CVD: Primary Care Intelligence Packs

Transcription

1 CVD: Primary Care Intelligence Packs NHS High Weald Lewes Havens CCG June 2017 Version 1

2 Contents 1. Introduction 3 2. CVD prevention The narrative 11 The data Hypertension 4. Stroke 5. Diabetes 6. Kidney 7. Heart The narrative 16 The data 17 The narrative 27 The data 28 The narrative 42 The data 43 The narrative 53 The data 54 The narrative 65 The data Outcomes 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

3 Introduction 3

4 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

5 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

6 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: The 10 most similar CCGs to NHS High Weald Lewes Havens CCG are: NHS South West Lincolnshire CCG NHS South Norfolk CCG NHS South Lincolnshire CCG NHS West Suffolk CCG NHS Hambleton, Richmondshire and Whitby CCG NHS South Worcestershire CCG NHS Rushcliffe CCG NHS North Somerset CCG NHS South Warwickshire CCG NHS Harrogate and Rural District 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

7 Why does variation matter? The variation that exists between demographically similar CCGs and between practices illustrates the local potential to improve care and outcomes for our patients Benchmarking is helpful because it highlights variation. Of course it has long been acknowledged that some variation is inevitable in the healthcare and outcomes experienced by patients. But John Wennberg, who has championed research into clinical variation over four decades and who founded the pioneering Dartmouth Atlas of Health Care, concluded that much variation is unwarranted ie it cannot be explained on the basis of illness, medical evidence, or patient preference, but is accounted for by the willingness and ability of doctors to offer treatment. A key observation about benchmarking data is that it does not tell us why there is variation. Some of the variation may be explained by population or case mix and some may be unwarranted. We will not know unless we investigate. Benchmarking may not be conclusive. Its strength lies not in the answers it provides but in the questions it generates for CCGs and practices. For example: 1. How much variation is there in detection, management, exception reporting and outcomes? 2. How many people would benefit if average performers improved to the level of the best performers? 3. How many people would benefit if the lowest performers matched the achievement of the average? 4. What are better performers doing differently in the way they provide services in order to achieve better outcomes? 5. How can the CCG support low and average performers to help them match the achievement of the best? 6. How can we build clinical leadership to drive quality improvement? 7 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 allows us to identify the practices that need support to implement the strategies adopted by low excepting practices.

8 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: 8

9 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 EMERSONS GREEN MEDICAL CENTRE LEAP VALLEY MEDICAL CENTRE CHRISTCHURCH FAMILY MEDICAL CENTRE CONISTON MEDICAL PRACTICE FROME VALLEY MEDICAL CENTRE ST MARY STREET SURGERY Raw difference between the practice value and the average of the highest or lowest 50% of similar cluster practices KINGSWOOD HEALTH CENTRE CONCORD MEDICAL CENTRE KENNEDY WAY SURGERY BRADLEY STOKE SURGERY THE WILLOW SURGERY CLOSE FARM SURGERY The difference between the benchmark and the selected practices is displayed on this chart. The benchmark will PILNING SURGERY 1 most likely be different for different practices as they are in different clusters, so the difference is the key measure COURTSIDE SURGERY here. If the practice performance is below the benchmark, the difference is applied to the denominator plus exceptions ALMONDSBURY to SURGERY demonstrate potential gains on a practice basis. The potential gains on a CCG basis are calculated based on the difference between the top 5 performing closest CCGs and the selected CCG, applied to the denominator plus exceptions. STOKE GIFFORD MEDICAL CENTRE ORCHARD MEDICAL CENTRE WEST WALK SURGERY THORNBURY HEALTH CENTRE - BURNEY 9 Potential opportunity if the practice value was to move to the average of the highest 50% of similar cluster practices Potential opportunity if the CCG value were to move to the average of the top 5 performing closest CCGs

10 CVD prevention 10

11 CVD prevention The NHS needs a radical upgrade in prevention if it is to be sustainable 5 year Forward View 2014 This is because England faces an epidemic of largely preventable non-communicable diseases, such as heart disease and stroke, cancer, Type 2 diabetes and liver disease. Dietary risks Tobacco smoke High body-mass index High systolic blood pressure Alcohol and drug use High fasting plasma glucose High total cholesterol Low glomerular filtration rate Low physical activity Occupational risks Air pollution Low bone mineral density Child and maternal malnutrition Sexual abuse and violence Other environmental risks Unsafe sex Unsafe water/ sanitation/ handwashing HIV/AIDS and tuberculosis Diarrhea, lower respiratory & other common infectious diseases Neglected tropical diseases & malaria Maternal disorders Neonatal disorders Nutritional deficiencies Other communicable, maternal, neonatal, & nutritional diseases Neoplasms Cardiovascular diseases Chronic respiratory diseases Cirrhosis Digestive diseases Neurological disorders Mental & substance use disorders Diabetes, urogenital, blood, & endocrine diseases Musculoskeletal disorders Other non-communicable diseases Transport injuries Unintentional injuries Self-harm and interpersonal violence Forces of nature, war, & legal intervention 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 11% 12% Percent of total disability-adjusted life-years (DALYs) The Global Burden of Disease Study (next slide) shows us that the leading causes of premature mortality include diet, tobacco, obesity, raised blood pressure, physical inactivity and raised cholesterol. The radical upgrade in prevention needs population-level approaches. But it also needs interventions in primary care for individuals with behavioural and clinical risk factors. The size of the prevention problem 2/3 of adults are obese or overweight 1/3 of adults are physically inactive average smoking prevalence is 17% but is much higher in some communities in high risk conditions like atrial fibrillation, high blood pressure, diabetes and high ten year CVD risk score, up to half of all people do not receive preventive treatments that are known to be highly effective at preventing heart attacks and strokes around 90% of people with familial hypercholesterolaemia are undiagnosed and untreated despite their average 10 year reduction in life expectancy Social prescribing and wellbeing hubs offer new models for supporting behaviour change while reducing burden on general practice. The NHS Health Check is a systematic approach to identifying local people at high risk of CVD, offering behaviour change support and early detection of the high risk but often undiagnosed conditions such as hypertension, atrial fibrillation, CKD, diabetes and prediabetes. Question: What proportion of our local eligible population is receiving the NHS Health Check and how effective is the follow-up management of their clinical risk factors in primary care? 11 11

12 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

13 Estimated smoking prevalence (QOF) by CCG Comparison with demographically similar CCGs NHS West Suffolk CCG 17.5% NHS South Lincolnshire CCG NHS South Worcestershire CCG 17.5% 16.7% prevalence of 15.1% in NHS High Weald Lewes Havens CCG NHS South West Lincolnshire CCG 16.7% NHS North Somerset CCG 16.4% NHS South Norfolk CCG 16.4% NHS High Weald Lewes Havens CCG 15.1% NHS Harrogate and Rural District CCG NHS South Warwickshire CCG NHS Hambleton, Richmondshire and Whitby CCG 14.4% 14.2% 14.0% Note: It has been found that the proportion of patients recorded as smokers correlates well with IHS smoking prevalence and is a good estimate of the actual smoking prevalence in local areas, tract NHS Rushcliffe CCG 11.6% 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% Definition: denominator of QOF clinical indicator SMOKE004 ( number of patients 15+ who are recorded as current smokers) divided by GP practice s estimated number of patients

14 Estimated smoking prevalence (QOF) by GP practice GP Practice CCG CHAPEL STREET SURGERY G81061 QUAYSIDE MEDICAL PRACTICE G81016 MERIDIAN SURGERY G81100 ROWE AVENUE SURGERY G81053 THE MEADS SURGERY G81037 SCHOOL HILL MEDICAL PRACTICE G81021 ST. ANDREWS SURGERY G81045 RIVER LODGE SURGERY G81035 ROTHERFIELD SURGERY G81043 BUXTED MEDICAL CENTRE G81102 BIRD-IN-EYE SURGERY G81086 BELMONT SURGERY G81030 BEACON SURGERY G81019 WOODHILL SURGERY G81040 SAXONBURY HOUSE SURGERY G81055 MANOR OAK SURGERY G % 22.0% 19.2% 17.5% 17.0% 15.8% 14.9% 14.9% 14.3% 14.1% 14.0% 13.7% 13.1% 12.9% 12.5% 12.5% 21,311 people who are recorded as smokers in NHS High Weald Lewes Havens CCG GP practice range: 11.8% to 25.5% MID DOWNS MEDICAL PRACTICE G % ASHDOWN FOREST HEALTH CENTRE G % HEATHFIELD SURGERY G % GROOMBRIDGE AND HARTFIELD MED GRP G % 0% 5% 10% 15% 20% 25% 30% Note: This method is thought to be a reasonably robust method in estimating smoking prevalence for the majority of GP practices. However, caution is advised for extreme estimates of smoking prevalence and those with high numbers of smoking status not recorded and exceptions. 14

15 Hypertension 15

16 Hypertension The Global Burden of Disease Study confirmed high blood pressure as a leading cause of premature death and disability High blood pressure is common and costly it affects around a quarter of all adults the NHS costs of hypertension are around 2bn social costs are probably considerably higher 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 factor for chronic kidney disease and cognitive decline treatment is very effective every 10mmHg reduction in systolic blood pressure lowers risk of heart attack and stroke by 20% despite this 4 out of 10 adults with hypertension, over 5 and a half million people in England, remain undiagnosed and even when the condition is identified, treatment is often suboptimal, with blood pressure poorly controlled in about 1 out of 3 individuals The Missing Millions On average, each CCG in England has 26,000 residents with undiagnosed hypertension these individuals are unaware of their increased cardiovascular risk and are untreated. 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 as well as the best? 3. how can we support practices who are average or below average to perform as well as the best in: detection of hypertension management of hypertension What might help? support practices to share audit data and systematically identify gaps and opportunities for improved detection and management of hypertension work with practices and local authorities to maximise uptake and follow up in the NHS Health Check support access to self-test BP stations in waiting rooms and to ambulatory blood pressure monitoring. commission community pharmacists to offer blood pressure measurement, diagnosis and management support, including support for adherence to medication 16

17 Hypertension observed prevalence compared with expected prevalence by CCG Comparison with CCGs in the STP NHS Hastings And Rother CCG 0.64 NHS Eastbourne, Hailsham And Seaford CCG NHS Coastal West Sussex CCG NHS Horsham And Mid Sussex CCG the ratio of those diagnosed with hypertension versus those expected to have hypertension is This compares to 0.59 for England this suggests that 59% of people with hypertension have been diagnosed NHS High Weald Lewes Havens CCG 0.59 NHS Crawley CCG 0.57 NHS East Surrey CCG 0.56 NHS Brighton And Hove CCG 0.52 England Ratio Note: this slide shows Hypertension prevalence estimates created using data from QOF hypertension registers 2014/15 and Undiagnosed hypertension estimates for adults 16 years and older Department of Primary Care & Public Health, Imperial College London 17

18 Hypertension observed prevalence compared with expected prevalence by CCG Comparison with demographically similar CCGs NHS South West Lincolnshire CCG 0.62 NHS North Somerset CCG 0.61 NHS South Lincolnshire CCG 0.61 NHS South Worcestershire CCG 0.60 NHS Hambleton, Richmondshire and Whitby CCG 0.60 NHS South Warwickshire CCG 0.59 NHS Harrogate and Rural District CCG 0.59 NHS Rushcliffe CCG 0.59 NHS South Norfolk CCG 0.59 NHS High Weald Lewes Havens CCG 0.59 NHS West Suffolk CCG % 10% 20% 30% 40% 50% 60% 70% 18

19 Hypertension observed prevalence compared with expected prevalence by GP practice GP practice CCG SAXONBURY HOUSE SURGERY G81055 ROTHERFIELD SURGERY G81043 MANOR OAK SURGERY G81097 QUAYSIDE MEDICAL PRACTICE G81016 THE MEADS SURGERY G81037 CHAPEL STREET SURGERY G81061 BUXTED MEDICAL CENTRE G81102 MID DOWNS MEDICAL PRACTICE G81007 ROWE AVENUE SURGERY G81053 BIRD-IN-EYE SURGERY G81086 BELMONT SURGERY G81030 BEACON SURGERY G81019 ASHDOWN FOREST HEALTH CENTRE G81024 MERIDIAN SURGERY G81100 HEATHFIELD SURGERY G81088 GROOMBRIDGE AND HARTFIELD MED GRP G81614 WOODHILL SURGERY G81040 RIVER LODGE SURGERY G81035 ST. ANDREWS SURGERY G81045 SCHOOL HILL MEDICAL PRACTICE G it is estimated that there are 17,555 people with undiagnosed hypertension in NHS High Weald Lewes Havens CCG GP practice range of observed to expected hypertension prevalence 0.45 to Ratio 19

20 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 Hastings And Rother CCG 80.4% NHS Horsham And Mid Sussex CCG NHS Crawley CCG NHS Eastbourne, Hailsham And Seaford CCG NHS East Surrey CCG NHS Coastal West Sussex CCG 80.3% 79.6% 77.3% 77.2% 76.1% 25,071 people with hypertension (diagnosed)* in NHS High Weald Lewes Havens CCG 18,911 (75.4%) people whose blood pressure is <= 150/90 1,285 (5.1%) people who are excepted from optimal control 4,875 (19.4%) additional people whose blood pressure is not <= 150/90 NHS High Weald Lewes Havens CCG 75.4% NHS Brighton And Hove CCG 73.3% England 79.6% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% *Using QOF clinical indicator HYP006 denominator plus exceptions 20

21 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 South Worcestershire CCG 85.2% NHS South Lincolnshire CCG 83.8% NHS Rushcliffe CCG 83.1% NHS Hambleton, Richmondshire and Whitby CCG 82.7% NHS South Warwickshire CCG 82.6% NHS South Norfolk CCG 82.4% NHS Harrogate and Rural District CCG 82.4% NHS South West Lincolnshire CCG 81.3% NHS West Suffolk CCG 81.2% NHS North Somerset CCG 79.8% NHS High Weald Lewes Havens CCG 75.4% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 21

22 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 GROOMBRIDGE AND HARTFIELD MED GRP G81614 ASHDOWN FOREST HEALTH CENTRE G81024 MANOR OAK SURGERY G81097 ROWE AVENUE SURGERY G81053 BUXTED MEDICAL CENTRE G81102 BIRD-IN-EYE SURGERY G81086 MERIDIAN SURGERY G81100 QUAYSIDE MEDICAL PRACTICE G81016 CHAPEL STREET SURGERY G81061 ROTHERFIELD SURGERY G81043 THE MEADS SURGERY G81037 BELMONT SURGERY G81030 BEACON SURGERY G81019 ST. ANDREWS SURGERY G81045 RIVER LODGE SURGERY G81035 WOODHILL SURGERY G81040 SAXONBURY HOUSE SURGERY G81055 HEATHFIELD SURGERY G81088 SCHOOL HILL MEDICAL PRACTICE G81021 MID DOWNS MEDICAL PRACTICE G in total, including exceptions, there are 6,160 people whose blood pressure is not <= 150/90 GP practice range: 15.5% to 36.5% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 22

23 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 Crawley CCG 75.0% NHS Hastings And Rother CCG NHS High Weald Lewes Havens CCG NHS Horsham And Mid Sussex CCG NHS Brighton And Hove CCG NHS East Surrey CCG 64.2% 61.9% 61.6% 60.5% 59.7% 105 people with a new diagnosis* of hypertension with a CVD risk of 20% or higher in NHS High Weald Lewes Havens CCG 65 (61.9%) people who are currently treated with statins 38 (36.2%) people who are exempted from treatment with statins 2 (1.9%) additional people who are not currently treated with statins NHS Coastal West Sussex CCG 59.6% NHS Eastbourne, Hailsham And Seaford CCG 54.9% England 66.5% 0% 10% 20% 30% 40% 50% 60% 70% 80% *Using the QOF clinical indicator CVD-PP001 denominator plus exceptions 23

24 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 Hambleton, Richmondshire and Whitby CCG 71.6% NHS South West Lincolnshire CCG 67.3% NHS Harrogate and Rural District CCG 65.3% NHS South Warwickshire CCG 64.4% NHS West Suffolk CCG 64.3% NHS Rushcliffe CCG 64.1% NHS High Weald Lewes Havens CCG 61.9% NHS South Lincolnshire CCG 61.8% NHS South Worcestershire CCG 55.1% NHS North Somerset CCG 53.9% NHS South Norfolk CCG 49.2% 0% 10% 20% 30% 40% 50% 60% 70% 80% 24

25 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 MID DOWNS MEDICAL PRACTICE G RIVER LODGE SURGERY G81035 ST. ANDREWS SURGERY G81045 MANOR OAK SURGERY G81097 BEACON SURGERY G81019 ASHDOWN FOREST HEALTH CENTRE G in total, including exceptions, there are 40 people who are not treated with statins GP practice range: 0.0% to 71.4% HEATHFIELD SURGERY G GROOMBRIDGE AND HARTFIELD MED GRP G BUXTED MEDICAL CENTRE G MERIDIAN SURGERY G QUAYSIDE MEDICAL PRACTICE G ROTHERFIELD SURGERY G BELMONT SURGERY G81030 CHAPEL STREET SURGERY G SAXONBURY HOUSE SURGERY G SCHOOL HILL MEDICAL PRACTICE G81021 WOODHILL SURGERY G81040 ROWE AVENUE SURGERY G81053 BIRD-IN-EYE SURGERY G81086 THE MEADS SURGERY G % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 25

26 Stroke 26

27 Stroke prevention Only a half of people with known AF who then suffer a stroke have been anticoagulated before their stroke. Stroke is one of the leading causes of premature death and disability. Stroke is devastating for individuals and families, and accounts for a substantial proportion of health and social care expenditure. Atrial fibrillation increases the risk of stroke by a factor of 5, and strokes caused by AF are often more severe, with higher mortality and greater disability. Anticoagulation reduces the risk of stroke in people with AF by two thirds. Despite this, AF is underdiagnosed and under treated: up to a third of people with AF are unaware they have the condition and even when diagnosed inadequate treatment is common large numbers do not receive anticoagulants or have poor anticoagulant control. What questions should we ask in our CCG? 1. for each indicator how wide is the variation in detection, treatment 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 average and below average to perform as well as the best in detection of atrial fibrillation and stroke prevention with anticoagulation. What might help? increase opportunistic pulse checking especially in over 65s support practices to share audit data and systematically identify gaps and opportunities for improved detection and management of AF - eg GRASP-AF promote systematic use of CHADS-VASC and HASBLED to ensure those at high risk are offered stroke prevention promote systematic use of Warfarin Patient Safety Audit Tool to ensure optimal time in therapeutic range for people on warfarin develop local consensus statement on risk-benefit balance for anticoagulants, including the newer treatments (NOACs) work with practices and local authorities to maximise uptake and clinical follow up in the NHS Health Check commission community pharmacists to offer pulse checks, anticoagulant monitoring, and support for adherence to medication 27

28 Atrial fibrillation observed prevalence compared to expected prevalence by CCG Comparison with CCGs in the STP NHS Eastbourne, Hailsham And Seaford CCG 0.84 NHS Hastings And Rother CCG NHS East Surrey CCG NHS High Weald Lewes Havens CCG the ratio of those diagnosed with atrial fibrillation versus those expected to have atrial fibrillation is This compares to 0.7 for England this suggests that 74% of people with atrial fibrillation have been diagnosed. NHS Coastal West Sussex CCG 0.72 NHS Horsham And Mid Sussex CCG 0.70 NHS Crawley CCG 0.67 NHS Brighton And Hove CCG 0.66 England 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 The estimates were developed by applying age-sex specific prevalence rates as reported by Norberg et al (2013) to GP population estimates from NHS Digital. Estimates reported are adjusted for age and sex of the local population. 28

29 Atrial fibrillation observed prevalence compared to expected prevalence by CCG Comparison with demographically similar CCGs NHS North Somerset CCG 0.80 NHS Harrogate and Rural District CCG 0.76 NHS Hambleton, Richmondshire and Whitby CCG 0.76 NHS High Weald Lewes Havens CCG 0.74 NHS South West Lincolnshire CCG 0.73 NHS South Lincolnshire CCG 0.73 NHS South Warwickshire CCG 0.72 NHS South Worcestershire CCG 0.71 NHS South Norfolk CCG 0.69 NHS Rushcliffe CCG 0.68 NHS West Suffolk CCG

30 Atrial fibrillation observed prevalence compared with expected prevalence by GP practice GP practice CCG WOODHILL SURGERY G81040 BUXTED MEDICAL CENTRE G81102 GROOMBRIDGE AND HARTFIELD MED GRP G81614 MID DOWNS MEDICAL PRACTICE G81007 QUAYSIDE MEDICAL PRACTICE G81016 ROTHERFIELD SURGERY G81043 ST. ANDREWS SURGERY G81045 SAXONBURY HOUSE SURGERY G81055 CHAPEL STREET SURGERY G81061 ASHDOWN FOREST HEALTH CENTRE G81024 RIVER LODGE SURGERY G81035 THE MEADS SURGERY G81037 ROWE AVENUE SURGERY G81053 BIRD-IN-EYE SURGERY G81086 HEATHFIELD SURGERY G81088 MANOR OAK SURGERY G81097 MERIDIAN SURGERY G81100 BEACON SURGERY G81019 SCHOOL HILL MEDICAL PRACTICE G81021 BELMONT SURGERY G it is estimated that there are 5,242 people with undiagnosed atrial fibrillation in NHS High Weald Lewes Havens CCG GP practice range of observed to expected atrial fibrillation prevalence 0.6 to Ratio 30

31 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 Eastbourne, Hailsham And Seaford CCG NHS High Weald Lewes Havens CCG NHS Hastings And Rother CCG NHS Crawley CCG NHS East Surrey CCG NHS Horsham And Mid Sussex CCG 78.1% 77.8% 77.6% 77.1% 76.5% 75.3% 3,144 people with atrial fibrillation* with a CHA2DS2-VASc score >= 2 in NHS High Weald Lewes Havens CCG 2,446 (77.8%) people treated with anti-coagulation therapy 332 (10.6%) people who are exceptions 366 (11.6%) additional people with a recorded CHA2DS2-VASc score >= 2 who are not treated NHS Coastal West Sussex CCG 74.7% NHS Brighton And Hove CCG 70.4% England 77.9% 0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator AF007 denominator plus exceptions 31

32 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 Hambleton, Richmondshire and Whitby CCG 83.7% NHS South Lincolnshire CCG 83.4% NHS South West Lincolnshire CCG 82.3% NHS South Worcestershire CCG 78.9% NHS Rushcliffe CCG 77.8% NHS High Weald Lewes Havens CCG 77.8% NHS North Somerset CCG 77.8% NHS South Norfolk CCG 77.4% NHS Harrogate and Rural District CCG 77.0% NHS West Suffolk CCG 75.7% NHS South Warwickshire CCG 75.4% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 32

33 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 BUXTED MEDICAL CENTRE G81102 ASHDOWN FOREST HEALTH CENTRE G81024 MERIDIAN SURGERY G81100 ST. ANDREWS SURGERY G81045 QUAYSIDE MEDICAL PRACTICE G81016 RIVER LODGE SURGERY G81035 MANOR OAK SURGERY G81097 SCHOOL HILL MEDICAL PRACTICE G81021 SAXONBURY HOUSE SURGERY G81055 ROWE AVENUE SURGERY G81053 CHAPEL STREET SURGERY G81061 THE MEADS SURGERY G81037 BIRD-IN-EYE SURGERY G81086 HEATHFIELD SURGERY G81088 WOODHILL SURGERY G81040 BELMONT SURGERY G81030 BEACON SURGERY G81019 GROOMBRIDGE AND HARTFIELD MED GRP G81614 MID DOWNS MEDICAL PRACTICE G81007 ROTHERFIELD SURGERY G in total, including exceptions, there are 698 people with a recorded CHA2DS2-VASc score >= 2 who are not treated GP practice range: 12.9% to 31.7% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 33

34 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 4% 2% 0% -2% -4% -6% -8% -10% -12% -14% -16% BUXTED MEDICAL CENTRE ASHDOWN FOREST HEALTH CENTRE MERIDIAN SURGERY ST. ANDREWS SURGERY MANOR OAK SURGERY QUAYSIDE MEDICAL PRACTICE SCHOOL HILL MEDICAL PRACTICE RIVER LODGE SURGERY ROWE AVENUE SURGERY CHAPEL STREET SURGERY using the GP cluster method of calculating potential gains, if each practice was to achieve as well as the upper quartile of its national cluster, then an additional 190 people would be treated SAXONBURY HOUSE SURGERY THE MEADS SURGERY BIRD-IN-EYE SURGERY WOODHILL SURGERY HEATHFIELD SURGERY GROOMBRIDGE AND HARTFIELD MED GRP MID DOWNS MEDICAL PRACTICE BELMONT SURGERY BEACON SURGERY ROTHERFIELD SURGERY Details of this methodology are available on slide 9. Click here to view them. 34

35 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 Hastings And Rother CCG NHS Horsham And Mid Sussex CCG NHS Crawley CCG NHS East Surrey CCG NHS Eastbourne, Hailsham And Seaford CCG 84.6% 84.2% 84.1% 82.8% 82.6% 3,395 people with a history of stroke or TIA* in NHS High Weald Lewes Havens CCG 2,786 (82.1%) people whose blood pressure is <= 150 / (5.7%) people who are exceptions 414 (12.2%) additional people whose blood pressure is not <= 150 / 90 NHS High Weald Lewes Havens CCG 82.1% NHS Coastal West Sussex CCG 79.7% NHS Brighton And Hove CCG 78.6% England 83.8% 0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator STIA003 denominator plus exceptions 35

36 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 South Worcestershire CCG 88.3% NHS Harrogate and Rural District CCG 87.6% NHS Rushcliffe CCG 86.7% NHS South Lincolnshire CCG 86.5% NHS South Warwickshire CCG 86.5% NHS West Suffolk CCG 85.5% NHS Hambleton, Richmondshire and Whitby CCG 85.4% NHS South West Lincolnshire CCG 85.3% NHS North Somerset CCG 85.0% NHS South Norfolk CCG 84.8% NHS High Weald Lewes Havens CCG 82.1% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 36

37 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 BELMONT SURGERY G81030 THE MEADS SURGERY G81037 BUXTED MEDICAL CENTRE G81102 MERIDIAN SURGERY G81100 GROOMBRIDGE AND HARTFIELD MED GRP G81614 ROWE AVENUE SURGERY G81053 ASHDOWN FOREST HEALTH CENTRE G81024 QUAYSIDE MEDICAL PRACTICE G81016 MANOR OAK SURGERY G81097 ST. ANDREWS SURGERY G81045 BIRD-IN-EYE SURGERY G81086 ROTHERFIELD SURGERY G81043 HEATHFIELD SURGERY G81088 CHAPEL STREET SURGERY G81061 RIVER LODGE SURGERY G81035 SCHOOL HILL MEDICAL PRACTICE G81021 BEACON SURGERY G81019 SAXONBURY HOUSE SURGERY G in total, including exceptions, there are 609 people whose blood pressure is not <= 150 / 90 GP practice range: 7.5% to 24.7% MID DOWNS MEDICAL PRACTICE G81007 WOODHILL SURGERY G % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 37

38 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 Crawley CCG NHS High Weald Lewes Havens CCG NHS Eastbourne, Hailsham And Seaford CCG NHS Hastings And Rother CCG NHS Horsham And Mid Sussex CCG NHS East Surrey CCG 92.8% 92.2% 92.1% 91.6% 91.4% 90.7% 2,408 people with a stroke shown to be non-haemorrhagic* in NHS High Weald Lewes Havens CCG 2,220 (92.2%) people who are taking an anti-platetet agent or anticoagulant 127 (5.3%) people who are exceptions 61 (2.5%) additional people with no treatment NHS Brighton And Hove CCG 90.2% NHS Coastal West Sussex CCG 90.2% England 91.8% 0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator STIA007 denominator plus exceptions 38

39 Percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record in the preceding 12 months that an anti-platelet agent, or an anti-coagulant is being taken by CCG Comparison with demographically similar CCGs Below 150/90 Not below 150/90 Exceptions reported NHS South Lincolnshire CCG 94.0% NHS Hambleton, Richmondshire and Whitby CCG 93.9% NHS West Suffolk CCG 92.9% NHS Rushcliffe CCG 92.8% NHS South West Lincolnshire CCG 92.5% NHS High Weald Lewes Havens CCG 92.2% NHS South Worcestershire CCG 92.1% NHS South Norfolk CCG 91.5% NHS North Somerset CCG 91.4% NHS Harrogate and Rural District CCG 91.4% NHS South Warwickshire CCG 91.3% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 39

40 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 ST. ANDREWS SURGERY G81045 BUXTED MEDICAL CENTRE G81102 ROTHERFIELD SURGERY G81043 BEACON SURGERY G81019 THE MEADS SURGERY G81037 MANOR OAK SURGERY G81097 BELMONT SURGERY G81030 ROWE AVENUE SURGERY G81053 SCHOOL HILL MEDICAL PRACTICE G81021 ASHDOWN FOREST HEALTH CENTRE G81024 WOODHILL SURGERY G81040 GROOMBRIDGE AND HARTFIELD MED GRP G81614 SAXONBURY HOUSE SURGERY G81055 RIVER LODGE SURGERY G81035 QUAYSIDE MEDICAL PRACTICE G81016 MERIDIAN SURGERY G81100 HEATHFIELD SURGERY G81088 MID DOWNS MEDICAL PRACTICE G81007 BIRD-IN-EYE SURGERY G81086 CHAPEL STREET SURGERY G % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% in total, including exceptions, there are 188 people who are not taking an anti-platelet agent or anti-coagulant GP practice range: 3.6% to 13.1% 40

41 Diabetes 41

42 Diabetes prevention and management Diabetes costs the NHS 9.8 billion per year and the prevalence is rising Type 2 diabetes is often preventable People at high risk of developing type 2 diabetes can be identified through the NHS Health Check, and the disease can be prevented or delayed in many through intensive behaviour change support. Complications of diabetes are preventable Diabetes is a major cause of premature death and disability and greatly increases the risk of heart disease and stroke, kidney failure, amputations and blindness. 80% of NHS spending on diabetes goes on managing these complications, most of which could be prevented. There are 8 essential care processes, in addition to retinal screening, that together substantially reduce complication rates. Despite this, around a half of people with diabetes do not receive all 8 care processes, and there is widespread variation between CCGs and practices in levels of achievement Type 2 Diabetes in numbers diagnosed prevalence 3.0 million undiagnosed diabetes 900,000 non-diabetic hyperglycaemia (high risk of diabetes) 5 million 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 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 diabetes delivery of the 8 care processes and achievement of the 3 treatment targets identification and management of Non-diabetic hyperglycaemia What might help ensure universal participation by practices in the National Diabetes Audit (NDA) benchmark practice level data from the NDA and support practices to explore variation increase support for patient education and shared management maximise uptake of the NHS Health Check to aid detection of diabetes and Non Diabetic Hyperglycaemia maximise uptake of the NHS Diabetes Prevention Programme 42

43 Diabetes observed prevalence compared with expected prevalence by CCG Comparison with CCGs in the STP NHS Crawley CCG NHS Coastal West Sussex CCG NHS Hastings And Rother CCG NHS East Surrey CCG ratio of observed to expected diabetes prevalence in NHS High Weald Lewes Havens CCG, compared to 0.77 in England this suggests 64% of people have been diagnosed NHS Horsham And Mid Sussex CCG 0.69 NHS Eastbourne, Hailsham And Seaford CCG 0.67 NHS High Weald Lewes Havens CCG 0.64 NHS Brighton And Hove CCG 0.60 England 0.77 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 produced in

44 Diabetes observed prevalence compared with expected prevalence by CCG Comparison with demographically similar CCGs NHS South Lincolnshire CCG 0.84 NHS South West Lincolnshire CCG 0.83 NHS South Worcestershire CCG 0.79 NHS West Suffolk CCG 0.73 NHS North Somerset CCG 0.71 NHS South Norfolk CCG 0.71 NHS Harrogate and Rural District CCG 0.70 NHS Rushcliffe CCG 0.70 NHS South Warwickshire CCG 0.68 NHS Hambleton, Richmondshire and Whitby CCG 0.66 NHS High Weald Lewes Havens CCG

45 Diabetes prevalence by GP practice GP practice CCG ROWE AVENUE SURGERY G81053 MERIDIAN SURGERY G81100 QUAYSIDE MEDICAL PRACTICE G81016 CHAPEL STREET SURGERY G81061 SAXONBURY HOUSE SURGERY G81055 HEATHFIELD SURGERY G81088 RIVER LODGE SURGERY G81035 BIRD-IN-EYE SURGERY G81086 MANOR OAK SURGERY G81097 BEACON SURGERY G81019 GROOMBRIDGE AND HARTFIELD MED GRP G81614 MID DOWNS MEDICAL PRACTICE G81007 THE MEADS SURGERY G81037 SCHOOL HILL MEDICAL PRACTICE G81021 BELMONT SURGERY G81030 BUXTED MEDICAL CENTRE G81102 ROTHERFIELD SURGERY G81043 ASHDOWN FOREST HEALTH CENTRE G % 7.6% 7.2% 6.8% 6.7% 5.8% 5.4% 5.3% 5.2% 5.0% 5.0% 4.8% 4.8% 4.8% 4.8% 4.7% 4.6% 4.3% GP practice range of observed diabetes 3.3% to 8.0% there are an estimated 4,139 people with undiagnosed diabetes in NHS High Weald Lewes Havens CCG WOODHILL SURGERY G % ST. ANDREWS SURGERY G % 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% Note: The estimated number of undiagnosed people with diabetes has been calculated by multiplying the estimated prevalence rate to the 2015/16 QOF list size and subtracting the number of people on the diabetes register. 45

46 Expected total prevalence of diabetes and non-diabetic hyperglycaemia Diabetes prevalence Expected non-diabetic hyperglycaemia prevalence Undiagnosed diabetes prevalence NHS Hastings And Rother CCG NHS Eastbourne, Hailsham And Seaford CCG 7.2% 6.4% 2.7% 3.1% 12.6% 12.9% the estimated total prevalence of diabetes in NHS High Weald Lewes Havens CCG is 8.5% (diagnosed and undiagnosed) NHS Coastal West Sussex CCG NHS High Weald Lewes Havens CCG NHS Horsham And Mid Sussex CCG 7.0% 5.5% 5.3% 2.2% 3.0% 2.3% 12.5% 12.1% 11.4% in addition, there are an estimated 12.1% of people in NHS High Weald Lewes Havens CCG who are at increased risk of developing diabetes (i.e. with non-diabetic hyperglycaemia) NHS East Surrey CCG NHS Crawley CCG 5.3% 6.6% 2.3% 1.2% 10.9% 10.4% this means that 20.5% of the population in NHS High Weald Lewes Havens CCG are estimated to have diabetes, or at high risk of developing of diabetes NHS Brighton And Hove CCG 4.1% 2.8% 8.4% England 6.5% 1.9% 11.2% 0% 5% 10% 15% 20% 25% Note: Prevalence estimates of non-diabetic hyperglycaemia were developed using Health Survey for England (HSE) data. Five years of HSE data were combined, The estimates take into account the age, ethnic group and estimated body mass index of the population. These estimates were produced using the GP registered population. 46

47 People with diabetes who had eight care processes by CCG 2015/16 NHS Coastal West Sussex CCG 63.3% NHS Hastings And Rother CCG NHS Eastbourne, Hailsham And Seaford CCG NHS Crawley CCG NHS Horsham And Mid Sussex CCG NHS High Weald Lewes Havens CCG 59.4% 57.9% 57.7% 55.4% 52.0% data on care processes and treatment targets are taken from the National Diabetes Audit (NDA) overall practice participation in the 2015/16 audit was 81.4% in England in NHS High Weald Lewes Havens CCG, 20 out of 20 practices (100.0%) participated in the NDA NHS Brighton And Hove CCG NHS East Surrey CCG 51.8% 50.4% 52.0% of people with diabetes (of practices who participated in the audit) had the eight recommended care processes in NHS High Weald Lewes Havens CCG, compared to 52.6% in England England 52.6% 0% 10% 20% 30% 40% 50% 60% 70% 47

48 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 BIRD-IN-EYE SURGERY G81086 SCHOOL HILL MEDICAL PRACTICE G81021 HEATHFIELD SURGERY G81088 QUAYSIDE MEDICAL PRACTICE G81016 SAXONBURY HOUSE SURGERY G81055 BEACON SURGERY G81019 MID DOWNS MEDICAL PRACTICE G81007 ST. ANDREWS SURGERY G81045 THE MEADS SURGERY G81037 BELMONT SURGERY G81030 ROTHERFIELD SURGERY G81043 MERIDIAN SURGERY G81100 RIVER LODGE SURGERY G81035 MANOR OAK SURGERY G81097 BUXTED MEDICAL CENTRE G81102 GROOMBRIDGE AND HARTFIELD MED GRP G81614 WOODHILL SURGERY G81040 ASHDOWN FOREST HEALTH CENTRE G81024 CHAPEL STREET SURGERY G81061 ROWE AVENUE SURGERY G % 74.0% 71.3% 69.9% 69.0% 68.4% 66.7% 60.9% 55.8% 54.4% 46.9% 46.6% 46.2% 42.2% 39.5% 28.9% 23.5% 23.2% 15.4% 15.4% achievement - 8 care processes: in practices who provided data via the NDA, between 15.4% and 75.0% of patients received all 8 care processes at least 3,459 people did not receive the eight care processes 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 48

49 People with diabetes who met all 3 treatment targets by CCG, 2015/16 NHS Hastings And Rother CCG 42.4% NHS Eastbourne, Hailsham And Seaford CCG NHS Horsham And Mid Sussex CCG NHS Brighton And Hove CCG 41.0% 39.9% 38.4% 37.9% of people with diabetes (of practices who participated in the audit) met the three treatment targets in NHS High Weald Lewes Havens CCG, compared to 39.0% in England NHS High Weald Lewes Havens CCG 37.9% NHS Coastal West Sussex CCG 37.2% NHS East Surrey CCG 35.4% NHS Crawley CCG 33.8% England 39.0% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 49

50 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 MID DOWNS MEDICAL PRACTICE G81007 ASHDOWN FOREST HEALTH CENTRE G81024 ROWE AVENUE SURGERY G81053 BIRD-IN-EYE SURGERY G81086 RIVER LODGE SURGERY G81035 MERIDIAN SURGERY G81100 SCHOOL HILL MEDICAL PRACTICE G81021 HEATHFIELD SURGERY G81088 QUAYSIDE MEDICAL PRACTICE G81016 THE MEADS SURGERY G81037 BELMONT SURGERY G81030 WOODHILL SURGERY G81040 MANOR OAK SURGERY G81097 ST. ANDREWS SURGERY G81045 SAXONBURY HOUSE SURGERY G81055 BEACON SURGERY G81019 GROOMBRIDGE AND HARTFIELD MED GRP G81614 CHAPEL STREET SURGERY G81061 BUXTED MEDICAL CENTRE G81102 ROTHERFIELD SURGERY G % 47.9% 43.0% 41.8% 41.6% 40.6% 40.1% 39.3% 37.9% 37.1% 36.7% 35.2% 34.7% 34.3% 33.1% 32.8% 32.2% 30.5% 29.8% 27.1% achievement - 3 treatment targets: in practices who provided data via the NDA, between 27.1% and 51.5% of patients achieved all 3 treatment targets at least 3,898 people did not meet the three treatment targets 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 50

51 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% ROTHERFIELD SURGERY CHAPEL STREET SURGERY BUXTED MEDICAL CENTRE GROOMBRIDGE AND HARTFIELD MED GRP BEACON SURGERY SAXONBURY HOUSE SURGERY MANOR OAK SURGERY WOODHILL SURGERY ST. ANDREWS SURGERY THE MEADS SURGERY using the GP cluster method of calculating potential gains, if each practice was to achieve as well as the upper quartile of its national cluster, then an additional 466 people would be treated BELMONT SURGERY QUAYSIDE MEDICAL PRACTICE SCHOOL HILL MEDICAL PRACTICE HEATHFIELD SURGERY BIRD-IN-EYE SURGERY MERIDIAN SURGERY RIVER LODGE SURGERY ROWE AVENUE SURGERY ASHDOWN FOREST HEALTH CENTRE MID DOWNS MEDICAL PRACTICE Details of this methodology are available on slide 9. Click here to view them. 51

52 Kidney 52

53 Management of chronic kidney disease Chronic Kidney Disease can progress to kidney failure and it substantially increases the risk of heart attack and stroke. Late diagnosis of CKD is common. Around a third of people with CKD are undiagnosed. More opportunistic testing and improved uptake of the NHS Health Check will increase detection rates. Chronic Kidney Disease (CKD) is common. It is one of the commonest co-morbidities and affects a third of people over 75. In 2010 it was estimated to cost the NHS around 1.5bn. Average length of stay in hospital tends to be longer and outcomes are considerably worse: approximately 7,000 excess strokes and 12,000 excess heart attacks occur each year in people with CKD compared to those without. Individuals with CKD are also at much higher risk of developing acute kidney injury when they have an intercurrent illness such as pneumonia Evidence based guidance from NICE highlights CVD risk reduction, good blood pressure control and management of proteinuria as essential steps to reduce the risk of cardiovascular events and progression to kidney failure. Despite this there is often significant variation between practices in achievement and exception reporting. 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 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 CKD more systematic delivery of evidence based care What might help Support practices to share audit data and systematically identify gaps and opportunities for improved detection and management of CKD. Promote uptake of and follow up from the NHS Health Check to aid detection and management of CKD Offer local training and education in the detection and management of CKD 53

54 Chronic kidney disease (CKD) observed prevalence (2015/16) compared with expected prevalence (2011) by CCG Comparison with CCGs in the STP NHS Crawley CCG 0.86 NHS Eastbourne, Hailsham And Seaford CCG NHS East Surrey CCG NHS Brighton And Hove CCG NHS Horsham And Mid Sussex CCG the ratio of those diagnosed with chronic kidney disease versus those expected to have chronic kidney disease is This compares to 0.68 for England this suggests that 62% of people with chronic kidney disease have been diagnosed NHS High Weald Lewes Havens CCG 0.62 NHS Coastal West Sussex CCG 0.58 NHS Hastings And Rother CCG 0.56 England Ratio 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 A small number of CCGs have a ratio greater than 1. It is unlikely that all people with CKD will be diagnosed in any CCG and therefore a ratio greater than 1 suggests that the figures are underestimating the true CKD prevalence in the area. These ratios should be taken as an indication of the comparative scale of undiagnosed CKD rather than absolute figures. 54

55 Chronic kidney disease (CKD) observed prevalence (2015/16) compared with expected prevalence (2011) by CCG Comparison with demographically similar CCGs NHS South West Lincolnshire CCG 0.98 NHS South Lincolnshire CCG 0.93 NHS Rushcliffe CCG 0.90 NHS South Worcestershire CCG 0.78 NHS South Warwickshire CCG 0.78 NHS North Somerset CCG 0.73 NHS Harrogate and Rural District CCG 0.70 NHS South Norfolk CCG 0.65 NHS High Weald Lewes Havens CCG 0.62 NHS Hambleton, Richmondshire and Whitby CCG 0.57 NHS West Suffolk CCG Ratio 55

56 CKD prevalence by GP practice, 2015/16 GP practice CCG ROWE AVENUE SURGERY G81053 MERIDIAN SURGERY G81100 SAXONBURY HOUSE SURGERY G81055 QUAYSIDE MEDICAL PRACTICE G81016 MANOR OAK SURGERY G81097 THE MEADS SURGERY G81037 ST. ANDREWS SURGERY G81045 BUXTED MEDICAL CENTRE G81102 GROOMBRIDGE AND HARTFIELD MED GRP G81614 SCHOOL HILL MEDICAL PRACTICE G81021 ASHDOWN FOREST HEALTH CENTRE G81024 MID DOWNS MEDICAL PRACTICE G81007 ROTHERFIELD SURGERY G81043 CHAPEL STREET SURGERY G81061 WOODHILL SURGERY G81040 RIVER LODGE SURGERY G % 6.1% 6.0% 5.6% 5.5% 5.4% 5.4% 5.1% 5.0% 4.6% 4.4% 4.0% 4.0% 3.8% 3.6% 3.6% it is estimated that there are 3,741 people with undiagnosed chronic kidney disease in NHS High Weald Lewes Havens CCG GP practice range of observed CKD: 2.7% to 7.7% BELMONT SURGERY G % BEACON SURGERY G % HEATHFIELD SURGERY G % BIRD-IN-EYE SURGERY G % 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% Note: CCG estimates for the estimated number of people with CKD are based on applying a proportion from a resident based population estimate to a GP registered population. The characteristics of registered and resident populations may vary in some CCGs, and local interpretation is required. 56

57 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 Hastings And Rother CCG NHS Eastbourne, Hailsham And Seaford CCG NHS East Surrey CCG NHS Crawley CCG NHS Brighton And Hove CCG NHS Horsham And Mid Sussex CCG 77.9% 74.7% 73.9% 73.5% 72.3% 72.2% 6,582 people with CKD (diagnosed*) in NHS High Weald Lewes Havens CCG 4,705 (71.5%) people whose blood pressure is <= 140 / (8.4%) people who are exceptions 1,324 (20.1%) additional people whose blood pressure is not <= 140 / 85 NHS High Weald Lewes Havens CCG 71.5% NHS Coastal West Sussex CCG 68.6% England 74.4% 0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator CKD002 denominator plus exceptions. Note: as the CKD002 indicator was removed from the QOF in 15/16 this is historic data taken from the 2014/15 QOF. 57

58 Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding 12 months) is 140/85 mmhg or less by CCG, 2014/15 Comparison with demographically similar CCGs Below 140/85 Not below 140/85 Exceptions reported NHS South Lincolnshire CCG 77.4% NHS Rushcliffe CCG 76.7% NHS South Worcestershire CCG 76.5% NHS South Warwickshire CCG 75.7% NHS North Somerset CCG 75.5% NHS Harrogate and Rural District CCG 75.4% NHS Hambleton, Richmondshire and Whitby CCG 75.2% NHS West Suffolk CCG 74.8% NHS South West Lincolnshire CCG 73.9% NHS South Norfolk CCG 73.7% NHS High Weald Lewes Havens CCG 71.5% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 58

59 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 BELMONT SURGERY G81030 SAXONBURY HOUSE PRACTICE G81055 CHAPEL STREET SURGERY G81061 ROTHERFIELD SURGERY G81043 BUXTED MEDICAL CENTRE G81102 THE BEACON SURGERY G81019 BIRD IN EYE SURGERY G81086 GROOMBRIDGE AND HARTFIELD MED GRP G81614 QUAYSIDE MEDICAL PRACTICE G81016 ASHDOWN FOREST HEALTH CENTRE G81024 HEATHFIELD SURGERY G81088 ROWE AVENUE SURGERY G81053 MANOR OAK SURGERY G81097 MERIDIAN SURGERY G81100 WOODHILL SURGERY G81040 ST ANDREWS SURGERY G81045 SCHOOL HILL MEDICAL PRACTICE G81021 FOXHILL MEDICAL CENTRE G81627 RIVER LODGE SURGERY G81035 THE MEADS SURGERY G in total, including exceptions, there are 1,877 people whose blood pressure is not <= 140 / 85 GP practice range: 16.6% to 37.0% MID DOWNS MEDICAL PRACTICE G % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 59

60 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 4% 2% 0% -2% -4% -6% -8% -10% -12% -14% -16% -18% BELMONT SURGERY CHAPEL STREET SURGERY BIRD IN EYE SURGERY ROTHERFIELD SURGERY SAXONBURY HOUSE PRACTICE GROOMBRIDGE AND HARTFIELD MED GRP BUXTED MEDICAL CENTRE THE BEACON SURGERY ROWE AVENUE SURGERY MANOR OAK SURGERY using the GP cluster method of calculating potential gains, if each practice was to achieve as well as the upper quartile of its national cluster, then an additional 558 people would be treated QUAYSIDE MEDICAL PRACTICE ASHDOWN FOREST HEALTH CENTRE WOODHILL SURGERY HEATHFIELD SURGERY MERIDIAN SURGERY SCHOOL HILL MEDICAL PRACTICE ST ANDREWS SURGERY RIVER LODGE SURGERY THE MEADS SURGERY MID DOWNS MEDICAL PRACTICE Details of this methodology are available on slide 9. Click here to view them. 60

61 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 Hastings And Rother CCG NHS Crawley CCG NHS Eastbourne, Hailsham And Seaford CCG NHS Brighton And Hove CCG NHS East Surrey CCG NHS High Weald Lewes Havens CCG 80.3% 76.1% 74.9% 73.8% 73.2% 73.0% 6,582 people with CKD (diagnosed*) in NHS High Weald Lewes Havens CCG 4,808 (73%) people who have a record of urine albumin:creatinine ratio test 360 (5.5%) people who are exceptions 1,414 (21.5%) additional people who have no record of urine albumin:creatinine ratio test NHS Horsham And Mid Sussex CCG 71.4% NHS Coastal West Sussex CCG 67.4% England 75.4% 0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator CKD004 denominator plus exceptions. Note: as the CKD004 indicator was removed from the QOF in 15/16 this is historic data taken from the 2014/15 QOF. 61

62 Percentage of patients on the CKD register whose notes have a record of a urine albumin: creatinine ratio test in the preceding 12 months by CCG, 2014/15 Comparison with demographically similar CCGs Recorded Not recorded Exceptions reported NHS South West Lincolnshire CCG 83.9% NHS Rushcliffe CCG 81.0% NHS Harrogate and Rural District CCG 80.7% NHS Hambleton, Richmondshire and Whitby CCG 78.3% NHS South Lincolnshire CCG 77.9% NHS South Norfolk CCG 77.4% NHS South Warwickshire CCG 77.0% NHS South Worcestershire CCG 76.7% NHS North Somerset CCG 74.8% NHS High Weald Lewes Havens CCG 73.0% NHS West Suffolk CCG 70.7% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 62

63 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 HEATHFIELD SURGERY G BELMONT SURGERY G81030 SAXONBURY HOUSE PRACTICE G81055 ASHDOWN FOREST HEALTH CENTRE G81024 CHAPEL STREET SURGERY G81061 BUXTED MEDICAL CENTRE G in total, including exceptions, there are 1,774 people who have no record of urine albumin:creatinine ratio test GP practice range: 14.1% to 64.3% MERIDIAN SURGERY G81100 THE BEACON SURGERY G81019 ST ANDREWS SURGERY G81045 GROOMBRIDGE AND HARTFIELD MED GRP G81614 RIVER LODGE SURGERY G81035 FOXHILL MEDICAL CENTRE G81627 THE MEADS SURGERY G MID DOWNS MEDICAL PRACTICE G81007 SCHOOL HILL MEDICAL PRACTICE G81021 ROTHERFIELD SURGERY G81043 WOODHILL SURGERY G81040 MANOR OAK SURGERY G81097 BIRD IN EYE SURGERY G81086 QUAYSIDE MEDICAL PRACTICE G81016 ROWE AVENUE SURGERY G % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 63

64 Heart 64

65 Management of Heart Disease Premature death and disability in people with CHD can be reduced significantly by systematic evidence based management in primary care Coronary Heart Disease is one of the principal causes of premature death and disability. The key elements of management for an individual who has already had a heart attack or angina are symptom control and secondary prevention of further cardiovascular events and premature mortality. There is robust evidence to support the use of anti-platelet treatment, statins, beta-blockers and angiotensin 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 and exception reporting at practice level shows that there is often considerable potential for improving management and outcomes. Heart failure is a common and an important complication of coronary heart disease and other conditions. Appropriate treatment including up-titration of ace inhibitors and beta blockers in heart failure due to LVSD can significantly improve symptom control and quality of life, and improve outcomes for patients. Despite this, around a quarter of people with heart failure are undetected and untreated. And amongst those who are diagnosed, there is significant variation in the quality of care. 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 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: more systematic delivery of evidence based care for people with CHD improved detection and management of heart failure What might help 1. roll out of GRASP-Heart Failure audit tool that identifies people with heart failure who are undiagnosed or under treated 2. education for health professionals to promote evidence based management of CHD and high quality measurement of blood pressure 3. ensure access to rapid access diagnostic clinics and specialist support for management of angina and heart failure 4. ensure access to cardiac rehab for individuals with CHD and heart failure 65

66 Heart failure prevalence by CCG Comparison with CCGs in the STP NHS Eastbourne, Hailsham And Seaford CCG 1.13% NHS Hastings And Rother CCG NHS Coastal West Sussex CCG 1.05% 0.88% prevalence of 0.73% in NHS High Weald Lewes Havens CCG compared to 0.76% in England NHS High Weald Lewes Havens CCG 0.73% NHS Horsham And Mid Sussex CCG 0.72% NHS East Surrey CCG 0.61% NHS Crawley CCG 0.58% NHS Brighton And Hove CCG 0.53% England 0.76% 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 66

67 Heart failure prevalence by CCG Comparison with demographically similar CCGs NHS South West Lincolnshire CCG 1.08% NHS South Lincolnshire CCG 1.01% NHS Hambleton, Richmondshire and Whitby CCG 0.95% NHS South Worcestershire CCG 0.93% NHS Harrogate and Rural District CCG 0.92% NHS North Somerset CCG 0.88% NHS West Suffolk CCG 0.83% NHS South Norfolk CCG 0.82% NHS South Warwickshire CCG 0.78% NHS Rushcliffe CCG 0.78% NHS High Weald Lewes Havens CCG 0.73% 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 67

68 Heart failure prevalence by GP practice GP practice CCG ROWE AVENUE SURGERY G81053 MERIDIAN SURGERY G81100 MANOR OAK SURGERY G81097 CHAPEL STREET SURGERY G81061 GROOMBRIDGE AND HARTFIELD MED GRP G81614 SAXONBURY HOUSE SURGERY G81055 RIVER LODGE SURGERY G81035 ASHDOWN FOREST HEALTH CENTRE G81024 BELMONT SURGERY G81030 WOODHILL SURGERY G81040 THE MEADS SURGERY G81037 BUXTED MEDICAL CENTRE G81102 SCHOOL HILL MEDICAL PRACTICE G81021 QUAYSIDE MEDICAL PRACTICE G81016 MID DOWNS MEDICAL PRACTICE G81007 HEATHFIELD SURGERY G81088 ST. ANDREWS SURGERY G81045 ROTHERFIELD SURGERY G81043 BIRD-IN-EYE SURGERY G81086 BEACON SURGERY G % 1.0% 0.9% 0.9% 0.9% 0.8% 0.8% 0.8% 0.8% 0.7% 0.7% 0.7% 0.7% 0.7% 0.7% 0.6% 0.6% 0.6% 0.5% 0.4% 1,227 people with diagnosed heart failure in NHS High Weald Lewes Havens CCG GP practice range: 0.4% to 1.1% 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 68

69 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 Crawley CCG NHS Hastings And Rother CCG NHS Eastbourne, Hailsham And Seaford CCG NHS High Weald Lewes Havens CCG NHS Horsham And Mid Sussex CCG 89.7% 84.2% 83.4% 82.7% 82.6% 312 people with heart failure* with LVSD in NHS High Weald Lewes Havens CCG 258 (82.7%) people treated with ACE- I or ARB 54 (17.3%) people who are exceptions 0 (0%) additional people who are not treated with ACE-I or ARB NHS East Surrey CCG 81.5% NHS Brighton And Hove CCG 81.3% NHS Coastal West Sussex CCG 79.4% England 84.7% 0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator HF003 denominator plus exceptions 69

70 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 Hambleton, Richmondshire and Whitby CCG 89.3% NHS South West Lincolnshire CCG 87.3% NHS Harrogate and Rural District CCG 85.9% NHS South Norfolk CCG 85.9% NHS Rushcliffe CCG 85.5% NHS South Worcestershire CCG 84.5% NHS North Somerset CCG 84.2% NHS South Warwickshire CCG 83.4% NHS High Weald Lewes Havens CCG 82.7% NHS South Lincolnshire CCG 79.9% NHS West Suffolk CCG 79.7% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 70

71 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 CHAPEL STREET SURGERY G81061 BUXTED MEDICAL CENTRE G81102 BEACON SURGERY G81019 RIVER LODGE SURGERY G81035 THE MEADS SURGERY G81037 SAXONBURY HOUSE SURGERY G81055 MANOR OAK SURGERY G81097 ROWE AVENUE SURGERY G81053 ST. ANDREWS SURGERY G81045 MERIDIAN SURGERY G81100 BELMONT SURGERY G in total, including exceptions, there are 54 people who are not treated with ACE-I or ARB GP practice range: 0.0% to 33.3% WOODHILL SURGERY G81040 GROOMBRIDGE AND HARTFIELD MED GRP G HEATHFIELD SURGERY G MID DOWNS MEDICAL PRACTICE G81007 QUAYSIDE MEDICAL PRACTICE G81016 SCHOOL HILL MEDICAL PRACTICE G81021 ASHDOWN FOREST HEALTH CENTRE G81024 ROTHERFIELD SURGERY G81043 BIRD-IN-EYE SURGERY G % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 71

72 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 Hastings And Rother CCG NHS Crawley CCG NHS East Surrey CCG NHS Horsham And Mid Sussex CCG NHS Brighton And Hove CCG 79.5% 78.6% 77.8% 76.9% 75.6% 258 people with heart failure* with LVSD treated with ACE-I/ARB in NHS High Weald Lewes Havens CCG 188 (72.9%) people treated with ACE- I/ARB and BB 58 (22.5%) people who are exceptions 12 (4.7%) additional people who are not treated with ACE-I/ARB and BB NHS Eastbourne, Hailsham And Seaford CCG 74.9% NHS Coastal West Sussex CCG 73.8% NHS High Weald Lewes Havens CCG 72.9% England 77.7% 0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator HF004 denominator plus exceptions 72

73 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 Hambleton, Richmondshire and Whitby CCG 81.3% NHS North Somerset CCG 79.9% NHS South West Lincolnshire CCG 79.2% NHS West Suffolk CCG 78.7% NHS Harrogate and Rural District CCG 75.9% NHS South Worcestershire CCG 74.4% NHS High Weald Lewes Havens CCG 72.9% NHS South Lincolnshire CCG 72.4% NHS South Warwickshire CCG 71.9% NHS Rushcliffe CCG 71.8% NHS South Norfolk CCG 68.8% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 73

74 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 BIRD-IN-EYE SURGERY G SAXONBURY HOUSE SURGERY G81055 WOODHILL SURGERY G81040 GROOMBRIDGE AND HARTFIELD MED GRP G81614 ROTHERFIELD SURGERY G81043 HEATHFIELD SURGERY G in total, including exceptions, there are 70 people who are not treated with ACE-I or ARB GP practice range: 0.0% to 60.0% MERIDIAN SURGERY G THE MEADS SURGERY G ROWE AVENUE SURGERY G MANOR OAK SURGERY G CHAPEL STREET SURGERY G MID DOWNS MEDICAL PRACTICE G81007 QUAYSIDE MEDICAL PRACTICE G81016 BELMONT SURGERY G81030 BUXTED MEDICAL CENTRE G BEACON SURGERY G SCHOOL HILL MEDICAL PRACTICE G ST. ANDREWS SURGERY G ASHDOWN FOREST HEALTH CENTRE G81024 RIVER LODGE SURGERY G % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 74

75 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 Hastings And Rother CCG NHS Horsham And Mid Sussex CCG NHS Crawley CCG NHS East Surrey CCG NHS Eastbourne, Hailsham And Seaford CCG 89.8% 89.3% 87.6% 86.6% 86.5% 5,246 people with coronary heart disease* in NHS High Weald Lewes Havens CCG 4,513 (86%) people whose blood pressure <= 150 / (6.1%) people who are exceptions 415 (7.9%) additional people whose blood pressure is not <= 150 / 90 NHS High Weald Lewes Havens CCG 86.0% NHS Coastal West Sussex CCG 84.3% NHS Brighton And Hove CCG 83.0% England 88.2% 0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator CHD002 denominator plus exceptions 75

76 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 South Worcestershire CCG 91.5% NHS Rushcliffe CCG 91.1% NHS South Warwickshire CCG 91.0% NHS South Lincolnshire CCG 91.0% NHS Hambleton, Richmondshire and Whitby CCG 91.0% NHS Harrogate and Rural District CCG 90.4% NHS North Somerset CCG 89.6% NHS South West Lincolnshire CCG 89.3% NHS South Norfolk CCG 88.6% NHS West Suffolk CCG 88.5% NHS High Weald Lewes Havens CCG 86.0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 76

77 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 BUXTED MEDICAL CENTRE G81102 GROOMBRIDGE AND HARTFIELD MED GRP G81614 ROWE AVENUE SURGERY G81053 ASHDOWN FOREST HEALTH CENTRE G81024 THE MEADS SURGERY G81037 WOODHILL SURGERY G81040 QUAYSIDE MEDICAL PRACTICE G81016 ROTHERFIELD SURGERY G81043 BEACON SURGERY G81019 BELMONT SURGERY G in total, including exceptions, there are 733 people whose blood pressure is not <= 150 / 90 GP practice range: 6.8% to 21.7% BIRD-IN-EYE SURGERY G81086 ST. ANDREWS SURGERY G81045 MERIDIAN SURGERY G81100 CHAPEL STREET SURGERY G81061 HEATHFIELD SURGERY G81088 MANOR OAK SURGERY G81097 SAXONBURY HOUSE SURGERY G MID DOWNS MEDICAL PRACTICE G81007 SCHOOL HILL MEDICAL PRACTICE G81021 RIVER LODGE SURGERY G % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 77

78 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 4% 2% 0% -2% -4% -6% -8% -10% -12% -14% -16% GROOMBRIDGE AND HARTFIELD MED GRP BUXTED MEDICAL CENTRE ROWE AVENUE SURGERY ASHDOWN FOREST HEALTH CENTRE THE MEADS SURGERY WOODHILL SURGERY ROTHERFIELD SURGERY QUAYSIDE MEDICAL PRACTICE BIRD-IN-EYE SURGERY BEACON SURGERY using the GP cluster method of calculating potential gains, if each practice was to achieve as well as the upper quartile of its national cluster, then an additional 325 people would be treated BELMONT SURGERY CHAPEL STREET SURGERY MANOR OAK SURGERY ST. ANDREWS SURGERY MERIDIAN SURGERY HEATHFIELD SURGERY SAXONBURY HOUSE SURGERY MID DOWNS MEDICAL PRACTICE SCHOOL HILL MEDICAL PRACTICE RIVER LODGE SURGERY Details of this methodology are available on slide 9. Click here to view them. 78

79 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 Hastings And Rother CCG NHS Eastbourne, Hailsham And Seaford CCG NHS Horsham And Mid Sussex CCG NHS Crawley CCG NHS High Weald Lewes Havens CCG NHS East Surrey CCG 92.9% 92.4% 91.7% 91.6% 91.4% 91.1% 5,246 people with coronary heart disease* in NHS High Weald Lewes Havens CCG 4,793 (91.4%) people who are taking aspirin, an alternative anti-platelet therapy, or an anti-coagulant 256 (4.9%) people who are exceptions 197 (3.8%) additional people who are not taking aspirin, an alternative antiplatelet therapy, or an anti-coagulant NHS Coastal West Sussex CCG 89.8% NHS Brighton And Hove CCG 89.4% England 91.8% 0% 20% 40% 60% 80% 100% *Using the QOF clinical indicator CHD005 denominator plus exceptions 79

80 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 Hambleton, Richmondshire and Whitby CCG 94.1% NHS Rushcliffe CCG 93.5% NHS West Suffolk CCG 93.0% NHS South Worcestershire CCG 92.9% NHS South Lincolnshire CCG 92.6% NHS North Somerset CCG 92.3% NHS South Warwickshire CCG 92.1% NHS South West Lincolnshire CCG 92.0% NHS South Norfolk CCG 91.7% NHS Harrogate and Rural District CCG 91.5% NHS High Weald Lewes Havens CCG 91.4% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 80

81 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 BIRD-IN-EYE SURGERY G BUXTED MEDICAL CENTRE G81102 ROWE AVENUE SURGERY G81053 ASHDOWN FOREST HEALTH CENTRE G81024 WOODHILL SURGERY G81040 THE MEADS SURGERY G81037 BEACON SURGERY G81019 ROTHERFIELD SURGERY G81043 SAXONBURY HOUSE SURGERY G81055 ST. ANDREWS SURGERY G81045 MANOR OAK SURGERY G81097 MID DOWNS MEDICAL PRACTICE G81007 SCHOOL HILL MEDICAL PRACTICE G81021 MERIDIAN SURGERY G81100 RIVER LODGE SURGERY G81035 BELMONT SURGERY G81030 QUAYSIDE MEDICAL PRACTICE G81016 CHAPEL STREET SURGERY G81061 GROOMBRIDGE AND HARTFIELD MED GRP G81614 HEATHFIELD SURGERY G % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% in total, including exceptions, there are 453 people are not taking aspirin, an alternative anti-platelet therapy, or an anti-coagulant GP practice range: 4.9% to 15.4% 81

82 Some data on outcomes for people with cardiovascular disease 82

83 Age standardised rate (per 100,000) Hospital admissions for coronary heart disease for all ages 2002/ /16 NHS High Weald Lewes Havens CCG England in NHS High Weald Lewes Havens CCG, the hospital admission rate for coronary heart disease in 2015/16 was (805) compared to for England /032003/042004/052005/062006/072007/082008/092009/102010/112011/122012/132013/142014/152015/16 Source: Hospital Episode Statistics (HES), 2002/ /16, Copyright 2017, Re used with the permission of NHS Digital. All rights reserved 83

84 Age standardised rate (per 100,000) Hospital admissions for stroke for all ages 2002/ /16 NHS High Weald Lewes Havens CCG England in NHS High Weald Lewes Havens CCG, the hospital admission rate for stroke in 2015/16 was (238) compared to for England /032003/042004/052005/062006/072007/082008/092009/102010/112011/122012/132013/142014/152015/16 Source: Hospital Episode Statistics (HES), 2002/ /16, Copyright 2017, Re used with the permission of NHS Digital. All rights reserved 84

85 Additional risk of complications for people with diabetes, three year follow up, 2013/14 NHS High Weald Lewes Havens CCG England Angina Heart Attack 124.7% 136.8% 98.5% 108.6% The risk of a stroke was 35.2% higher and the risk of a heart attack was 98.5% higher compared to people without diabetes. Heart failure 121.4% 150.0% Stroke 35.2% 81.3% Major amputation 0.0% 445.8% Minor amputation 596.8% 753.5% RRT 281.2% 293.0% 85 0% 100% 200% 300% 400% 500% 600% 700% 800% Note: This slide uses data from the National Diabetes Audit (NDA)

86 Age standardised rate (per 1000,000) Deaths from coronary heart disease, under 75s NHS High Weald Lewes Havens CCG England in NHS High Weald Lewes Havens CCG, the early mortality rate for coronary heart disease in was 21.2, compared to 40.6 for England Source: Office for National Statistics (ONS) mortality data

87 Age standardised rate (per 100,000) Deaths from stroke, under 75s NHS High Weald Lewes Havens CCG England in NHS High Weald Lewes Havens CCG, the early mortality rate for stroke in was 8, compared to 13.6 for England Source: Office for National Statistics (ONS) mortality data

88 Data sources Appendix 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: Diabetes prevalence estimates, NCVIN, PHE: CKD Prevalence model, G.Aitken, University of Southampton, 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 Department of Primary Care & Public Health, Imperial College London 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 ; 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/ /16, Copyright 2017, Re used with the permission of NHS Digital. All rights reserved Office for National Statistics (ONS) mortality data , Copyright 2017, Re-used with the permission of the Office for National Statistics. All rights reserved 88

89 About Public Health England Public Health England exists to protect and improve the nation s health and wellbeing, and reduce health inequalities. We do this through world-class science, knowledge and intelligence, advocacy, partnerships and the delivery of specialist public health services. We are an executive agency of the Department of Health, and are a distinct delivery organisation with operational autonomy to advise and support government, local authorities and the NHS in a professionally independent manner. Public Health England Wellington House Waterloo Road London SE1 8UG Tel: Facebook: Crown copyright 2017 You may re-use this information (excluding logos) free of charge in any format or medium, under the terms of the Open Government Licence v3.0. To view this licence, visit OGL or psi@nationalarchives.gsi.gov.uk. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. Published June 2017 Gateway number