CVD: Primary Care Intelligence Packs

Transcription

1 CVD: Primary Care Intelligence Packs NHS Greater Preston 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 Greater Preston CCG are: NHS East Lancashire CCG NHS Leeds North CCG NHS South Tees CCG NHS Leeds South and East CCG NHS Stoke On Trent CCG NHS Calderdale CCG NHS Lincolnshire West CCG NHS North East Lincolnshire CCG NHS West Lancashire CCG NHS Tameside and Glossop 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 Leeds South and East CCG 23.8% NHS North East Lincolnshire CCG NHS Stoke On Trent CCG 23.5% 22.6% prevalence of 19.2% in NHS Greater Preston CCG NHS Tameside and Glossop CCG 21.9% NHS East Lancashire CCG 21.4% NHS South Tees CCG 21.2% NHS Calderdale CCG 20.4% NHS Greater Preston CCG NHS Lincolnshire West CCG NHS Leeds North CCG 19.2% 18.2% 16.1% 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 West Lancashire CCG 15.7% 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 DR A HUSSAIN P % THE GEOFFREY STREET SURGERY P % AVENHAM LANE PRACTICE P % RIBBLETON MEDICAL CENTRE P % THE NEW HALL LANE PRACTICE P % ST WALBURGE'S MEDICAL PRACTICE P % MOOR PARK SURGERY P % FRENCHWOOD SURGERY P % DOCLANDS MEDICAL CENTRE P % THE ST PAULS SURGERY P % COTTAM LANE - DR NATH P % PARK VIEW SURGERY P % THE PARK MEDICAL PRACTICE P % FISHERGATE HILL SURGERY P % ISSA MEDICAL CENTRE - PATEL P % MEDICOM LTD P % LOSTOCK HALL MEDICAL CTR. P % THE SURGERY P % BRIARWOOD MEDICAL CENTRE P % DR SZ SHAHID P % DR D C PATEL & PARTNERS P % DR HP CHAKRABARTI P % DR JHA & DR YERRA SURGERY P % THE HEALTHCARE CENTRE P % BERRY LANE MEDICAL CENTRE P % STONEBRIDGE SURGERY P % LYTHAM ROAD SURGERY P % ST.MARY'S HEALTH CENTRE P % GREAT ECCLESTON HLTH CTR P % RIVERSIDE MEDICAL CENTRE P % BEECH DRIVE SURGERY P % LONGTON HEALTH CENTRE P % ST FILLAN'S MEDICAL CTRE P % 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 33,515 people who are recorded as smokers in NHS Greater Preston CCG GP practice range: 10.1% to 44.2% 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 Blackpool CCG 0.62 NHS Fylde & Wyre CCG NHS West Lancashire CCG NHS Chorley And South Ribble 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 East Lancashire CCG 0.59 NHS Greater Preston CCG 0.59 NHS Lancashire North CCG 0.58 NHS Blackburn With Darwen CCG 0.57 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 Stoke On Trent CCG 0.62 NHS Tameside and Glossop CCG 0.61 NHS West Lancashire CCG 0.61 NHS North East Lincolnshire CCG 0.61 NHS South Tees CCG 0.60 NHS East Lancashire CCG 0.59 NHS Greater Preston CCG 0.59 NHS Lincolnshire West CCG 0.58 NHS Leeds South and East CCG 0.58 NHS Calderdale CCG 0.58 NHS Leeds North CCG % 10% 20% 30% 40% 50% 60% 70% 18

19 Hypertension observed prevalence compared with expected prevalence by GP practice GP practice CCG STONEBRIDGE SURGERY P81107 GREAT ECCLESTON HLTH CTR P81059 THE ST PAULS SURGERY P81163 LONGTON HEALTH CENTRE P81040 BERRY LANE MEDICAL CENTRE P81055 RIVERSIDE MEDICAL CENTRE P81185 THE SURGERY P81152 LOSTOCK HALL MEDICAL CTR. P81179 BRIARWOOD MEDICAL CENTRE P81748 MEDICOM LTD P81785 DR HP CHAKRABARTI P81763 DR D C PATEL & PARTNERS P81103 BEECH DRIVE SURGERY P81691 THE PARK MEDICAL PRACTICE P81664 DOCLANDS MEDICAL CENTRE P81119 FISHERGATE HILL SURGERY P81169 THE HEALTHCARE CENTRE P81067 ST FILLAN'S MEDICAL CTRE P81018 LYTHAM ROAD SURGERY P81015 ISSA MEDICAL CENTRE - PATEL P81196 RIBBLETON MEDICAL CENTRE P81184 COTTAM LANE - DR NATH P81700 DR A HUSSAIN P81735 DR JHA & DR YERRA SURGERY P81647 THE NEW HALL LANE PRACTICE P81071 ST.MARY'S HEALTH CENTRE P81213 DR SZ SHAHID P81685 MOOR PARK SURGERY P81176 THE GEOFFREY STREET SURGERY P81093 ST WALBURGE'S MEDICAL PRACTICE P81667 PARK VIEW SURGERY P81046 FRENCHWOOD SURGERY P81750 AVENHAM LANE PRACTICE P it is estimated that there are 19,641 people with undiagnosed hypertension in NHS Greater Preston CCG GP practice range of observed to expected hypertension prevalence 0.36 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 West Lancashire CCG 82.5% NHS Fylde & Wyre CCG NHS Blackpool CCG NHS Blackburn With Darwen CCG NHS Chorley And South Ribble CCG NHS Greater Preston CCG 81.4% 80.9% 80.7% 80.6% 80.5% 28,026 people with hypertension (diagnosed)* in NHS Greater Preston CCG 22,572 (80.5%) people whose blood pressure is <= 150/ (3.5%) people who are excepted from optimal control 4,466 (15.9%) additional people whose blood pressure is not <= 150/90 NHS East Lancashire CCG 80.5% NHS Lancashire North CCG 76.8% 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 West Lancashire CCG 82.5% NHS Lincolnshire West CCG 82.3% NHS North East Lincolnshire CCG 82.2% NHS Stoke On Trent CCG 81.5% NHS Tameside and Glossop CCG 81.4% NHS Calderdale CCG 81.2% NHS Greater Preston CCG 80.5% NHS East Lancashire CCG 80.5% NHS South Tees CCG 80.0% NHS Leeds South and East CCG 79.7% NHS Leeds North CCG 78.4% 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 FRENCHWOOD SURGERY P81750 LOSTOCK HALL MEDICAL CTR. P81179 DR HP CHAKRABARTI P81763 AVENHAM LANE PRACTICE P81770 RIBBLETON MEDICAL CENTRE P81184 PARK VIEW SURGERY P81046 BERRY LANE MEDICAL CENTRE P81055 MEDICOM LTD P81785 DR JHA & DR YERRA SURGERY P81647 GREAT ECCLESTON HLTH CTR P81059 BRIARWOOD MEDICAL CENTRE P81748 THE ST PAULS SURGERY P81163 THE GEOFFREY STREET SURGERY P81093 DR SZ SHAHID P81685 THE PARK MEDICAL PRACTICE P81664 COTTAM LANE - DR NATH P81700 BEECH DRIVE SURGERY P81691 ST.MARY'S HEALTH CENTRE P81213 DR D C PATEL & PARTNERS P81103 DR A HUSSAIN P81735 THE SURGERY P81152 THE NEW HALL LANE PRACTICE P81071 STONEBRIDGE SURGERY P81107 ISSA MEDICAL CENTRE - PATEL P81196 FISHERGATE HILL SURGERY P81169 LONGTON HEALTH CENTRE P81040 RIVERSIDE MEDICAL CENTRE P81185 ST FILLAN'S MEDICAL CTRE P81018 THE HEALTHCARE CENTRE P81067 LYTHAM ROAD SURGERY P81015 MOOR PARK SURGERY P81176 ST WALBURGE'S MEDICAL PRACTICE P81667 DOCLANDS MEDICAL CENTRE P in total, including exceptions, there are 5,454 people whose blood pressure is not <= 150/90 GP practice range: 12.0% to 42.4% 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 West Lancashire CCG 75.0% NHS Blackburn With Darwen CCG NHS Fylde & Wyre CCG NHS East Lancashire CCG NHS Chorley And South Ribble CCG NHS Greater Preston CCG 70.9% 64.5% 64.3% 62.9% 59.7% 129 people with a new diagnosis* of hypertension with a CVD risk of 20% or higher in NHS Greater Preston CCG 77 (59.7%) people who are currently treated with statins 47 (36.4%) people who are exempted from treatment with statins 5 (3.9%) additional people who are not currently treated with statins NHS Blackpool CCG 57.7% NHS Lancashire North CCG 55.6% 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 North East Lincolnshire CCG 82.5% NHS West Lancashire CCG 75.0% NHS South Tees CCG 74.5% NHS Tameside and Glossop CCG 74.4% NHS Leeds South and East CCG 73.2% NHS Calderdale CCG 71.7% NHS Stoke On Trent CCG 68.8% NHS Lincolnshire West CCG 68.4% NHS Leeds North CCG 67.9% NHS East Lancashire CCG 64.3% NHS Greater Preston CCG 59.7% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 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 BEECH DRIVE SURGERY P81691 GREAT ECCLESTON HLTH CTR P81059 PARK VIEW SURGERY P81046 RIBBLETON MEDICAL CENTRE P81184 FRENCHWOOD SURGERY P81750 BERRY LANE MEDICAL CENTRE P81055 RIVERSIDE MEDICAL CENTRE P81185 ST FILLAN'S MEDICAL CTRE P81018 LONGTON HEALTH CENTRE P81040 DOCLANDS MEDICAL CENTRE P81119 STONEBRIDGE SURGERY P81107 LYTHAM ROAD SURGERY P81015 THE NEW HALL LANE PRACTICE P81071 DR D C PATEL & PARTNERS P81103 FISHERGATE HILL SURGERY P81169 ISSA MEDICAL CENTRE - PATEL P81196 ST.MARY'S HEALTH CENTRE P81213 THE ST PAULS SURGERY P81163 BRIARWOOD MEDICAL CENTRE P81748 THE HEALTHCARE CENTRE P in total, including exceptions, there are 52 people who are not treated with statins GP practice range: 0.0% to 100.0% THE GEOFFREY STREET SURGERY P81093 THE SURGERY P81152 LOSTOCK HALL MEDICAL CTR. P81179 THE PARK MEDICAL PRACTICE P81664 ST WALBURGE'S MEDICAL PRACTICE P81667 DR SZ SHAHID P81685 COTTAM LANE - DR NATH P81700 AVENHAM LANE PRACTICE P81770 MEDICOM LTD P81785 DR HP CHAKRABARTI P81763 DR A HUSSAIN P81735 DR JHA & DR YERRA SURGERY P81647 MOOR PARK SURGERY P % 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 Blackpool CCG 0.77 NHS Lancashire North CCG NHS Chorley And South Ribble CCG NHS Fylde & Wyre CCG the ratio of those diagnosed with atrial fibrillation versus those expected to have atrial fibrillation is 0.7. This compares to 0.7 for England this suggests that 70% of people with atrial fibrillation have been diagnosed. NHS West Lancashire CCG 0.71 NHS Greater Preston CCG 0.70 NHS East Lancashire CCG 0.68 NHS Blackburn With Darwen CCG 0.65 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 Stoke On Trent CCG 0.75 NHS North East Lincolnshire CCG 0.75 NHS South Tees CCG 0.72 NHS West Lancashire CCG 0.71 NHS Greater Preston CCG 0.70 NHS Lincolnshire West CCG 0.70 NHS Tameside and Glossop CCG 0.70 NHS Leeds South and East CCG 0.70 NHS Leeds North CCG 0.69 NHS East Lancashire CCG 0.68 NHS Calderdale CCG

30 Atrial fibrillation observed prevalence compared with expected prevalence by GP practice GP practice CCG RIBBLETON MEDICAL CENTRE P81184 LYTHAM ROAD SURGERY P81015 GREAT ECCLESTON HLTH CTR P81059 THE HEALTHCARE CENTRE P81067 ST.MARY'S HEALTH CENTRE P81213 COTTAM LANE - DR NATH P81700 ST FILLAN'S MEDICAL CTRE P81018 LONGTON HEALTH CENTRE P81040 BERRY LANE MEDICAL CENTRE P81055 THE NEW HALL LANE PRACTICE P81071 DR D C PATEL & PARTNERS P81103 STONEBRIDGE SURGERY P81107 DOCLANDS MEDICAL CENTRE P81119 FISHERGATE HILL SURGERY P81169 MOOR PARK SURGERY P81176 DR JHA & DR YERRA SURGERY P81647 THE PARK MEDICAL PRACTICE P81664 ST WALBURGE'S MEDICAL PRACTICE P81667 BRIARWOOD MEDICAL CENTRE P81748 MEDICOM LTD P81785 PARK VIEW SURGERY P81046 LOSTOCK HALL MEDICAL CTR. P81179 RIVERSIDE MEDICAL CENTRE P81185 THE SURGERY P81152 DR SZ SHAHID P81685 DR A HUSSAIN P81735 THE GEOFFREY STREET SURGERY P81093 THE ST PAULS SURGERY P81163 ISSA MEDICAL CENTRE - PATEL P81196 FRENCHWOOD SURGERY P81750 DR HP CHAKRABARTI P81763 AVENHAM LANE PRACTICE P it is estimated that there are 4,954 people with undiagnosed atrial fibrillation in NHS Greater Preston 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 Fylde & Wyre CCG NHS Blackpool CCG NHS Blackburn With Darwen CCG NHS West Lancashire CCG NHS Greater Preston CCG NHS Lancashire North CCG 76.5% 75.3% 74.9% 74.4% 74.1% 73.4% 2,865 people with atrial fibrillation* with a CHA2DS2-VASc score >= 2 in NHS Greater Preston CCG 2,123 (74.1%) people treated with anti-coagulation therapy 317 (11.1%) people who are exceptions 425 (14.8%) additional people with a recorded CHA2DS2-VASc score >= 2 who are not treated NHS Chorley And South Ribble CCG 72.5% NHS East Lancashire 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 Lincolnshire West CCG 84.5% NHS South Tees CCG 81.9% NHS Tameside and Glossop CCG 80.9% NHS North East Lincolnshire CCG 80.3% NHS Stoke On Trent CCG 79.0% NHS Calderdale CCG 76.7% NHS Leeds North CCG 76.6% NHS West Lancashire CCG 74.4% NHS Leeds South and East CCG 74.3% NHS Greater Preston CCG 74.1% NHS East Lancashire CCG 72.3% 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 AVENHAM LANE PRACTICE P81770 DR A HUSSAIN P81735 DR SZ SHAHID P81685 THE HEALTHCARE CENTRE P81067 MEDICOM LTD P81785 THE SURGERY P81152 PARK VIEW SURGERY P81046 LYTHAM ROAD SURGERY P81015 ST FILLAN'S MEDICAL CTRE P81018 THE PARK MEDICAL PRACTICE P81664 FISHERGATE HILL SURGERY P81169 THE NEW HALL LANE PRACTICE P81071 ST.MARY'S HEALTH CENTRE P81213 ST WALBURGE'S MEDICAL PRACTICE P81667 STONEBRIDGE SURGERY P81107 BRIARWOOD MEDICAL CENTRE P81748 RIVERSIDE MEDICAL CENTRE P81185 MOOR PARK SURGERY P81176 DR D C PATEL & PARTNERS P81103 GREAT ECCLESTON HLTH CTR P81059 DOCLANDS MEDICAL CENTRE P81119 BEECH DRIVE SURGERY P81691 COTTAM LANE - DR NATH P81700 RIBBLETON MEDICAL CENTRE P81184 LOSTOCK HALL MEDICAL CTR. P81179 THE GEOFFREY STREET SURGERY P81093 ISSA MEDICAL CENTRE - PATEL P81196 LONGTON HEALTH CENTRE P81040 BERRY LANE MEDICAL CENTRE P81055 FRENCHWOOD SURGERY P81750 DR JHA & DR YERRA SURGERY P81647 THE ST PAULS SURGERY P81163 DR HP CHAKRABARTI P in total, including exceptions, there are 742 people with a recorded CHA2DS2-VASc score >= 2 who are not treated GP practice range: 0.0% to 62.5% 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 20% 10% 0% -10% -20% -30% -40% -50% -60% AVENHAM LANE PRACTICE DR A HUSSAIN DR SZ SHAHID THE HEALTHCARE CENTRE MEDICOM LTD THE SURGERY PARK VIEW SURGERY ST FILLAN'S MEDICAL CTRE LYTHAM ROAD SURGERY FISHERGATE HILL 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 281 people would be treated COTTAM LANE - DR NATH THE GEOFFREY STREET SURGERY LOSTOCK HALL MEDICAL CTR. ISSA MEDICAL CENTRE - PATEL LONGTON HEALTH CENTRE BERRY LANE MEDICAL CENTRE FRENCHWOOD SURGERY DR JHA & DR YERRA SURGERY THE ST PAULS SURGERY DR HP CHAKRABARTI 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 West Lancashire CCG NHS Blackburn With Darwen CCG NHS Fylde & Wyre CCG NHS East Lancashire CCG NHS Greater Preston CCG 87.2% 86.6% 86.0% 85.7% 85.4% 3,926 people with a history of stroke or TIA* in NHS Greater Preston CCG 3,352 (85.4%) people whose blood pressure is <= 150 / (3.5%) people who are exceptions 436 (11.1%) additional people whose blood pressure is not <= 150 / 90 NHS Blackpool CCG 84.0% NHS Chorley And South Ribble CCG 83.9% NHS Lancashire North CCG 81.0% 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 North East Lincolnshire CCG 87.4% NHS West Lancashire CCG 87.2% NHS Tameside and Glossop CCG 86.4% NHS Lincolnshire West CCG 86.1% NHS Calderdale CCG 86.0% NHS East Lancashire CCG 85.7% NHS Greater Preston CCG 85.4% NHS Stoke On Trent CCG 84.9% NHS Leeds South and East CCG 84.5% NHS South Tees CCG 83.2% NHS Leeds North CCG 82.6% 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 DR SZ SHAHID P81685 LOSTOCK HALL MEDICAL CTR. P81179 DR HP CHAKRABARTI P81763 AVENHAM LANE PRACTICE P81770 RIBBLETON MEDICAL CENTRE P81184 FRENCHWOOD SURGERY P81750 PARK VIEW SURGERY P81046 BEECH DRIVE SURGERY P81691 ST.MARY'S HEALTH CENTRE P81213 GREAT ECCLESTON HLTH CTR P81059 BERRY LANE MEDICAL CENTRE P81055 ISSA MEDICAL CENTRE - PATEL P81196 THE NEW HALL LANE PRACTICE P81071 MEDICOM LTD P81785 LONGTON HEALTH CENTRE P81040 DOCLANDS MEDICAL CENTRE P81119 BRIARWOOD MEDICAL CENTRE P81748 DR D C PATEL & PARTNERS P81103 THE PARK MEDICAL PRACTICE P81664 RIVERSIDE MEDICAL CENTRE P81185 MOOR PARK SURGERY P81176 FISHERGATE HILL SURGERY P81169 THE HEALTHCARE CENTRE P81067 THE SURGERY P81152 ST FILLAN'S MEDICAL CTRE P81018 LYTHAM ROAD SURGERY P81015 COTTAM LANE - DR NATH P81700 STONEBRIDGE SURGERY P81107 DR JHA & DR YERRA SURGERY P81647 THE GEOFFREY STREET SURGERY P81093 DR A HUSSAIN P81735 THE ST PAULS SURGERY P81163 ST WALBURGE'S MEDICAL PRACTICE P % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% in total, including exceptions, there are 574 people whose blood pressure is not <= 150 / 90 GP practice range: 0.0% to 32.3% 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 Greater Preston CCG NHS West Lancashire CCG NHS Blackburn With Darwen CCG NHS East Lancashire CCG NHS Chorley And South Ribble CCG NHS Fylde & Wyre CCG 93.5% 92.2% 91.7% 90.9% 90.6% 90.1% 2,516 people with a stroke shown to be non-haemorrhagic* in NHS Greater Preston CCG 2,353 (93.5%) people who are taking an anti-platetet agent or anticoagulant 103 (4.1%) people who are exceptions 60 (2.4%) additional people with no treatment NHS Lancashire North CCG 90.1% NHS Blackpool CCG 89.6% 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 Greater Preston CCG 93.5% NHS South Tees CCG 92.9% NHS North East Lincolnshire CCG 92.9% NHS Leeds South and East CCG 92.7% NHS Calderdale CCG 92.6% NHS Tameside and Glossop CCG 92.5% NHS Stoke On Trent CCG 92.2% NHS West Lancashire CCG 92.2% NHS Leeds North CCG 91.8% NHS East Lancashire CCG 90.9% NHS Lincolnshire West CCG 90.6% 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 DR HP CHAKRABARTI P81763 PARK VIEW SURGERY P81046 ST.MARY'S HEALTH CENTRE P81213 RIBBLETON MEDICAL CENTRE P81184 DOCLANDS MEDICAL CENTRE P81119 LOSTOCK HALL MEDICAL CTR. P81179 BERRY LANE MEDICAL CENTRE P81055 THE GEOFFREY STREET SURGERY P81093 THE SURGERY P81152 STONEBRIDGE SURGERY P81107 FRENCHWOOD SURGERY P81750 BRIARWOOD MEDICAL CENTRE P81748 THE PARK MEDICAL PRACTICE P81664 FISHERGATE HILL SURGERY P81169 RIVERSIDE MEDICAL CENTRE P81185 GREAT ECCLESTON HLTH CTR P81059 LYTHAM ROAD SURGERY P81015 ST FILLAN'S MEDICAL CTRE P81018 THE HEALTHCARE CENTRE P81067 DR D C PATEL & PARTNERS P81103 ISSA MEDICAL CENTRE - PATEL P81196 DR SZ SHAHID P81685 MEDICOM LTD P81785 BEECH DRIVE SURGERY P81691 LONGTON HEALTH CENTRE P81040 MOOR PARK SURGERY P81176 THE NEW HALL LANE PRACTICE P81071 THE ST PAULS SURGERY P in total, including exceptions, there are 163 people who are not taking an anti-platelet agent or anti-coagulant GP practice range: 0.0% to 20.0% DR JHA & DR YERRA SURGERY P81647 ST WALBURGE'S MEDICAL PRACTICE P81667 COTTAM LANE - DR NATH P81700 DR A HUSSAIN P81735 AVENHAM LANE PRACTICE P % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 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 Blackburn With Darwen CCG NHS Lancashire North CCG NHS Chorley And South Ribble CCG NHS West Lancashire CCG ratio of observed to expected diabetes prevalence in NHS Greater Preston CCG, compared to 0.77 in England this suggests 77% of people have been diagnosed NHS Blackpool CCG 0.80 NHS East Lancashire CCG 0.78 NHS Greater Preston CCG 0.77 NHS Fylde & Wyre CCG 0.75 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 Stoke On Trent CCG 0.89 NHS Tameside and Glossop CCG 0.85 NHS Lincolnshire West CCG 0.82 NHS Leeds South and East CCG 0.82 NHS North East Lincolnshire CCG 0.82 NHS West Lancashire CCG 0.81 NHS East Lancashire CCG 0.78 NHS Greater Preston CCG 0.77 NHS South Tees CCG 0.76 NHS Leeds North CCG 0.73 NHS Calderdale CCG

45 Diabetes prevalence by GP practice GP practice CCG DR SZ SHAHID P % DR JHA & DR YERRA SURGERY P % THE ST PAULS SURGERY P % FISHERGATE HILL SURGERY P % ISSA MEDICAL CENTRE - PATEL P % DR HP CHAKRABARTI P % THE NEW HALL LANE PRACTICE P % DR D C PATEL & PARTNERS P % THE PARK MEDICAL PRACTICE P % PARK VIEW SURGERY P % MEDICOM LTD P % THE HEALTHCARE CENTRE P % BRIARWOOD MEDICAL CENTRE P % RIBBLETON MEDICAL CENTRE P % GREAT ECCLESTON HLTH CTR P % BEECH DRIVE SURGERY P % LYTHAM ROAD SURGERY P % ST WALBURGE'S MEDICAL PRACTICE P % MOOR PARK SURGERY P % LONGTON HEALTH CENTRE P % LOSTOCK HALL MEDICAL CTR. P % FRENCHWOOD SURGERY P % THE GEOFFREY STREET SURGERY P % DOCLANDS MEDICAL CENTRE P % THE SURGERY P % BERRY LANE MEDICAL CENTRE P % ST FILLAN'S MEDICAL CTRE P % STONEBRIDGE SURGERY P % RIVERSIDE MEDICAL CENTRE P % AVENHAM LANE PRACTICE P % COTTAM LANE - DR NATH P % DR A HUSSAIN P % ST.MARY'S HEALTH CENTRE P % 0% 2% 4% 6% 8% 10% 12% 14% GP practice range of observed diabetes 3.3% to 11.6% there are an estimated 3,259 people with undiagnosed diabetes in NHS Greater Preston 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 Fylde & Wyre CCG NHS Blackpool CCG 7.1% 7.6% 2.4% 1.9% 12.8% 11.9% the estimated total prevalence of diabetes in NHS Greater Preston CCG is 8.4% (diagnosed and undiagnosed) NHS Blackburn With Darwen CCG NHS East Lancashire CCG NHS West Lancashire CCG 8.2% 7.1% 6.8% 1.4% 2.0% 1.6% 11.7% 11.4% 11.3% in addition, there are an estimated 11.1% of people in NHS Greater Preston CCG who are at increased risk of developing diabetes (i.e. with non-diabetic hyperglycaemia) NHS Greater Preston CCG NHS Chorley And South Ribble CCG 6.5% 6.9% 1.9% 1.4% 11.1% 11.0% this means that 19.5% of the population in NHS Greater Preston CCG are estimated to have diabetes, or at high risk of developing of diabetes NHS Lancashire North CCG 6.8% 1.2% 10.8% 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 Blackburn With Darwen CCG 61.3% NHS Fylde & Wyre CCG NHS Lancashire North CCG NHS Blackpool CCG NHS East Lancashire CCG NHS Chorley And South Ribble CCG 61.1% 56.5% 53.3% 50.2% 49.6% 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 Greater Preston CCG, 23 out of 32 practices (71.9%) participated in the NDA. Data is not available for the remaining practices NHS Greater Preston CCG NHS West Lancashire CCG 45.4% 34.2% 45.4% of people with diabetes (of practices who participated in the audit) had the eight recommended care processes in NHS Greater Preston 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 THE NEW HALL LANE PRACTICE P81071 GREAT ECCLESTON HLTH CTR P81059 STONEBRIDGE SURGERY P81107 RIBBLETON MEDICAL CENTRE P81184 THE SURGERY P81152 THE HEALTHCARE CENTRE P81067 BERRY LANE MEDICAL CENTRE P81055 DR D C PATEL & PARTNERS P81103 DOCLANDS MEDICAL CENTRE P81119 ST FILLAN'S MEDICAL CTRE P81018 LONGTON HEALTH CENTRE P81040 BEECH DRIVE SURGERY P81691 FISHERGATE HILL SURGERY P81169 RIVERSIDE MEDICAL CENTRE P81185 ST.MARY'S HEALTH CENTRE P81213 ISSA MEDICAL CENTRE - PATEL P81196 THE PARK MEDICAL PRACTICE P81664 COTTAM LANE - DR NATH P81700 DR JHA & DR YERRA SURGERY P81647 BRIARWOOD MEDICAL CENTRE P81748 DR A HUSSAIN P81735 ST WALBURGE'S MEDICAL PRACTICE P81667 THE GEOFFREY STREET SURGERY P81093 MEDICOM LTD P81785 AVENHAM LANE PRACTICE P81770 DR HP CHAKRABARTI P81763 FRENCHWOOD SURGERY P81750 DR SZ SHAHID P81685 LOSTOCK HALL MEDICAL CTR. P81179 MOOR PARK SURGERY P81176 THE ST PAULS SURGERY P81163 PARK VIEW SURGERY P81046 LYTHAM ROAD SURGERY P % 69.5% 63.5% 60.5% 57.8% 51.8% 51.1% 48.9% 48.0% 48.0% 46.1% 45.7% 45.6% 42.6% 38.0% 34.3% 28.1% 25.4% 18.7% 11.8% 9.7% 7.4% 5.8% achievement - 8 care processes: in practices who provided data via the NDA, between 5.8% and 73.6% of patients received all 8 care processes at least 4,821 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 Chorley And South Ribble CCG 44.8% NHS Blackpool CCG NHS Greater Preston CCG NHS West Lancashire CCG 44.0% 43.2% 43.2% 43.2% of people with diabetes (of practices who participated in the audit) met the three treatment targets in NHS Greater Preston CCG, compared to 39.0% in England NHS Fylde & Wyre CCG 41.6% NHS Lancashire North CCG 41.6% NHS Blackburn With Darwen CCG 39.9% NHS East Lancashire CCG 39.5% England 39.0% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 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 ST WALBURGE'S MEDICAL PRACTICE P81667 THE GEOFFREY STREET SURGERY P81093 STONEBRIDGE SURGERY P81107 FISHERGATE HILL SURGERY P81169 THE HEALTHCARE CENTRE P81067 BEECH DRIVE SURGERY P81691 COTTAM LANE - DR NATH P81700 RIVERSIDE MEDICAL CENTRE P81185 ST FILLAN'S MEDICAL CTRE P81018 ST.MARY'S HEALTH CENTRE P81213 THE SURGERY P81152 ISSA MEDICAL CENTRE - PATEL P81196 LONGTON HEALTH CENTRE P81040 THE PARK MEDICAL PRACTICE P81664 DR D C PATEL & PARTNERS P81103 RIBBLETON MEDICAL CENTRE P81184 DR A HUSSAIN P81735 DR JHA & DR YERRA SURGERY P81647 THE NEW HALL LANE PRACTICE P81071 BRIARWOOD MEDICAL CENTRE P81748 BERRY LANE MEDICAL CENTRE P81055 DOCLANDS MEDICAL CENTRE P81119 GREAT ECCLESTON HLTH CTR P81059 MEDICOM LTD P81785 AVENHAM LANE PRACTICE P81770 DR HP CHAKRABARTI P81763 FRENCHWOOD SURGERY P81750 DR SZ SHAHID P81685 LOSTOCK HALL MEDICAL CTR. P81179 MOOR PARK SURGERY P81176 THE ST PAULS SURGERY P81163 PARK VIEW SURGERY P81046 LYTHAM ROAD SURGERY P % 50.0% 48.4% 48.1% 46.4% 45.7% 45.6% 45.5% 45.4% 45.0% 44.2% 43.4% 43.2% 42.6% 42.4% 42.4% 41.9% 41.2% 41.2% 38.8% 38.5% 38.4% 33.9% achievement - 3 treatment targets: in practices who provided data via the NDA, between 33.9% and 54.5% of patients achieved all 3 treatment targets at least 4,472 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% GREAT ECCLESTON HLTH CTR DOCLANDS MEDICAL CENTRE BRIARWOOD MEDICAL CENTRE BERRY LANE MEDICAL CENTRE THE NEW HALL LANE PRACTICE THE SURGERY DR JHA & DR YERRA SURGERY DR D C PATEL & PARTNERS COTTAM LANE - DR NATH DR A HUSSAIN 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 166 people would be treated ST FILLAN'S MEDICAL CTRE THE PARK MEDICAL PRACTICE BEECH DRIVE SURGERY FISHERGATE HILL SURGERY RIVERSIDE MEDICAL CENTRE THE HEALTHCARE CENTRE ST.MARY'S HEALTH CENTRE STONEBRIDGE SURGERY THE GEOFFREY STREET SURGERY ST WALBURGE'S MEDICAL PRACTICE 1 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 Blackpool CCG 1.17 NHS Chorley And South Ribble CCG NHS Fylde & Wyre CCG NHS Greater Preston CCG NHS Lancashire North 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 84% of people with chronic kidney disease have been diagnosed NHS West Lancashire CCG 0.70 NHS Blackburn With Darwen CCG 0.65 NHS East Lancashire CCG 0.59 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 Lincolnshire West CCG 1.00 NHS North East Lincolnshire CCG 0.92 NHS Greater Preston CCG 0.84 NHS West Lancashire CCG 0.70 NHS Leeds South and East CCG 0.67 NHS Stoke On Trent CCG 0.66 NHS Calderdale CCG 0.64 NHS South Tees CCG 0.59 NHS East Lancashire CCG 0.59 NHS Leeds North CCG 0.57 NHS Tameside and Glossop CCG Ratio 55

56 CKD prevalence by GP practice, 2015/16 GP practice CCG RIVERSIDE MEDICAL CENTRE P81185 LYTHAM ROAD SURGERY P81015 FISHERGATE HILL SURGERY P81169 ST FILLAN'S MEDICAL CTRE P81018 STONEBRIDGE SURGERY P81107 DR D C PATEL & PARTNERS P81103 BRIARWOOD MEDICAL CENTRE P81748 THE NEW HALL LANE PRACTICE P81071 DOCLANDS MEDICAL CENTRE P81119 THE HEALTHCARE CENTRE P81067 BERRY LANE MEDICAL CENTRE P81055 GREAT ECCLESTON HLTH CTR P81059 LONGTON HEALTH CENTRE P81040 THE ST PAULS SURGERY P81163 THE SURGERY P81152 RIBBLETON MEDICAL CENTRE P81184 THE PARK MEDICAL PRACTICE P81664 LOSTOCK HALL MEDICAL CTR. P81179 BEECH DRIVE SURGERY P81691 DR JHA & DR YERRA SURGERY P81647 DR SZ SHAHID P81685 ISSA MEDICAL CENTRE - PATEL P81196 PARK VIEW SURGERY P81046 ST WALBURGE'S MEDICAL PRACTICE P81667 MOOR PARK SURGERY P81176 ST.MARY'S HEALTH CENTRE P81213 COTTAM LANE - DR NATH P81700 THE GEOFFREY STREET SURGERY P81093 DR HP CHAKRABARTI P81763 MEDICOM LTD P81785 DR A HUSSAIN P81735 FRENCHWOOD SURGERY P81750 AVENHAM LANE PRACTICE P % 8.3% 8.1% 7.3% 6.8% 6.8% 6.3% 5.9% 5.7% 5.5% 5.4% 5.4% 5.3% 5.2% 4.9% 4.8% 4.7% 4.5% 3.3% 2.7% 2.7% 2.6% 2.3% 2.2% 2.2% 2.1% 2.0% 2.0% 1.9% 1.9% 1.5% 1.3% 0.7% 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% it is estimated that there are 1,549 people with undiagnosed chronic kidney disease in NHS Greater Preston CCG GP practice range of observed CKD: 0.7% to 8.3% 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 Blackburn With Darwen CCG NHS West Lancashire CCG NHS Chorley And South Ribble CCG NHS East Lancashire CCG NHS Blackpool CCG 78.4% 77.9% 77.4% 77.2% 77.1% 7,810 people with CKD (diagnosed*) in NHS Greater Preston CCG 5,999 (76.8%) people whose blood pressure is <= 140 / (6.6%) people who are exceptions 1,299 (16.6%) additional people whose blood pressure is not <= 140 / 85 NHS Greater Preston CCG 76.8% NHS Fylde & Wyre CCG 74.9% NHS Lancashire North CCG 74.4% 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 North East Lincolnshire CCG 79.4% NHS Stoke On Trent CCG 78.3% NHS Tameside and Glossop CCG 78.1% NHS West Lancashire CCG 77.9% NHS East Lancashire CCG 77.2% NHS Greater Preston CCG 76.8% NHS Lincolnshire West CCG 76.0% NHS Leeds South and East CCG 75.6% NHS Calderdale CCG 74.7% NHS South Tees CCG 73.9% NHS Leeds North CCG 71.9% 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 MOOR PARK SURGERY P81176 LOSTOCK HALL MEDICAL CTR. P81179 LONGTON HEALTH CENTRE P81040 DR HP CHAKRABARTI P81763 MEDICOM LTD P81785 DR SZ SHAHID P81685 RIBBLETON MEDICAL CENTRE P81184 BRIARWOOD MEDICAL CENTRE P81748 DR A ROBB P81152 DR JN JHA P81647 GREAT ECCLESTON HEALTH CENTRE P81059 FRENCHWOOD SURGERY P81750 ST FILLAN'S MEDICAL CTRE P81018 DR D C PATEL & PARTNERS P81103 THE ST PAULS SURGERY P81163 PARK VIEW SURGERY P81046 DOCLANDS MEDICAL CENTRE P81119 COTTAM LANE - DR NATH P81700 RIVERSIDE MEDICAL CENTRE P81185 BERRY LANE MEDICAL CENTRE P81055 DR Z H PATEL P81667 BEECH DRIVE SURGERY P81691 LYTHAM ROAD SURGERY P81015 DR A HUSSAIN P81735 ISSA MEDICAL CENTRE - PATEL P81196 STONEBRIDGE SURGERY P81107 THE NEW HALL LANE PRACTICE P81071 THE HEALTHCARE CENTRE P81067 THE PARK MEDICAL PRACTICE P81664 ST.MARY'S HEALTH CENTRE P81213 THE GEOFFREY STREET SURGERY P81093 FISHERGATE HILL SURGERY P81169 AVENHAM LANE PRACTICE P in total, including exceptions, there are 1,811 people whose blood pressure is not <= 140 / 85 GP practice range: 11.8% to 44.7% 0% 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% -30% MOOR PARK SURGERY LOSTOCK HALL MEDICAL CTR. DR HP CHAKRABARTI DR SZ SHAHID MEDICOM LTD RIBBLETON MEDICAL CENTRE LONGTON HEALTH CENTRE BRIARWOOD MEDICAL CENTRE DR A ROBB DR JN JHA 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 355 people would be treated RIVERSIDE MEDICAL CENTRE STONEBRIDGE SURGERY ST.MARY'S HEALTH CENTRE BERRY LANE MEDICAL CENTRE LYTHAM ROAD SURGERY THE HEALTHCARE CENTRE THE GEOFFREY STREET SURGERY THE PARK MEDICAL PRACTICE FISHERGATE HILL SURGERY AVENHAM LANE 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 Chorley And South Ribble CCG NHS West Lancashire CCG NHS Blackpool CCG NHS Blackburn With Darwen CCG NHS Fylde & Wyre CCG NHS Greater Preston CCG 81.0% 77.7% 77.1% 77.0% 76.4% 75.7% 7,810 people with CKD (diagnosed*) in NHS Greater Preston CCG 5,913 (75.7%) people who have a record of urine albumin:creatinine ratio test 300 (3.8%) people who are exceptions 1,597 (20.4%) additional people who have no record of urine albumin:creatinine ratio test NHS East Lancashire CCG 75.7% NHS Lancashire North CCG 74.1% 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 North East Lincolnshire CCG 83.6% NHS Tameside and Glossop CCG 79.8% NHS Stoke On Trent CCG 79.2% NHS Calderdale CCG 79.1% NHS Lincolnshire West CCG 78.3% NHS West Lancashire CCG 77.7% NHS South Tees CCG 76.1% NHS Leeds South and East CCG 75.8% NHS Greater Preston CCG 75.7% NHS East Lancashire CCG 75.7% NHS Leeds North CCG 73.8% 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 HP CHAKRABARTI P81763 DR A HUSSAIN P81735 MEDICOM LTD P81785 PARK VIEW SURGERY P81046 MOOR PARK SURGERY P81176 RIBBLETON MEDICAL CENTRE P81184 DR D C PATEL & PARTNERS P81103 DR SZ SHAHID P81685 BRIARWOOD MEDICAL CENTRE P81748 GREAT ECCLESTON HEALTH CENTRE P81059 DR A ROBB P81152 BEECH DRIVE SURGERY P81691 LOSTOCK HALL MEDICAL CTR. P81179 THE NEW HALL LANE PRACTICE P81071 LYTHAM ROAD SURGERY P81015 DOCLANDS MEDICAL CENTRE P81119 BERRY LANE MEDICAL CENTRE P81055 LONGTON HEALTH CENTRE P81040 FISHERGATE HILL SURGERY P81169 AVENHAM LANE PRACTICE P81770 ST.MARY'S HEALTH CENTRE P81213 RIVERSIDE MEDICAL CENTRE P81185 FRENCHWOOD SURGERY P81750 THE HEALTHCARE CENTRE P81067 ST FILLAN'S MEDICAL CTRE P81018 COTTAM LANE - DR NATH P81700 ISSA MEDICAL CENTRE - PATEL P81196 THE ST PAULS SURGERY P81163 DR Z H PATEL P81667 THE PARK MEDICAL PRACTICE P81664 DR JN JHA P81647 STONEBRIDGE SURGERY P81107 THE GEOFFREY STREET SURGERY P in total, including exceptions, there are 1,897 people who have no record of urine albumin:creatinine ratio test GP practice range: 0.0% to 87.0% 0% 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 Fylde & Wyre CCG 1.49% NHS Blackpool CCG NHS West Lancashire CCG 1.45% 1.05% prevalence of 0.92% in NHS Greater Preston CCG compared to 0.76% in England NHS Chorley And South Ribble CCG 0.96% NHS Greater Preston CCG 0.92% NHS East Lancashire CCG 0.88% NHS Blackburn With Darwen CCG 0.82% NHS Lancashire North CCG 0.80% England 0.76% 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6% 66

67 Heart failure prevalence by CCG Comparison with demographically similar CCGs NHS West Lancashire CCG 1.05% NHS Greater Preston CCG 0.92% NHS East Lancashire CCG 0.88% NHS Tameside and Glossop CCG 0.83% NHS South Tees CCG 0.82% NHS Leeds South and East CCG 0.80% NHS Stoke On Trent CCG 0.80% NHS Lincolnshire West CCG 0.78% NHS Calderdale CCG 0.71% NHS Leeds North CCG 0.71% NHS North East Lincolnshire CCG 0.67% 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 ST WALBURGE'S MEDICAL PRACTICE P81667 STONEBRIDGE SURGERY P81107 ST FILLAN'S MEDICAL CTRE P81018 DR D C PATEL & PARTNERS P81103 BEECH DRIVE SURGERY P81691 GREAT ECCLESTON HLTH CTR P81059 LONGTON HEALTH CENTRE P81040 LYTHAM ROAD SURGERY P81015 THE NEW HALL LANE PRACTICE P81071 RIVERSIDE MEDICAL CENTRE P81185 MEDICOM LTD P81785 BERRY LANE MEDICAL CENTRE P81055 DR JHA & DR YERRA SURGERY P81647 THE PARK MEDICAL PRACTICE P81664 RIBBLETON MEDICAL CENTRE P81184 LOSTOCK HALL MEDICAL CTR. P81179 THE HEALTHCARE CENTRE P81067 THE SURGERY P81152 DOCLANDS MEDICAL CENTRE P81119 FRENCHWOOD SURGERY P81750 DR SZ SHAHID P81685 COTTAM LANE - DR NATH P81700 BRIARWOOD MEDICAL CENTRE P81748 DR HP CHAKRABARTI P81763 FISHERGATE HILL SURGERY P81169 THE ST PAULS SURGERY P81163 ISSA MEDICAL CENTRE - PATEL P81196 MOOR PARK SURGERY P81176 ST.MARY'S HEALTH CENTRE P81213 PARK VIEW SURGERY P81046 DR A HUSSAIN P81735 THE GEOFFREY STREET SURGERY P81093 AVENHAM LANE PRACTICE P % 1.8% 1.4% 1.3% 1.3% 1.2% 1.2% 1.1% 1.1% 1.0% 0.9% 0.9% 0.9% 0.8% 0.8% 0.8% 0.8% 0.8% 0.8% 0.8% 0.7% 0.7% 0.7% 0.7% 0.7% 0.6% 0.6% 0.6% 0.6% 0.5% 0.4% 0.4% 0.4% 1,943 people with diagnosed heart failure in NHS Greater Preston CCG GP practice range: 0.4% to 2.2% 0.0% 0.5% 1.0% 1.5% 2.0% 2.5% 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 Blackpool CCG NHS Lancashire North CCG NHS East Lancashire CCG NHS Fylde & Wyre CCG NHS Greater Preston CCG 88.2% 87.6% 87.5% 86.9% 86.2% 428 people with heart failure* with LVSD in NHS Greater Preston CCG 369 (86.2%) people treated with ACE- I or ARB 56 (13.1%) people who are exceptions 3 (0.7%) additional people who are not treated with ACE-I or ARB NHS Chorley And South Ribble CCG 85.3% NHS Blackburn With Darwen CCG 85.1% NHS West Lancashire CCG 81.9% 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 Stoke On Trent CCG 89.1% NHS Calderdale CCG 88.3% NHS South Tees CCG 87.8% NHS East Lancashire CCG 87.5% NHS Greater Preston CCG 86.2% NHS Tameside and Glossop CCG 85.6% NHS North East Lincolnshire CCG 85.1% NHS Lincolnshire West CCG 83.0% NHS Leeds South and East CCG 82.6% NHS West Lancashire CCG 81.9% NHS Leeds North CCG 76.3% 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 DR A HUSSAIN P81735 THE ST PAULS SURGERY P81163 BERRY LANE MEDICAL CENTRE P81055 LOSTOCK HALL MEDICAL CTR. P81179 GREAT ECCLESTON HLTH CTR P81059 THE GEOFFREY STREET SURGERY P81093 ST FILLAN'S MEDICAL CTRE P81018 RIVERSIDE MEDICAL CENTRE P81185 THE HEALTHCARE CENTRE P81067 ISSA MEDICAL CENTRE - PATEL P81196 LYTHAM ROAD SURGERY P81015 FISHERGATE HILL SURGERY P81169 MOOR PARK SURGERY P81176 STONEBRIDGE SURGERY P81107 MEDICOM LTD P81785 DR D C PATEL & PARTNERS P81103 THE NEW HALL LANE PRACTICE P81071 RIBBLETON MEDICAL CENTRE P81184 THE PARK MEDICAL PRACTICE P81664 LONGTON HEALTH CENTRE P81040 ST.MARY'S HEALTH CENTRE P81213 PARK VIEW SURGERY P in total, including exceptions, there are 59 people who are not treated with ACE-I or ARB GP practice range: 0.0% to 100.0% DOCLANDS MEDICAL CENTRE P81119 THE SURGERY P81152 DR JHA & DR YERRA SURGERY P81647 ST WALBURGE'S MEDICAL PRACTICE P81667 DR SZ SHAHID P81685 BEECH DRIVE SURGERY P81691 BRIARWOOD MEDICAL CENTRE P81748 FRENCHWOOD SURGERY P81750 DR HP CHAKRABARTI P81763 AVENHAM LANE PRACTICE P81770 COTTAM LANE - DR NATH P % 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 Blackpool CCG NHS Fylde & Wyre CCG NHS Greater Preston CCG NHS Lancashire North CCG NHS Chorley And South Ribble CCG 88.1% 84.9% 84.6% 82.1% 81.0% 369 people with heart failure* with LVSD treated with ACE-I/ARB in NHS Greater Preston CCG 312 (84.6%) people treated with ACE- I/ARB and BB 31 (8.4%) people who are exceptions 26 (7%) additional people who are not treated with ACE-I/ARB and BB NHS Blackburn With Darwen CCG 78.7% NHS East Lancashire CCG 75.5% NHS West Lancashire CCG 68.3% 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 South Tees CCG 87.3% NHS Leeds South and East CCG 84.7% NHS Greater Preston CCG 84.6% NHS North East Lincolnshire CCG 83.6% NHS Stoke On Trent CCG 82.5% NHS Leeds North CCG 82.4% NHS Tameside and Glossop CCG 79.8% NHS Calderdale CCG 77.2% NHS East Lancashire CCG 75.5% NHS Lincolnshire West CCG 75.0% NHS West Lancashire CCG 68.3% 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 THE ST PAULS SURGERY P81163 MEDICOM LTD P81785 ST WALBURGE'S MEDICAL PRACTICE P81667 THE NEW HALL LANE PRACTICE P81071 THE PARK MEDICAL PRACTICE P81664 PARK VIEW SURGERY P81046 RIVERSIDE MEDICAL CENTRE P81185 STONEBRIDGE SURGERY P81107 ISSA MEDICAL CENTRE - PATEL P81196 LONGTON HEALTH CENTRE P81040 FISHERGATE HILL SURGERY P81169 BERRY LANE MEDICAL CENTRE P81055 DOCLANDS MEDICAL CENTRE P81119 ST.MARY'S HEALTH CENTRE P81213 THE HEALTHCARE CENTRE P81067 THE SURGERY P81152 LYTHAM ROAD SURGERY P81015 ST FILLAN'S MEDICAL CTRE P81018 DR D C PATEL & PARTNERS P81103 GREAT ECCLESTON HLTH CTR P in total, including exceptions, there are 57 people who are not treated with ACE-I or ARB GP practice range: 0.0% to 50.0% THE GEOFFREY STREET SURGERY P81093 MOOR PARK SURGERY P81176 LOSTOCK HALL MEDICAL CTR. P81179 RIBBLETON MEDICAL CENTRE P81184 DR JHA & DR YERRA SURGERY P81647 DR SZ SHAHID P81685 BEECH DRIVE SURGERY P81691 BRIARWOOD MEDICAL CENTRE P81748 FRENCHWOOD SURGERY P81750 DR HP CHAKRABARTI P81763 AVENHAM LANE PRACTICE P81770 DR A HUSSAIN P81735 COTTAM LANE - DR NATH P % 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 Blackburn With Darwen CCG NHS West Lancashire CCG NHS Fylde & Wyre CCG NHS Greater Preston CCG NHS Chorley And South Ribble CCG 89.4% 89.1% 88.8% 88.8% 88.8% 7,248 people with coronary heart disease* in NHS Greater Preston CCG 6,434 (88.8%) people whose blood pressure <= 150 / (3.5%) people who are exceptions 557 (7.7%) additional people whose blood pressure is not <= 150 / 90 NHS East Lancashire CCG 88.7% NHS Blackpool CCG 88.6% NHS Lancashire North CCG 85.4% 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 Tameside and Glossop CCG 90.1% NHS North East Lincolnshire CCG 90.0% NHS Stoke On Trent CCG 89.9% NHS Lincolnshire West CCG 89.4% NHS Calderdale CCG 89.1% NHS West Lancashire CCG 89.1% NHS Greater Preston CCG 88.8% NHS East Lancashire CCG 88.7% NHS South Tees CCG 88.6% NHS Leeds South and East CCG 87.6% NHS Leeds North CCG 87.2% 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 LOSTOCK HALL MEDICAL CTR. P81179 DR HP CHAKRABARTI P81763 AVENHAM LANE PRACTICE P81770 FRENCHWOOD SURGERY P81750 PARK VIEW SURGERY P81046 RIBBLETON MEDICAL CENTRE P81184 GREAT ECCLESTON HLTH CTR P81059 BERRY LANE MEDICAL CENTRE P81055 DR JHA & DR YERRA SURGERY P81647 DR SZ SHAHID P81685 DR D C PATEL & PARTNERS P81103 THE NEW HALL LANE PRACTICE P81071 ST.MARY'S HEALTH CENTRE P81213 MEDICOM LTD P81785 THE PARK MEDICAL PRACTICE P81664 THE ST PAULS SURGERY P81163 THE HEALTHCARE CENTRE P81067 DR A HUSSAIN P81735 DOCLANDS MEDICAL CENTRE P81119 BEECH DRIVE SURGERY P81691 LONGTON HEALTH CENTRE P81040 ST FILLAN'S MEDICAL CTRE P81018 RIVERSIDE MEDICAL CENTRE P81185 FISHERGATE HILL SURGERY P81169 STONEBRIDGE SURGERY P81107 LYTHAM ROAD SURGERY P81015 ISSA MEDICAL CENTRE - PATEL P81196 THE GEOFFREY STREET SURGERY P81093 COTTAM LANE - DR NATH P81700 MOOR PARK SURGERY P81176 THE SURGERY P81152 BRIARWOOD MEDICAL CENTRE P81748 ST WALBURGE'S MEDICAL PRACTICE P in total, including exceptions, there are 814 people whose blood pressure is not <= 150 / 90 GP practice range: 1.8% to 26.9% 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 10% 5% 0% -5% -10% -15% -20% -25% LOSTOCK HALL MEDICAL CTR. DR HP CHAKRABARTI AVENHAM LANE PRACTICE FRENCHWOOD SURGERY PARK VIEW SURGERY RIBBLETON MEDICAL CENTRE GREAT ECCLESTON HLTH CTR DR JHA & DR YERRA SURGERY BERRY LANE MEDICAL CENTRE DR SZ SHAHID 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 293 people would be treated ISSA MEDICAL CENTRE - PATEL RIVERSIDE MEDICAL CENTRE LONGTON HEALTH CENTRE THE GEOFFREY STREET SURGERY COTTAM LANE - DR NATH MOOR PARK SURGERY THE SURGERY LYTHAM ROAD SURGERY BRIARWOOD MEDICAL CENTRE ST WALBURGE'S MEDICAL 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 Greater Preston CCG NHS Blackburn With Darwen CCG NHS East Lancashire CCG NHS West Lancashire CCG NHS Fylde & Wyre CCG NHS Chorley And South Ribble CCG 93.1% 92.5% 92.2% 92.1% 91.5% 91.3% 7,248 people with coronary heart disease* in NHS Greater Preston CCG 6,749 (93.1%) people who are taking aspirin, an alternative anti-platelet therapy, or an anti-coagulant 283 (3.9%) people who are exceptions 216 (3%) additional people who are not taking aspirin, an alternative antiplatelet therapy, or an anti-coagulant NHS Blackpool CCG 91.0% NHS Lancashire North CCG 90.7% 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 Greater Preston CCG 93.1% NHS Stoke On Trent CCG 92.6% NHS Leeds South and East CCG 92.5% NHS South Tees CCG 92.5% NHS Tameside and Glossop CCG 92.4% NHS East Lancashire CCG 92.2% NHS West Lancashire CCG 92.1% NHS Calderdale CCG 91.7% NHS Leeds North CCG 91.3% NHS North East Lincolnshire CCG 91.3% NHS Lincolnshire West CCG 91.1% 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 FRENCHWOOD SURGERY P81750 THE SURGERY P81152 AVENHAM LANE PRACTICE P81770 LOSTOCK HALL MEDICAL CTR. P81179 MEDICOM LTD P81785 PARK VIEW SURGERY P81046 DR SZ SHAHID P81685 DR D C PATEL & PARTNERS P81103 THE ST PAULS SURGERY P81163 THE HEALTHCARE CENTRE P81067 COTTAM LANE - DR NATH P81700 LYTHAM ROAD SURGERY P81015 MOOR PARK SURGERY P81176 GREAT ECCLESTON HLTH CTR P81059 RIBBLETON MEDICAL CENTRE P81184 THE PARK MEDICAL PRACTICE P81664 FISHERGATE HILL SURGERY P81169 ISSA MEDICAL CENTRE - PATEL P81196 BRIARWOOD MEDICAL CENTRE P81748 ST.MARY'S HEALTH CENTRE P81213 STONEBRIDGE SURGERY P81107 ST WALBURGE'S MEDICAL PRACTICE P81667 ST FILLAN'S MEDICAL CTRE P81018 BERRY LANE MEDICAL CENTRE P81055 THE NEW HALL LANE PRACTICE P81071 RIVERSIDE MEDICAL CENTRE P81185 LONGTON HEALTH CENTRE P81040 DR HP CHAKRABARTI P81763 THE GEOFFREY STREET SURGERY P81093 DOCLANDS MEDICAL CENTRE P81119 BEECH DRIVE SURGERY P81691 DR A HUSSAIN P81735 DR JHA & DR YERRA SURGERY P in total, including exceptions, there are 499 people are not taking aspirin, an alternative anti-platelet therapy, or an anti-coagulant GP practice range: 0.0% to 17.5% 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 Greater Preston CCG England in NHS Greater Preston CCG, the hospital admission rate for coronary heart disease in 2015/16 was (1,264) 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 Greater Preston CCG England in NHS Greater Preston CCG, the hospital admission rate for stroke in 2015/16 was (269) 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 Greater Preston CCG England Angina Heart Attack Heart failure 134.2% 136.8% 120.7% 108.6% 155.8% 150.0% The risk of a stroke was 71.7% higher and the risk of a heart attack was 120.7% higher compared to people without diabetes. The risk of a major amputation was 343.2% higher. Stroke 71.7% 81.3% Major amputation 343.2% 445.8% Minor amputation 876.8% 753.5% RRT 275.2% 293.0% 85 0% 100% 200% 300% 400% 500% 600% 700% 800% 900% 1000% 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 Greater Preston CCG England in NHS Greater Preston CCG, the early mortality rate for coronary heart disease in was 48.6, 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 Greater Preston CCG England in NHS Greater Preston CCG, the early mortality rate for stroke in was 13.5, 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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