY J82180 15 ALDERMOOR SURGERY J82092 20 ST.PETERS SURGERY J82208 16 HILL LANE SURGERY J82207 15 CHEVIOT ROAD SURGERY J82062 35 OLD FIRE STATION SURGERY J82128 20 ST.MARY'S SURGERY J82081 23 LADIES WALK PRACTICE J82622 22 WESTON LANE SURGERY J82187 17 BITTERNE PARK SURGERY J82171 15 WEST END ROAD SURGERY J82040 13 HIGHFIELD HEALTH J82663 1 UNIVERSITY HEALTH SERVICE J82080 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%

ADELAIDE GP SURGERY 14

BURGESS ROAD SURGERY 29

ATHERLEY HOUSE SURGERY 11 • using the GP cluster method of MULBERRY HOUSE SURGERY 15 calculating potential gains, if each CHESSEL PRACTICE 42 practice was to achieve as well as the NICHOLS TOWN SURGERY 6 upper quartile of its national cluster, then an additional 271 people would REGENTS PARK SURGERY 10 be treated BROOK HOUSE SURGERY 10

STONEHAM LANE SURGERY 16

WALNUT TREE SURGERY 4

LORDSHILL HEALTH CENTRE 7

ALMA ROAD SURGERY 4

CHEVIOT ROAD SURGERY 3

LADIES WALK PRACTICE 2

OLD FIRE STATION SURGERY 1

WESTON LANE SURGERY

BITTERNE PARK SURGERY

WEST END ROAD SURGERY

HIGHFIELD HEALTH

UNIVERSITY HEALTH SERVICE 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 Southampton CCG 92.6% • 6,607 people with coronary heart NHS West Hampshire CCG 92.6% disease* in NHS Southampton CCG • 6,116 (92.6%) people who are taking aspirin, an alternative anti-platelet NHS Fareham And Gosport CCG 92.2% therapy, or an anti-coagulant • 255 (3.9%) people who are exceptions NHS North Hampshire CCG 92.1% • 236 (3.6%) additional people who are not taking aspirin, an alternative anti- NHS Isle Of Wight CCG 91.6% platelet therapy, or an anti-coagulant

NHS South Eastern Hampshire CCG 91.5%

NHS Portsmouth CCG 89.5%

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 Newcastle Gateshead CCG 93.7%

NHS Canterbury and Coastal CCG 92.6%

NHS Southampton CCG 92.6%

NHS Leeds West CCG 92.1%

NHS Bristol CCG 91.8%

NHS Nottingham City CCG 91.3%

NHS Norwich CCG 90.6%

NHS South Manchester CCG 90.5%

NHS Portsmouth CCG 89.5%

NHS Hull CCG 89.5%

NHS Brighton and Hove CCG 89.4%

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

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

No treatment Exceptions reported

HOMELESS HEALTHCARE TEAM J82217 3 HIGHFIELD HEALTH J82663 7 WALNUT TREE SURGERY J82605 10 PORTSWOOD SOLENT SURGERY J82619 19 • in total, including exceptions, there ADELAIDE GP SURGERY Y02838 8 are 491 people are not taking aspirin, HILL LANE SURGERY J82207 17 ATHERLEY HOUSE SURGERY J82115 10 an alternative anti-platelet therapy, or STONEHAM LANE SURGERY J82087 21 an anti-coagulant MULBERRY HOUSE SURGERY J82183 15 REGENTS PARK SURGERY J82203 12 • GP practice range: 3.7% to 100.0% ST.MARY'S SURGERY J82081 28 ALMA ROAD SURGERY J82122 22 GROVE MEDICAL PRACTICE J82088 26 CHESSEL PRACTICE J82101 40 OLD FIRE STATION SURGERY J82128 18 LADIES WALK PRACTICE J82622 23 WOOLSTON LODGE SURGERY J82076 32 BITTERNE PARK SURGERY J82171 19 RAYMOND ROAD SURGERY J82126 6 BATH LODGE PRACTICE J82141 24 ST.PETERS SURGERY J82208 10 VICTOR STREET SURGERY J82022 24 BROOK HOUSE SURGERY J82213 7 BURGESS ROAD SURGERY J82001 11 LORDSHILL HEALTH CENTRE J82002 19 UNIVERSITY HEALTH SERVICE J82080 1 WESTON LANE SURGERY J82187 12 CHEVIOT ROAD SURGERY J82062 18 TOWNHILL SURGERY J82180 7 NICHOLS TOWN SURGERY J82024 3 ALDERMOOR SURGERY J82092 9 WEST END ROAD SURGERY J82040 10 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 Southampton CCG England 800

700 • in NHS Southampton CCG, the hospital admission rate for coronary heart disease in 2015/16 was 338.4 600 (605) 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 Southampton CCG England 300

• in NHS Southampton CCG, the 250 hospital admission rate for stroke in 2015/16 was 176 (314) 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 Southampton CCG England

137.3% Angina 136.8% • The risk of a stroke was 82.2% higher and the risk of a heart attack was 97.8% 97.8% higher compared to people Heart Attack 108.6% without diabetes. The risk of a major amputation was 812.3% higher. 151.8% Heart failure 150.0%

82.2% Stroke 81.3%

812.3% Major amputation 445.8%

1118.3% Minor amputation 753.5%

345.3% 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 Southampton CCG England 100

90 • in NHS Southampton CCG, the early mortality rate for coronary heart 80 disease in 2013-15 was 47.7, 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 Southampton CCG England 30

• in NHS Southampton CCG, the early 25 mortality rate for stroke in 2013-15 was 14.4, compared to 13.6 for England

20

15

10 Age Age standardised (per rate 100,000)

5

0 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11 2010-12 2011-13 2012-14 2013-15

Source: Office for National Statistics (ONS) mortality data 2002 - 2015

87 CVD: Primary Care Intelligence Packs Appendix Data sources

• Quality and Outcomes Framework (QOF), 2015/16, Copyright © 2016, re-used with the permission of NHS Digital. All rights reserved

• Non-diabetic hyperglycaemia prevalence estimates, NCVIN, PHE: https://www.gov.uk/government/publications/nhs-diabetes- prevention-programme-non-diabetic-hyperglycaemia

• Diabetes prevalence estimates, NCVIN, PHE: https://www.gov.uk/government/publications/diabetes-prevalence-estimates-for- local-populations

• CKD Prevalence model, G.Aitken, University of Southampton , 2014 https://www.gov.uk/government/publications/ckd- prevalence-estimates-for-local-and-regional-populations

• Hypertension prevalence estimates for local CCG populations. Created using data from: QOF hypertension registers 2014/15 and; Undiagnosed hypertension estimates for adults 16 years and older. 2014. Department of Primary Care & Public Health, Imperial College London https://www.gov.uk/government/publications/hypertension-prevalence-estimates-for-local-populations

• NHS Stop smoking services Copyright © 2014, NHS Digital

• Norberg J, Bäckström S , Jansson J-H, Johansson L. Estimating the prevalence of atrial fibrillation in a general population using validated electronic health data. Clin Epidemiol 2013 ; 5 475 – 81.

• National Diabetes Audit, 2013/14 and 2015/16, Copyright © 2016, re-used with the permission of NHS Digital. All rights reserved

• Hospital Episode Statistics (HES), 2002/03 - 2015/16, Copyright © 2017, Re‐used with the permission of NHS Digital. All rights reserved

• Office for National Statistics (ONS) mortality data 2002 – 2015, Copyright © 2017, Re-used with the permission of the Office for National Statistics. All rights reserved

88 CVD: Primary Care Intelligence Packs About Public Health England

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Published June 2017 Gateway number 2017095

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