Cardiovascular Disease Joint Strategic Needs Assessment 2015

Transcription

1 Cardiovascular Disease Joint Strategic Needs Assessment 2015

2 Contents - Section Number Section Page Number 1 Introduction Population, Geography & Current 6 CVD Prevalence 1.2 Predicted Future CVD Prevalence 16 2 Epidemiology Mortality (including premature 19 mortality) overview 2.2 LCG/Deprivation Quintile 25 Epidemiology Overview Coronary Heart Disease Heart Failure Stroke Hypertension Angiography Revascularisation 46 3 Lifestyle Determinants Risk Factors Associated with 48 Cardiovascular Disease Overview 3.2 Ethnicity Smoking Physical Inactivity Poor Diet Obesity Harmful Use of Alcohol Diabetes Modifiable Risk Factors 75 Population Level Interventions 4 Services for Cardiovascular 78 Disease 4.1 Health Checks in Primary Care Hospital Services Quality 79 Standards & National Audit Data Cardiovascular Disease (MINAP) Stroke (SSNAP) Tackling CHD Inequalities 85 Programme 5 Evidence of Effectiveness Individual Level Interventions Population Level Interventions Clinical Guidance & Quality 96 Standards 5.4 Effective CVD Prevention Programmes 101 2

3 1. Introduction Joint Strategic Needs Assessments (JSNAs) analyse the health needs of populations to inform and guide commissioning of health, well-being and social care services within local authority areas. The JSNA process helps identify current and future health and wellbeing needs, leading to agreed commissioning priorities to improve outcomes and reduce health inequalities. JSNA analysis includes assessment of: Demography Social and environmental context Lifestyle/Risk Factors Burden of Ill-Health Current service provision and projected future requirements JSNAs contribute towards the evidence base that informs the decisions taken by our Health and Wellbeing Board to improve the health and wellbeing of everyone in Peterborough. This JSNA focuses specifically on cardiovascular disease (CVD) - an umbrella term for all diseases of the heart and circulation, including coronary heart disease (CHD), stroke and peripheral arterial disease. There are eight local commissioning groups (LCGs) within the remit of Cambridgeshire & Peterborough Clinical Commissioning Group, as highlighted in the below table. This JSNA focuses primarily on the two LCGs within C&P CCG that are most closely associated with Peterborough City Council, Borderline LCG and Peterborough LCG. Data pertaining to other LCGs will be presented in other projects by Cambridgeshire County Council s Public Health Intelligence team. 3

4 Figure 1 Cambridgeshire & Peterborough CCG Local Commissioning Group Data Local Commissioning Group Number of General Practices Registered Population at 01/01/2015 Borderline ,972 CAM Health 9 88,413 CATCH ,971 Hunts Care Partners ,020 Hunts Health 9 69,829 Isle of Ely 10 96,168 Peterborough ,613 Wisbech 4 49,476 Total ,462 Source: Cambridgeshire & Peterborough Clinical Commissioning Group Cardiovascular Disease Cardiovascular disease (CVD) is generally caused by reduced blood flow to the heart, brain or body due to atheroma or thrombosis (blockages of the arteries). It is increasingly common after the age of 60 and relatively rare below the age of 30. Plaques (plates) of fatty atheroma build up in arteries during adult life; these can eventually cause narrowing of the arteries, or trigger a local thrombosis (blood clot) which completely blocks blood flow. 1 CVD causes more than a quarter of all deaths in the UK, or around 160,000 deaths each year. There are an estimated 7 million people living with CVD in the UK. The total cost of premature death, lost productivity, hospital treatment and prescriptions relating to cardiovascular disease is estimated at 19 billion. 2 The Global Burden of Disease Study 3 has demonstrated that the UK does not perform well compared with a range of similar countries in terms of CVD related mortality and disability. Coronary Heart Disease CHD is caused by the narrowing of coronary arteries (the arteries that supply the heart muscle with oxygen-rich blood) due to gradual build-up of fatty material atheroma-within their walls. CHD is the UK's single biggest killer; nearly one in six men and one in ten women die from coronary heart disease 4. CHD is responsible for around 73,000 deaths in the UK each year, an average of 200 people each day, or one every seven minutes. Around 23,000 people under the age of 75 in the UK die from CHD each year. Approximately 2.3 million people are living with CHD in the UK - over 1.4 million 1 NICE: Prevention of cardiovascular disease: 2 British Heart Foundation: 3 The LANCET: 4 NHS: 4

5 men and 850,000 women. Death rates from coronary heart disease are highest in Scotland and the north of England and lowest in the south of England. 2 Stroke & Transient Ischaemic Attack (TIA) A stroke happens when the blood supply to part of the brain is cut off, causing brain cells to become damaged or die. The two most common types of stroke are ischaemic and haemorrhagic stroke: Ischaemic strokes happen when the artery that supplies blood to the brain is blocked, for example by a blood clot. Haemorrhagic strokes happen when a blood vessel bursts and bleeds into the brain, damaging brain tissue and depriving brain cells of blood and oxygen. Without a constant blood supply, brain cells will be damaged or die, which can affect the way the body and mind work. Stroke causes more than 40,000 deaths in the UK each year. 5 In the UK there are 235,000 hospital episodes attributed to stroke each year. It is estimated that 1.3 million people living in the UK have had a stroke - 650,000 men and 650,000 women. Almost half of these people are under the age of A transient ischaemic attack (also called a TIA or mini-stroke) happens when there is a temporary blockage in the blood supply to the brain. A TIA doesn t cause permanent damage to the brain and the symptoms usually pass within 24 hours. 2 However, a TIA needs assessment for stroke risk and referral for investigation and preventive treatment. Aortic Disease The aorta is the largest blood vessel in the body. The most common type of aortic disease is an aortic aneurysm, where the wall of the aorta becomes weakened and bulges outwards. The aorta is usually around 2cm wide but can swell to over 5.5cm; if a large aneurysm bursts, it causes internal bleeding and can cause death. Abdominal aortic aneurysms (AAAs) are most common in men over 65; a rupture accounts for more than 1 in 50 of all deaths in this group and a total of 6,000 deaths in England and Wales each year. 6 All men are invited for a screening test when they turn 65. If there is evidence of widening of the aorta they are offered an elective operation or followed up with repeat tests if the aneurysm does not meet the threshold for surgery. Peripheral Arterial Disease Peripheral arterial disease (PAD), also known as peripheral vascular disease (PVD) is a condition in which a build-up of fatty deposits (called atheroma and made up of cholesterol and other waste substances) in the arteries restricts blood supply to leg muscles. Many people within the condition have no symptoms. However it can cause pain in the legs when walking which usually disappears after a short rest; this is known as intermittent claudication. 7 5 Jump Start: 6 NHS:

6 PAD/PVD is most prevalent amongst people aged over 60, with one in five affected by the condition. Men tend to develop the condition more often than women, and smokers, those with high blood pressure/high cholesterol and those with type 1/type 2 diabetes are also more susceptible. The five main suggestions recommended to mediate the risk of developing PAD/PVD are: Stop smoking Exercise regularly Maintain a healthy weight Eat a healthy diet Moderate consumption of alcohol. Vascular Dementia Although having similar risk factors as CVD and being caused by similar processes in the blood vessels of the brain, vascular dementia or vascular cognitive impairment is not included in this CVD JSNA as dementia is classified as a mental disorder. A stroke, multiple small strokes or damage to the small blood vessels in the brain can cause dementia. The NHS Health Check programme offers information on the signs and symptoms of dementia to people over 65 years of age and identifies vascular risk factors for all CVD in those age without a pre-existing condition. 1.1 Population, Geography & Current CVD Prevalence Data from the Cambridgeshire County Council Research Group showed Peterborough to have a population of 183,700 in This is predicted to rise by 20.1% to 220,700 by 2021 and then a further 6.6% to 235,300 by Population growth to 2021 is expected to be particularly high for males in the 90+, 85-89, and 5-9 age groups, with increases of 100.0%, 50.0%, 42.9% and 40.7% respectively. Among females, the highest growth predictions are for the 90+, 5-9, and age groups, with predicted rises of 50.0%, 43.6%, 43.3% and 32.3% respectively. Figure 2 Peterborough Population Projected to 2031 Source: Cambridgeshire County Council Research Group 6

7 Comprehensive data regarding the overall demographics of Peterborough City Council, including a detailed exploration of various population growth estimates, is included in our JSNA core dataset, available via the Public Health Intelligence section of the Peterborough City Council website. This JSNA assesses the current and future health needs of the population of the Borderline and Peterborough Local Commissioning Groups (LCGs) via a focus on the number of people registered at each of the 30 General Practices that comprise the two LCGs - 10 within Borderline and 20 within Peterborough. This focus on our 'GP Registered Population' allows us to utilise routinely published data at this level and to concentrate on residents who attend practices within the remit of this JSNA, whilst simultaneously excluding residents who may live in Peterborough but receive healthcare advice and treatment at providers outside of the scope of this JSNA. Deprivation quintile refers to the registered population s level of deprivation as calculated by the English Indices of Deprivation 2010 which collates data on seven different dimensions of deprivation (income, employment, health/disability, education, crime, housing/services and living environment) to give one final deprivation score 8 indicating overall levels of deprivation. A placement in a higher deprivation quintile suggests higher levels of deprivation amongst a population, therefore quintile 1 = least deprived and quintile 5 = most deprived. The table below shows the composition of quintiles of deprivation within Cambridgeshire & Peterborough CCG. Borderline & Peterborough registered populations account for 17 of 22 (77.3%) of practices in the most deprived quintile and 24 of 43 (55.8%) of practices within the most deprived two quintiles in the CCG. Conversely, Borderline & Peterborough registered populations comprise only 2 of 42 (4.8%) practices in the least deprived two quintiles. Figure 3: Cambridgeshire & Peterborough CCG Practices by Quintile of Deprivation LCG Quintile 1 (Least Deprived) Quintile 2 Quintile 3 Quintile 4 Quintile 5 (Most Deprived) Total BORDERLINE CAM HEALTH CATCH HUNTS CARE PARTNERS HUNTS HEALTH ISLE OF ELY PETERBOROUGH WISBECH QUINTILE TOTAL Source: Quintiles generated based on ranks of Index of Multiple Deprivation Scores UK Govt: 7

8 The tables and map below outline the geographical location of each of the 30 general practices within the Borderline & Peterborough LCGs. Figure 4: Borderline & Peterborough LCGs General Practices # Local Commissioning Group Practice Code Practice Name 1 Borderline D81020 NENE VALLEY MEDICAL PRACTICE 2 Borderline D81022 THORNEY 3 Borderline D81029 OLD FLETTON SURGERY 4 Borderline D81031 YAXLEY GROUP PRACTICE 5 Borderline D81039 JENNER HEALTH CENTRE 6 Borderline D81046 NEW QUEEN STREET SURGERY 7 Borderline D81053 BRETTON MEDICAL PRACTICE 8 Borderline D81630 HAMPTON HEALTH 9 Borderline K83017 WANSFORD SURGERY 10 Borderline K83023 OUNDLE 11 Peterborough D81006 NORTH STREET MED.PRACTICE 12 Peterborough D81007 PARK MEDICAL CENTRE 13 Peterborough D81019 MINSTER MEDICAL PRACTICE 14 Peterborough D81023 PASTON HEALTH CENTRE 15 Peterborough D81024 THOMAS WALKER 16 Peterborough D81026 LINCOLN ROAD SURGERY 17 Peterborough D81063 WESTGATE 18 Peterborough D81065 WELLAND MEDICAL PRACTICE 19 Peterborough D81073 WESTWOOD CLINIC 20 Peterborough D81605 HUNTLY GROVE PRACTICE 21 Peterborough D81615 THORPE ROAD SURGERY 22 Peterborough D81616 HODGSON MEDICAL CENTRE 23 Peterborough D81618 AILSWORTH MEDICAL CENTRE 24 Peterborough D81620 PARNWELL MEDICAL CENTRE 25 Peterborough D81624 DOGSTHORPE MEDICAL CENTRE 26 Peterborough D81625 THISTLEMOOR MEDICAL CENTRE 27 Peterborough D81629 BUSHFIELD 28 Peterborough D81631 MILLFIELD MEDICAL CENTRE 29 Peterborough D81645 THE GRANGE MEDICAL CENTRE 30 Peterborough Y00486 BOTOLPH BRIDGE COMMUNITY HEALTH Source: Cambridgeshire & Peterborough Clinical Commissioning Group 8

9 Figure 5: Borderline & Peterborough LCG General Practice Map Source: Ordnance Survey /Cambridgeshire & Peterborough CCG

10 The table below describes GP registered populations for the practices within the Borderline and Peterborough LCGs for 2013/14, the most recent time period for which practice-level QOF data are available for many of the indicators used within this JSNA. Practices are ranked by total registered population. Where a practice is geographically located within a Peterborough City Council Electoral Ward, the ward is stated in column Ward Geographically located within. The adjacent column Ward Majority population registered within shows where the majority of residents registered with the practice live. Figure 6: Borderline LCG & Peterborough LCG General Practice Overview 2013/14 LCG Practice Name Ward - Geographically located within Ward - Majority population registered within Deprivation Quintile* Borderline NEW QUEEN STREET SURGERY N/A (Outside Peterborough UA) N/A (Outside Peterborough UA) 2 15,993 Peterborough NORTH STREET MED.PRACTICE Central East 4 15,506 Borderline YAXLEY GROUP PRACTICE N/A (Outside Peterborough UA) N/A (Outside Peterborough UA) 1 15,295 Peterborough THISTLEMOOR MEDICAL CENTRE North North 4 14,199 Peterborough PASTON HEALTH CENTRE Paston Paston 4 13,341 Borderline NENE VALLEY MEDICAL PRACTICE Orton Longueville Orton Longueville 4 12,054 Borderline BRETTON MEDICAL PRACTICE Bretton North Bretton North 5 11,915 Peterborough MILLFIELD MEDICAL CENTRE Park Central 5 11,798 Borderline OLD FLETTON SURGERY Fletton Fletton 3 11,720 Borderline OUNDLE N/A (Outside Peterborough UA) N/A (Outside Peterborough UA) 1 10,892 Peterborough LINCOLN ROAD SURGERY Central Werrington South 3 10,736 Peterborough WESTGATE Central Central 5 9,793 Peterborough PARK MEDICAL CENTRE Park Park 4 8,884 Borderline HAMPTON HEALTH Orton & Hampton Orton & Hampton 1 8,193 Borderline JENNER HEALTH CENTRE N/A (Outside Peterborough UA) N/A (Outside Peterborough UA) 2 7,975 Borderline THORNEY Eye & Thorney Eye & Thorney 2 7,653 Peterborough THOMAS WALKER Park Park 3 6,976 Peterborough BOTOLPH BRIDGE COMMUNITY HEALTH Fletton Fletton 2 6,821 Borderline WANSFORD SURGERY N/A (Outside Peterborough UA) N/A (Outside Peterborough UA) 1 6,794 Peterborough BUSHFIELD Orton Waterville Orton Waterville 4 5,439 Peterborough WESTWOOD CLINIC Ravensthorpe Ravensthorpe 5 5,134 Peterborough THORPE ROAD SURGERY West West 2 5,076 Peterborough DOGSTHORPE MEDICAL CENTRE Welland Welland 5 4,914 Peterborough WELLAND MEDICAL PRACTICE Dogsthorpe Dogsthorpe 5 4,387 Peterborough MINSTER MEDICAL PRACTICE Park East 3 3,982 Population

11 LCG Practice Name Ward - Geographically located within Ward - Majority population registered within Deprivation Quintile* Peterborough HODGSON MEDICAL CENTRE Werrington North Werrington North 1 3,949 Peterborough THE GRANGE MEDICAL CENTRE West West 2 2,941 Peterborough AILSWORTH MEDICAL CENTRE Glinton & Wittering Glinton & Wittering 1 2,367 Peterborough HUNTLY GROVE PRACTICE Park Park 3 2,051 Peterborough PARNWELL MEDICAL CENTRE East East 3 1,632 Source: Public Health England, National General Practice Profiles *Quintiles in this table calculated for the 30 practices that comprise Borderline & Peterborough LCGs only. Figure 7: Estimated General Practice Populations 65+, 2021 & 2031 The table below estimates population growth by registered practice of resident for the 65+ and 85+ age groups to illustrate possible future CVD burden, based on Cambridgeshire Research Group estimates of 12.06% population growth between and 22.5% between 2015 and April 2015 population totals are used as the baseline, rather than the 2013/14 populations used above (which are required due to the most recent available QOF data covering the 2013/14 period). This methodology is relatively crude due to being based on current population estimates; actual changes will vary depending on future demographic changes and planned housing development. The number of residents aged 65+ registered with Borderline/Peterborough LCG practices in April 2015 is 35,732 for April 2015 and is estimated to increase to 40,041 by 2021 and subsequently to 49,051 by ,772 persons aged 85 or older were registered with a Borderline/Peterborough LCG practice in April 2015; this is predicted to rise to 5,348 by 2021 and 6,551 by Blue = Borderline LCG Practice Green = Peterborough LCG Practice Total Population Total 65+ GP NAME Estimated Total 2021 Estimated Total 2031 Total Total Total Total Total AILSWORTH MEDICAL CENTRE 2,343 2,626 2, BOTOLPH BRIDGE COMMUNITY HEALTH 6,823 7,646 8, BRETTON MEDICAL PRACTICE 11,924 13,362 14,607 1,572 1,762 2, BUSHFIELD 5,446 6,103 6, DOGSTHORPE MEDICAL CENTRE 4,939 5,535 6, HAMPTON HEALTH 8,295 9,295 10, HODGSON MEDICAL CENTRE 4,001 4,484 4, HUNTLY GROVE PRACTICE 2,052 2,299 2, JENNER HEALTH CENTRE 7,929 8,885 9,713 1,836 2,057 2, LINCOLN ROAD SURGERY 10,674 11,961 13,076 2,148 2,407 2, MILLFIELD MEDICAL CENTRE 12,060 13,514 14, MINSTER MEDICAL PRACTICE 3,998 4,480 4, , NENE VALLEY MEDICAL PRACTICE 12,114 13,575 14,840 1,548 1,735 2, Population 11

12 Total Population Total 65+ GP NAME Estimated Total 2021 Estimated Total 2031 Total Total Total Total Total NEW QUEEN STREET SURGERY 16,126 18,071 19,754 2,942 3,297 4, NORTH STREET MED.PRACTICE 15,496 17,365 18,983 3,083 3,455 4, OLD FLETTON SURGERY 11,757 13,175 14,402 2,101 2,354 2, OUNDLE 10,792 12,094 13,220 2,324 2,604 3, PARK MEDICAL CENTRE 8,893 9,965 10,894 1,365 1,530 1, PARNWELL MEDICAL CENTRE 1,660 1,860 2, PASTON HEALTH CENTRE 13,449 15,071 16,475 1,558 1,746 2, THE GRANGE MEDICAL CENTRE 2,927 3,280 3, THISTLEMOOR MEDICAL CENTRE 14,495 16,243 17, , THOMAS WALKER 6,964 7,804 8,531 1,324 1,484 1, THORNEY 7,659 8,583 9,382 1,525 1,709 2, THORPE ROAD SURGERY 5,154 5,776 6, WANSFORD SURGERY 6,851 7,677 8,392 1,495 1,675 2, WELLAND MEDICAL PRACTICE 4,353 4,878 5, WESTGATE 9,914 11,110 12,145 1,150 1,289 1, WESTWOOD CLINIC 5,121 5,739 6, YAXLEY GROUP PRACTICE 15,386 17,242 18,848 2,354 2,638 3, Borderline LCG Total 108, , ,320 10,248 11,484 14,068 1,383 1,550 1,898 Peterborough LCG Total 140, , ,433 25,484 28,557 34,983 3,389 3,798 4,652 Peterborough & Borderline LCG Total 249, , ,754 35,732 40,041 49,051 4,772 5,348 6,551 Source: Cambridgeshire County Council Research Group 12

13 Figure 8: CVD & Associated Conditions by Practice The table below ranks the practices within Borderline & Peterborough LCGs by estimated prevalence of cardiovascular disease and also provides prevalence estimates for coronary heart disease, hypertension and stroke. These data are based on the Quality Outcomes Framework (QOF). QOF data are collected by primary care services (general practices). They represent GP diagnosed disease and hence GP recorded levels of illness (prevalence), rather than true population prevalence which would include undiagnosed disease. QOF data are not available by age and hence a practice, or a geographic area, with a relatively older population would expect to have a higher level of disease than an area with a younger population, for most cardiovascular diseases. Comparisons of local values to local or national benchmarks are made through an assessment of statistical significance. 95% confidence intervals provide a measure of uncertainty around a calculated value which arises due to random variation. If the confidence interval for a local value excludes the value for the benchmark, the difference between the local value and the benchmark is said to be statistically significant. The percentage of the population aged over 40 (the age at which it is first possible to receive an NHS Health Check) 9 ; over 60 and over 80 is also included. Dark blue cells represent a percentage above the Peterborough value whereas light blue cells represent a percentage below the Peterborough value. This table illustrates that a key contributing factor to the expected prevalence of CVD and associated conditions is an older population, even if the population is relatively affluent. Need in relation to CVD is likely to be highest in areas of relative deprivation with an older population and the below data suggest need to be highest for populations within the electoral wards of Park, Central, East and Fletton. Prevalence calculations are taken from Public Health England s National GP Practice Profiles NHS:

14 LCG Practice Name Ward - Geographically located within Ward - Majority population registered within Deprivation Quintile* Age 40+ Age 60+ Age 80+ Estimated prevalence of CVD (%, all ages) 2011 Estimated prevalence of CHD (%, all ages) 2011 Estimated prevalence of hypertension (%, all ages) 2011 Estimated prevalence of stroke (%, 2011, all ages) Peterborough MINSTER MEDICAL PRACTICE Park East % 26.4% 5.9% Peterborough HUNTLY GROVE PRACTICE Park Park % 26.3% 6.6% Peterborough NORTH STREET MED.PRACTICE Central East % 25.8% 6.2% Peterborough THOMAS WALKER Park Park % 25.3% 6.3% Peterborough LINCOLN ROAD SURGERY Central Werrington South % 25.4% 6.3% Borderline JENNER HEALTH CENTRE N/A (Outside Peterborough N/A (Outside UA) Peterborough UA) % 29.0% 7.0% Borderline OLD FLETTON SURGERY Fletton Fletton % 23.1% 5.2% Borderline WANSFORD SURGERY N/A (Outside Peterborough N/A (Outside UA) Peterborough UA) % 28.8% 5.4% Peterborough PARK MEDICAL CENTRE Park Park % 20.1% 4.9% Borderline THORNEY Eye & Thorney Eye & Thorney % 25.4% 5.1% Borderline NEW QUEEN STREET N/A (Outside Peterborough N/A (Outside SURGERY UA) Peterborough UA) % 24.4% 4.8% Peterborough AILSWORTH MEDICAL CENTRE Glinton & Wittering Glinton & Wittering % 23.8% 4.8% Borderline BRETTON MEDICAL PRACTICE Bretton North Bretton North % 18.5% 2.7% Borderline NENE VALLEY MEDICAL PRACTICE Orton Longueville Orton Longueville % 17.5% 2.8% Peterborough WESTGATE Central Central % 16.0% 3.7% Peterborough THE GRANGE MEDICAL CENTRE West West % 16.8% 3.2% Peterborough WELLAND MEDICAL PRACTICE Dogsthorpe Dogsthorpe % 10.0% 1.4% Borderline OUNDLE N/A (Outside Peterborough N/A (Outside UA) Peterborough UA) % 27.6% 5.5% Peterborough PASTON HEALTH CENTRE Paston Paston % 16.1% 3.3% Peterborough DOGSTHORPE MEDICAL CENTRE Welland Welland % 9.4% 1.5% Borderline YAXLEY GROUP N/A (Outside Peterborough N/A (Outside PRACTICE UA) Peterborough UA) % 20.8% 3.0% Peterborough THORPE ROAD SURGERY West West % 17.0% 3.2% Peterborough BUSHFIELD Orton Waterville Orton Waterville % 18.1% 3.5% Peterborough WESTWOOD CLINIC Ravensthorpe Ravensthorpe % 14.4% 2.0% Peterborough HODGSON MEDICAL CENTRE Werrington North Werrington North % 16.5% 3.4% Peterborough THISTLEMOOR MEDICAL CENTRE North North % 9.3% 1.3%

15 LCG Practice Name Ward - Geographically located within Ward - Majority population registered within Deprivation Quintile* Age 40+ Age 60+ Age 80+ Estimated prevalence of CVD (%, all ages) 2011 Estimated prevalence of CHD (%, all ages) 2011 Estimated prevalence of hypertension (%, all ages) 2011 Estimated prevalence of stroke (%, 2011, all ages) Peterborough MILLFIELD MEDICAL CENTRE Park Central % 6.5% 1.4% Peterborough BOTOLPH BRIDGE COMMUNITY HEALTH Fletton Fletton % 10.9% 1.9% Peterborough PARNWELL MEDICAL CENTRE East East % 10.1% 1.3% Borderline HAMPTON HEALTH Orton & Hampton Orton & Hampton % 6.8% 1.8% Cambridgeshire & Peterborough CCG % 21.2% 4.3% England % 22.1% 4.6% Source: Public Health England, National General Practice Profiles *Quintiles calculated for the 30 practices that comprise Borderline & Peterborough LCGs only. 15

16 1.2 Predicted Future CVD Prevalence Figure 9: CVD & Associated Conditions Predicted Future Prevalence 11 The table below illustrates predicted growth rates in numbers of residents registered to GP Practices within the Borderline & Peterborough LCGs. These figures are based on current disease prevalence estimates from Public Health England 12 and the Cambridgeshire Research Group s growth predictions to 2031, which suggest population growth of 12.06% over the 6 years and 22.5% over the 16 years The estimates are resultantly susceptible to revision based on future demographic changes, local growth/housing strategy etc. Most data within this JSNA are based on 2013/14 national GP practice profiles, to allow us to fully assess all available information. However, the below table includes registered population data from April 2015 to allow us to more accurately project future demand; population numbers therefore differ between this table and others within the JSNA based on published 2013/14 data. LCG Borderline Peterborough Borderline Peterborough Peterborough Borderline Peterborough Borderline Practice Code D81046 D81006 D81031 D81625 D81023 D81020 D81631 D81053 Practice Name NEW QUEEN STREET SURGERY NORTH STREET MED.PRACTICE YAXLEY GROUP PRACTICE THISTLEMOOR MEDICAL CENTRE PASTON HEALTH CENTRE NENE VALLEY MEDICAL PRACTICE MILLFIELD MEDICAL CENTRE BRETTON MEDICAL PRACTICE Ward - Geographically located within N/A (Outside Peterborough UA) Ward - Majority population registered within N/A (Outside Peterborough UA) Deprivation Quintile Total Registered Population Estimated persons with CVD Estimated persons with CHD Estimated persons with hypertension Estimated persons with stroke ,126 1,486 1,673 1, ,902 4,393 4, Central East 4 15,496 1,402 1,578 1, ,741 4,212 4, N/A (Outside Peterborough UA) N/A (Outside Peterborough UA) 1 15,386 1,219 1,372 1, ,450 3,885 4, North North 4 14, , ,465 2,776 3, Paston Paston 4 13,449 1,421 1,600 1, ,685 4,150 4, Orton Longueville Orton Longueville 4 12,114 1,325 1,492 1, ,367 3,791 4, Park Central 5 12,060 1,166 1,313 1, ,194 3,597 4, Bretton North Bretton North 5 11,924 1,373 1,546 1, ,520 3,963 4, PHE: 12 PHE:

17 LCG Borderline Practice Code D81029 Practice Name OLD FLETTON SURGERY Borderline K83023 OUNDLE Ward - Geographically located within Ward - Majority population registered within Deprivation Quintile Total Registered Population Estimated persons with CVD Estimated persons with CHD Estimated persons with hypertension Estimated persons with stroke Fletton Fletton 3 11,757 1,235 1,391 1, ,183 3,584 4, N/A (Outside Peterborough UA) N/A (Outside Peterborough UA) Werrington South 1 10, ,762 1,984 2, Peterborough D81026 LINCOLN ROAD SURGERY Central 3 10, ,563 1,760 1, Peterborough D81063 WESTGATE Central Central 5 9,914 1,080 1,216 1, ,855 3,215 3, Peterborough D81007 PARK MEDICAL CENTRE Park Park 4 8, ,974 2,222 2, Borderline D81630 HAMPTON Orton & Orton & HEALTH Hampton Hampton 1 8, ,121 1, Borderline D81039 N/A (Outside N/A (Outside JENNER HEALTH Peterborough Peterborough CENTRE UA) UA) 2 7, ,113 2,379 2, Borderline D81022 THORNEY Eye & Thorney Eye & Thorney 2 7, ,013 2,267 2, Peterborough D81024 THOMAS WALKER Park Park 3 6, ,392 1,568 1, Borderline K83017 N/A (Outside N/A (Outside WANSFORD Peterborough Peterborough SURGERY UA) UA) 1 6, ,869 2,105 2, BOTOLPH Peterborough Y00486 BRIDGE COMMUNITY HEALTH Fletton Fletton 2 6, ,157 1,302 1, Peterborough D81629 BUSHFIELD Peterborough Peterborough Peterborough Peterborough Peterborough D81615 D81073 D81624 D81065 D81616 THORPE ROAD SURGERY WESTWOOD CLINIC DOGSTHORPE MEDICAL CENTRE WELLAND MEDICAL PRACTICE HODGSON MEDICAL CENTRE Orton Waterville Orton Waterville 4 5, ,197 1,348 1, West West 2 5, ,127 1,268 1, Ravensthorpe Ravensthorpe 5 5, , Welland Welland 5 4, ,012 1,140 1, Dogsthorpe Dogsthorpe 5 4, ,177 1,325 1, Werrington North Werrington North 1 4, ,

18 LCG Peterborough Peterborough Peterborough Peterborough Peterborough Practice Code D81019 D81645 D81618 D81605 D81620 Practice Name MINSTER MEDICAL PRACTICE THE GRANGE MEDICAL CENTRE AILSWORTH MEDICAL CENTRE HUNTLY GROVE PRACTICE PARNWELL MEDICAL CENTRE Peterborough LCG Ward - Geographically located within Ward - Majority population registered within Deprivation Quintile Total Registered Population Estimated persons with CVD Estimated persons with CHD Estimated persons with hypertension Estimated persons with stroke Park East 3 3, , West West 2 2, Glinton & Wittering Glinton & Wittering 1 2, Park Park 3 2, East East 3 1, ,762 14,167 15,952 18,020 6,955 7,832 8,847 37,776 42,536 48,051 2,997 3,375 3,812 Borderline LCG 108,833 7,300 8,220 9,286 3,679 4,143 4,680 19,365 21,805 24,632 1,556 1,752 1,979 Peterborough & Borderline LCGs 249,595 21,467 24,171 27,306 10,635 11,975 13,527 57,141 64,340 72,683 4,553 5,127 5,791 Source: Public Health England, National General Practice Profiles *Quintiles calculated for the 30 practices that comprise Borderline & Peterborough LCGs only. 18

19 2. Epidemiology 2.1 Mortality (including premature mortality) overview Figure 10: Public Health Outcomes Framework Healthcare & Premature Mortality Overview 13 Data from Public Health England show Peterborough to be a substantial negative outlier with regards mortality rates from causes considered preventable and under 75 mortality rates from all cardiovascular diseases. Peterborough is statistically significantly high for seven of nine related metrics, whereas the East of England region is collectively statistically significantly low for all nine indicators. Source: Public Health Outcomes Framework 13 PHE:

20 Figure 11: Breakdown of Life Expectancy Gap between Peterborough and England by Broad Cause of Death, Source: Public Health England Segmenting Life Expectancy Gaps By Cause Of Death The life expectancy gap at birth for Peterborough residents versus England overall is 1.3 years for males (Peterborough = 77.9, England 79.2) and 0.5 years for females (Peterborough = 82.5, England = 83.0). The table above illustrates Public Health England projections of the contributing causes to this life expectancy gap. Circulatory disease is, by some margin, the largest contributing factor to the life expectancy gap for both males (accounting for 33.6% of the gap) and females (53.9% of the gap). Within this figure, circulatory diseases include coronary heart disease and stroke. Figure below illustrates life expectancy years gained or lost if Peterborough had the same mortality rates as England as a whole, by broad cause of death London Knowledge & Intelligence Team 15 London Knowledge & Intelligence Team 20

21 Figure 12: Life expectancy years gained/lost most common conditions Source: Public Health England Segmenting Life Expectancy Gaps By Cause Of Death Figure 13: Mortality from all circulatory diseases (all ages), Directly Age-Standardised Rate Source: Health & Social Care Information Centre

22 Peterborough s directly age-standardised rate (DSR) for mortality from circulatory diseases is 222.9/100,000 for females (England DSR = 221.8/100,000) and 313.0/100,000 for males (England = 332.7/100,000). The Peterborough mortality rates have fallen more substantially than those for England over the last three years for which data are available, bringing Peterborough close to the national rate for both males and females. Figure 14: Mortality from all circulatory diseases (under 75), Directly Age- Standardised Rate Source: Health & Social Care Information Centre Peterborough s directly age-standardised mortality rate for circulatory diseases, age under 75 is 66.4/100,000 for females and /100,000 for males. This compares unfavourably with the England rates of 47.3/100,000 for females and 107.5/100,000 for males and illustrates that there is a disparity between the standardised rate of mortality from circulatory diseases in Peterborough for people of all ages, which is relatively similar to the national rate, and the rate of mortality for under 75s (i.e. premature mortality) which is above the national rate for females for every year since 2008 and males for every year since In addition, the graph suggests a widening gap in premature CVD mortality for females in Peterborough which needs to be monitored and addressed. 22

23 Figure 15: Mortality from Coronary Heart Disease, Directly Age-standardised rate Source: Health & Social Care Information Centre The DSR for females in Peterborough for coronary heart disease is 94.6/100,000 in 2013; for England the DSR is Although the Peterborough DSR for males is also above the England rate, 176.1/100,000 vs nationally, this difference is markedly less pronounced. Figure 16: Mortality from Coronary Heart Disease, (under 75) Directly Age-standardised rate Source: Health & Social Care Information Centre 23

24 The directly age standardised rate of mortality from coronary heart disease for females is 30.6/100,000 in 2013, an increase from 22.2/100,000 in Nationally, the rate for 2013 is For males, the directly age standardised rate has fallen for the third consecutive year, to 86.6/100,000. Nationally the age standardised rate has also fallen in three consecutive years and is now 65.4/100,000. Figure 17: Mortality from Stroke, Directly Age-Standardised Rate Source: Health & Social Care Information Centre Peterborough s DSR from stroke, all ages, is marginally below the England rate for both females (57.6/100,000 vs 65.1/100,000) and males (64.1/100,000 vs 68.7/100,000). Figure 18: Mortality from stroke (under 75), Directly Age-Standardised Rate Source: Health & Social Care Information Centre 24

25 Peterborough s DSR of mortality from stroke under the age of 75 years is similar to England s for females (11.8/100,000 vs 11.6/100,000 nationally). For males, Peterborough s rate fell from 17.5/100,000 in 2012 to 10.9/100,000 in 2013; this latter figure is substantially better than the England rate of 16.0/100,000. Figure 19: Mortality from Hypertensive Disease, Directly Age-Standardised Rate Source: Health & Social Care Information Centre Peterborough s DSR for mortality from hypertensive disease for women is similar to the national rate (10.6/100,000 vs 9.0/100,000). For males, the Peterborough rate is 6.6/100,000, almost half of the national rate of 10.3/100,000 (although due to small numbers, this could be an anomaly rather than indicative of a consistent trend). 2.2 Cambridgeshire & Peterborough Clinical Commissioning Group Local Commissioning Group/Quintiles of Deprivation Epidemiology Within the below tables, a cell shaded green illustrates the value being statistically significantly low in comparison to Cambridgeshire & Peterborough CCG, which usually means the value for the Local Commissioning Group/quintile is better than the CCG, i.e. a lower prevalence of stroke. Conversely, a red cell indicates the value is statistically significantly high and therefore usually worse than the CCG the exception to this is indicators such as numbers of angiography/revascularisation procedures performed, which may relate to CHD/CVD prevalence. 25

26 Figure 20: Epidemiology Summary (LCGs, QOF Prevalence Data 2013/14) Data show that the Borderline LCG has a statistically significantly low prevalence of atrial fibrillation and a statistically significantly high prevalence of stroke, diabetes, hypertension, smoking and obesity in comparison to the whole of Cambridgeshire & Peterborough Clinical Commissioning Group. Peterborough LCG has a statistically significantly low prevalence of CHD, stroke, hypertension and atrial fibrillation and a statistically significantly high prevalence of diabetes, smoking and obesity. Peterborough s significantly low prevalence of conditions such as CHD and stroke may be partially explained by only 12.7% of registered population being aged 65+, compared to 15.9% within the CCG as a whole, as CVD prevalence is higher in relatively older people. LCG Age 65+ Age 85+ CHD Stroke Heart Failure Diabetes Hypertension Atrial Fibrillation Smoking Obesity BORDERLINE 16.2% 2.1% 3.0% 1.6% 0.7% 6.2% 14.3% 1.3% 19.7% 9.6% CAM HEALTH 13.9% 2.5% 2.4% 1.3% 0.6% 4.3% 10.7% 1.5% 15.8% 6.1% CATCH 15.0% 2.1% 2.4% 1.2% 0.5% 4.0% 10.9% 1.4% 13.7% 6.1% HUNTS CARE PARTNERS 19.2% 2.4% 3.6% 1.7% 0.7% 6.6% 15.0% 1.9% 18.2% 10.0% HUNTS HEALTH 16.2% 1.9% 3.1% 1.5% 0.6% 5.8% 14.3% 1.7% 18.2% 9.3% ISLE OF ELY 18.0% 2.2% 3.3% 1.5% 0.7% 6.5% 13.5% 1.7% 18.5% 9.7% PETERBOROUGH 12.7% 1.7% 2.7% 1.3% 0.6% 6.4% 12.2% 1.0% 25.5% 10.7% WISBECH 19.8% 2.5% 3.9% 2.0% 0.7% 7.3% 15.1% 1.8% 26.7% 12.1% CCG 15.9% 2.1% 2.9% 1.5% 0.6% 5.6% 12.8% 1.5% 18.6% 8.7% Source: 2013/14 Quality Outcomes Framework Data Figure 21: Epidemiology Summary (Deprivation Quintiles within Cambridgeshire & Peterborough CCG, QOF Prevalence Data 2013/14) Quintile Age 65+ Age 85+ CHD Stroke Heart Failure Diabetes Hypertension Atrial Fibrillation Smoking Obesity 5 - Most Deprived 14.6% 1.9% 3.1% 1.5% 0.6% 6.8% 13.0% 1.2% 26.7% 11.0% % 2.2% 3.2% 1.5% 0.7% 6.1% 13.5% 1.5% 21.7% 10.2% % 2.0% 2.7% 1.3% 0.6% 5.0% 11.9% 1.4% 16.1% 7.6% % 2.1% 2.6% 1.4% 0.5% 4.7% 11.8% 1.5% 13.4% 6.6% 1 - Least Deprived 19.1% 2.6% 3.1% 1.6% 0.7% 5.1% 14.0% 1.8% 13.4% 7.8% CCG 15.9% 2.1% 2.9% 1.5% 0.6% 5.6% 12.8% 1.5% 18.6% 8.7% Source: 2013/14 Quality Outcomes Framework Data Borderline & Peterborough practices comprise the majority (17/22, 77.3%) of practices in the most deprived quintile within the CCG. Within this quintile, prevalence is significantly higher than the CCG for CHD and diabetes despite only 14.6% of population being aged 65 or older, 1.3% lower than the CCG. There are also statistically significantly higher numbers of population that smoke and are obese in comparison to the CCG within these quintiles. Prevalence of CHD, stroke, heart failure, hypertension and atrial fibrillation are also statistically significantly high in the least deprived quintile, although this may be in part due to having 19.1% of population aged 65 or older (vs 15.9% across the CCG). 26

27 Figure 22: Epidemiology Summary (LCGs, Hospital Admissions Data for Key CVD-Related Conditions (All Ages) 2014/15) DSR per 100,000 DSR per 1,000,000 LCG Age 65+ Age 85+ CHD Heart Failure Stroke Angiography Revascularisation BORDERLINE 16.2% 2.1% , ,821.0 CAM HEALTH 13.9% 2.5% , ,416.1 CATCH 15.0% 2.1% , ,309.7 HUNTS CARE PARTNERS 19.2% 2.4% , ,847.6 HUNTS HEALTH 16.2% 1.9% , ,015.9 ISLE OF ELY 18.0% 2.2% , ,881.6 PETERBOROUGH 12.7% 1.7% , ,937.6 WISBECH 19.8% 2.5% , ,973.0 CCG 15.9% 2.1% , ,714.9 Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset Neither the Borderline nor Peterborough LCGs show any statistically significant variance with regards to admission rates for coronary heart disease, heart failure, stroke, angiography or revascularisation. These data are directly age-standardised to account for differences in age among the population. Figure 23: Epidemiology Summary (LCGs, Hospital Admissions Data for Key CVD-Related Conditions (U75 Only) 2014/15) DSR per 100,000 DSR per 1,000,000 LCG Age <75 Age 75+ CHD Heart Failure Stroke Angiography Revascularisation BORDERLINE 92.8% 7.2% , ,407.0 CAM HEALTH 92.9% 7.1% , ,134.6 CATCH 93.2% 6.8% , ,034.0 HUNTS CARE PARTNERS 91.7% 8.3% , ,435.1 HUNTS HEALTH 93.1% 6.9% , ,582.0 ISLE OF ELY 92.0% 8.0% , ,532.8 PETERBOROUGH 93.9% 6.1% , ,671.7 WISBECH 90.8% 9.2% , ,794.4 CCG 91.4% 8.6% , ,387.1 Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset 27

28 As with admissions for all ages, Borderline and Peterborough LCGs are both statistically similar to the CCG as a whole with regards to directly age-standardised admission rates for coronary heart disease, heart failure, stroke, angiography and revascularisation. Figure 24: Epidemiology Summary (Quintiles of Deprivation, Hospital Admissions Data for Key CVD-Related Conditions (All Ages) 2014/15) DSR per 100,000 DSR per 1,000,000 Quintile Age 65+ Age 85+ CHD Heart Failure Stroke Angiography Revascularisation 5 - Most Deprived 14.6% 1.9% , , % 2.2% , , % 2.0% , , % 2.1% , , Least Deprived 19.1% 2.6% , ,325.7 CCG 15.9% 2.1% , ,714.9 Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset Admissions are statistically significantly high with regards to CHD in the most deprived quintile and CHD and heart failure in the second most deprived quintile. In the least deprived quintile, admissions are statistically significantly low for CHD, heart failure and revascularisation. This suggests a degree of correlation between economic deprivation and the risk of admission for a CVD-related condition/procedure. Figure 25: Epidemiology Summary (Quintiles of Deprivation, Hospital Admissions Data for Key CVD-Related Conditions (U75 Only) 2014/15) DSR per 100,000 DSR per 1,000,000 Quintile Age <75 Age 75+ CHD Heart Failure Stroke Angiography Revascularisation 5 - Most Deprived 93.2% 6.8% , , % 7.5% , , % 6.5% , , % 7.1% , , Least Deprived 91.4% 8.6% , ,089.6 CCG 15.9% 2.1% , ,387.1 Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset Within the most deprived quintile, under 75 hospital admissions for CHD, stroke and revascularisation are statistically significantly higher in comparison to the CCG. 28

29 CATCH CAM HEALTH PETERBOROUGH BORDERLINE HUNTS HEALTH ISLE OF ELY HUNTS CARE PARTNERS WISBECH Coronary Heart Disease Figure 26: Coronary Heart Disease Prevalence 2013/14, Cambridgeshire & Peterborough CCG LCGs Patients Aged Patients Aged LCG Persons Prevalence Lower Interval Upper Interval CATCH 5, % 2.3% 2.4% 15.0% 2.1% CAM HEALTH 2, % 2.3% 2.5% 13.9% 2.5% PETERBOROUGH 3, % 2.6% 2.8% 12.7% 1.7% BORDERLINE 3, % 2.9% 3.1% 16.2% 2.1% HUNTS HEALTH 2, % 3.0% 3.2% 16.2% 1.9% ISLE OF ELY 3, % 3.2% 3.5% 18.0% 2.2% HUNTS CARE PARTNERS 4, % 3.5% 3.7% 19.2% 2.4% WISBECH 1, % 3.8% 4.1% 19.8% 2.5% BORDERLINE & PETERBOROUGH LCGs 7, % 2.8% 2.9% 14.3% 1.9% ALL OTHER LCGs 18, % 2.9% 3.0% 16.6% 2.2% C&P CCG 25, % 2.9% 2.9% 15.9% 2.1% Source: 2013/14 Quality Outcomes Framework Data Peterborough has a statistically significantly low prevalence of coronary heart disease in comparison to the CCG (2.7% vs 2.9%), which may be partially as a result of having a younger population than the CCG generally; only 14.3% of patients registered with Borderline/Peterborough practices are aged 65 or over, compared to 15.9% across the CCG. The collective prevalence of Borderline & Peterborough LCGs is 2.8%, statistically similar to that of the CCG. Figure 27: Coronary Heart Disease Prevalence 2013/14, Cambridgeshire & Peterborough CCG LCGs 4.5% 4.0% 3.5% 3.0% 2.5% 2.4% 2.4% 2.7% 3.0% 3.1% 3.3% 3.6% 3.9% 2.0% 1.5% 1.0% 0.5% 0.0% Source: 2013/14 Quality Outcomes Framework Data = CCG Value Green = Statistically significantly low in comparison to CCG Blue = No statistical significance in comparison to CCG Red = Statistically significantly high in comparison to CCG

30 Figure 28: Coronary Heart Disease Prevalence 2013/14, Borderline & Peterborough vs All Other LCGs 3.0% 2.9% 2.9% 2.8% 2.8% 2.7% 2.6% Borderline & Peterborough LCGs All Other LCGs Source: 2013/14 Quality Outcomes Framework Data Figure 29: Coronary Heart Disease Prevalence 2013/14, Cambridgeshire & Peterborough CCG Quintiles of Deprivation Patients Aged Patients Aged Quintile Persons Prevalence Lower Interval Upper Interval Most deprived 6, % 3.0% 3.1% 14.6% 1.9% 4 5, % 3.1% 3.2% 16.1% 2.2% 3 5, % 2.6% 2.7% 14.6% 2.0% 2 4, % 2.5% 2.7% 16.0% 2.1% 1 Least Deprived 4, % 3.0% 3.2% 19.1% 2.6% C&P CCG 25, % 2.9% 2.9% 15.9% 2.1% Source: 2013/14 Quality Outcomes Framework Data As noted above, practice populations within the Borderline & Peterborough LCGs comprise the majority of the most deprived two quintiles within the LCG, both of which have statistically significantly high CHD prevalence. The least deprived quintile is also statistically significantly high. 30

31 Figure 30: Coronary Heart Disease Admissions (All Admission Types, All Ages) 2014/15, Cambridgeshire & Peterborough CCG LCGs, Directly Age-Standardised Admission Rate per 100,000 Area Observed Admissions DSR Lower Interval Upper Interval CATCH CAM HEALTH PETERBOROUGH BORDERLINE ISLE OF ELY HUNTS CARE PARTNERS HUNTS HEALTH WISBECH BORDERLINE & PETERBOROUGH LCGs 1, ALL OTHER LCGs 3, C&P CCG 4, Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset The age-standardised admission rate for 2014/15 for CHD is statistically similar to the CCG for both Borderline & Peterborough LCGs. Figure 31: Coronary Heart Disease Admissions (All Admission Types, All Ages) 2014/15, Cambridgeshire & Peterborough Quintiles of Deprivation, Directly Age-Standardised Admission Rate per 100,000 Quintile Observed Admissions DSR Lower Interval Upper Interval 5 Most deprived Least Deprived C&P CCG 4, Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset The age-standardised admission rate for 2014/15 for CHD follows a trend of admissions reducing as economic deprivation decreases, with statistically significantly high rates in the most deprived two quintiles and a significantly low rate in the most affluent quintile. Figure 32: Coronary Heart Disease Admissions (All Admission Types, Under 75 Only) 2014/15, Cambridgeshire & Peterborough CCG LCGs, Directly Age-Standardised Admission Rate per 100,000 Area Observed Admissions DSR Lower Interval Upper Interval CATCH CAM HEALTH BORDERLINE ISLE OF ELY HUNTS CARE PARTNERS PETERBOROUGH HUNTS HEALTH WISBECH BORDERLINE & PETERBOROUGH LCGs ALL OTHER LCGs 2, C&P CCG 2, Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset 31

32 Amongst under 75s, as with for all ages, age-standardised CHD admission rates show Borderline & Peterborough LCGs to be similar to the CCG rate and, as shown in figure 33 below, rates fall in correlation with reduced levels of relative deprivation. Figure 33: Coronary Heart Disease Admissions (All Admission Types, Under 75 Only) 2014/15, Cambridgeshire & Peterborough Quintiles of Deprivation, Directly Age-Standardised Admission Rate per 100,000 Quintile Observed Admissions DSR Lower Interval Upper Interval 5 Most deprived Least Deprived C&P CCG 2, Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset Figure 34: Coronary Heart Disease Admissions (Emergency Admissions Only, All Ages) 2014/15, Cambridgeshire & Peterborough CCG LCGs, Directly Age-Standardised Admission Rate per 100,000 Area Observed Admissions DSR Lower Interval Upper Interval CATCH CAM HEALTH PETERBOROUGH ISLE OF ELY BORDERLINE HUNTS CARE PARTNERS HUNTS HEALTH WISBECH BORDERLINE & PETERBOROUGH LCGs ALL OTHER LCGs 1, C&P CCG 2, Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset The Borderline & Peterborough LCGs are both statistically similar to the CCG with regards to emergency admissions attributable to CHD. Figure 35: Coronary Heart Disease Admissions (Emergency Admissions Only, All Ages) 2014/15, Cambridgeshire & Peterborough Quintiles of Deprivation, Directly Age-Standardised Admission Rate per 100,000 Quintile Observed Admissions DSR Lower Interval Upper Interval 5 Most deprived Least Deprived C&P CCG 2, Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset Emergency admission rates for CHD are highest in areas of economic deprivation and statistically significantly low in the least deprived two quintiles. 32

33 Figure 36: Coronary Heart Disease Admissions (Emergency Admissions Only, Under 75 Only) 2014/15, Cambridgeshire & Peterborough LCGs, Directly Age-Standardised Admission Rate per 100,000 Area Observed Admissions DSR Lower Interval Upper Interval CATCH CAM HEALTH HUNTS CARE PARTNERS ISLE OF ELY BORDERLINE HUNTS HEALTH PETERBOROUGH WISBECH BORDERLINE & PETERBOROUGH LCGs ALL OTHER LCGs C&P CCG 1, Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset As with admissions for all ages, both Borderline & Peterborough LCGs are statistically similar to the CCG for under 75 CHD admissions. Figure 37: Coronary Heart Disease Admissions (Emergency Admissions Only, All Ages) 2014/15, Cambridgeshire & Peterborough CCG Quintiles, Directly Age-Standardised Admission Rate per 100,000 Quintile Observed Admissions DSR Lower Interval Upper Interval 5 Most deprived Least Deprived C&P CCG 1, Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset 33

34 CATCH PETERBOROUGH CAM HEALTH HUNTS HEALTH ISLE OF ELY BORDERLINE WISBECH HUNTS CARE PARTNERS HEART FAILURE Figure 38: Heart Failure Prevalence 2013/14, Cambridgeshire & Peterborough CCG LCGs LCG Persons Prevalence Lower Interval Upper Interval Patients Aged 65+ Patients Aged 85+ CATCH 1, % 0.5% 0.6% 15.0% 2.1% PETERBOROUGH % 0.5% 0.6% 12.7% 1.7% CAM HEALTH % 0.6% 0.7% 13.9% 2.5% HUNTS HEALTH % 0.6% 0.7% 16.2% 1.9% ISLE OF ELY % 0.6% 0.7% 18.0% 2.2% BORDERLINE % 0.6% 0.7% 16.2% 2.1% WISBECH % 0.7% 0.8% 19.8% 2.5% HUNTS CARE PARTNERS % 0.7% 0.8% 19.2% 2.4% BORDERLINE & PETERBOROUGH LCGs 1, % 0.6% 0.6% 14.3% 1.9% ALL OTHER LCGs 3, % 0.6% 0.6% 16.6% 2.2% C&P CCG 5, % 0.6% 0.6% 15.9% 2.1% Source: 2013/14 Quality Outcomes Framework Data Borderline & Peterborough LCGs have a collective heart failure prevalence of 0.6%, statistically similar to that of the CCG. Figure 39: Heart Failure Prevalence 2013/14, Cambridgeshire & Peterborough CCG LCGs 0.9% 0.8% 0.7% 0.6% 0.5% 0.5% 0.6% 0.6% 0.6% 0.7% 0.7% 0.7% 0.7% 0.4% 0.3% 0.2% 0.1% 0.0% Source: 2013/14 Quality Outcomes Framework Data = CCG Value Green = Statistically significantly low in comparison to CCG Blue = No statistical significance in comparison to CCG Red = Statistically significantly high in comparison to CCG 34

35 Figure 40: Heart Failure Prevalence 2013/14, Borderline & Peterborough vs All Other LCGs 0.7% 0.6% 0.6% 0.6% 0.5% Borderline & Peterborough LCGs All Other LCGs Source: 2013/14 Quality Outcomes Framework Data = CCG Value Green = Statistically significantly low in comparison to CCG Blue = No statistical significance in comparison to CCG Red = Statistically significantly high in comparison to CCG Figure 41: Heart Failure Prevalence 2013/14, Cambridgeshire & Peterborough CCG Quintiles of Deprivation Quintile Persons Prevalence Lower Interval Upper Interval Patients Aged 65+ Patients Aged Most deprived 1, % 0.6% 0.6% 14.6% 1.9% 4 1, % 0.6% 0.7% 16.1% 2.2% 3 1, % 0.5% 0.6% 14.6% 2.0% % 0.5% 0.6% 16.0% 2.1% 1 Least Deprived 1, % 0.7% 0.8% 19.1% 2.6% CCG 5, % 0.6% 0.6% 15.9% 2.1% Source: 2013/14 Quality Outcomes Framework Data Heart failure prevalence is statistically significantly high in the least socio-economically deprived quintile, however this may as a result of 19.1% of the population within the quintile being aged 65 or older, compared to 15.9% across the CCG as a whole. 35

36 Figure 42: Heart Failure Admissions (All Admission Types, All Ages) 2014/15, Cambridgeshire & Peterborough CCG LCGs, Directly Age-Standardised Admission Rate per 100,000 Area Observed Admissions DSR Lower Interval Upper Interval ISLE OF ELY CAM HEALTH CATCH PETERBOROUGH HUNTS CARE PARTNERS HUNTS HEALTH BORDERLINE WISBECH BORDERLINE & PETERBOROUGH LCGs ALL OTHER LCGs C&P CCG 1, Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset The directly age-standardised admission rate as a result of heart failure is statistically significantly high in only one LCG, Wisbech. As noted in figure 46 below, it is significantly high in the second most-deprived quintile but significantly low in the least deprived quintiles. Figure 43: Heart Failure Admissions (All Admission Types, All Ages) 2014/15, Cambridgeshire & Peterborough Quintiles of Deprivation, Directly Age-Standardised Admission Rate per 100,000 Quintile Observed Admissions DSR Lower Interval Upper Interval 5 Most deprived Least Deprived C&P CCG 1, Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset All LCGs and quintiles of deprivation are statistically similar to the CCG overall with regards to under 75 admissions for heart failure. 36

37 Figure 44: Heart Failure Admissions (All Admission Types, Under 75 Only) 2014/15, Cambridgeshire & Peterborough CCG LCGs, Directly Age-Standardised Admission Rate per 100,000 Area Observed Admissions DSR Lower Interval Upper Interval ISLE OF ELY CATCH CAM HEALTH PETERBOROUGH HUNTS HEALTH HUNTS CARE PARTNERS BORDERLINE WISBECH BORDERLINE & PETERBOROUGH LCGs ALL OTHER LCGs C&P CCG Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset Figure 45: Heart Failure Admissions (All Admission Types, Under 75 Only) 2014/15, Cambridgeshire & Peterborough Quintiles of Deprivation, Directly Age-Standardised Admission Rate per 100,000 Quintile Observed Admissions DSR Lower Interval Upper Interval 5 Most deprived Least Deprived C&P CCG Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset STROKE With an overall prevalence of 1.3%, Peterborough LCG is one of three LCGs to be statistically significantly better than the CCG prevalence of 1.5% for Stroke. The Borderline LCG prevalence is 1.6%, statistically significantly high; collectively the two LCGs have a prevalence of 1.4%. Data show evidence of correlation between stroke prevalence and age, with the LGCs with statistically significantly higher prevalence of stroke also having a higher percentage of registered residents aged 65+. Peterborough LCG has a prevalence 0.2% lower than the CCG but also 3.2% fewer registered persons over 65 and 0.4% fewer persons over

38 CATCH CAM HEALTH PETERBOROUGH ISLE OF ELY HUNTS HEALTH BORDERLINE HUNTS CARE PARTNERS WISBECH Figure 46: Stroke Prevalence 2013/14, Cambridgeshire & Peterborough CCG LCGs LCG Number Prevalence LI UI 65+ % 85+ CATCH 2, % 1.2% 1.3% 15.0% 2.1% CAM HEALTH 1, % 1.2% 1.4% 13.9% 2.5% PETERBOROUGH 1, % 1.3% 1.4% 12.7% 1.7% ISLE OF ELY 1, % 1.4% 1.6% 18.0% 2.2% HUNTS HEALTH 1, % 1.4% 1.6% 16.2% 1.9% BORDERLINE 1, % 1.5% 1.6% 16.2% 2.1% HUNTS CARE PARTNERS 2, % 1.6% 1.8% 19.2% 2.4% WISBECH % 1.9% 2.2% 19.8% 2.5% BORDERLINE & PETERBOROUGH LCGs 3, % 1.4% 1.5% 14.3% 1.9% ALL OTHER LCGs 9, % 1.4% 1.5% 16.6% 2.2% CCG 12, % 1.4% 1.5% 15.9% 2.1% Source: 2013/14 Quality Outcomes Framework Data Figure 47: Stroke Prevalence 2013/14, Cambridgeshire & Peterborough CCG LCGs 2.5% 2.0% 2.0% 1.5% 1.2% 1.3% 1.3% 1.5% 1.5% 1.6% 1.7% 1.0% 0.5% 0.0% Source: 2013/14 Quality Outcomes Framework Data = CCG Value Green = Statistically significantly low in comparison to CCG Blue = No statistical significance in comparison to CCG Red = Statistically significantly high in comparison to CCG 38

39 Figure 48: Stroke Prevalence 2013/14, Borderline & Peterborough vs All Other LCGs 1.5% 1.5% 1.4% 1.4% 1.3% Borderline & Peterborough LCGs All Other LCGs Source: 2013/14 Quality Outcomes Framework Data = CCG Value Green = Statistically significantly low in comparison to CCG Blue = No statistical significance in comparison to CCG Red = Statistically significantly high in comparison to CCG Figure 49: Stroke Prevalence 2013/14, Cambridgeshire & Peterborough CCG Quintiles of Deprivation Quintile Persons Prevalence Lower Interval Upper Interval Patients Aged 65+ Patients Aged Most deprived 3, % 1.5% 1.6% 14.6% 1.9% 4 2, % 1.4% 1.5% 16.1% 2.2% 3 2, % 1.3% 1.4% 14.6% 2.0% 2 2, % 1.3% 1.4% 16.0% 2.1% 1 Least Deprived 2, % 1.5% 1.6% 19.1% 2.6% CCG 12, % 1.4% 1.5% 15.9% 2.1% Source: 2013/14 Quality Outcomes Framework Data Stroke prevalence is statistically significantly high in the least economically deprived quintile, potentially as a result of a high proportion of older persons. 39

40 Figure 50: Stroke Admissions (All Admission Types, All Ages) 2014/15, Cambridgeshire & Peterborough CCG LCGs, Directly Age-Standardised Admission Rate per 100,000 Area Observed Admissions DSR Lower Interval Upper Interval CATCH CAM HEALTH HUNTS HEALTH ISLE OF ELY BORDERLINE HUNTS CARE PARTNERS PETERBOROUGH WISBECH Peterborough & Borderline LCGs All Other LCGs 1, C&P CCG 1, Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset The collective directly age-standardised admission rate for Stroke for Borderline & Peterborough LCGs stands at 200.7/100,000 which is statistically similar to the CCG rate of 187.5/100,000. Figure 51: Stroke Admissions (All Admission Types, All Ages) 2014/15, Cambridgeshire & Peterborough Quintiles of Deprivation, Directly Age-Standardised Admission Rate per 100,000 Quintile Observed Admissions DSR Lower Interval Upper Interval 5 Most deprived Least Deprived C&P CCG 1, Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset Although the DSR as a result of Stroke falls as economic affluence increases, no quintile is statistically significantly different to the CCG admission rate of 187.5/100,

41 Figure 52: Stroke admissions 2014/15 by discharge destination Discharge Destination # % Of Total Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by Local Authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation % Not applicable % Patient died or still birth % NHS other hospital provider - ward for general Patients or the younger physically disabled % NHS run Care Home % Non-NHS (other than Local Authority) run Care Home % Temporary place of residence when usually resident elsewhere (includes hotel, residential educational establishment) % Non-NHS run hospital % NHS other hospital provider - high security psychiatric accommodation % NHS other hospital provider - ward for Patients who are mentally ill or have learning disabilities 7 0.5% Other (Categories with 5 or fewer admissions) 7 0.5% Total (includes admitted patients who are registered with General Practices outside C&P CCG % Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset The patient was discharged to their normal place of residence in 57.1% (872/1528) of cases. Data from Peterborough City Council Adult Social Care shows 22.1% (151/681) of assigned social care packages were necessitated by a Stroke/Cerebral Vascular Accident (CVA) condition, with the overall annual cost amounting to 4.02 million. Figure 53: Stroke Admissions (All Admission Types, Under 75 Only) 2014/15, Cambridgeshire & Peterborough CCG LCGs, Directly Age-Standardised Admission Rate per 100,000 Area Observed Admissions DSR Lower Interval Upper Interval HUNTS HEALTH CATCH HUNTS CARE PARTNERS BORDERLINE ISLE OF ELY CAM HEALTH PETERBOROUGH WISBECH

42 Area Observed Admissions DSR Lower Interval Upper Interval Borderline & Peterborough LCGs All Other LCGs C&P CCG Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset With regards to stroke admissions for patients aged under 75 years, both Peterborough & Borderline LCGs are statistically similar to the CCG average. Figure 54: Stroke Admissions (All Admission Types, Under 75 Only) 2014/15, Cambridgeshire & Peterborough Quintiles of Deprivation, Directly Age-Standardised Admission Rate per 100,000 Quintile Observed Admissions DSR Lower Interval Upper Interval C&P CCG Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset Admissions are statistically significantly high in the most deprived quintile, at 132.0/100,000 versus a CCG rate of 94.7/100, Hypertension Figure 55: Hypertension Prevalence 2013/14, Cambridgeshire & Peterborough CCG LCGs LCG Number Prevalence Lower Interval Upper Interval Patients Aged 65+ Patients Aged 85+ CAM HEALTH 9, % 10.5% 10.9% 13.9% 2.5% CATCH 24, % 10.7% 11.0% 15.0% 2.1% PETERBOROUGH 17, % 12.0% 12.4% 12.7% 1.7% ISLE OF ELY 12, % 13.3% 13.7% 18.0% 2.2% HUNTS HEALTH 9, % 14.0% 14.6% 16.2% 1.9% BORDERLINE 15, % 14.1% 14.6% 16.2% 2.1% HUNTS CARE PARTNERS 18, % 14.8% 15.2% 19.2% 2.4% WISBECH 7, % 14.8% 15.5% 19.8% 2.5% BORDERLINE & PETERBOROUGH LCGs 32, % 13.0% 13.3% 14.3% 1.9% ALL OTHER LCGs 81, % 12.6% 12.8% 16.6% 2.2% CCG 114, % 12.7% 12.9% 15.9% 2.1% Source: 2013/14 Quality Outcomes Framework Data Peterborough LCG has a statistically significantly low prevalence of hypertension; however Borderline LCG s prevalence of 14.3% contributes towards a collective prevalence for the two LCGs of 13.1%, significantly higher than the CCG prevalence of 12.8%. 42

43 CAM HEALTH CATCH PETERBOROUGH ISLE OF ELY HUNTS HEALTH BORDERLINE HUNTS CARE PARTNERS WISBECH Figure 56: Hypertension Prevalence 2013/14, Cambridgeshire & Peterborough CCG LCGs 18.0% 16.0% 14.0% 12.0% 10.7% 10.9% 12.2% 13.5% 14.3% 14.3% 15.0% 15.1% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% Source: 2013/14 Quality Outcomes Framework Data = CCG Value Green = Statistically significantly low in comparison to CCG Blue = No statistical significance in comparison to CCG Red = Statistically significantly high in comparison to CCG Figure 57: Hypertension Prevalence 2013/14, Borderline & Peterborough vs All Other LCGs 13.4% 13.2% 13.1% 13.0% 12.8% 12.7% 12.6% 12.4% 12.2% Borderline & Peterborough LCGs All Other LCGs Source: 2013/14 Quality Outcomes Framework Data 43

44 ----- = CCG Value Green = Statistically significantly low in comparison to CCG Blue = No statistical significance in comparison to CCG Red = Statistically significantly high in comparison to CCG Figure 58: Hypertension Prevalence 2013/14, Cambridgeshire & Peterborough CCG Quintiles of Deprivation Quintile Persons Prevalence Lower Interval Upper Interval Patients Aged 65+ Patients Aged Most deprived 25, % 12.9% 13.2% 14.6% 1.9% 4 24, % 13.3% 13.6% 16.1% 2.2% 3 22, % 11.8% 12.0% 14.6% 2.0% 2 20, % 11.7% 12.0% 16.0% 2.1% 1 Least Deprived 20, % 13.8% 14.2% 19.1% 2.6% CCG 114, % 12.7% 12.9% 15.9% 2.1% Source: 2013/14 Quality Outcomes Framework Data Hypertension prevalence is significantly high in the least deprived quintile and the fourth quintile, both of which have a higher percentage of patients aged 65+ and 85+ than the CCG collectively Angiography Figure 59: Angiography Admissions (All Admission Types, All Ages) 2014/15, Cambridgeshire & Peterborough CCG LCGs, Directly Age-Standardised Admission Rate per 1,000,000 Area Observed Events DSR Lower Interval Upper Interval WISBECH 95 2, , ,485.0 CATCH 381 2, , ,341.3 CAM HEALTH 143 2, , ,663.8 HUNTS HEALTH 145 2, , ,686.4 PETERBOROUGH 247 2, , ,782.8 BORDERLINE 247 2, , ,884.8 HUNTS CARE PARTNERS 312 2, , ,878.5 ISLE OF ELY 233 2, , ,977.1 Peterborough & Borderline LCGs 494 2, , ,717.8 All Other LCGs 1,309 2, , ,447.2 C&P CCG 1,803 2, , ,475.2 Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset The DSR for angiography admissions 2014/15 is calculated as rate per 1,000,000 rather than rate per 100,000 due to relatively low numbers of operations. All LCGs are statistically similar to the CCG rate of 2,

45 Figure 60: Angiography Admissions (All Admission Types, All Ages) 2014/15, Cambridgeshire & Peterborough Quintiles of Deprivation, Directly Age-Standardised Admission Rate per 1,000,000 Quintile Observed Admissions DSR Lower Interval Upper Interval 5 Most deprived 366 2, , , , , , , , , , , , Least Deprived 328 2, , ,445.4 CCG 1,803 2, , ,475.2 Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset There is no statistical significance to note between rates of admission across the quintiles of deprivation in the CCG compared to the collective CCG rate. Figure 61: Angiography Admissions (All Admission Types, Under 75 Only) 2014/15, Cambridgeshire & Peterborough CCG LCGs, Directly Age-Standardised Admission Rate per 1,000,000 Area Observed Events DSR Lower Interval Upper Interval CATCH 275 1, , ,835.6 CAM HEALTH 106 1, , ,219.6 BORDERLINE 176 1, , ,208.0 HUNTS CARE PARTNERS 216 1, , ,179.9 WISBECH 82 1, , ,394.6 ISLE OF ELY 165 1, , ,295.7 HUNTS HEALTH 124 2, , ,475.3 PETERBOROUGH 199 2, , ,429.0 Peterborough & Borderline LCGs 375 1, , ,213.4 All Other LCGs 968 1, , ,958.5 C&P CCG 1,343 1, , ,986.1 Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset As with the directly age-standardised rates for all ages, data for under 75 only angiography admissions shows no statistical outliers among C&P CCGs in comparison to the CCG rate of 1,882.0/1,000,000. Figure 62: Angiography Admissions (All Admission Types, Under 75 Only) 2014/15, Cambridgeshire & Peterborough Quintiles of Deprivation, Directly Age-Standardised Admission Rate per 1,000,000 Quintile Observed Admissions DSR Lower Interval Upper Interval 5 Most deprived 306 2, , , , , , , , , , , , Least Deprived 235 1, , ,924.0 CCG 1,343 1, , ,986.1 Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset 45

46 Although observed admissions fall in line with economic deprivation declining, no quintiles of deprivation have statistically significant DSRs in comparison to the CCG value Revascularisation Figure 63: Revascularisation Admissions (All Admission Types, All Ages) 2014/15, Cambridgeshire & Peterborough CCG LCGs, Directly Age-Standardised Admission Rate per 1,000,000 Area Observed Events DSR Lower Interval Upper Interval CATCH 237 1, , ,488.8 CAM HEALTH 89 1, , ,747.2 BORDERLINE 177 1, , ,112.1 HUNTS CARE PARTNERS 223 1, , ,107.7 ISLE OF ELY 168 1, , ,190.3 PETERBOROUGH 196 1, , ,234.1 WISBECH 94 1, , ,415.6 HUNTS HEALTH 124 2, , ,406.8 Peterborough & Borderline LCGs 373 1, , ,087.8 All Other LCGs 935 1, , ,766.0 C&P CCG 1,308 1, , ,811.1 Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset Admissions for revascularisation are statistically significantly low in the CATCH LCG and similar to that of the CCG for all other LCGs, however it should be noted that revascularisation rates will pertain to observed CVD/CHD prevalence and therefore, although statistically significantly different, the DSR of the CATCH LCG should not be interpreted as necessarily better than the CCG DSR. Figure 64: Revascularisation Admissions (All Admission Types, All Ages) 2014/15, Cambridgeshire & Peterborough Quintiles of Deprivation, Directly Age-Standardised Admission Rate per 1,000,000 Quintile Observed Admissions DSR Lower Interval Upper Interval 5 Most deprived 315 1, , , , , , , , , , , , Least Deprived 199 1, , ,524.5 CCG 1,308 1, , ,811.1 Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset Revascularisation admissions fall in line with declining economic deprivation, with the rate of 1,325.7/1,000,000 standing as statistically significantly low in comparison to the CCG rate of 1,714.9/1,000,

47 Figure 65: Revascularisation Admissions (All Admission Types, Under 75 Only) 2014/15, Cambridgeshire & Peterborough CCG LCGs, Directly Age-Standardised Admission Rate per 1,000,000 Area Observed Events DSR Lower Interval Upper Interval CATCH 174 1, ,200.8 CAM HEALTH 65 1, ,450.7 BORDERLINE 129 1, , ,673.5 HUNTS CARE PARTNERS 162 1, , ,674.7 ISLE OF ELY 128 1, , ,823.7 HUNTS HEALTH 93 1, , ,940.5 PETERBOROUGH 157 1, , ,960.4 WISBECH 78 1, , ,240.5 Peterborough & Borderline LCGs 286 1, , ,739.2 All Other LCGs 700 1, , ,434.6 C&P CCG 986 1, , ,477.0 Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset As with admissions of all ages, the CATCH LCG is statistically significantly low in comparison to the CCG for revascularisation admissions in the under 75 only age range. Figure 66: Revascularisation Admissions (All Admission Types, Under 75 Only) 2014/15, Cambridgeshire & Peterborough Quintiles of Deprivation, Directly Age-Standardised Admission Rate per 1,000,000 Quintile Observed Admissions DSR Lower Interval Upper Interval 5 Most deprived 258 1, , , , , , , , , , , , Least Deprived 152 1, ,278.3 CCG 986 1, , ,477.0 Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset Amongst under 75s, admissions are statistically significantly high in comparison to the CCG in the most deprived quintile and significantly low in the least deprived quintile. 47

48 3 Lifestyle Determinants 3.1 Risk Factors Associated with Cardiovascular Disease A number of common risk factors are recognised as increasing the likelihood of individuals developing atherosclerosis and consequently CVD. There are three broad groups. 16 Fixed risk factors are by definition unmodifiable, but are taken into account in calculating and advising people about their overall risk: age; gender family history/genetic factors ethnicity Lifestyle/behavioural risk factors reflect an individual s circumstances and choices, and can be changed for the better to reduce personal risk: smoking physical inactivity; poor diet obesity; and harmful use of alcohol Bodily or physiological risk factors reflect changes to body systems that are preventable or reversible in their early stages, but may require medical treatment to manage the risk: hypertension/raised blood pressure; raised cholesterol/disordered lipids; impaired glucose tolerance/diabetes; and chronic kidney disease (CKD). Individuals will often have a number of these risk factors, and may also have more than one clinical manifestation of CVD. For instance people with diabetes or CKD or who are smokers or suffer from hypertension are more likely to have strokes, heart attacks, or develop heart failure. It is estimated that each additional risk factor present doubles the previous overall risk for that individual. 17 This multiplicative association of risk factors underpins the need for an integrated approach to reducing risk both at population and individual level. It is also estimated that in over 90% of cases, the risk of a first heart attack is related to one or more of nine potentially modifiable risk factors 18 - smoking, poor diet, insufficient physical activity, high blood pressure, obesity, diabetes, psychosocial stress, alcohol consumption and high blood cholesterol. 3.2 Ethnicity as a risk factor contributing to CVD British Heart Foundation statistics show that there is a disparity between ethnicities with regards to the prevalence of cardiovascular disease and associated risk factors for example, Black Caribbean, Indian, Pakistani and Bangladeshi men have a considerably higher prevalence of diabetes than the general population and stroke 16 Department of Health: 17 Yusuf S et al; INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004;364: p.5 48

49 incidence rates in the black ethnic group are higher than in the white ethnic group for both sexes. 19 Although identifying particular ethnic factors that influence cardiovascular disease is complicated (with a requirement to factor in genetic makeup, cultural and social practices and risk factors such as obesity and diabetes), there is evidence of inequalities between ethnicities with regards to access to treatment 20 as well as behavioural factors such as smoking, alcohol consumption, diet and physical activity. Peterborough has a relatively high proportion of black & ethnic minority (BME) residents in the 2011 national census, 17.5% of residents identified as BME compared to 14.6% of respondents nationally. Figure 70 ranks Peterborough s 24 electoral wards by percentage of BME residents and includes statistics related to cardiovascular disease for each ward. Data show that there is clear correlation between hospital admissions from, and deaths as a result of, circulatory diseases and high percentages of BME ethnicities as a percentage of overall population. However, there is also strong correlation between levels of income deprivation and the hospital admission and mortality rates. Deprivation is associated with the wider determinants of cardiovascular diseasehigher levels of smoking and obesity, a less healthy diet, lower levels of physical activity, more stress and less control in employment

50 Figure 67: Peterborough ward ethnicity & CVD-related metrics Area Name % Black & Minority Ethnic Population (2011) % living in income deprived households (2010) Standardised Mortality Ratio: Deaths from circulatory diseases, all ages ( ) Standardised Mortality Ratio: Deaths from circulatory diseases, under 75 years ( ) Standardised Mortality Ratio: Deaths from coronary heart disease, all ages ( ) Standardised Mortality Ratio: Deaths from coronary heart disease, under 75 years ( ) Standardised Mortality Ratio: Deaths from stroke, all ages ( ) Standardised Admission Ratio: Emergency hospital admissions for coronary heart disease (2008/ /13) Standardised Admission Ratio: Elective hospital admissions for coronary heart disease (2008/ /13) Standardised Admission Ratio: Emergency hospital admissions for stroke (2008/ /13) Standardised Admission Ratio: Emergency hospital admissions for myocardial infarction (2008/ /13) Central Park Ravensthorpe West East North Dogsthorpe Bretton South Orton with Hampton Bretton North Fletton and Woodston Orton Longueville Paston Stanground East Walton Werrington North Orton Waterville Stanground Central Eye and Thorney Werrington South Newborough

51 Area Name % Black & Minority Ethnic Population (2011) % living in income deprived households (2010) Standardised Mortality Ratio: Deaths from circulatory diseases, all ages ( ) Standardised Mortality Ratio: Deaths from circulatory diseases, under 75 years ( ) Standardised Mortality Ratio: Deaths from coronary heart disease, all ages ( ) Standardised Mortality Ratio: Deaths from coronary heart disease, under 75 years ( ) Standardised Mortality Ratio: Deaths from stroke, all ages ( ) Standardised Admission Ratio: Emergency hospital admissions for coronary heart disease (2008/ /13) Standardised Admission Ratio: Elective hospital admissions for coronary heart disease (2008/ /13) Standardised Admission Ratio: Emergency hospital admissions for stroke (2008/ /13) Standardised Admission Ratio: Emergency hospital admissions for myocardial infarction (2008/ /13) Glinton and Wittering Barnack Northborough Peterborough Unitary Authority Source: Local Health Profiles Figure 68: Peterborough Hospitals Admissions 2014/15 Ethnic Breakdown Ethnicity Category All Admissions All CHD All Heart Failure All Stroke All Angiography All Revascularisation British 72.2% 78.0% 76.7% 70.7% 81.5% 77.4% Not Known 9.4% 11.6% 11.2% 9.7% 5.8% 15.8% Not Stated 7.3% 3.5% 4.2% 10.9% 4.8% 1.5% Any Other White Background 4.7% 1.8% 3.7% 3.8% 2.2% 0.4% Pakistani 1.5% 1.4% 1.2% 1.4% 1.3% 1.1% Indian 0.9% 1.0% 0.4% 0.6% 1.4% 1.2% Any Other Ethnic Group 0.7% 0.6% 0.5% 0.4% 0.7% 0.6% Any Other Asian Background 0.6% 0.4% 0.3% 0.5% 0.6% 0.3% Irish 0.6% 0.6% 0.4% 0.7% 0.6% 0.6% African 0.4% 0.0% 0.0% 0.1% 0.1% 0.0% Any Other Mixed Background 0.3% 0.1% 0.2% 0.1% 0.1% 0.1% Chinese 0.3% 0.2% 0.1% 0.1% 0.1% 0.2% 51

52 Ethnicity Category All Admissions All CHD All Heart Failure All Stroke All Angiography All Revascularisation Any Other Black Background 0.2% 0.1% 0.1% 0.4% 0.2% 0.1% Caribbean 0.2% 0.1% 0.3% 0.4% 0.1% 0.0% Bangladeshi 0.2% 0.3% 0.9% 0.2% 0.5% 0.3% White and Asian 0.2% 0.1% 0.0% 0.0% 0.2% 0.1% White and Black Caribbean 0.2% 0.0% 0.1% 0.1% 0.1% 0.0% White and Black African 0.1% 0.1% 0.0% 0.0% 0.0% 0.3% Total 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Source: Cambridgeshire & Peterborough Clinical Commissioning Group SUS Dataset Data show that 72.2% of patients admitted to Peterborough City Hospital in 2014/15 self-identified as British; this ethnic group accounted for a 78.0% of admissions as a result of CHD, 76.7% of heart failure admissions, 81.5% of angiography procedures and 77.4% of revascularisation procedures. 9.4% of all admissions had a Not Known ethnicity status this also applies to 11.6% of CHD admissions, 11.2% of heart failure admissions, 9.7% of stroke admissions and 15.8% of revascularisation procedures. Caution should therefore be exercised in use of these data as it is difficult to draw conclusions with regards to proportion of admissions attributable to ethnic groups when, incorporating Not Known and Not Stated status in ethnicity field, 16.7% of admissions do not provide the data required for analysis by ethnicity of admitted patient. 52

53 3.3 Smoking as a CVD risk factor Reducing tobacco use is one of the most important actions that can be taken to improve health. Tobacco is addictive and harms the people that use it, those around them and communities. Smoking remains the leading cause of preventable death and disease in England, accounting for more preventable deaths than the following five preventable causes, combined. Over 81,400 deaths in England each year in those aged 35 years and over are caused by smoking. That equates to 18% of deaths in this age group. Smoking is also one of the most significant factors that has an impact on health inequalities and ill health, with an estimated 461,000 hospital admissions for people aged 35 years and older estimated to be attributable to smoking. 21 The table below shows that tobacco smoking is the primary leading risk factor contributing to Years of Life Lost in the United Kingdom. Figure 69: Leading Risk Factors, % of total Years of Life Lost, 2010 (United Kingdom) Source: Yorkshire & Humber Public Health Observatory 21 BMA: 53

54 However, by successfully stopping smoking, people can avoid smoking-related diseases and live longer, whatever their age 22. The table below demonstrates the benefits in terms of life expectancy and associated overall health associated with stopping smoking: Age at which stopped smoking Years of life gained Source: HM Government Healthy Lives, Healthy People: A Tobacco Control Plan for England The Government strategy, Healthy Lives, healthy people: A Tobacco Control Plan for England 23 set out an assessment of what could be delivered through national action, supported and associated with locally driven comprehensive tobacco control practice. The plan s ambition of reducing smoking prevalence among adults in England to 18.5% or less by the end of 2015 appears achievable with 2013 data showing national prevalence of 18.4%. Although the 2015 ASH report Smoking Still Kills advocates an ambition to reduce smoking in the adult population to 13% by 2020 and 9% by Smoking rates in Peterborough have been declining over recent years. In 2010 one in four (25.2%) adults in Peterborough smoked, while in 2013 this rate had declined to one in five (20.8%) adults smoking, a reduction of 4.4 percentage points. In comparison the England average rate has reduced 2.4 percentage points to 18.4% and the East of England average rate has reduced 2.1 percentage points to 17.5% over the same period. Figure 70: Smoking prevalence among persons aged 18 years and over Trend (%) Source: Public Health Outcomes Framework Indicator 2.14 Smoking rates in Peterborough do however remain worse that the England and the East of England average rates as shown in figure UK Govt:

55 Figure 71: Smoking prevalence among persons aged 18 years and over 2013 East of England (%) Source: Public Health Outcomes Framework Indicator 2.14 There is a strong relationship between smoking and people suffering from mental health problems. People with longstanding anxiety, depression or another mental health condition are twice as likely to be smokers as those who do not have any mental health problems. Depression is two to three times more common in a range of cardiovascular diseases including cardiac disease, coronary artery disease, stroke, angina, congestive heart failure, or following a heart attack 25. Rates of smoking increase with the severity of the mental health disorder, ranging from 25 per cent among people with eating disorders to 56 per cent among those with probable psychosis. Over the last 20 years, smoking prevalence has changed little in those with severe illness 26. It has been estimated that 42% of overall tobacco consumption in England is by this group 27. There is also a strong relationship between smoking and occupation. Smoking prevalence is twice as high among people in routine and manual occupations compared to those in managerial and professional occupations. In Peterborough smoking prevalence among people in routine and manual occupations is 34%, the highest in the East of England. Prevalence has been consistently falling nationally over the period but rose in Peterborough from 34.3% to 34.7% between 2012 and Figure 72: Smoking prevalence among persons working in routine and manual occupations 2013 (%) Source: Public Health Outcomes Framework Indicator

56 Figure 73: Smoking prevalence among persons working in routine and manual occupations Trend (%) Source: Public Health Outcomes Framework Indicator 2.14 Smoking status of residents registered with GP practices in 2013/14 demonstrates an association between high levels of deprivation and high rates of smoking. Of the eight registered GP practice populations with highest smoking rates in Peterborough and Borderline, six are in the most deprived 30% of the England population as defined by the 2010 Index of Multiple Deprivation. Figure 74: Smoking Prevalence 2013/14, Cambridgeshire & Peterborough CCG LCGs Patients Patients LCG Number Prevalence Lower Interval Upper Interval Aged 65+ Aged 85+ CATCH 26, % 13.5% 13.9% 15.0% 2.1% CAM HEALTH 11, % 15.5% 16.1% 13.9% 2.5% HUNTS CARE PARTNERS 18, % 17.9% 18.5% 19.2% 2.4% HUNTS HEALTH 10, % 17.9% 18.6% 16.2% 1.9% ISLE OF ELY 14, % 18.2% 18.8% 18.0% 2.2% BORDERLINE 17, % 19.4% 20.0% 16.2% 2.1% PETERBOROUGH 28, % 25.2% 25.7% 12.7% 1.7% WISBECH 10, % 26.2% 27.2% 19.8% 2.5% BORDERLINE & PETERBOROUGH LCGs 45, % 22.7% 23.1% 14.3% 1.9% ALL OTHER LCGs 91, % 16.8% 17.1% 16.6% 2.2% CCG 137, % 18.5% 18.7% 15.9% 2.1% Source: 2013/14 Quality Outcomes Framework Data Data show both the Borderline and Peterborough LCGs to have a statistically significantly high level of smoking prevalence, with a collective prevalence of 22.9% vs 18.6% across the CCG collectively. These data are not age-standardised so prevalence may be affected by the relatively young population of Peterborough, due to smoking prevalence generally declining with age. 56

57 CATCH CAM HEALTH HUNTS CARE PARTNERS HUNTS HEALTH ISLE OF ELY BORDERLINE PETERBOROUGH WISBECH Figure 75: Smoking Prevalence 2013/14, Cambridgeshire & Peterborough CCG LCGs 30.0% 25.0% 25.5% 26.7% 20.0% 15.0% 13.7% 15.8% 18.2% 18.2% 18.5% 19.7% 10.0% 5.0% 0.0% Source: 2013/14 Quality Outcomes Framework Data = CCG Value Green = Statistically significantly low in comparison to CCG Blue = No statistical significance in comparison to CCG Red = Statistically significantly high in comparison to CCG Figure 76: Smoking Prevalence 2013/14, 16+, Cambridgeshire & Peterborough CCG LCGs 25.0% 22.9% 20.0% 17.0% 15.0% 10.0% 5.0% 0.0% Borderline & Peterborough LCGs All Other LCGs Source: 2013/14 Quality Outcomes Framework Data 57

58 ----- = CCG Value Green = Statistically significantly low in comparison to CCG Blue = No statistical significance in comparison to CCG Red = Statistically significantly high in comparison to CCG Figure 77: Smoking Prevalence 2013/14, Cambridgeshire & Peterborough CCG Quintiles of Deprivation Quintile Persons Prevalence LI UI 65+ % Most deprived 42, % 26.5% 27.0% 14.5% 1.9% 4 33, % 21.4% 21.9% 16.2% 2.3% 3 26, % 15.9% 16.3% 14.8% 2.0% 2 18, % 13.2% 13.6% 16.2% 2.1% 1 Least Deprived 16, % 13.2% 13.6% 19.5% 2.6% CCG 137, % 18.5% 18.7% 14.5% 1.9% Source: 2013/14 Quality Outcomes Framework Data Smoking prevalence is significantly higher amongst the more deprived elements of the CCG population, falling as deprivation decreases to a low of 13.4% in the two least deprived quintiles. Addressing current levels of smoking prevalence in Peterborough will have a direct impact on the prevalence of cardiovascular disease. The further development of comprehensive tobacco control locally, including targeted action to reduce smoking prevalence among specific groups, should be considered. Figure 78: NICE smoking and tobacco guidance PH1 Brief interventions and referral for smoking cessation PH5 Workplace interventions to promote smoking cessation PH10 Smoking cessation services PH14 Preventing the uptake of smoking by children and young people PH15 - Identifying and supporting people most at risk of dying prematurely PH23 School based interventions to prevent smoking PH39 Smokeless tobacco cessation: South Asian communities PH45 Tobacco Harm reduction PH48 Smoking cessation in secondary care and tobacco guidance Source: 58

59 3.4 Physical inactivity as a CVD Risk Factor There is growing evidence that sedentary behaviours (e.g. sitting for long periods at work, for travel, study and screen time ) is independently and adversely linked to all-cause mortality, cardiovascular deaths, type 2 diabetes, some cancers and depression. 28 An increase in sedentary behaviour can be associated with social, economic and cultural trends that have removed physical activity from daily life, evidenced by a reduction in manual jobs and the continual use of technology for work and leisure that requires people to sit for long periods. Studies show that doing more than 150 minutes of moderate physical activity or 75 minutes of vigorous physical activity reduces the risk of coronary heart disease by approximately 30%. 29 Physical activity promotes cardiovascular health through regulating weight and the body s use of insulin, as well as providing health benefits relating to blood pressure, blood lipid levels, blood glucose levels, blood clotting factors and the health of blood vessels. Figure 79: The percentage of adults who are physically active in Peterborough (54.6%) is lower than the East of England average (57.8%) and the England average (56.0%). Area Physically active % Physically inactive % Peterborough 54.6% 31.2% East of England 57.8% 26.9% England 56.0% 28.9% Source: Sport England Local Sport Profiles 2014 Approximately eight deaths could be prevented annually if 25% more persons aged in Peterborough engaged in physical activity. The reduction in deaths could rise to 117 if 100% more were involved. Figure 80: Number of deaths that could be prevented by increasing levels of physical activity among year olds Percentage more active Peterborough East of England England 25% ,749 50% 45 1,394 13,438 75% 81 2,625 25, % 117 3,856 36,815 Source: Sport England Local Sport Profiles Start active, stay active - a report on physical activity and health from the four home countries Chief Medical Officers, 29 Start active, stay active - a report on physical activity and health from the four home countries Chief Medical Officers, 59

60 The cost of physical inactivity in terms of expenditure on related ailments in Peterborough in 2009/10 financial year was estimated to be over 2.7 million. More than half of the estimated expenditure ( 1.4 million) was on coronary heart disease. Figure 81: Health costs of physical inactivity, split by disease type, 2009/10 Disease category Peterborough East of England England Coronary heart disease 1,463,791 60,186, ,095,943 Diabetes 787,339 19,484, ,660,420 Cerebrovascular disease e.g. stroke 267,574 11,718, ,359,285 Cancer lower GI e.g. bowel cancer 133,227 5,853,928 67,816,189 Breast Cancer 94,798 5,755,887 60,357,887 Total Cost 2,746, ,999, ,289,723 Source: Sport England Local Sport Profiles 2014 There is a clear correlation between health and where we live. A number of published studies have provided evidence that our local environments can have a positive effect on individual health and wellbeing. However, many aspects of cities and towns deter people from being physically active. Lack of access to open and green spaces can be detrimental to people s physical and mental health. This is particularly evident within areas of deprivation that have access to green space. Within such areas all-cause mortality rates of residents have been found to be significantly lower compared to those of other residents in deprived areas with less access to green space. Barriers to walking or cycling as part of everyday life also restrict and discourage people to from becoming more physically active. The Campaign for Better Transport s 2014 Car Dependency Scorecard 30 rated Peterborough as the most car-dependent of 29 assessed cities. Figure 82: Campaign for Better Transport 2014 Car Dependency Scorecard Source: Campaign for Better Transport

61 Figure 83: NICE physical activity guidance PH2 Four commonly used methods to increase physical activity PH8 Physical activity and the environment PH41 Walking and cycling: local measures to promote walking and cycling as forms of travel and recreation PH44 Brief advice for adults in primary care PH54 Exercise referral schemes to promote physical activity Source: Poor Diet as a CVD Risk Factor Evidence shows that the risk of a new major cardiac event can be reduced up to 73% by consuming a diet low in saturated fats and including substantial amounts of fresh fruit and vegetables 31. Foods that can contribute towards cardiovascular health include: Fresh fruits and vegetables low intake of fresh fruit and vegetables accounts for about 20% of cardiovascular disease worldwide, as they contain components that protect against heart disease and stroke. Fish in countries where fish consumption is high there is a reduced risk of death from all causes, including cardiovascular mortality Nuts eating nuts regularly is associated with decreased risk of coronary heart disease Wholegrain cereals Unrefined whole grains contain folic acid, B vitamins and fibre, all of which protect against heart disease. Soy Evidence shows that soy has a beneficial effect on blood lipid levels and reduces cholesterol levels. Dietary factors that are known to damage cardiovascular health include: A diet high in trans fats (e.g. fast food, cakes) and saturated fats (e.g. cheese, butter) increases levels of cholesterol and can contribute towards abnormal blood lipid levels, which have a strong

62 correlation with the risk of coronary artery disease. 32 It is recommended that the average man should eat no more than 30g of saturated fat per day and the average woman no more than 20g. Salt/Sodium high consumption of sodium is linked to high blood pressure, a major risk factor for cardiovascular disease. It has been estimated that a universal reduction in dietary intake of sodium by approximately 1g of sodium per day (about 3g of salt) would lead to a 50% reduction in the number of people needing treatment for hypertension, a 22% drop in the number of deaths from strokes and a 16% fall in deaths from coronary heart disease. 33 In 2013, the UK government introduced front-of-pack nutrition labelling to help consumers easily assess the content of their food. Red colour coding means the food or drink is high in this nutrient and should be consumed in moderation or avoided. Amber colour coding means the food or drink has a relatively average amount of the nutrient and can be safely consumed on a regular basis. Green colour coding means the food or drink is low in this nutrient and is therefore likely to represent the healthier choice within a diet. Figure 84: UK front-of-pack nutrition labelling example Government guidance suggests that people should consume at least 5 portions of fruit and vegetables per day to maintain their health. The below table shows the percentage of residents within each of Peterborough s wards that self-reported as consuming at least 5 portions of fruit and vegetables per day, as well as data pertaining to the number of emergency hospital admissions and deaths within wards. Data show a clear correlation between low levels of economic deprivation, high levels of healthy eating and relatively low levels of emergency hospital admissions and deaths. Conversely, where deprivation is relatively high, levels of healthy eating tend to be relatively low and hospital admission rates are high

63 Figure 85: % of Healthy eating adults and associated emergency hospital admission/mortality metrics Within the table below, indirectly age-standardised rates are presented from emergency hospital admissions for all causes and deaths from all causes. Indirect age-standardisation provides a method through which the rate of observed events can be compared between two or more areas (e.g. Peterborough City Council electoral wards compared to England) in the absence of age-specific data that would be required for direct age standardisation. The rate for England is set at 100.0; a local rate below illustrates fewer observed events than would be expected based on values for England, whereas conversely a rate above shows a greater number of observed events than would be expected in comparison to the rate for England. Area % living in income deprived households (2010) % health eating adults ( ) Standardised Admission Ratio: Emergency hospital admissions for all causes (2008/ /13) Standardised Mortality Ratio: Deaths from all causes, all ages ( ) Barnack Glinton and Wittering Northborough Newborough Werrington South Orton Waterville Orton with Hampton West Werrington North Eye and Thorney Stanground East Bretton South Stanground Central Walton Fletton and Woodston Park Bretton North Orton Longueville East Ravensthorpe Central Paston North Dogsthorpe Peterborough Unitary Authority

64 Area Cambridgeshire & Peterborough Clinical Commissioning Group % living in income deprived households (2010) % health eating adults ( ) Standardised Admission Ratio: Emergency hospital admissions for all causes (2008/ /13) Standardised Mortality Ratio: Deaths from all causes, all ages ( ) England Source: Local Health Profiles Figure 86: NICE diet guidance PH47 Managing overweight and obesity in children and young people PH53 - Managing overweight and obesity in adults lifestyle weight management services Source: Obesity as a CVD Risk Factor Obesity is a term used to describe somebody who is very overweight, with a lot of body fat 34. Being obese can dramatically increase the risk of developing a range of serious diseases. Additionally, moderate obesity (a BMI of 30-35) was found to reduce life expectancy by an average of three years, while morbid obesity (a BMI of 40-50) reduces life expectancy by 8-10 years a similar reduction in life expectancy to that caused by a lifetime of smoking tobacco. 35 NICE guidance recommends lower thresholds of obesity for intervening to prevent ill health among adults from black, Asian and other ethnic groups (with an increased risk of chronic conditions BMI 23 kg/m² and a high risk of chronic conditions BMI 27.5kg/m²). 36 Obesity can lead to physical problems including type 2 diabetes, cardiovascular disease and obstructive sleep apnoea as well as psychosocial risks such as low self-esteem and impaired quality of life for both children and adults

65 Source: The most widely used method for classifying a person s general health in relation to their weight is body mass index (BMI). For adults, BMI is calculated as: Weight in kilograms/height in metres/height in metres For example, an adult weighing 70kg and 1.75 tall would calculate their BMI as: 70 / 1.75 / 1.75 = BMI is calculated differently for adults and children. For adults: A BMI under 18.5 is considered underweight; A BMI of 18.5 to 24.9 is considered a healthy weight; A BMI of 25 to 29.9 is considered overweight; A BMI of 30 to 39.9 is considered obese; A BMI of 40 or above is considered morbidly obese. The below chart provides a broad indication of healthy weight for height ranges for adults. 65

66 Figure 87: Healthy Weight/BMI Chart Source: Diabetes UK For children, BMI is interpreted by reference to a child s BMI centile how they compare in relation to other children of the same age, height and sex. 38 Public Health England predict that 70% of adults will be overweight or obese by the year this would amount to approximately 170,000 people within Peterborough if Cambridgeshire research group population growth projections prove accurate. The most recent estimates released by Public Health England (based on the 2012 Active People Survey) suggest the actual percentage of adults classified as obese in Peterborough to be 24.1%, 2.5% higher than the estimate for Cambridgeshire (21.6%). The Public Health Outcomes Framework also includes an estimated percentage of adults classified as either overweight or obese; in Peterborough, this figure is 65.5% whereas in Cambridgeshire it is 65.0%

67 CATCH CAM HEALTH HUNTS HEALTH BORDERLINE ISLE OF ELY HUNTS CARE PARTNERS PETERBOROUGH WISBECH Area % of adults classified as obese (Active People Survey, 2012) % of adults with excess weight (PHOF indicator 2.12), 2012 Peterborough 24.1% 65.5% Cambridgeshire 21.6% 65.0% Source: Active People Survey, Public Health England Figure 88: Recorded Obesity Prevalence 2013/14, 16+, Cambridgeshire & Peterborough CCG LCGs LCG Number Prevalence LI UI CATCH 11, % 6.0% 6.2% 15.0% 2.1% CAM HEALTH 4, % 5.9% 6.3% 13.9% 2.5% HUNTS HEALTH 5, % 9.1% 9.6% 16.2% 1.9% BORDERLINE 8, % 9.4% 9.8% 16.2% 2.1% ISLE OF ELY 7, % 9.5% 9.9% 18.0% 2.2% HUNTS CARE PARTNERS 9, % 9.8% 10.2% 19.2% 2.4% PETERBOROUGH 11, % 10.5% 10.8% 12.7% 1.7% WISBECH 4, % 11.8% 12.4% 19.8% 2.5% BORDERLINE & PETERBOROUGH LCGs 19, % 10.0% 10.3% 14.3% 1.9% ALL OTHER LCGs 43, % 8.1% 8.2% 16.6% 2.2% CCG 63, % 8.6% 8.8% 15.9% 2.1% Source: 2013/14 Quality Outcomes Framework Data The prevalence of recorded obesity across the CCG is 8.7%. Both Borderline & Peterborough LCGs have prevalence statistically significantly higher than the CCG, with the combined prevalence of the two LCGs standing at 10.2% (19,964 people). Figure 89: Recorded Obesity Prevalence 2013/14, 16+, Cambridgeshire & Peterborough CCG LCGs 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 6.1% 6.1% 9.3% 9.6% 9.7% 10.0% 10.7% 12.1% Source: 2013/14 Quality Outcomes Framework Data 67

68 ----- = CCG Value Green = Statistically significantly low in comparison to CCG Blue = No statistical significance in comparison to CCG Red = Statistically significantly high in comparison to CCG Figure 90: Recorded Obesity Prevalence 2013/14, 16+, Cambridgeshire & Peterborough CCG LCGs The combined prevalence of obesity amongst all LCGs other than Borderline & Peterborough is statistically significantly below that of the CCG (8.1% vs 8.7%). Prevalence in Borderline & Peterborough LCGs is statistically significantly higher at 10.2%. 12.0% 10.0% 8.0% 10.2% 8.1% 6.0% 4.0% 2.0% 0.0% Borderline & Peterborough LCGs All Other LCGs Source: 2013/14 Quality Outcomes Framework Data = CCG Value Green = Statistically significantly low in comparison to CCG Blue = No statistical significance in comparison to CCG Red = Statistically significantly high in comparison to CCG Figure 91: Recorded Obesity Prevalence 2013/14, Cambridgeshire & Peterborough CCG Quintiles of Deprivation Quintile Persons Prevalence LI UI 65+ % Most deprived 17, % 10.8% 11.2% 14.6% 1.9% 4 15, % 10.0% 10.3% 16.1% 2.2% 3 12, % 7.4% 7.7% 14.6% 2.0% 2 9, % 6.4% 6.7% 16.0% 2.1% 1 Least Deprived 9, % 7.6% 7.9% 19.1% 2.6% CCG 63, % 8.6% 8.8% 15.9% 2.1% Source: 2013/14 Quality Outcomes Framework Data 68

69 3.7 Harmful use of alcohol as a CVD Risk Factor People who consume alcohol in excessive amounts place themselves at a substantial risk of damaging their health, which in turn places a higher financial burden on the local healthcare economy. The NHS recommends that men should not exceed 3-4 units of alcohol a day and women not more than 2-3units a day. 40 There are approximately 2 units of alcohol in a regular strength (ABV 3.6%) beer, 3 units in a large glass of wine (ABV 12%) and 1 unit in a standard 25ml shot of spirits (ABV 40%). Figure 95 below shows that Peterborough City Council s directly age standardised rate of hospital admissions for alcohol-related cardiovascular disease (all persons) has been statistically significantly higher than the England rate for the six consecutive years spanning 2008/ /14. The Unitary Authority rate has, however, remained relatively consistent over the past there years, during which time the England rate has increased. Figure 92: Alcohol Related Cardiovascular Disease Hospital Admissions, All Persons 2008/ /14 (Directly Age-Standardised Rate per 100,000) 41 1,400 1,200 1, / / / / / /14 Peterborough UA Cambridgeshire & Peterborough CCG England Source: Local Alcohol Profiles for England

70 Admissions Period Peterborough UA Cambridgeshire & Peterborough CCG England 2008/09 1, /10 1,172 1, /11 1,249 1, /12 1,168 1, /13 1,172 1, /14 1,168 1,085 1,049 Source: Local Alcohol Profiles for England Figure 93 shows that Peterborough s admissions rate for all persons and for males is statistically significantly high for each year between 2008/09 and 2013/14. For both all persons and for males only, the Peterborough rate has remained relatively similar for each of the past three years, during which time the rate for England has risen. Figure 93: Alcohol Related Cardiovascular Disease Hospital Admissions, Males, 2008/ /14 (Directly Age-Standardised Rate per 100,000) 2,000 1,800 1,600 1,400 1,200 1, / / / / / /14 Peterborough UA Cambridgeshire & Peterborough CCG England Source: Local Alcohol Profiles for England 70

71 Admissions Period Peterborough UA Cambridgeshire & Peterborough CCG England 2008/09 1,548 1,382 1, /10 1,721 1,503 1, /11 1,864 1,623 1, /12 1,724 1,547 1, /13 1,715 1,553 1, /14 1,703 1,616 1,524 Source: Local Alcohol Profiles for England The rate for females is statistically significantly high in Peterborough for each year between 2008/09 and 2013/14. Within the CCG overall, the rate was statistically significantly high for the three years 2008/ /11 but has been similar to that of England for the most recent three years for which data are available. The admission rate is, however, much lower for females than for males. Figure 94: Alcohol Related Cardiovascular Disease Hospital Admissions, Females, 2008/ /14 (Directly Age-Standardised Rate per 100,000) / / / / / /14 Peterborough UA Cambridgeshire & Peterborough CCG England Source: Local Alcohol Profiles for England 71

72 Admissions Period Peterborough UA Cambridgeshire & Peterborough CCG England 2008/ / / / / / Source: Local Alcohol Profiles for England Figure 95: NICE alcohol guidance PH24 - Alcohol-use disorders: preventing harmful drinking Source: Diabetes as a CVD risk factor Diabetes occurs when the body doesn t produce, or respond to, the hormone insulin which maintains blood glucose. There are 3.2 million people diagnosed with diabetes in the UK and an estimated 630,000 people who have the condition, but don t know it. 42 There are two main types of diabetes: Type 1 diabetes and Type 2 diabetes. In Type 1 diabetes, the cells that produce insulin are damaged by the body s immune system. This usually develop before the age of 40, requires insulin injections and accounts for about 10% of diabetes. Type 2 diabetes accounts for about 90% of cases and is caused when the body doesn t produce enough insulin or the insulin produced doesn t work effectively. It is treated with diet and exercise and often progresses to need drugs or insulin. It is more common with increasing age and in people who are overweight or obese-including a rising number of young people. Ethnicity is a factor in the development of diabetes with South Asians having a 50% higher lifetime risk of Type 2 diabetes than white Europeans and in often develops at a younger age and at a lower level of obesity. Deprived people are 2.5 times more likely to have diabetes on average, at any given age, mostly as deprivation is associated with higher levels of obesity and physical inactivity. The risk in people with a mental illness is also 2-3 times higher than in those without; this is thought to be due to differences in diet and physical activity and also a side effects of drugs which can promote weight gain and affect glucose metabolism. 72

73 There is a strong correlation between cardiovascular disease (CVD) and diabetes. Heart diseases and stroke are the number one causes of death and disability among people with type 2 diabetes. At least 65 percent of people with diabetes die from some form of heart disease or stroke. Adults with diabetes are two to four times more likely to have heart disease or a stroke than adults without diabetes. The American Heart Association considers diabetes to be one of the seven major controllable risk factors for cardiovascular disease. People with diabetes, particularly type 2 diabetes, often have the following conditions that contribute to their risk for developing cardiovascular disease. High blood pressure (hypertension); Abnormal cholesterol and high triglycerides; Obesity; Lack of physical activity/ sedentary lifestyles; Poorly controlled blood sugars (too high) or out of normal range which damages small blood vessels; Smoking; Insulin Resistance. Figure 96: Public Health Outcomes Framework East of England Diabetes Profile Source: Public Health England, East of England Diabetes Profile 73

74 CATCH CAM HEALTH HUNTS HEALTH BORDERLINE PETERBOROUGH ISLE OF ELY HUNTS CARE PARTNERS WISBECH Figure 97: Diabetes Prevalence 2013/14, Cambridgeshire & Peterborough CCG LCGs LCG Number Prevalence LI UI 65+ % 85+ CATCH 7, % 3.9% 4.1% 15.0% 2.1% CAM HEALTH 3, % 4.1% 4.4% 13.9% 2.5% HUNTS HEALTH 3, % 5.6% 6.0% 16.2% 1.9% BORDERLINE 5, % 6.1% 6.4% 16.2% 2.1% PETERBOROUGH 6, % 6.3% 6.6% 12.7% 1.7% ISLE OF ELY 4, % 6.3% 6.7% 18.0% 2.2% HUNTS CARE PARTNERS 6, % 6.4% 6.7% 19.2% 2.4% WISBECH 2, % 7.0% 7.6% 19.8% 2.5% BORDERLINE & PETERBOROUGH LCGs 12, % 6.2% 6.5% 14.3% 1.9% ALL OTHER LCGs 27, % 5.2% 5.4% 16.6% 2.2% CCG 40, % 5.5% 5.6% 15.9% 2.1% Source: 2013/14 Quality Outcomes Framework Data Both Borderline & Peterborough LCGs have statistically significantly high prevalence of diabetes; collectively the prevalence for the two LCGs is 6.3% vs 5.6% across the LCG as a whole. Figure 98: Diabetes Prevalence 2013/14, Cambridgeshire & Peterborough CCG LCGs 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% 4.0% 4.3% 5.8% 6.2% 6.4% 6.5% 6.6% 7.3% Source: 2013/14 Quality Outcomes Framework Data = CCG Value Green = Statistically significantly low in comparison to CCG Blue = No statistical significance in comparison to CCG Red = Statistically significantly high in comparison to CCG 74

75 Figure 99: Diabetes Prevalence 2013/14, Borderline & Peterborough vs All Other LCGs 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% 6.3% Borderline & Peterboruogh LCGs 5.3% All Other LCGs Source: 2013/14 Quality Outcomes Framework Data = CCG Value Green = Statistically significantly low in comparison to CCG Blue = No statistical significance in comparison to CCG Red = Statistically significantly high in comparison to CCG 3.9 Modifiable Risk Factors - Population Level Interventions These are interventions also focusing on modifiable risk factors but at population-level which could lead to further substantial reduction in cardiovascular disorders. These can be achieved in a number of ways but must be supported by national and/or local policies and legislation. The table below summarises NICE guidance Prevention of Cardiovascular Disease (PH25) recommendations for policy. Figure 100: NICE guidance Prevention of Cardiovascular Disease (PH25) Issue Summary of rationale Policy Goal Salt High levels of salt in the diet are linked with high blood pressure which, in turn, can lead to stroke and coronary heart disease. High levels of salt in processed food have a major impact on the total amount consumed by the population. To reduce population-level consumption of salt. Saturated Fats Reducing general consumption of saturated fat is crucial to preventing CVD. To reduce population-level consumption of saturated fats including the continued promotion of semi-skimmed milk for children aged over 2 years. 75

76 Trans fats Marketing and promotions aimed at children and young people Commercial Interests Product labelling Health impact assessment Physically active travel Industrially-produced trans fatty acids (IPTFAs) constitute a significant health hazard. Eating and drinking patterns get established at an early age so measures to protect children from the dangers of a poor diet should be given serious consideration. If deaths and illnesses associated with CVD are to be reduced, it is important that food and drink manufacturers, retailers, caterers, producers and growers, along with associated organisations, deliver goods that underpin this goal. Clear labelling which describes the content of food and drink products is important because it helps consumers to make informed choices. It may also be an important means of encouraging manufacturers and retailers to reformulate processed foods high in saturated fats, salt and added sugars. Policies in a wide variety of areas can have a positive or negative impact on CVD risk factors and frequently the consequences are unintended. The Cabinet Office has indicated that, where relevant, government departments should assess the impact of policies on the health of the population. Travel offers an important opportunity to help people become more physically active. However, Ensure all groups in the population are protected from the harmful effects of IPTFAs. This includes establishing guidelines for local authorities to monitor independently IPTFA levels in the restaurant, fast-food and home food trades using existing statutory powers (in relation to trading standards or environmental health). Ensure children and young people under 16 are protected from all forms of marketing, advertising and promotions (including product placements) which encourage an unhealthy diet. Ensure dealings between government, government agencies and the commercial sector are conducted in a transparent manner that supports public health objectives. Evidence shows that simple traffic light labelling consistently works better than more complex schemes and should be encouraged. Use a variety of methods to assess the potential impact (positive and negative) that all local policies and plans may have on rates of CVD and related chronic diseases. Take account of any potential impact on health inequalities. Ensure guidance for local transport plans supports physically active travel. This can be achieved by 76

77 inactive modes of transport have increasingly dominated in recent years. allocating a percentage of the integrated block allocation fund to schemes which support walking and cycling as modes of transport. Create an environment and incentives which promote physical activity, including physically active travel to and at work. Public sector catering guidelines Public sector organisations are important providers of food and drink to large sections of the population. It is estimated that they provide around one in three meals eaten outside the home. Hence, an effective way to reduce the risk of CVD would be to improve the nutritional quality of the food and drink they provide. Consider and address factors which discourage physical activity, including physically active travel to and at work. An example of the latter is subsidised parking. Ensure publicly funded food and drink provision contributes to a healthy, balanced diet and the prevention of CVD. Ensure public sector catering practice offers a good example of what can be done to promote a healthy, balanced diet. Take-aways and other food outlets Food from take-aways and other outlets (the 'informal eating out sector') comprises a significant part of many people's diet. Local planning authorities have powers to control fast food outlets. Encourage local planning authorities to restrict planning permission for take-aways and other food retail outlets in specific areas (for example,within walking distance of schools). Help them implement existing planning policy guidance in line with public health objectives. Monitoring CVD is responsible for around 33% of the observed gap in life expectancy among people living in areas with the worst health and deprivation indicators compared with those living elsewhere in England. Independent monitoring, using a full range of available data, is vital when assessing the need for additional measures to address such health inequalities, including those related to CVD. Use available data to assess the need for additional measures to address health inequalities related to CVD. 77

78 4 Services for Cardiovascular Disease 4.1 Health Checks in Primary Care Everyone aged who is does not have a pre-existing condition is eligible for an NHS Health Check every five years to identify those with risk factors for cardiovascular and kidney disease and diabetes. Older people, aged over 65 years, are provided with information on the signs and symptoms of dementia and on local services. Figure 101: Observed Number of People Invited for an NHS Health Check Q1 2013/14 Q3 2014/15 43 Source: Public Health Outcomes Framework Indicator 2.22iii 22,462 people have now been invited for an NHS Health Check in Peterborough; 45.8% of the eligible population. This figure is statistically significantly better than the percentage observed in England overall which stands at 33.1%. However, the proportion taking up the tests remains disappointing. Only 10,769 eligible people in Peterborough took up an NHS Health Check in 2014/5, 47.9% of the total of invites (22,462). This number is statistically similar to England; in the previous six periods of measurement, Peterborough has been statistically significantly worse than England with regards to converting invitations in to Health Checks. Figure 102: Outcome of NHS Heath Checks, Tackling Inequalities in Coronary Heart Disease programme update 3, May

79 In 2013/14, Peterborough planned to undertake health checks on 6,059 registered patients aged All 25 GP practices participated in the programme with individual targets supported by clinical coaching and Public Health events across all communities. The programme has achieved 99.7% of the target (6042 completed checks against a target of 6059). This is 12% increase on the number of completed health checks compared to the 2012/13 programme. Based on national and regional statistics Peterborough city council is 22nd out 151 LAs and second across Eastern LAs. This is an excellent effort from all GP practices working in partnership with the local authority to reduce the prevalence of chronic disease. Specific outcomes for Peterborough include: 777 patients assessed with a CVD risk of more than 20% (10 year risk of developing a chronic disease. 164 Hypertensive patients identified (high blood pressure) 54 Diabetics diagnosed 495 patients referred to weight management programmes 1840 patients received dementia awareness advice 2003 patients received Alcohol Audit C assessment 557 patient referred to physical activity programme 471 patients prescribed statins to lower cholesterol 4.2 Hospital Services Quality Standards & National Audit Data The majority of Peterborough residents with cardiovascular conditions are admitted to Peterborough and Stamford Hospitals NHS Foundation Trust. The hospital participates in the national audits of treatments for heart disease and stroke. However, patients with acute chest pain are taken to Papworth Hospital, the specialist cardiac hospital. Peterborough doesn t offer emergency treatment to restore the blood flow in the coronary arteries and there is some evidence that specialist centres, with high numbers of cases, achieve better outcomes for patients Coronary heart disease (MINAP) MINAP, the Myocardial Ischaemia National Audit Project, analyses data from ambulance and hospital services on the process and outcomes of care to inform the public, clinicians and commissioners on the quality of local care by publishing an annual report. Heart attack or myocardial infarction is part of a spectrum of conditions know as acute coronary syndrome. The term includes both ST-elevation myocardial infarction (STEMI- named for the ECG changes seen ) where emergency re-perfusion of the coronary arteries with primary percutaneous 79

80 intervention (PCI) or thrombolytic drugs is indicated in eligible patients; and non-st-elevation myocardial infarction (nstemi) which is more common and requires different treatment. The vast majority of patients (99.8%) with STEMI admitted to Papworth, (not just Peterborough residents) received primary PCI in (1) and 30 day mortality unadjusted rates were below the national average (6.3% vs 7.2% in primary PCI capable centres, ). (1) Data for non-stemi patients is more likely to be incomplete, particularly if they are not admitted to a cardiac ward. In Peterborough, as in England, 94% were seen by a cardiologist or a member of their team. Of those admitted to Peterborough hospital, all who were eligible were referred for angiography with increasing numbers receiving this during their admission. 80

81 Figure 103: Primary PCI in hospitals in England, Wales and Belfast (extract of local data) Source: MINAP National Clinical Audit

82 Use of secondary prevention medication after the acute admission is proven to improve outcomes for patients with either STEMI or n-stemi by reducing the risk of a further heart attack or complications such as heart failure. NICE Clinical Guidance 48 supports the use of combinations of drugs in all eligible patients who have had a heart attack. The audit also collects information on the percentage of patients with an acute coronary syndrome and eligible for each secondary prevention medication who are discharged on that treatment. (Patients are not included if they die, are transferred to another hospital, are not eligible for a medication or decline treatment) Figure 104: Secondary prevention medication eligibility, 2012/13 and 2013/14 (extract of local data) Source: MINAP National Clinical Audit

83 Stroke (SSNAP) The Sentinel Stroke National Audit Programme (SSNAP) aims to improve the quality of stroke care by auditing stroke services against evidence based standards, and national and local benchmarks. There are six domains for acute stroke care, each scored into five bands. The total organisational score is obtained by calculating the average of the 6 domain scores, which are divided into bands A- E, with A as the highest performance band. These results reflect the stroke service audit data of July Figure 105: The six domains of stroke services organisation, SNAPP, 2014 Source: Sentinel Stroke National Audit Programme (SNAPP), RCP, regional results, 2014 Local hospitals, including Peterborough and Stamford Hospitals NHS Foundation Trust participate in the audit. Peterborough City Hospital provided acute stroke care, including thrombolysis available 24/7 for eligible patients, a 36 bed stroke unit with access to a range of specialist staff and prompt access to investigate and initiate treatment in high risk transient ischaemic attacks (TIA). 83

84 Figure 106: Stroke national acute organisational audit, east of England, 2014 Source: Sentinel Stroke National Audit Programme (SNAPP), RCP, Regional Results

85 4.2.3 Tackling Coronary Heart Disease inequalities programme Recognising the challenge in inequalities in coronary heart disease, the Peterborough and Borderline LCGs instigated a programme of work to improve population outcomes. The programme had four areas of activity: Smoking cessation Health checks Cardiac rehabilitation Primary care and prevention. Physiological/metabolic risk factors are generally managed in primary care with support from hospital services and clinicians. It was not possible to include information on the management of high blood pressure, hypercholesterolaemia, atrial fibrillation etc. or these services in this JSNA although some data is included in the quality and outcomes framework. Following Peterborough City Council prioritising cardiovascular disease, the programme is reviewing its remit and with a view to including the detection and management of atrial fibrillation, a risk factor for strokes and transient ischaemic attacks. Across Cambridgeshire and Peterborough CCG, the East Midlands Strategic Clinical Network model suggests that 348 strokes and 115 deaths per year could be prevented by optimum management of atrial fibrillation compared to the 134 strokes and 44 deaths per year prevented by current management. Figure 107: Tackling Health Inequalities in Coronary Heart Disease 2015/16 Source: Tackling Inequalities in Coronary Heart Disease Board,