CVD: Primary Care Intelligence Packs

Transcription

1 CVD: Primary Care Intelligence Packs NHS South Tyneside 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 South Tyneside CCG are: NHS South Sefton CCG NHS St Helens CCG NHS Sunderland CCG NHS North Tyneside CCG NHS Southend CCG NHS Wirral CCG NHS Hardwick CCG NHS Mansfield and Ashfield CCG NHS Thanet CCG NHS Barnsley 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 Thanet CCG 22.6% NHS Mansfield and Ashfield CCG NHS Barnsley CCG 21.6% 21.6% prevalence of 21.1% in NHS South Tyneside CCG NHS Sunderland CCG 21.2% NHS South Tyneside CCG 21.1% NHS Hardwick CCG 20.2% NHS Southend CCG 20.0% NHS South Sefton CCG NHS St Helens CCG NHS Wirral CCG 19.4% 18.9% 18.5% 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 North Tyneside CCG 17.8% 0% 5% 10% 15% 20% 25% 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 JARROW GP PRACTICE Y % FLAGG COURT (DR N WIN) A % THE PARK SURGERY A % STANHOPE PARADE HEALTH CENTRE A % ST GEORGE & RIVERSIDE MEDICAL PRACTICE A % VICTORIA MEDICAL CENTRE A % EAST WING PRACTICE A % FLAGG COURT (DR S CHANDER) A % WENLOCK ROAD SURGERY A % TALBOT MEDICAL CENTRE A % FARNHAM MEDICAL CTR. A % THE G.P.SUITE A % RAVENSWORTH SURGERY A % WESTOE SURGERY A % TRINITY MEDICAL CENTRE A % WAWN STREET SURGERY A % ELLISON VIEW SURGERY A % MAYFIELD MEDICAL GROUP A % CHICHESTER PRACTICE A % CENTRAL SURGERY A % THE GLEN MEDICAL GROUP A % ALBERT ROAD SURGERY A % MARSDEN RD. HEALTH CENTRE A % DR THORNILEY-WALKER & PARTNERS A % IMEARY STREET PRACTICE A % COLLIERY COURT MEDICAL GROUP A % WHITBURN SURGERY A % 0% 5% 10% 15% 20% 25% 30% 35% 27,663 people who are recorded as smokers in NHS South Tyneside CCG GP practice range: 14.2% to 31.9% 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 Sunderland CCG 0.61 NHS Northumberland CCG NHS South Tyneside CCG the ratio of those diagnosed with hypertension versus those expected to have hypertension is 0.6. This compares to 0.59 for England this suggests that 60% of people with hypertension have been diagnosed NHS North Tyneside CCG 0.60 NHS Newcastle Gateshead CCG 0.59 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 St Helens CCG 0.64 NHS Hardwick CCG 0.63 NHS South Sefton CCG 0.63 NHS Thanet CCG 0.62 NHS Sunderland CCG 0.61 NHS Barnsley CCG 0.61 NHS Wirral CCG 0.60 NHS South Tyneside CCG 0.60 NHS North Tyneside CCG 0.60 NHS Southend CCG 0.60 NHS Mansfield and Ashfield CCG % 10% 20% 30% 40% 50% 60% 70% 18

19 Hypertension observed prevalence compared with expected prevalence by GP practice GP practice CCG ALBERT ROAD SURGERY A88010 VICTORIA MEDICAL CENTRE A88001 FARNHAM MEDICAL CTR. A88002 MARSDEN RD. HEALTH CENTRE A88003 IMEARY STREET PRACTICE A88601 COLLIERY COURT MEDICAL GROUP A88016 EAST WING PRACTICE A88613 STANHOPE PARADE HEALTH CENTRE A88014 ST GEORGE & RIVERSIDE MEDICAL PRACTICE A88015 CHICHESTER PRACTICE A88611 RAVENSWORTH SURGERY A88608 MAYFIELD MEDICAL GROUP A88004 WESTOE SURGERY A88011 WENLOCK ROAD SURGERY A88005 CENTRAL SURGERY A88013 THE G.P.SUITE A88025 THE GLEN MEDICAL GROUP A88022 FLAGG COURT (DR S CHANDER) A88020 TRINITY MEDICAL CENTRE A88008 DR THORNILEY-WALKER & PARTNERS A88009 WAWN STREET SURGERY A88007 TALBOT MEDICAL CENTRE A88006 THE PARK SURGERY A88603 FLAGG COURT (DR N WIN) A88614 WHITBURN SURGERY A88023 ELLISON VIEW SURGERY A it is estimated that there are 16,409 people with undiagnosed hypertension in NHS South Tyneside CCG GP practice range of observed to expected hypertension prevalence 0.5 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 Northumberland CCG 81.8% NHS North Tyneside CCG NHS Newcastle Gateshead CCG NHS South Tyneside CCG 81.5% 81.3% 80.0% 24,869 people with hypertension (diagnosed)* in NHS South Tyneside CCG 19,887 (80%) people whose blood pressure is <= 150/90 1,200 (4.8%) people who are excepted from optimal control 3,782 (15.2%) additional people whose blood pressure is not <= 150/90 NHS Sunderland CCG 79.5% 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 North Tyneside CCG 81.5% NHS Hardwick CCG 81.0% NHS St Helens CCG 80.5% NHS Mansfield and Ashfield CCG 80.5% NHS South Tyneside CCG 80.0% NHS Sunderland CCG 79.5% NHS Wirral CCG 79.4% NHS Barnsley CCG 78.8% NHS Southend CCG 78.0% NHS South Sefton CCG 77.5% NHS Thanet CCG 77.0% 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 WHITBURN SURGERY A88023 WENLOCK ROAD SURGERY A88005 ST GEORGE & RIVERSIDE MEDICAL PRACTICE A88015 JARROW GP PRACTICE Y02999 WAWN STREET SURGERY A88007 FARNHAM MEDICAL CTR. A88002 ALBERT ROAD SURGERY A88010 THE PARK SURGERY A88603 CHICHESTER PRACTICE A88611 COLLIERY COURT MEDICAL GROUP A88016 WESTOE SURGERY A88011 CENTRAL SURGERY A88013 MARSDEN RD. HEALTH CENTRE A88003 ELLISON VIEW SURGERY A88012 STANHOPE PARADE HEALTH CENTRE A88014 EAST WING PRACTICE A88613 THE GLEN MEDICAL GROUP A88022 FLAGG COURT (DR N WIN) A88614 RAVENSWORTH SURGERY A88608 IMEARY STREET PRACTICE A88601 TALBOT MEDICAL CENTRE A88006 VICTORIA MEDICAL CENTRE A88001 MAYFIELD MEDICAL GROUP A88004 TRINITY MEDICAL CENTRE A88008 THE G.P.SUITE A88025 FLAGG COURT (DR S CHANDER) A88020 DR THORNILEY-WALKER & PARTNERS A in total, including exceptions, there are 4,982 people whose blood pressure is not <= 150/90 GP practice range: 11.9% to 35.6% 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 Newcastle Gateshead CCG 73.6% NHS North Tyneside CCG NHS Northumberland CCG NHS Sunderland CCG 64.3% 61.9% 61.8% 141 people with a new diagnosis* of hypertension with a CVD risk of 20% or higher in NHS South Tyneside CCG 82 (58.2%) people who are currently treated with statins 58 (41.1%) people who are exempted from treatment with statins 1 (0.7%) additional people who are not currently treated with statins NHS South Tyneside CCG 58.2% 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 Hardwick CCG 74.5% NHS Thanet CCG 72.2% NHS South Sefton CCG 71.1% NHS St Helens CCG 70.2% NHS Wirral CCG 69.2% NHS Mansfield and Ashfield CCG 65.5% NHS North Tyneside CCG 64.3% NHS Southend CCG 63.0% NHS Sunderland CCG 61.8% NHS Barnsley CCG 60.3% NHS South Tyneside CCG 58.2% 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 CENTRAL SURGERY A WESTOE SURGERY A EAST WING PRACTICE A88613 MARSDEN RD. HEALTH CENTRE A88003 MAYFIELD MEDICAL GROUP A88004 STANHOPE PARADE HEALTH CENTRE A88014 COLLIERY COURT MEDICAL GROUP A88016 FLAGG COURT (DR S CHANDER) A in total, including exceptions, there are 59 people who are not treated with statins GP practice range: 0.0% to 76.9% IMEARY STREET PRACTICE A THE GLEN MEDICAL GROUP A VICTORIA MEDICAL CENTRE A DR THORNILEY-WALKER & PARTNERS A ELLISON VIEW SURGERY A ALBERT ROAD SURGERY A THE PARK SURGERY A WAWN STREET SURGERY A FARNHAM MEDICAL CTR. A TALBOT MEDICAL CENTRE A THE G.P.SUITE A WENLOCK ROAD SURGERY A88005 TRINITY MEDICAL CENTRE A88008 ST GEORGE & RIVERSIDE MEDICAL PRACTICE A88015 WHITBURN SURGERY A88023 RAVENSWORTH SURGERY A88608 CHICHESTER PRACTICE A88611 FLAGG COURT (DR N WIN) A88614 JARROW GP PRACTICE Y % 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 Sunderland CCG 0.74 NHS South Tyneside CCG NHS Northumberland 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 73% of people with atrial fibrillation have been diagnosed. NHS North Tyneside CCG 0.70 NHS Newcastle Gateshead CCG 0.70 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 Wirral CCG 0.86 NHS South Sefton CCG 0.80 NHS St Helens CCG 0.76 NHS Sunderland CCG 0.74 NHS South Tyneside CCG 0.73 NHS Hardwick CCG 0.73 NHS Thanet CCG 0.72 NHS Barnsley CCG 0.72 NHS North Tyneside CCG 0.70 NHS Mansfield and Ashfield CCG 0.68 NHS Southend CCG

30 Atrial fibrillation observed prevalence compared with expected prevalence by GP practice GP practice CCG MAYFIELD MEDICAL GROUP A88004 THE PARK SURGERY A88603 VICTORIA MEDICAL CENTRE A88001 TALBOT MEDICAL CENTRE A88006 TRINITY MEDICAL CENTRE A88008 DR THORNILEY-WALKER & PARTNERS A88009 WESTOE SURGERY A88011 CENTRAL SURGERY A88013 ST GEORGE & RIVERSIDE MEDICAL PRACTICE A88015 THE GLEN MEDICAL GROUP A88022 WHITBURN SURGERY A88023 THE G.P.SUITE A88025 RAVENSWORTH SURGERY A88608 FARNHAM MEDICAL CTR. A88002 MARSDEN RD. HEALTH CENTRE A88003 WAWN STREET SURGERY A88007 ELLISON VIEW SURGERY A88012 COLLIERY COURT MEDICAL GROUP A88016 CHICHESTER PRACTICE A88611 ALBERT ROAD SURGERY A88010 STANHOPE PARADE HEALTH CENTRE A88014 FLAGG COURT (DR S CHANDER) A88020 IMEARY STREET PRACTICE A88601 EAST WING PRACTICE A88613 WENLOCK ROAD SURGERY A88005 FLAGG COURT (DR N WIN) A it is estimated that there are 4,202 people with undiagnosed atrial fibrillation in NHS South Tyneside CCG GP practice range of observed to expected atrial fibrillation prevalence 0.3 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 South Tyneside CCG NHS Sunderland CCG NHS Newcastle Gateshead CCG NHS North Tyneside CCG 80.0% 80.0% 78.4% 73.8% 2,540 people with atrial fibrillation* with a CHA2DS2-VASc score >= 2 in NHS South Tyneside CCG 2,032 (80%) people treated with anticoagulation therapy 291 (11.5%) people who are exceptions 217 (8.5%) additional people with a recorded CHA2DS2-VASc score >= 2 who are not treated NHS Northumberland CCG 72.3% 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 Hardwick CCG 82.6% NHS South Tyneside CCG 80.0% NHS Sunderland CCG 80.0% NHS Wirral CCG 79.3% NHS Barnsley CCG 79.1% NHS Southend CCG 79.0% NHS Mansfield and Ashfield CCG 78.9% NHS St Helens CCG 77.8% NHS South Sefton CCG 76.2% NHS Thanet CCG 76.2% NHS North Tyneside CCG 73.8% 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 THE PARK SURGERY A88603 JARROW GP PRACTICE Y02999 TRINITY MEDICAL CENTRE A88008 CHICHESTER PRACTICE A88611 FARNHAM MEDICAL CTR. A88002 IMEARY STREET PRACTICE A88601 WAWN STREET SURGERY A88007 WHITBURN SURGERY A88023 FLAGG COURT (DR N WIN) A88614 THE GLEN MEDICAL GROUP A88022 MAYFIELD MEDICAL GROUP A88004 CENTRAL SURGERY A88013 WESTOE SURGERY A88011 TALBOT MEDICAL CENTRE A88006 ELLISON VIEW SURGERY A88012 ST GEORGE & RIVERSIDE MEDICAL PRACTICE A88015 WENLOCK ROAD SURGERY A88005 EAST WING PRACTICE A88613 MARSDEN RD. HEALTH CENTRE A88003 VICTORIA MEDICAL CENTRE A88001 ALBERT ROAD SURGERY A88010 RAVENSWORTH SURGERY A88608 THE G.P.SUITE A88025 DR THORNILEY-WALKER & PARTNERS A88009 COLLIERY COURT MEDICAL GROUP A88016 FLAGG COURT (DR S CHANDER) A88020 STANHOPE PARADE HEALTH CENTRE A in total, including exceptions, there are 508 people with a recorded CHA2DS2-VASc score >= 2 who are not treated GP practice range: 7.1% to 42.0% 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 10% 5% 0% -5% -10% -15% -20% -25% -30% THE PARK SURGERY TRINITY MEDICAL CENTRE CHICHESTER PRACTICE IMEARY STREET PRACTICE FARNHAM MEDICAL CTR. WAWN STREET SURGERY WHITBURN SURGERY FLAGG COURT (DR N WIN) THE GLEN MEDICAL GROUP MAYFIELD MEDICAL GROUP 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 123 people would be treated EAST WING PRACTICE VICTORIA MEDICAL CENTRE ALBERT ROAD SURGERY MARSDEN RD. HEALTH CENTRE RAVENSWORTH SURGERY THE G.P.SUITE DR THORNILEY-WALKER & PARTNERS COLLIERY COURT MEDICAL GROUP FLAGG COURT (DR S CHANDER) STANHOPE PARADE HEALTH CENTRE 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 Newcastle Gateshead CCG NHS Northumberland CCG NHS North Tyneside CCG 85.7% 84.7% 84.5% 3,422 people with a history of stroke or TIA* in NHS South Tyneside CCG 2,883 (84.2%) people whose blood pressure is <= 150 / (3.8%) people who are exceptions 408 (11.9%) additional people whose blood pressure is not <= 150 / 90 NHS South Tyneside CCG 84.2% NHS Sunderland CCG 83.0% 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 Mansfield and Ashfield CCG 85.5% NHS Hardwick CCG 85.3% NHS St Helens CCG 85.1% NHS North Tyneside CCG 84.5% NHS Wirral CCG 84.3% NHS South Tyneside CCG 84.2% NHS Thanet CCG 83.5% NHS Barnsley CCG 83.0% NHS Sunderland CCG 83.0% NHS Southend CCG 82.5% NHS South Sefton CCG 82.4% 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 ST GEORGE & RIVERSIDE MEDICAL PRACTICE A WENLOCK ROAD SURGERY A WHITBURN SURGERY A88023 THE PARK SURGERY A88603 VICTORIA MEDICAL CENTRE A88001 STANHOPE PARADE HEALTH CENTRE A88014 FLAGG COURT (DR N WIN) A88614 FLAGG COURT (DR S CHANDER) A in total, including exceptions, there are 539 people whose blood pressure is not <= 150 / 90 GP practice range: 0.0% to 31.2% COLLIERY COURT MEDICAL GROUP A TALBOT MEDICAL CENTRE A WAWN STREET SURGERY A MARSDEN RD. HEALTH CENTRE A CENTRAL SURGERY A CHICHESTER PRACTICE A FARNHAM MEDICAL CTR. A ALBERT ROAD SURGERY A ELLISON VIEW SURGERY A EAST WING PRACTICE A TRINITY MEDICAL CENTRE A MAYFIELD MEDICAL GROUP A THE G.P.SUITE A RAVENSWORTH SURGERY A WESTOE SURGERY A THE GLEN MEDICAL GROUP A IMEARY STREET PRACTICE A DR THORNILEY-WALKER & PARTNERS A JARROW GP PRACTICE Y % 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 South Tyneside CCG NHS Newcastle Gateshead CCG NHS Sunderland CCG NHS North Tyneside CCG 93.5% 93.4% 93.2% 92.8% 2,204 people with a stroke shown to be non-haemorrhagic* in NHS South Tyneside CCG 2,060 (93.5%) people who are taking an anti-platetet agent or anticoagulant 111 (5%) people who are exceptions 33 (1.5%) additional people with no treatment NHS Northumberland CCG 92.3% 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 Tyneside CCG 93.5% NHS Sunderland CCG 93.2% NHS Thanet CCG 92.9% NHS North Tyneside CCG 92.8% NHS Hardwick CCG 92.8% NHS South Sefton CCG 92.6% NHS Mansfield and Ashfield CCG 92.5% NHS Southend CCG 91.6% NHS Barnsley CCG 91.4% NHS St Helens CCG 90.0% NHS Wirral CCG 89.7% 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 FLAGG COURT (DR N WIN) A88614 WAWN STREET SURGERY A88007 THE GLEN MEDICAL GROUP A88022 TRINITY MEDICAL CENTRE A88008 ALBERT ROAD SURGERY A88010 THE PARK SURGERY A88603 CENTRAL SURGERY A88013 WESTOE SURGERY A88011 COLLIERY COURT MEDICAL GROUP A88016 FARNHAM MEDICAL CTR. A88002 VICTORIA MEDICAL CENTRE A88001 IMEARY STREET PRACTICE A88601 MARSDEN RD. HEALTH CENTRE A88003 EAST WING PRACTICE A88613 MAYFIELD MEDICAL GROUP A88004 WENLOCK ROAD SURGERY A88005 ST GEORGE & RIVERSIDE MEDICAL PRACTICE A88015 WHITBURN SURGERY A88023 DR THORNILEY-WALKER & PARTNERS A88009 THE G.P.SUITE A88025 RAVENSWORTH SURGERY A88608 ELLISON VIEW SURGERY A88012 TALBOT MEDICAL CENTRE A88006 STANHOPE PARADE HEALTH CENTRE A88014 FLAGG COURT (DR S CHANDER) A88020 CHICHESTER PRACTICE A88611 JARROW GP PRACTICE Y % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% in total, including exceptions, there are 144 people who are not taking an anti-platelet agent or anti-coagulant GP practice range: 0.0% to 13.3% 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 North Tyneside CCG NHS Northumberland CCG NHS Newcastle Gateshead CCG ratio of observed to expected diabetes prevalence in NHS South Tyneside CCG, compared to 0.77 in England this suggests 79% of people have been diagnosed NHS South Tyneside CCG 0.79 NHS Sunderland CCG 0.78 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 Hardwick CCG 0.94 NHS North Tyneside CCG 0.84 NHS Barnsley CCG 0.83 NHS St Helens CCG 0.83 NHS Mansfield and Ashfield CCG 0.82 NHS Wirral CCG 0.79 NHS South Tyneside CCG 0.79 NHS Thanet CCG 0.78 NHS Sunderland CCG 0.78 NHS South Sefton CCG 0.76 NHS Southend CCG

45 Diabetes prevalence by GP practice GP practice CCG FLAGG COURT (DR S CHANDER) A % TALBOT MEDICAL CENTRE A % ALBERT ROAD SURGERY A % RAVENSWORTH SURGERY A % VICTORIA MEDICAL CENTRE A % MARSDEN RD. HEALTH CENTRE A % EAST WING PRACTICE A % WENLOCK ROAD SURGERY A % ST GEORGE & RIVERSIDE MEDICAL PRACTICE A % ELLISON VIEW SURGERY A % WHITBURN SURGERY A % THE G.P.SUITE A % THE PARK SURGERY A % FARNHAM MEDICAL CTR. A % COLLIERY COURT MEDICAL GROUP A % WESTOE SURGERY A % MAYFIELD MEDICAL GROUP A % WAWN STREET SURGERY A % TRINITY MEDICAL CENTRE A % CENTRAL SURGERY A % IMEARY STREET PRACTICE A % CHICHESTER PRACTICE A % THE GLEN MEDICAL GROUP A % DR THORNILEY-WALKER & PARTNERS A % STANHOPE PARADE HEALTH CENTRE A % FLAGG COURT (DR N WIN) A % JARROW GP PRACTICE Y % 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% GP practice range of observed diabetes 2.4% to 8.6% there are an estimated 2,454 people with undiagnosed diabetes in NHS South Tyneside CCG 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 Northumberland CCG NHS South Tyneside CCG NHS North Tyneside CCG 7.6% 7.1% 7.1% 1.6% 1.9% 1.3% 12.2% 11.4% 11.5% the estimated total prevalence of diabetes in NHS South Tyneside CCG is 9.0% (diagnosed and undiagnosed) in addition, there are an estimated 11.4% of people in NHS South Tyneside CCG who are at increased risk of developing diabetes (i.e. with non-diabetic hyperglycaemia) NHS Sunderland CCG NHS Newcastle Gateshead CCG 6.8% 6.2% 1.9% 1.5% 11.1% 10.1% this means that 20.4% of the population in NHS South Tyneside CCG are estimated to have diabetes, or at high risk of developing of diabetes 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 South Tyneside CCG NHS North Tyneside CCG NHS Northumberland CCG NHS Newcastle Gateshead CCG 77.8% 68.4% 66.2% 61.0% 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 South Tyneside CCG, 10 out of 27 practices (37.0%) participated in the NDA. Data is not available for the remaining practices NHS Sunderland CCG 54.8% 77.8% of people with diabetes (of practices who participated in the audit) had the eight recommended care processes in NHS South Tyneside CCG, compared to 52.6% in England England 52.6% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 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 FLAGG COURT (DR N WIN) A88614 WESTOE SURGERY A88011 TRINITY MEDICAL CENTRE A88008 WAWN STREET SURGERY A88007 MARSDEN RD. HEALTH CENTRE A88003 IMEARY STREET PRACTICE A88601 MAYFIELD MEDICAL GROUP A88004 COLLIERY COURT MEDICAL GROUP A88016 THE GLEN MEDICAL GROUP A88022 THE PARK SURGERY A88603 JARROW GP PRACTICE Y02999 EAST WING PRACTICE A88613 CHICHESTER PRACTICE A88611 RAVENSWORTH SURGERY A88608 THE G.P.SUITE A88025 WHITBURN SURGERY A88023 FLAGG COURT (DR S CHANDER) A88020 ST GEORGE & RIVERSIDE MEDICAL PRACTICE A88015 STANHOPE PARADE HEALTH CENTRE A88014 CENTRAL SURGERY A88013 ELLISON VIEW SURGERY A88012 ALBERT ROAD SURGERY A88010 DR THORNILEY-WALKER & PARTNERS A88009 TALBOT MEDICAL CENTRE A88006 WENLOCK ROAD SURGERY A88005 FARNHAM MEDICAL CTR. A88002 VICTORIA MEDICAL CENTRE A % 84.6% 82.4% 80.0% 79.8% 79.2% 78.9% 73.2% 71.7% 61.8% achievement - 8 care processes: in practices who provided data via the NDA, between 61.8% and 90.0% of patients received all 8 care processes at least 774 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 Northumberland CCG NHS Sunderland CCG NHS South Tyneside CCG 41.1% 41.1% 40.5% 40.5% of people with diabetes (of practices who participated in the audit) met the three treatment targets in NHS South Tyneside CCG, compared to 39.0% in England NHS North Tyneside CCG 40.0% NHS Newcastle Gateshead CCG 38.9% 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 FLAGG COURT (DR N WIN) A88614 TRINITY MEDICAL CENTRE A88008 COLLIERY COURT MEDICAL GROUP A88016 IMEARY STREET PRACTICE A88601 WAWN STREET SURGERY A88007 MARSDEN RD. HEALTH CENTRE A88003 WESTOE SURGERY A88011 MAYFIELD MEDICAL GROUP A88004 THE GLEN MEDICAL GROUP A88022 THE PARK SURGERY A88603 JARROW GP PRACTICE Y02999 EAST WING PRACTICE A88613 CHICHESTER PRACTICE A88611 RAVENSWORTH SURGERY A88608 THE G.P.SUITE A88025 WHITBURN SURGERY A88023 FLAGG COURT (DR S CHANDER) A88020 ST GEORGE & RIVERSIDE MEDICAL PRACTICE A88015 STANHOPE PARADE HEALTH CENTRE A88014 CENTRAL SURGERY A88013 ELLISON VIEW SURGERY A88012 ALBERT ROAD SURGERY A88010 DR THORNILEY-WALKER & PARTNERS A88009 TALBOT MEDICAL CENTRE A88006 WENLOCK ROAD SURGERY A88005 FARNHAM MEDICAL CTR. A88002 VICTORIA MEDICAL CENTRE A % 48.6% 45.8% 45.1% 41.7% 40.2% 39.6% 38.1% 30.5% 27.0% achievement - 3 treatment targets: in practices who provided data via the NDA, between 27.0% and 52.2% of patients achieved all 3 treatment targets at least 1,826 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% THE PARK SURGERY 25 THE GLEN MEDICAL GROUP MAYFIELD MEDICAL GROUP WESTOE 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 181 people would be treated WAWN STREET SURGERY 25 MARSDEN RD. HEALTH CENTRE 26 IMEARY STREET PRACTICE 0 COLLIERY COURT MEDICAL GROUP 0 TRINITY MEDICAL CENTRE FLAGG COURT (DR N WIN) 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 Newcastle Gateshead CCG 0.89 NHS North Tyneside CCG NHS Northumberland CCG NHS Sunderland 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 58% of people with chronic kidney disease have been diagnosed NHS South Tyneside CCG 0.58 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 Sefton CCG 0.90 NHS North Tyneside CCG 0.86 NHS Hardwick CCG 0.84 NHS Thanet CCG 0.83 NHS Mansfield and Ashfield CCG 0.83 NHS Barnsley CCG 0.82 NHS Wirral CCG 0.71 NHS Sunderland CCG 0.68 NHS St Helens CCG 0.68 NHS South Tyneside CCG 0.58 NHS Southend CCG Ratio 55

56 CKD prevalence by GP practice, 2015/16 GP practice CCG MARSDEN RD. HEALTH CENTRE A % COLLIERY COURT MEDICAL GROUP A % THE G.P.SUITE A % IMEARY STREET PRACTICE A % THE GLEN MEDICAL GROUP A % CHICHESTER PRACTICE A % STANHOPE PARADE HEALTH CENTRE A % CENTRAL SURGERY A % TALBOT MEDICAL CENTRE A % FLAGG COURT (DR N WIN) A % RAVENSWORTH SURGERY A % THE PARK SURGERY A % FARNHAM MEDICAL CTR. A % WENLOCK ROAD SURGERY A % VICTORIA MEDICAL CENTRE A % DR THORNILEY-WALKER & PARTNERS A % ALBERT ROAD SURGERY A % WESTOE SURGERY A % WAWN STREET SURGERY A % ST GEORGE & RIVERSIDE MEDICAL PRACTICE A % MAYFIELD MEDICAL GROUP A % ELLISON VIEW SURGERY A % FLAGG COURT (DR S CHANDER) A % TRINITY MEDICAL CENTRE A % EAST WING PRACTICE A % WHITBURN SURGERY A % JARROW GP PRACTICE Y % 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% it is estimated that there are 3,447 people with undiagnosed chronic kidney disease in NHS South Tyneside CCG GP practice range of observed CKD: 0.9% to 8.2% 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 South Tyneside CCG NHS Northumberland CCG NHS Newcastle Gateshead CCG 78.2% 76.5% 74.9% 3,250 people with CKD (diagnosed*) in NHS South Tyneside CCG 2,543 (78.2%) people whose blood pressure is <= 140 / (9.7%) people who are exceptions 393 (12.1%) additional people whose blood pressure is not <= 140 / 85 NHS Sunderland CCG 74.6% NHS North Tyneside CCG 73.7% 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 St Helens CCG 78.9% NHS South Sefton CCG 78.4% NHS South Tyneside CCG 78.2% NHS Wirral CCG 75.6% NHS Mansfield and Ashfield CCG 74.8% NHS Thanet CCG 74.7% NHS Sunderland CCG 74.6% NHS Southend CCG 74.6% NHS North Tyneside CCG 73.7% NHS Hardwick CCG 72.9% NHS Barnsley CCG 72.9% 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 WHITBURN SURGERY A IMEARY STREET PRACTICE A ALBERT ROAD SURGERY A88010 STANHOPE PARADE HC (DR KULKARNI) A88014 MARSDEN ROAD HEALTH CENTRE A88003 THE PARK SURGERY A88603 DR HAQUE & PARTNER A88005 VICTORIA MEDICAL CENTRE A in total, including exceptions, there are 707 people whose blood pressure is not <= 140 / 85 GP practice range: 10.3% to 41.2% ST.GEORGE'S MEDICAL CTR A DR PERRINS & PARTNERS A CHICHESTER PRACTICE A DR BHALLA & PARTNERS A HEBBURN HEALTH CENTRE PRACTICE A DR GALLAGHER AND PARTNERS A TALBOT MEDICAL CENTRE A DR SIMPSON & PARTNERS A THE GLEN MEDICAL GROUP A DR THORNILEY-WALKER AND PARTNERS A WESTOE SURGERY A THE G.P.SUITE A DR VIS-NATHAN & BOWES A DR SANDBACH AND PARTNERS A EAST WING SURGERY A MAYFIELD MEDICAL GROUP A DR N E WIN A TRINITY RIVERSIDE PRACTICE Y DR CHANDER A % 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 10% 5% 0% -5% -10% -15% -20% -25% WHITBURN SURGERY IMEARY STREET PRACTICE ALBERT ROAD SURGERY STANHOPE PARADE HC (DR KULKARNI) THE PARK SURGERY DR HAQUE & PARTNER ST.GEORGE'S MEDICAL CTR DR PERRINS & PARTNERS CHICHESTER PRACTICE VICTORIA MEDICAL CENTRE 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 137 people would be treated DR GALLAGHER AND PARTNERS WESTOE SURGERY THE G.P.SUITE DR VIS-NATHAN & BOWES DR THORNILEY-WALKER AND PARTNERS EAST WING SURGERY MAYFIELD MEDICAL GROUP DR SANDBACH AND PARTNERS DR N E WIN DR CHANDER 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 South Tyneside CCG NHS Northumberland CCG NHS North Tyneside CCG NHS Newcastle Gateshead CCG 80.9% 78.9% 76.4% 76.1% 3,279 people with CKD (diagnosed*) in NHS South Tyneside CCG 2,654 (80.9%) people who have a record of urine albumin:creatinine ratio test 139 (4.2%) people who are exceptions 486 (14.8%) additional people who have no record of urine albumin:creatinine ratio test NHS Sunderland CCG 74.7% 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 Tyneside CCG 80.9% NHS South Sefton CCG 78.6% NHS St Helens CCG 77.8% NHS North Tyneside CCG 76.4% NHS Thanet CCG 75.5% NHS Sunderland CCG 74.7% NHS Hardwick CCG 72.5% NHS Mansfield and Ashfield CCG 72.4% NHS Barnsley CCG 72.2% NHS Wirral CCG 71.1% NHS Southend CCG 67.8% 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 DR HAQUE & PARTNER A WHITBURN SURGERY A VICTORIA MEDICAL CENTRE A88001 ALBERT ROAD SURGERY A88010 DR N E WIN A88614 DR BHALLA & PARTNERS A88007 DR SIMPSON & PARTNERS A88016 DR SANDBACH AND PARTNERS A in total, including exceptions, there are 625 people who have no record of urine albumin:creatinine ratio test GP practice range: 7.0% to 39.2% THE G.P.SUITE A MARSDEN ROAD HEALTH CENTRE A TALBOT MEDICAL CENTRE A ST.GEORGE'S MEDICAL CTR A DR VIS-NATHAN & BOWES A WESTOE SURGERY A MAYFIELD MEDICAL GROUP A STANHOPE PARADE HC (DR KULKARNI) A EAST WING SURGERY A HEBBURN HEALTH CENTRE PRACTICE A DR GALLAGHER AND PARTNERS A DR THORNILEY-WALKER AND PARTNERS A THE GLEN MEDICAL GROUP A TRINITY RIVERSIDE PRACTICE Y DR CHANDER A THE PARK SURGERY A IMEARY STREET PRACTICE A DR PERRINS & PARTNERS A CHICHESTER PRACTICE A % 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 North Tyneside CCG 1.18% NHS South Tyneside CCG 1.16% prevalence of 1.16% in NHS South Tyneside CCG compared to 0.76% in England NHS Northumberland CCG 1.07% NHS Sunderland CCG 1.01% NHS Newcastle Gateshead CCG 0.82% England 0.76% 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 66

67 Heart failure prevalence by CCG Comparison with demographically similar CCGs NHS South Sefton CCG 1.28% NHS North Tyneside CCG 1.18% NHS South Tyneside CCG 1.16% NHS St Helens CCG 1.12% NHS Hardwick CCG 1.04% NHS Sunderland CCG 1.01% NHS Wirral CCG 0.94% NHS Barnsley CCG 0.89% NHS Thanet CCG 0.86% NHS Southend CCG 0.86% NHS Mansfield and Ashfield CCG 0.84% 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 67

68 Heart failure prevalence by GP practice GP practice CCG TRINITY MEDICAL CENTRE A88008 THE PARK SURGERY A88603 ST GEORGE & RIVERSIDE MEDICAL PRACTICE A88015 FLAGG COURT (DR S CHANDER) A88020 RAVENSWORTH SURGERY A88608 WAWN STREET SURGERY A88007 MAYFIELD MEDICAL GROUP A88004 ALBERT ROAD SURGERY A88010 VICTORIA MEDICAL CENTRE A88001 TALBOT MEDICAL CENTRE A88006 IMEARY STREET PRACTICE A88601 THE GLEN MEDICAL GROUP A88022 COLLIERY COURT MEDICAL GROUP A88016 EAST WING PRACTICE A88613 THE G.P.SUITE A88025 WESTOE SURGERY A88011 MARSDEN RD. HEALTH CENTRE A88003 CENTRAL SURGERY A88013 DR THORNILEY-WALKER & PARTNERS A88009 FARNHAM MEDICAL CTR. A88002 CHICHESTER PRACTICE A88611 WHITBURN SURGERY A88023 ELLISON VIEW SURGERY A88012 FLAGG COURT (DR N WIN) A88614 WENLOCK ROAD SURGERY A88005 STANHOPE PARADE HEALTH CENTRE A88014 JARROW GP PRACTICE Y % 1.7% 1.6% 1.5% 1.5% 1.4% 1.4% 1.3% 1.2% 1.2% 1.2% 1.1% 1.1% 1.1% 1.1% 1.1% 1.1% 1.1% 1.1% 1.0% 1.0% 0.8% 0.7% 0.6% 0.6% 0.5% 0.3% 1,812 people with diagnosed heart failure in NHS South Tyneside CCG GP practice range: 0.3% to 1.7% 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6% 1.8% 2.0% 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 North Tyneside CCG NHS Newcastle Gateshead CCG NHS Sunderland CCG 87.4% 87.0% 86.4% 1,253 people with heart failure* with LVSD in NHS South Tyneside CCG 1,054 (84.1%) people treated with ACE-I or ARB 199 (15.9%) people who are exceptions 0 (0%) additional people who are not treated with ACE-I or ARB NHS Northumberland CCG 85.1% NHS South Tyneside CCG 84.1% 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 North Tyneside CCG 87.4% NHS Barnsley CCG 86.7% NHS Sunderland CCG 86.4% NHS Southend CCG 86.2% NHS St Helens CCG 84.6% NHS Hardwick CCG 84.4% NHS South Tyneside CCG 84.1% NHS Thanet CCG 83.4% NHS Wirral CCG 82.4% NHS Mansfield and Ashfield CCG 81.8% NHS South Sefton CCG 78.9% 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 WESTOE SURGERY A88011 FLAGG COURT (DR N WIN) A88614 FLAGG COURT (DR S CHANDER) A88020 THE GLEN MEDICAL GROUP A88022 THE PARK SURGERY A88603 VICTORIA MEDICAL CENTRE A88001 COLLIERY COURT MEDICAL GROUP A88016 IMEARY STREET PRACTICE A88601 STANHOPE PARADE HEALTH CENTRE A88014 CENTRAL SURGERY A88013 MARSDEN RD. HEALTH CENTRE A88003 WAWN STREET SURGERY A88007 RAVENSWORTH SURGERY A88608 ST GEORGE & RIVERSIDE MEDICAL PRACTICE A88015 ALBERT ROAD SURGERY A88010 TRINITY MEDICAL CENTRE A88008 MAYFIELD MEDICAL GROUP A88004 ELLISON VIEW SURGERY A88012 FARNHAM MEDICAL CTR. A88002 TALBOT MEDICAL CENTRE A88006 CHICHESTER PRACTICE A88611 WENLOCK ROAD SURGERY A88005 THE G.P.SUITE A88025 WHITBURN SURGERY A88023 DR THORNILEY-WALKER & PARTNERS A88009 EAST WING PRACTICE A88613 JARROW GP PRACTICE Y in total, including exceptions, there are 199 people who are not treated with ACE-I or ARB GP practice range: 0.0% to 30.4% 0% 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 North Tyneside CCG NHS Sunderland CCG NHS Northumberland CCG 79.8% 79.8% 78.8% 1,054 people with heart failure* with LVSD treated with ACE-I/ARB in NHS South Tyneside CCG 764 (72.5%) people treated with ACE- I/ARB and BB 242 (23%) people who are exceptions 48 (4.6%) additional people who are not treated with ACE-I/ARB and BB NHS Newcastle Gateshead CCG 78.7% NHS South Tyneside CCG 72.5% 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 Hardwick CCG 80.8% NHS North Tyneside CCG 79.8% NHS Sunderland CCG 79.8% NHS Mansfield and Ashfield CCG 79.2% NHS Southend CCG 77.8% NHS Wirral CCG 77.1% NHS Thanet CCG 76.1% NHS Barnsley CCG 75.5% NHS St Helens CCG 74.1% NHS South Tyneside CCG 72.5% NHS South Sefton CCG 71.5% 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 FLAGG COURT (DR S CHANDER) A88020 ALBERT ROAD SURGERY A88010 THE G.P.SUITE A88025 DR THORNILEY-WALKER & PARTNERS A88009 MAYFIELD MEDICAL GROUP A88004 CHICHESTER PRACTICE A88611 EAST WING PRACTICE A88613 FARNHAM MEDICAL CTR. A88002 WHITBURN SURGERY A88023 TRINITY MEDICAL CENTRE A88008 MARSDEN RD. HEALTH CENTRE A88003 VICTORIA MEDICAL CENTRE A88001 FLAGG COURT (DR N WIN) A88614 WENLOCK ROAD SURGERY A88005 ST GEORGE & RIVERSIDE MEDICAL PRACTICE A88015 THE GLEN MEDICAL GROUP A88022 WAWN STREET SURGERY A88007 THE PARK SURGERY A88603 STANHOPE PARADE HEALTH CENTRE A88014 COLLIERY COURT MEDICAL GROUP A88016 CENTRAL SURGERY A88013 ELLISON VIEW SURGERY A88012 RAVENSWORTH SURGERY A88608 TALBOT MEDICAL CENTRE A88006 IMEARY STREET PRACTICE A88601 WESTOE SURGERY A88011 JARROW GP PRACTICE Y in total, including exceptions, there are 290 people who are not treated with ACE-I or ARB GP practice range: 0.0% to 42.9% 0% 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 Newcastle Gateshead CCG NHS Northumberland CCG NHS South Tyneside CCG 89.2% 88.8% 88.3% 7,118 people with coronary heart disease* in NHS South Tyneside CCG 6,287 (88.3%) people whose blood pressure <= 150 / (4%) people who are exceptions 545 (7.7%) additional people whose blood pressure is not <= 150 / 90 NHS Sunderland CCG 88.2% NHS North Tyneside CCG 88.1% 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 St Helens CCG 89.9% NHS Hardwick CCG 89.2% NHS South Tyneside CCG 88.3% NHS Sunderland CCG 88.2% NHS Wirral CCG 88.2% NHS North Tyneside CCG 88.1% NHS Thanet CCG 88.0% NHS Mansfield and Ashfield CCG 87.3% NHS South Sefton CCG 86.8% NHS Southend CCG 86.5% NHS Barnsley CCG 86.1% 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 WENLOCK ROAD SURGERY A88005 ST GEORGE & RIVERSIDE MEDICAL PRACTICE A88015 WAWN STREET SURGERY A88007 JARROW GP PRACTICE Y02999 WHITBURN SURGERY A88023 ALBERT ROAD SURGERY A88010 EAST WING PRACTICE A88613 COLLIERY COURT MEDICAL GROUP A88016 THE PARK SURGERY A88603 MARSDEN RD. HEALTH CENTRE A88003 WESTOE SURGERY A88011 VICTORIA MEDICAL CENTRE A88001 THE GLEN MEDICAL GROUP A88022 IMEARY STREET PRACTICE A88601 FARNHAM MEDICAL CTR. A88002 FLAGG COURT (DR S CHANDER) A88020 FLAGG COURT (DR N WIN) A88614 ELLISON VIEW SURGERY A88012 TALBOT MEDICAL CENTRE A88006 TRINITY MEDICAL CENTRE A88008 CENTRAL SURGERY A88013 RAVENSWORTH SURGERY A88608 STANHOPE PARADE HEALTH CENTRE A88014 MAYFIELD MEDICAL GROUP A88004 THE G.P.SUITE A88025 DR THORNILEY-WALKER & PARTNERS A88009 CHICHESTER PRACTICE A in total, including exceptions, there are 831 people whose blood pressure is not <= 150 / 90 GP practice range: 3.6% to 23.7% 0% 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 5% 0% -5% -10% -15% -20% WENLOCK ROAD SURGERY ST GEORGE & RIVERSIDE MEDICAL PRACTICE WAWN STREET SURGERY WHITBURN SURGERY ALBERT ROAD SURGERY EAST WING PRACTICE COLLIERY COURT MEDICAL GROUP THE PARK SURGERY WESTOE SURGERY VICTORIA MEDICAL CENTRE 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 311 people would be treated TALBOT MEDICAL CENTRE TRINITY MEDICAL CENTRE FARNHAM MEDICAL CTR. RAVENSWORTH SURGERY STANHOPE PARADE HEALTH CENTRE CENTRAL SURGERY MAYFIELD MEDICAL GROUP THE G.P.SUITE DR THORNILEY-WALKER & PARTNERS CHICHESTER PRACTICE 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 Newcastle Gateshead CCG NHS Sunderland CCG NHS South Tyneside CCG NHS North Tyneside CCG 93.7% 93.6% 93.6% 92.2% 7,118 people with coronary heart disease* in NHS South Tyneside CCG 6,661 (93.6%) people who are taking aspirin, an alternative anti-platelet therapy, or an anti-coagulant 293 (4.1%) people who are exceptions 164 (2.3%) additional people who are not taking aspirin, an alternative antiplatelet therapy, or an anti-coagulant NHS Northumberland CCG 92.2% 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 Sunderland CCG 93.6% NHS South Tyneside CCG 93.6% NHS Thanet CCG 92.5% NHS South Sefton CCG 92.4% NHS North Tyneside CCG 92.2% NHS Hardwick CCG 91.8% NHS Mansfield and Ashfield CCG 91.6% NHS Barnsley CCG 91.4% NHS St Helens CCG 91.1% NHS Wirral CCG 89.6% NHS Southend CCG 89.1% 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 EAST WING PRACTICE A88613 VICTORIA MEDICAL CENTRE A88001 THE PARK SURGERY A88603 FLAGG COURT (DR N WIN) A88614 TRINITY MEDICAL CENTRE A88008 ELLISON VIEW SURGERY A88012 FARNHAM MEDICAL CTR. A88002 ALBERT ROAD SURGERY A88010 ST GEORGE & RIVERSIDE MEDICAL PRACTICE A88015 WENLOCK ROAD SURGERY A88005 FLAGG COURT (DR S CHANDER) A88020 IMEARY STREET PRACTICE A88601 THE GLEN MEDICAL GROUP A88022 MARSDEN RD. HEALTH CENTRE A88003 WAWN STREET SURGERY A88007 COLLIERY COURT MEDICAL GROUP A88016 DR THORNILEY-WALKER & PARTNERS A88009 RAVENSWORTH SURGERY A88608 JARROW GP PRACTICE Y02999 CENTRAL SURGERY A88013 THE G.P.SUITE A88025 WESTOE SURGERY A88011 STANHOPE PARADE HEALTH CENTRE A88014 MAYFIELD MEDICAL GROUP A88004 TALBOT MEDICAL CENTRE A88006 CHICHESTER PRACTICE A88611 WHITBURN SURGERY A in total, including exceptions, there are 457 people are not taking aspirin, an alternative anti-platelet therapy, or an anti-coagulant GP practice range: 0.4% to 18.8% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 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 South Tyneside CCG England in NHS South Tyneside CCG, the hospital admission rate for coronary heart disease in 2015/16 was (1,238) 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 83

84 Age standardised rate (per 100,000) Hospital admissions for stroke for all ages 2002/ /16 NHS South Tyneside CCG England in NHS South Tyneside CCG, the hospital admission rate for stroke in 2015/16 was (244) 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 South Tyneside CCG England Angina Heart Attack Heart failure 119.5% 136.8% 84.7% 108.6% 152.6% 150.0% The risk of a stroke was 70.6% higher and the risk of a heart attack was 84.7% higher compared to people without diabetes. The risk of a major amputation was 255.8% higher. Stroke 70.6% 81.3% Major amputation 255.8% 445.8% Minor amputation 451.8% 753.5% RRT 264.7% 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 South Tyneside CCG England in NHS South Tyneside CCG, the early mortality rate for coronary heart disease in was 46.3, 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 South Tyneside CCG England in NHS South Tyneside CCG, the early mortality rate for stroke in was 15.3, 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

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