NORTH EAST ESSEX. Joint Strategic Needs Assessment for Clinical Commissioning Group. October 2011

Transcription

1 Embracing better health for all NORTH EAST ESSEX Joint Strategic Needs Assessment for Clinical Commissioning Group October 2011 Public Health Team Vittoria Polito Krishna Ramkhelawon Natacha Bines 1

2 CONTENT Introduction 6 Summary of Key Issues 6 Key Demographics 10 Population & Deprivation 10 Health Inequalities & Life Expectancy 11 Burden of Disease & Preventing Ill-health 12 Disease Prevalence by GP Registers 12 Observed vs Expected Register Sizes for CHD, Hypertension, COPD & Stroke 13 Use of Emergency Care: A&E Attendances & Admissions 14 Predicted Risk Modelling 15 Mortality & Premature Deaths 15 OVERALL ANALYSIS OF SPEND 17 Spend and Outcome 17 Programme Budgeting SPOT Tool Analysis 18 Procedures with Limited Clinical Value 19 COST & QUALITY ANALYSIS BY DISEASE/ CONDITION 20 Cancers & Tumours 20 Expenditure per 100,000 of population 20 Key Indicators for Cancer 20 SMR for Colorectal Cancer & Cervical Cancer 21 SMR v.s Screening uptake(for Cervical cancer) 21 SMR v.s Screening uptake(for Breast cancer) 21 Cancer 2 Week Waiting Times 21 Endocrine, Nutritional and Metabolic Problems 22 Expenditure per 100,000 of population 22 Key Indicators for Endocrine, Nutritional and Metabolic Problems 22 DM - Lower Limb amputations by PCT 23 DM - Percentage of people receiving nine key care processes by PCT 23 DM - Diagnosed v.s Expected prevalence 23 DM SMR (U75) 23 DM - Hospital Admissions (Ketoacidosis) 24 DM - QOF Indicators DM13, DM15, DM17 & DM23 24 Mental Disorders 25 Expenditure per 100,000 of population 25 Key Indicators for Mental Disorders 25 Mental health expenditure per 1, IAPT & CMHT 26 Mental Health Admissions Emergency Admissions for Neuroses, Schizophrenia, Neurotic Conditions 26 Claimants of Incapacity Benefit/Severe Disablement Allowance with MH 27 Dementia QOF DM2 27 Comprehensive Care Plan for Patients on the MH register (MH6) 27 Child & Adolescent Mental Health (CAMH) 27 Problems of Learning Disability 28 Expenditure per 100,000 of population 28 Neurological Problems 28 Expenditure per 100,000 of population 28 2

3 Key Indicators for Neurological Disorders 29 DSR of Emergency Admissions for Epilepsy by PCT 29 Patients with Managed Epilepsy (Epilepsy 8) 29 Problems of Vision 30 Expenditure per 100,000 of population 30 DSR of Cataract Surgery Recorded in Hospital Admissions 30 Problems of Circulation 31 Expenditure per 100,000 of population 31 Key Indicators for Problems of Circulation 31 SMR for Hypertensive Disease (U75) 32 Patients Admitted to Hospital Following a Stroke who Spend 90% on Stroke Unit 32 CABG & PCTA Admissions 32 QOF for Hypertension, BP and Cholesterol 32/33 Hospital Admissions Emergency CHD Admissions per 100 on Disease Register 33 Observed vs Expected Prevalences for CHD, HF, Hypertension & Stroke 33/34 Problems of the Respiratory System 34 Expenditure per 100,000 of Population 34 Key Indicators for Problems of the Respiratory System 35 SMR for Asthma, Bronchitis, Emphysema & Other COPD (U75) 35 Emergency bed-days per 1,000 for COPD 35 Emergency Admissions for Thoracic Medicine 36 Observed vs Expected Prevalence of Asthma & COPD 36 Dental Problems 36 Expenditure per 100,000 of population 36 Problems of the Skin 37 Expenditure per 100,000 of population 37 Problems of the Musculo-Skeletal System & Trauma 37 Expenditure per 100,000 of population 37 Key Indictors for Problems of the Musculo-Skeletal System & Trauma 38 Primary & Revision Hip Replacement 38 PROMS Pre Operative Score for Hip Replacement days readmission rates & 28 days mortality rates 39 Problems of the Genito-Urinary System 39 Expenditure per 100,000 of population 39 Key Indicators for Problems of the Genito-Urinary System 40 Observes vs Expected Prevalence of CKD 40 Use of ACE Inhibitor & ARB Therapy for CKD (CKD 5) 40 Maternity & Reproductive Health 40 Expenditure per 100,000 of population 40 Home Births 41 Healthy Individuals Preventing Ill Health & Immunisation 41 Expenditure per 100,000 of population 41 Smoking Cessation 42 Alcohol Related Admissions & 3 Year Alcohol Related Admission Trend 42 Comparison of Selected Childhood Immunisation Programmes 43 Flu Uptake in 65+ Years 43 3

4 Social Care Needs & Third Sector Commissioning 43 Expenditure per 100,000 of population 43 GMS/PMS & Pharmaceutical Services 44 Expenditure per 100,000 of population 44 Older People: Health & Wellbeing 44 Emergency Admissions in Persons Over 75 years 44 Percentage of Population Providing Unpaid Care 45 End-of-Life Care 45 Percentage of All Deaths in an Area Occurring in Hospital by Local Authority 45 Diagnostic Services 46 Rate of Magnetic Resonance Imaging (MRI) Activity per 1,000 by PCT 46 Rate of Computed Axial Tomography (CT) Activity per 1,000 by PCT 46 Prescribing 47 Ezetimibe Prescribing July-Sept Cephalosporin Prescribing Quinolone items per 1000 Antibacterial STAR(09)-PUs by PCT /Practice ( ) 47 Cephalosporin Prescribing PCT and Cluster comparison ( ) 48 Primvastatin and Simvastatin Prescribing by PCT/ GP practice ( ) 49 Generic Prescribing by PCT/Cluster and GP practice ( ) 49 Conclusion 50 Appendix List of Additional Figures and Tables Map of Deprivation with GPs 51 Procedures with Limited Clinical Value 51 Emergency Appendectomy Admissions 51 Elective Cataract Admissions 51 Tonsillectomy Elective Admissions 51 Hernia Elective/ Emergency Admissions 51/52 Cancers & Tumours 52 SMR from Breast Cancer & U75 52 SMR from Prostate Cancer & U75 52 SMR from Lung Cancer & U75 53 Cancer Bed Days per 1, Emergency Cancer Admissions per 100 on Disease Register 54 Inpatient Expenditure per 1, Endocrine, Nutritional and Metabolic Problems 55 DM Lower Limb amputations in Diabetic Patients 55 Emergency Diabetes Admissions per 100 on Disease Register 55 DM - Hospital Admissions (Ketoacidosis & Coma) 56 DM QOF Indicators: DM12, DM18, DM21 & DM22 56 DSR of bariatric procedures in hospital by PCT v.s Obesity rate 57 Mental Disorders 57 DSR of suicide mortality per 100,000 by PCT (and U75 Mortality) 57 Total Adults Receiving Secondary MH Services (18-69) 57 Hospital Admissions Emergency Hospital Admissions for Schizophrenia 58 4

5 Substance Use Elective and Emergency Admissions 58 Neurological Problems 59 SMR from Epilepsy (and U75 SMR) 59 DSR of Elective & emergency admissions for epilepsy by PCT 59 Problems of Vision 60 Expenditure on phako-emulsification cataract extraction & insertion of lens 60 Problems of Circulation 60 SMR of All Circulatory Diseases by PCT (and U75) 60 SMR for MI (U75) 61 SMR for CHD (U75) 61 SMR for Hypertensive Disease 61 SMR for Stroke (U75) 61 Percentage of TIA cases with a higher risk who are treated within 24 hrs 61 Percentage of Patients with a history of MI, currently treated with ACE inhibitor or Angiotensin II 62 (CHD 11) Percentage of Patients with a history of CHD, with a record of influenza immunisation (CHD 12) 62 Percentage of Patients with TIA of Stroke, with a record of influenza immunisation (Stroke 10) 62 QOF BP for Hypertension (BP5) 62 Emergency Admissions for Acute Hypertensive Disease 62 Elective & Emergency Angiogram Admissions 62/63 Hospital Admissions Emergency AF Admissions per 100 on Disease Register 63 Problems of the Respiratory System 64 Mortality from Bronchitis, Emphysema and Other COPD 64 Mortality from Pneumonia (and U75) 64 DSR for Emergency Admissions for Asthma (U18) 64 Problems of the Musculo-Skeletal System and Trauma 65 Primary Knee Replacement Expenditure per 1,000 Population 65 SMR for Falls (& U75) 65 Mean Pre-Operative EQ-5D Index Score for Knee Replacement 65 Hospital Procedure: Fractured Proximal Femur 66 Hospital Procedure: Primary Knee Replacement 66 Hospital Procedure: Primary Hip Replacement & Revision Hip Replacement 66 Elective Hip and Knee Replacement 66 Mortality from Fracture of Femur (& U75) 67 5

6 INTRODUCTION North East Essex Clinical Commissioning Group (NEECCG) is the overarching consortium that covers Colchester and Tendring, which are coterminous with the local authority boundaries. There are 44 practices in NE Essex, with 24 being located in Colchester and 20 located within Tendring. The needs of each area are quite distinct as both localities have different demographics that are reflected in their health and social care needs. This high-level report summarises some of the key issues facing NEECCG and is linked to information within the overarching Joint Strategic Needs Assessment for Essex, Southend & Thurrock 1 as well as a number of other relevant documents (e.g. Pharmacy Needs Assessment (NA) 2, Dental NA 3, Alcohol Profile 3, GP Profiles 3, Urgent Care NA 3, Carers Health Needs Assessment 3 etc). It provides NEECCG with an opportunity to initiate a debate around the areas of greatest challenge and supports the prioritisation of healthcare needs, areas of joint investment (e.g. integrated care for older people, children services, health improvement services) and suggests some key interventions that are evidence-based. (Please refer to the Public Health Outcomes Evidence Based Practice 4 and the NHS Outcomes Evidence Based Practice 3 documents). SUMMARY OF KEY ISSUES Demographics Colchester and Tendring have distinct population groupings with a much larger ageing population in Tendring and higher level of deprivation. By 2021, the population will grow by around 17% in Colchester and 12% in Tendring and whilst Tendring will see a pronounced drop in <50s (especially in the 15-19yrs group), the populace of NE Essex will see a large growth in people aged >70yrs. Despite an upward trend in life expectancy, there are significant pocket of inequalities clearly related to deprivation, lifestyle choices and poor engagement with statutory agencies. In comparison with the best area, there is still a 5-year gap in men s and 6-year gap in women s life expectancy. Burden of Illness With the growth of an ageing population and the drive to ensure earlier identification of some chronic conditions, we can expect a rise in disease prevalence and consequential increase in demand on health and social care services. Disease Prevalence With the exception of overall mental health conditions (where NE Essex is on par with the national average), Tendring has a higher proportion of patients on their disease registers compared to the national average. Areas where NE Essex practitioners need to improve disease ascertainment include mental health, COPD, diabetes, epilepsy and asthma. Modelling of prevalence based on observed versus expected also suggests a difference in areas such as hypertension. Mortality There still is a significant gap in mortality between Tendring & Colchester, with a significant proportion of premature mortality (people <75yrs) among men in NE Essex. This is further analysed under the sections below. Emergency Hospitalisation The use of A&E service is heavily influenced by the geographical location of this service to the populace hence a higher level of A&E attendances from patients registered to Colchester practices nearer the A&E department. However, Tendring patients are more likely to be admitted which requires further investigation as modelling of hospital admissions based on observed versus expected shows that two thirds of practices would be Colchester practices. Spending on NHS-related Activities there are some discrepancies in how individual PCTs may have allocated some of their expenditure to the list of categories used in the national Programme Budgeting analysis. Therefore, some information provided in this report should be treated with a little caution. Overall Spend The spending across the different disease areas vary widely with some areas needing closer investigation. E.g. a high spend on problems associated with vision and dentistry, albeit with better outcomes, may not be the best use of NHS resources locally. In regards to the spend on gastro intestinal (GI) diseases (very low) and learning disability (very high), NE Essex is an outlier. Whereas, in some areas, such as genito-urinary and neurology, NE Essex have both low spend and poorer outcomes. Procedures of Limited Clinical Value (LCV) Overall NE Essex has seen a gradual reduction in procedures deemed to be of limited clinical value over the past 3 years. However, with some of these interventions costing more than in previous years, this reduction has yielded less saving than anticipated. Myringotomy, Breast surgery and Wisdom Teeth extraction are areas still with a high intervention rate. Primary v. Secondary Care - NE Essex has one the highest spend in primary care for problems associated with vision, learning disability, cancers, neurology, GI, neonatal care, maternity/reproductive health and circulatory conditions To be uploaded on to Essex Insight

7 Cancers & Tumours Despite a comparably low incidence of some cancers (e.g. lung cancer) and lower use of hospital beds, NE Essex is in the top quintile for spend. Cancer mortality is lower than the national average. Better prevention (mainly tackling lifestyle behaviours), increasing the uptake of screening programmes (e.g. cervical screening variation in GP practices) and prompt diagnostics can further reduce the incidence and need for emergency hospital admissions. The 2-week waiting times is generally better than average, but we note a downward trend in the past 15 months. Broader actions should include: Smoking prevention and cessation Promotion of 5-a-day fruit and vegetable consumption Alcohol reduction and signposting/ referring problem drinkers Skin cancer reduction initiatives Targeted promotion of cancer screening programmes in areas with low uptake Maximise domiciliary/community support & treatment Endocrine related - Diabetes This is an area of lower spend and if we focus on diabetes, we have a higher level of premature mortality and morbidity rates. Better management in primary care such as ACE inhibitor therapy and better managed hyperglycaemia will improve health outcomes and reduce hospitalisation rates. Investing in an evidenced-based health improvement programme (e.g. lifestyle advice, individual support) will help manage lifestyle issues. Primary care should aim to achieve a reduction in HbA1c ( to 8%) and delay complications associated with diabetes. Broader actions should include: All ages obesity strategy with defined pathway High quality diabetic retinopathy screening with high uptake Promote self-confidence to improve self-management Diabetes ascertainment to increase earlier diagnosis Dissemination, implementation and monitoring of National Institute for Health & Clinical Excellence (NICE) guidance Improve primary care management of blood pressure (BP) Mental Health Problems Marginally lower spend than average but with significantly high level of hospital admissions and neurotic conditions (especially depression). NE Essex compares unfavourably in regards to the completion of comprehensive care plan for known mental health patients. The 10-yr projected increase in dementia prevalence is expected to reach 38%. There has been little change in the level of access to Community Mental Health Teams (CMHT) despite projected increases in prevalence highlighted in the Essex JSNA 1 in 2008 and increases in hospitalisation. The level of access to therapeutic intervention, such as Improving Access to Psychological Therapies (IAPT), requires closer scrutiny as NE Essex is not performing as well as some other PCTs. Broader actions should include: Promote physical activity and make better use of Health Trainers Increase referral to e.g. talking therapies Ensure better case management to reduce demand & improve outcomes Support flexible employment opportunities to prevent relapses Better support for carers will be beneficial Learning Disabilities This is an area with a significantly high spend (one of the highest nationally) with Colchester and Tendring having a larger than average groups of people with learning disabilities. Good collaborative working is required to minimise poor health and social care outcomes, especially for those who have more challenging needs and may require intensive care. Broader actions should include: Ensure good access to antenatal screening and genetic advice Improve community care and carers support & respite care Neurological Conditions Lower level of spend in this area may be masking poor management of patients (e.g. epilepsy) which impacts on quality of life. Neurological disorders are often chronic and intractable, so the aim is to minimise hospital attendance in favour of community interventions. The growth in an ageing population will impact on this area of spend. Eye & Vision This is an area of high spend and highest in Primary Care nationally. Commissioners will need to review the opportunity cost of spending on this programme. It is important that the NHS aims to delay the average age of onset of loss of visual acuity in patients with hypertension, diabetes and glaucoma. Circulatory Diseases Spend in this area is below average but the associated mortality rates continue to improve and are significantly better than average, except premature mortality in men. However, we have below average performance in the management of patients on the relevant cardio vascular disease (CVD) registers, especially around the management of BP and cholesterol levels in stroke and coronary heart disease (CHD) patients (may be considering further stretched Quality & Outcome Framework (QOF) targets?). Consistent and effective lifestyle interventions will improve management of these patients. We have a high rate of coronary artery bypass graphs (CABG) and its additional cost can be justified only if it offers 7

8 continuing benefit at no further increase in cost relative to percutaneous transluminal coronary angioplasty (PTCA). Broader actions should include: Smoking prevention and cessation Promotion of physical activity at all ages Improve management of high BP and cholesterol Secondary prevention following angina, myocardial infarction (MI) and stroke Dissemination, implementation and monitoring of NICE guidance Improve uptake of flu immunisation programme for at risk groups Redeploy resources from lower cost-effectiveness interventions Respiratory Diseases Generally good services being delivered with better than average health outcomes. This area has a high level of GP prescribing reflecting the importance of primary care in care management and the capacity to keep people out of hospital by focusing on prevention, treatment and rehabilitation. However, we have the third highest prevalence of chronic obstructive pulmonary disease (COPD) in region with 30% expected to be undiagnosed. We also have significantly higher emergency admission & readmissions, and bed utilisation rates nationally. Early disease ascertainment and the management of childhood respiratory conditions are crucial and will also positively impact on the use of ambulances. Broader actions should include: Smoking prevention and cessation Promotion of physical activity at all ages Disease ascertainment and improved management Regular lung function testing in primary care for patients with COPD Dissemination, implementation and monitoring of NICE guidance Improve uptake of flu immunisation programme for at risk groups Promote pulmonary rehabilitation and explore partnerships outside the NHS, e.g. leisure centres Dental/Oral Health This is an area of high spend with good health outcomes. NE Essex has one of the lowest rates of dental decay and good access to NHS dentistry. Whether the current level of investment is necessary and sustainable, needs to be debated. Good health promotion work must be sustained, especially with families with young children. Skin Conditions This is an area of relatively higher spend in primary care. There is a balance to be struck between managing the common skin problems such as eczema, dermatitis and psoriasis with the appropriate balance of primary care, community and specialist services. Broader actions should include: Awareness campaign on sun safety and the risk associated with tanning Implement new quality standards 5 Dissemination, implementation and monitoring of NICE guidance Musculo-skeletal Conditions - With the rising number of revisions of joint replacement from earlier years coming through, and the growing problem of obesity leading to arthritis and the projected increase in falls leading to a fracture neck of femur (NOF), the spend is likely to rise. More attention should be given to risk factors for osteoporosis (primary & secondary prevention Re: NICE guidance) and fracture. This is an area where broad partnerships and collaboration with prevention (e.g. falls, physical activity) and rehabilitation (e.g. mobility) should be promoted. We need to review priorities in terms of hip/knee interventions and clinical behaviour in regards to procedures undertaken (e.g. cemented v. uncemented arthroplasty). NE Essex has a significantly high rate of emergency admissions for hip replacement. Broader actions should include: Review and further develop integrated falls prevention programme Promotion of non-weight bearing physical activity Identify and tackle risk factors for osteoporosis and fractures Dissemination, implementation and monitoring of NICE guidance Support for long-term carers Genito-Urinary Conditions This is an area of lower spend but requires improved ascertainment of chronic kidney disease (CKD) and better management in primary care to prevent early complication/ renal failure. Continue to improve prevention around sexually transmitted infections (STIs) and review local service configuration to maximize STI screening opportunities. Broader actions should include: Better management of diabetes and hypertension to prevent renal failure Provide good sexual health prevention work in primary care Promote uptake of chlamydia screening programme for people aged 15-24yrs Better assessment and support for patients with incontinence 5 Quality Standards for Dermatology, Primary Care Commissioning, July

9 Maternity & Reproductive Health An area of high spend with high teenage and unwanted pregnancies, comparatively lower levels of home births and breastfeeding. More prevention should be undertaken and antenatal and postnatal care needs to be reviewed to minimise complications arising from childbirth. Broader actions should include: Improving access to barrier protection, long acting reversible contraception (LARC) and emergency hormonal contraception (EHC) Social marketing and multi-agency engagement in promoting breastfeeding Smoking cessation in pregnant women Reduce level of caesarean sections Healthy Individuals NE Essex has a higher spend in this area but this investment is still considerably lower than other areas. The national immunisation programme provides both protection for the population as well as reducing morbidity and mortality rates. NE Essex has seen an increase in childhood immunisation in 2011 but more sustained efforts are required to ensure that we achieve a appropriate level of herd immunity. The average flu jab uptake (for those aged 65+) has been consistently lower that the proposed national target of 75%. However, with the group of at-risk patients, the uptake has been consistently high (90%+). Better targeting of pregnant women from is expected. In regards to the challenge of tackling health behaviours, NE Essex has been very proactive in implementing targeted prevention programmes but these must be sustained to have a medium to longer term impact. However, much effort is required to tackle the continuing rise in alcohol-related morbidity and hospital admissions. Social Care Needs The evidence suggests that collaborative working around carers support, community development and improved engagement with the third sector will promote innovative approaches in prevention work, support improved productivity and can contribute to significant savings to health and social care spend. Older People Health & Well-being People aged 65+ living on their own are the highest users of statutory services and this age group will increase by 44% by Tendring has the highest rate of unpaid carers (c. 6,500) in Essex and two thirds of people with dementia are looked after by unpaid carers. The growth in the ageing population will translate into additional pressure on all services, especially with an increase in neurological, circulatory, endocrinology, respiratory and mental health conditions. End of Life Care The aim should be to achieve higher rates for patients dying at their place of choice (e.g. at home) and this requires collaborative working and good planning. Tendring has a significantly higher level of deaths happening in hospital, with Colchester just below the national average. With nearly 40% of hospital deaths not having needed medical help, it is important that we review local policies and procedures and ensure we respond better to patients choice. Prescribing There are a number of indicators that can be used to measure or monitor prescribing in primary care. Areas of poor performance should be investigated and clinicians are encouraged to improve their practices so as to ensure patients are receiving optimal care, minimising the over-prescription of antibiotics and for overall cost-reduction measures. We must also ensure we minimise medicine waste. Broader actions should include: Targeted practice-level interventions Targeted social marketing initiatives Systematic monitoring of the level of patient and medicine reviews NEECCG needs to consider the introduction of innovative interventions, such as the use of assistive technology (e.g. pill dispenser project for people with dementia), which will require a level of adaptability to ensure maximum gain for our target population. 9

10 KEY DEMOGRAPHICS Population & Predicated Rise o In April 2011, the GP registered population of NE Essex was 320, % males and 51% females. o The district level population was 182,475 in Colchester and 137,698 in Tendring. o The population trees (Figs 1 & 2) show the age composition for the two districts: Age Group Figure 1: Colchester Population Colchester GPC Population - April % of Total Population Colchester Males Colchester Females NE Essex Males NE Essex Females Figure 2: Tendring Population Age Group Tendring GPC Population - April % of Total Population Tendring Males Tendring Females NE Essex Males NE Essex Females o o The population of Colchester is expected to rise from 184,900 in 2011 to 215,900 in a 17% increase. The population of Tendring is expected to rise from 152,400 in 2011 to 170,800 in a 12% increase. Tendring is expected to see a decline in people aged years & years; with rises in both areas for people aged 70 plus. Level Of Deprivation Deprivation is commonly linked with poorer health and social care outcomes and increased risk of premature mortality. Figure 3 shows a proxy practice level deprivation score based on the index of multiple deprivation (IMD) Using a number of other measures, we have also shown a proxy measure of needs by GP practice (figure 4). Figure 3: IMD at GP Practice 8 Figure 4: Needs Score by Practice 9 IMD2010 GP Deprivation Score Calculated Needs Score Colchester Practices Tendring Practices 2.00 Deprivation Score (High Score=High Deprivation) Need Score (1=average need) Colchester Practices Tendring Practices 0.00 F81028 F81133 F81636 F81736 F81012 F81067 F81094 F81716 F81069 F81044 F81757 F81746 F81115 F81679 F81116 F81109 F81633 F81026 Y02646 F81005 F81141 F81606 F81021 F81672 F81091 F81213 F81095 F81042 F81157 F81079 F81129 F81221 F81017 F81077 F81019 F81670 F81018 F81741 Y00484 F81052 F81156 F81037 F81212 F F81069 F81115 F81067 F81012 F81736 F81633 F81028 F81716 F81109 F81116 F81094 F81213 F81606 F81044 F81133 F81042 F81005 F81757 F81141 F81679 F81026 F81095 Y02646 F81079 F81670 F81157 F81221 F81672 F81091 F81018 F81636 F81052 F81021 F81019 F81746 F81017 F81077 F81129 Y00484 F81741 F81156 F81037 F81212 F81681 Source: Index of Multiple Deprivation, 2010 and Exeter Download of registered Source: calculated in house in NE Essex PCT Health Inequalities & Life Expectancy The greatest number of years of life lost is due to behaviours associated with a higher risk of developing heart disease, stroke, lung cancer, chronic pulmonary disease, mental health disorders and liver disease. Many of the risk factors associated with these conditions are lifestyle based. Inequalities in health are also influenced by the wider socio-economic factors, the environment, employment & education. The upward trend in life expectancy (figure 5) is masking a widening of the gap in inequalities between the most deprived and the least deprived populations of North East Essex (figure 6). 6 GP registered population, taken from Open Exeter Sub National Population Projections, Office of National Statistics 8 Calculated from IMD 2010 and patient postcode 9 Calculated using IMD, population aged 75+, under 75s SMR, DLA & Incapacity Benefit claimants 10

11 Figure 5: Life Expectancy in N. East Essex Life Expectancy (Years) Life Expectancy Trends 2004/ / / /09 Year (Pooled) Colchester Males Tendring Males Colchester Females Tendring Females Figure 6: Relative inequality across N. East Essex NORTH EAST ESSEX PCT Relative inequality: Person Relative Difference All age, all cause mortality 60% 50% 40% 30% 20% 10% 0% Most deprived vs Least deprived Most deprived vs All other (80/20) Most deprived vs Area average Table 1 shows the difference in life expectancy against the best PCT is 5.2yrs for men and 6yrs for women. Locally Pier ward within Tendring has the 7 th lowest life expectancy in England. Table 1: Life Expectancy across N.East Essex Best LA Colchester Tendring Worst LA Best PCT NEEPCT Worst PCT Males Females

12 BURDEN OF DISEASE & PREVENTING ILL-HEALTH This section provides an overall summary for North East Essex. More detailed information will be shown for the individual disease areas in later sections. Disease Prevalence Table 2 shows the current prevalence and number of patients on the disease registers compared to England for selected conditions. Early identification of at risk patients and better management of chronic conditions will enhance and improve quality of life, increase life expectancy and reduce costs by preventing hospital admissions. Table 2: Disease Prevalence by GP Registers (QOF) Disease register (QOF ) ENGLAND NE ESSEX PCT (All Practices) COLCHESTER Practices Only TENDRING Practices Only CHD Heart Failure Stroke or TIA Hypertension Diabetes (aged 17+) COPD Epilepsy (aged 18+) Hypothyroidism Cancer Palliative Care Mental Health Asthma Dementia Heart Failure due to LVD Depression (aged 18+) Chronic Kidney Disease (aged 18+) Atrial Fibrillation Obesity (aged 16+) Learning Disabilities Count Count Count Count Count Count Count Count Count Count Count Count Count Count Count Count Count Count Count 1,885, , ,819 7,321,472 2,338, , ,001 1,603, ,623 74, ,223 3,254, , ,654 4,648,287 1,817, ,965 4,634, ,064 12,645 2,813 5,867 49,227 14,656 5,442 2,175 13,403 5, ,537 19,499 1,555 1,369 22,157 14,263 5,669 28,964 1,726 5,576 1,230 2,579 23,198 6,600 2,228 1,089 6,508 2, ,431 10, ,651 7,439 2,578 14, ,069 1,583 3,288 26,029 8,056 3,214 1,086 6,895 2, ,106 9, ,506 6,824 3,091 14, Key The same as England Prevalence Prevalence Prevalence Prevalence Prevalence Prevalence Prevalence Prevalence Prevalence Prevalence Prevalence Prevalence Prevalence Prevalence Prevalence Prevalence Prevalence Prevalence Prevalence 3.4% 0.7% 1.7% 13.4% 5.4% 1.6% 0.8% 2.9% 1.4% 0.1% 0.8% 5.9% 0.5% 0.4% 10.9% 4.3% 1.4% 10.5% 0.4% 3.9% 0.9% 1.8% 15.2% 5.6% 1.7% 0.8% 4.1% 1.6% 0.1% 0.8% 6.0% 0.5% 0.4% 8.6% 5.6% 1.7% 11.0% 0.7% 3.0% 0.7% 1.4% 12.5% 4.5% 1.2% 0.8% 3.5% 1.3% 0.1% 0.8% 5.6% 0.4% 0.3% 6.7% 5.2% 1.4% 9.6% 0.6% 5.1% 1.1% 2.4% 18.7% 7.1% 2.3% 1.0% 5.0% 1.9% 0.1% 0.8% 6.5% 0.6% 0.5% 11.2% 6.1% 2.2% 12.7% 0.7% Lower than England Higher than England In Tendring practices, 17 out of the 19 disease areas had a higher prevalence than the England average while in Colchester there are only 3 disease areas that were higher than the England average. In subsequent sections we will investigate and compare the current prevalence of diseases on the local registers with the expected prevalence based on national measures. Modelling of Disease Prevalence & QOF Registers In comparison to the rest of England, North East Essex GP practices are very effective in ascertaining poor health in the local population (figure 7). Depression is a marked exception with concerns also with COPD, Epilepsy, Mental Health, and Asthma. 12

13 Figure 7: NE Essex Disease/Condition Prevalence against England average Key: England Key: Significantly higher than England average Not significantly different from England average Significantly lower than England average No significance can be calculated Regional Key: Indicator Local Number Local Value Eng Avg Eng Lowest England Range Eng Highest 1 Coronary Heart Disease Heart Failure Stroke or TIA Hypertension DM COPD Epilepsy Mental Health Asthma Dementia Depression CKD Atrial Fibrillation Obesity Learning Disabilities However, using modelled estimates at a local level, a comparison of the observed QOF register sizes and expected register sizes for CHD, Hypertension, COPD and Stroke by practice, shows a significant gap in patient identification: Value of 0% means observed= expected; above 0% means observed= higher than expected; below 0% means observed= lower than expected). Figure 8: CHD Observed v. Expected Register Size Observed Number on Register Relative to Expected Coronary Heart Disease NE Essex Practices Observed = Expected 95% CI 99% CI + 60% + 50% + 40% + 30% + 20% + 10% 0% 10% 20% 30% 40% Expected Number on Register Source: QOF CHD Register & ERPHO Modelled Estimates, 2009 Figure 9: Hypertension Observed v. Expected Register Size Observed Number on Register Relative to Expected Hypertension NE Essex Practices 95% CI 99% CI + 30% + 20% + 10% 0% 10% 20% 30% 40% 50% 60% 70% Expected Number on Register Source: QOF Hypertension Register & ERPHO Modelled Estimates, 2009 Figure 10: COPD Observed v. Expected Register Size COPD NE Essex Practices Observed = Expected 95% CI 99% CI + 60% Figure 11: Stroke/TIA Observed v. Expected Register Size Stroke NE Essex Practices Observed = Expected 95% CI 99% CI + 50% Observed Number on Register Relative to Expected + 40% + 20% 0% 20% 40% 60% 80% Observed Number on Register Relative to Expected + 30% + 10% 10% 30% 50% 100% Expected Number on Register Source: QOF COPD Register & ERPHO Modelled Estimates, % Expected Number on Register Source: QOF Stroke Register & ERPHO Modelled Estimates, 2009 Table 3 shows the projected prevalence of certain conditions over the next 10 years by district. This shows the rising burden of disease within the local population and more significant in Tendring. 13

14 Table 3: Estimated Prevalence of Specific Conditions by Local Authority 10 Colchester Tendring Estimated Disease Prevalence Prevalence of CHD (persons 16+) 4.7% 4.7% 4.9% 8.8% 9.2% 9.6% Prevalence of COPD (persons 16+) 2.7% 2.7% 2.8% 4.2% 4.3% 4.5% Prevalence of hypertension (persons 16+) 27.9% 28.0% 28.4% 39.3% 40.2% 41.1% Prevalence of stroke (persons 16+) 2.1% 2.1% 2.2% 3.7% 3.9% 4.1% Use of Emergency Care: A&E Attendances & Admissions The geographical location of A&E appears to influence service utilisation as illustrated in figures 12 &13. People registered in Colchester are more likely to use A&E facilities but patients are more likely to be admitted if they are from Tendring - top 4 practices with admissions via A&E are from Tendring residents. Figure 12: Emergency Admission Attendances by GP Practice 11 Figure 13: A&E Admissions by GP Practice 11 Emergency Admission Attendances (Q1 & Q2) A&E Admissions (Q1 & Q2) National East of England SHA NE Essex PCT National East of England SHA North East Essex PCT Colchester Practices Tendring Practices 350 Colchester Practices Tendring Practices 100 Standardised Rate per 1, Standardised Rate per 1, F81077 F81141 F81026 F81670 F81157 F81606 F81213 F81021 F81044 F81052 F81019 F81633 F81221 F81156 F81018 F81028 F81116 F81017 F81757 F81037 F81736 F81133 F81115 F81012 F81212 Y0264 F81741 F81094 F81067 F81681 F81636 F81716 F81005 F81042 F81091 F81746 F81079 F81069 F81129 F81109 F81679 F81672 F81095 Y F81141 F81044 F81606 F81028 F81077 F81026 F81012 F81115 F81670 F81757 F81633 F81094 F81636 F81213 F81157 F81005 F81133 F81091 F81221 F81017 F81021 F81736 F81042 F81018 F81716 F81156 F81116 F81067 F81079 F81019 F81109 F81746 F81679 Y0264 F81672 F81129 F81095 F81069 F81052 Y0048 F81741 F81212 F81037 F81681 Source: NHS Comparators Source: NHS Comparators Emergency Admissions Using Poisson regression modelling, we can predict the number of emergency admissions expected by practices as (figure 14). The 21 practices outside of the funnel s doted lines are either seeing a higher (top half) or lower number of emergency admission than predicted. The nine practices with higher than expected emergency admissions may need to review why this is happening locally, as six of these are in Colchester and relatively close to the A&E department. Figure 14: Actual vs. Expected Emergency Admissions by NE Essex s GP Practices 10 Disease prevalence models, APHO 11 NHS Comparators 14

15 Predictive Risk Modelling (PRM) for Hospital Admissions The use of PRM can highlight the likelihood of hospital admissions of Colchester and Tendring patients. Based on admissions data over the last 3 years, patients resident in NEE have been grouped based on their modelled likelihood of having a hospital admission over the next 2 years. Tendring (78.3%) has a lower proportion of low risk patients, with a greater proportion (21.7%) than Colchester (18.7%) of high risk, medium risk and very high risk patients. Table 4: Likelihood of admissions from Colchester and Tendring over the next 2 years Tendring Colchester Total % of % of Number of Number of Number of % of those those at those at people people people at risk* risk* risk* Low risk 107, % 148, % 256, % Medium risk 22, % 25, % 48, % High risk 6, % 7, % 14, % Very high risk % % 1, % Source: Sussex Health Informatics modelling of North East Essex Patient Risk, August 2011 * - Includes 1% error margin Social Care Need Modelling Table 5 shows the percentage of the NEE 2011 population with different levels of social care needs. Table 5: Estimated percent of 2011 NEE population with social care needs Measure Number of people 2011 % of population No needs 250, % Moderate needs 24, % High needs 17, % Very high needs % Total 314,470 Source: Essex Planning 4 Care, 2011 The proportion of the population who are at risk of admission is very similar to those who have social care needs. However, there are more people with high risk social care needs who are more likely to use A&E. This is possibly reflective of numbers with continuing care needs due to disability, who with good care packages will not be at risk of emergency admission. Mortality & Premature Deaths There is still a significant gap in mortality between districts/pcts and the gap in Tendring is wider (table 4). A significant proportion of premature mortality is among men (table 5). Table 6: All Age All Cause Mortality Standardised Rate per 100,000 ( ) Best LA Colchester Tendring Worst LA Best PCT NEEPCT Worst PCT Males Females Persons

16 Table 7: Absolute Difference in Mortality between PCTs & East of England (EoE) significantly worse than EoE not significantly different EoE significantly better than EoE Under-75 All Cause Mortality (DSR in years) PERSONS MALES FEMALES LUTON PCT SOUTH EAST ESSEX PCT BEDFORDSHIRE PCT EAST & NORTH HERTS PCT WEST HERTFORDSHIRE PCT PETERBOROUGH PCT CAMBRIDGESHIRE PCT NORFOLK PCT GT YARMOUTH & W. PCT SUFFOLK PCT WEST ESSEX PCT NORTH EAST ESSEX PCT MID ESSEX PCT SOUTH WEST ESSEX PCT

17 OVERALL ANALYSIS OF SPEND Spend and Outcome It should be noted that even though NE Essex are spending less in a number of areas (such as neurological disease and GUM), this is likely to be at the expense of good health outcomes (Figure 15). Respiratory disease is an area where there has been little increase in investment between and and this has seen a worsening in health outcomes (figure 15). However, in comparison to our cluster, more specifically investment in the improvement of our COPD service has had a positive health outcome (figure 16). Figure 15: Programme Budgeting Analysis Comparative Spend for NE Essex vs. other PCTs North East Essex PCT 2009/10 Spend and Outcome relative to other PCTs in England Lower Spend, Better Outcome Higher Spend, Better Outcome Trauma Health Outcome Z Score Gastro Pois Resp GU Dent Inf Hlth Circ MH Mat Blood,End,Musc,Neo Hear,Skin,Soc Neuro Canc Vision LD Lower Spend, Worse Outcome Higher Spend, Worse Outcome Spend per head Z Score High investments in community services (e.g. ophthalmology and dentistry) as well as maternity services may have yielded better outcomes, but these need to be reviewed in line with other disease areas which have a higher impact on overall morbidity and mortality rates. Primary v. Secondary Care Spend NE Essex has one the highest spend in primary care for problems associated with vision, learning disability, cancers, neurology, GI, neonatal care, maternity/reproductive health and circulatory conditions. With the exception of spend on maternity/reproductive health, cancers and learning disability, the corresponding spend in secondary care was amongst the lowest nationally (table 8). Table 8: Spending in Primary and Secondary Care across NE Essex ( ) Programme Budgeting Category North East Essex PCT Expenditure million per 100,000 population Primary care Secondary care Expenditure National rank % Share Expenditure National rank % Share 01 Infectious diseases % % 02 Cancers and tumours % % 03 Disorders of blood % % 04 Endocrine, nutritional and metabolic problems % % 05 Mental health disorders % % 06 Problems of learning disability % % 07 Neurological % % 08 Problems of vision % % 09 Problems of hearing % % 10 Problems of circulation % % 11 Problems of the respiratory system % % 12 Dental problems % % 13 Problems of the gastro intestinal system % % 14 Problems of the skin % % 15 Problems of the musculoskeletal system % % 16 Problems due to trauma and injuries % % 17 Problems of the genito urinary system % % 18 Maternity and reproductive health % % 19 Conditions of neonates % % 20 Adverse effects and poisoning % % 21 Healthy individuals % % 22 Social care needs % % 23 Other % % 23a GMS/PMS % % 23x Miscellaneous Other % % Total expenditure % % 17

18 Figure 16: Programme Budgeting SPOT Tool Analysis North East Essex PCT Prospering Smaller Towns Lower spend z score ** Higher spend Worse outcome Better outcome PCT 08/09 PCT 09/ /10 values ONS Cluster SHA England Notes Overall Overall spend per weighted head of population 1,481 1,551 1,655 1,642 1,681 All age all cause mortality Deprivation Slope Index of Inequality in Life Expectancy (males) Slope Index of Inequality in Life Expectancy (females) Cancers and Tumours Cancer spend per weighted head of population Mortality from all cancers, DSR*, under 75 years % cancer patients receiving treatment within 2 months 97% 83% 86% 86% 86% 3 Mental Health Mental Health spend per weighted head of population % CPA* follow-up within seven days 98% 98% 93% 90% 93% 3 Mortality from suicide and undetermined injury, DSR* Neurological Disease Neurological spend per weighted head of population Mortality from epilepsy, DSR*, under 75 years Circulation Circulation spend per weighted head of population Mortality from circulatory diseases, DSR*, under 75 years Patients with CHD whose last blood pressure < 150/90 89% 89% 90% 90% 90% 4 Respiratory Disease Respiratory spend per weighted head of population Mortality from Bronchitis, Emphysema & COPD*, DSR*, u Gastrointestinal Disease Gastrointestinal spend per weighted head of population Musculoskeletal system Musculoskeletal spend per weighted head of population Genitourinary system Genitourinary spend per weighted head of population Genitourinary deaths within 30 days of admissions, ISR* % CRF* with hypertension on ACE*/ARB* therapy 88% 91% 92% 91% 92% 4 Maternity Maternity spend per weighted head of population % Low birth weights 7.6% 7.3% 6.7% 7.1% 7.5% 2 Other Primary Care GMS*/PMS* spend per weighted head of population Miscellaneous spend per weighted head of population ** z scores A z score essentially measures the distance of a value from the mean (average) in units of standard deviations. A positive z score indicates that the value is above the mean whereas a negative z score indicates that the value is below the mean. A z score below -2 or above +2 may indicate the need to investigate further. Lower spend Worse outcome England mean Higher spend Better outcome SHA range PCT value ONS Cluster value ONS Cluster range *ACE - Angiotensin converting enzyme inhibitor *ARB - Angiotensin receptor blocker *COPD - Chronic Obstructive Pulmonary Disease *CPA - Care Programme Approach *CRF - Chronic Renal Failure * DSR - Directly Standardised Rate per 100,000 *GMS - General Medical Services contract *ISR - Indirectly Standardised Rate per 100,000 *PMS - Patient Medical Services contract ONS Cluster Clusters are used to group PCTs together according to key characteristics common to the population in that grouping. The Office of National Statistics derive these groupings, known as clusters, from census data. Notes 1. Population weighted average Index of Multiple Deprivation (IMD) score, NCHOD data 3. Healthcare Commission 2009/10 4. Quality and Outcomes Framework 2009/10 5. SHA and Cluster values are PCT averages Spend: By population, Population: Unified Weighted 18

19 Procedures with Limited Clinical Value It is essential that we continuously review all of our interventions to ensure that the highest possible quality of care is always provided to our patients. One such area that merits closer scrutiny is surgical interventions that, according to the evidence, provide little benefit to patients. This includes a number of procedures of deemed to be of Limited Clinical Value (LCV). This means commissioners need to review low priority treatments: 1. Identifying those procedures where NHS investment should be reduced; 2. In collaboration with clinicians, develop policies that restrict access; 3. Secure full implementation of policies working with provider management and clinicians in both primary and secondary care. We have listed some of these procedures with LCV in table 9, showing some differences in practice over the past 3 years. Although there has been an overall reduction in costs, from 4.4m to 2.6m, and a reduction in activity (excluding minor skin lesions), from 2,123 to 1,575 procedures, more can be done in some areas. For examples, in regards to interventions related to Carpal Tunnel, Hysterectomy, Tonsillectomy and Hernias, the number of activities has reduced considerable but this is not reflected in the cost savings. In other areas, such as Myringotomy, Breast surgery and Wisdom Teeth extraction, NE Essex continues to see a high intervention rate and these may need to be reviewed an audit of Myringotomy has now been completed. Table 9: Procedure Type & Activity Procedure Activity Cost ( ) Activity Cost ( ) Activity Cost ( ) Aesthetic Breast Surgery , , ,317 Aesthetic ENT surgery 33 36, , ,851 Aesthetic Opthalmology Surgery 36 32, , ,731 Aesthetic Surgery Plastics 15 23, , ,803 Back Pain: Injections & Fusions 20 99, , ,156 Carpal Tunnel , , ,439 Dilation & Curretage 16 12, , ,997 Dupuytrens Contracture 67 94, , ,604 Elective Cardiac Ablation 18 37, , ,317 Hysterectomy for Menorrhagia , , ,754 Incisional & Ventral Hernias , , ,096 Jaw Replacement 9 17, , ,032 Knee Washouts , , ,407 Minor Skin Lesions ,649,493 Awaiting data Myringotomy , , ,437 Spinal Cord Stimulation 3 16, , ,350 Tonsillectomy , , ,206 Trigger Finger , , ,641 Varicose veins 27 32, , ,899 Wisdom Teeth Extraction , , ,369 Totals 4,442 4,375,164 1,701 2,808,781 1,575 2,586,406 19

20 COST & QUALITY ANALYSIS BY DISEASE/ CONDITION In this section, the focus of our analyses is centred on the areas of high or marginal significance, as compared to the national average (PCTs as denominator) or the ONS Cluster comparator group. All other related and/or associated analyses have been included in the appendices. Cancers & Tumours In NE Essex, our spend on cancer services ( 11.6m /100k) is on par with the ONS group but is in the top quintile for spend nationally. This is the case, despite a lower cancer incidence in some areas such as lung and prostate cancers and lower bed utilisation per 1,000 population (approx 51 bed days). However, cancer mortality rates are better than the national average, suggesting that the investment has yielded some good outcomes. Figure 17: Programme Budgeting Spend on Cancers & Tumours Select year: Select commissioner: Select programme: Select expenditure basis: EXPENDITURE ON OWN POPULATION Q35 North East Essex PCT (5PW) Select cluster level: 3 SUB GROUP (20 groups) 02. Cancers and tumours Select population weighting: UNIFIED WEIGHTED POPULATION Select comparison: Cluster average Cluster description: Prospering Smaller Towns - B All PCTs expenditure per 100,000 population for the selected programme Expenditure ( million per 100,000 population) Shropshire County PCT Norfolk PCT Herefordshire PCT Northumberland Care Trust Gloucestershire PCT East Riding Of Yorkshire PCT Somerset PCT North Somerset PCT North East Essex PCT East Sussex Downs and Weald PCT North Yorkshire and York PCT Suffolk PCT Lincolnshire Teaching PCT 1st quintile 2nd quintile 3rd quintile 4th quintile 5th quintile North East Essex PCT PCTs within selected cluster level Cluster average 0.0 National Rank Lowest to Highest Source: Programme Budgeting Figure 18: Key Indicators for Cancer Key: Significantly better than England average Not significantly different from England average Significantly worse than England average No significance can be calculated England Key: Indicator Local Number Local Value Eng Eng Avg Worst England Range 1 INCIDENCE OF CANCER 2 All cancers All cancers u75 years Breast cancer Breast cancer u75 years Colorectal cancer Colorectal cancer u75 years Cervical cancer Cervical cancer u75 years Lung cancer Lung cancer u75 years Prostate cancer Prostate cancer u75 years MORTALITY FROM CANCER (DSR) 15 All cancers All cancers u75 years Breast cancer Breast cancer u75 years Colorectal cancer Colorectal cancer u75 years Cervical cancer Cervical cancer u75 years Lung cancer Lung cancer u75 years Prostate cancer Prostate cancer u75 years SECONDARY CARE 28 Cancer bed days per 1,000 popuation Cancer inpatient expenditure per 1000 population n/a Cancer Emergency admissions per 100 on disease register ( ) Eng Best 20

21 Figure 19: Mortality (SMR) from Colorectal Cancers Figure 20: Mortality (SMR) from Cervical Cancer Mortality from Colorectal Cancer, u75 years Mortality from Cervical Cancer, u75 years, Standardised Mortality Ratio Standardised Mortality Ratio Expected Deaths Expected Deaths Source: Compe ndium of Clinical and Health Indicators Crown Copyright - N.B All funnel plot graphs show all other PCTs highlighted in blue (unless otherwise stated), with E Essex PCT highlighted as the red dot. Even though NE Essex has a lower than average incidence for all cancers, there is a higher than average incidence of cervical cancer. SMR vs Screening Uptake It should be noted that overall, NE Essex has a very good cervical (81.1%) and breast screening (82.1%) coverage, compared to other programmes nationally. However, the mortality rate is higher than the national rate in both cases; cervical (SMR=117.9) and breast (SMR=105.1). Higher screening coverage is more likely to reduce the burden of these cancers on the local health economy. Figure 21: SMR vs Screening Uptake Cervical Cancer Figure 22: SMR vs Screening Uptake Breast Cancer Figure 23: Cancer 2 Week Waiting Times Early diagnosis of cancer helps with prognosis, improved quality of life and can help delay mortality. The referral to assessment 2-week wait target is very good in NE Essex, except for a couple of months where we have been below the national target (93%) in the past 15 months (figure 23). However, we should note that there has been a downward trend during that period of time. 21

22 Endocrine, Nutritional and Metabolic Problems This programme covers diseases such as diabetes (lack of insulin); thyroid and other endocrine gland disorders; malnutrition and other nutritional disorders. However, the focus of our analysis will be on Diabetes as a key area of concern. In NE Essex, the spend on these services (4.4m /100k) is below the ONS group average and is in the second from bottom quintile for spend nationally. However, this low spend may be masking a number of issues associated with high levels of premature mortality and poor disease management in primary care such as ACE inhibitor therapy and unmanaged hyperglycaemia (figure 25, lines 9 & 14). The latter may be contributing to an increase in diabetes-related hospital admissions (figure 25, line 19). NE Essex has a hospital admission rate, associated with ketoacidosis & coma, that is higher than both the East of England and national average (figure 30 below). Figure 24: Programme Budgeting Spend on Endocrine, Nutritional and Metabolic Problems Select year: Select commissioner: Select programme: Select expenditure basis: EXPENDITURE ON OWN POPULATION Q35 North East Essex PCT (5PW) Select cluster level: 3 SUB GROUP (20 groups) 04. Endocrine, nutritional and metabolic problems Select population weighting: UNIFIED WEIGHTED POPULATION Select comparison: Cluster average Cluster description: Prospering Smaller Towns - B Expenditure ( million per 100,000 population) All PCTs expenditure per 100,000 population for the selected programme Shropshire County PCT Lincolnshire Teaching PCT Gloucestershire PCT Herefordshire PCT North Somerset PCT North East Essex PCT Somerset PCT East Riding Of Yorkshire PCT Norfolk PCT North Yorkshire and York PCT Suffolk PCT Northumberland Care Trust East Sussex Downs and Weald PCT 1st quintile 2nd quintile 3rd quintile 4th quintile 5th quintile North East Essex PCT PCTs within selected cluster level Cluster average National Rank Lowest to Highest Figure 25: Key Indicators for Endocrine, Nutritional and Metabolic Problems Key: Significantly better than England average Not significantly different from England average Significantly worse than England average No significance can be calculated England Key: Indicator Local Number Local Value Eng Eng Avg Worst England Range 1 ENDOCRINE, NUTRITIONAL & METABOLIC MORTALITY 2 Diabetes Diabetes u75 years QOF ATTAINMENT 5 Peripheral pulse checking (DM9) Neuropathy testing (DM10) Blood pressure ((DM12) Micro-albuminuria testing DM13) ACE inhibitor therapy (DM15) Cholesterol levels (DM17) Influenza Vaccination (DM18) Retinal screening (DM21) Renal function testing (DM22) Controlled blood glucose levels (7 or less) (D23) Blood glucose levels (8 or less) (DM24) Blood glucose levels (9 or less) (DM25) SECONDARY CARE 18 Diabetes Emergency admissions per 100 on disease register ( ) Emergency hospital admissions: diabetic ketoacidosis & coma Lower limb amputations ( ) Bariatric procedures Eng Best 22

23 Although it appears that the general spend on secondary care is comparably more favourable, some areas of concern still remain around the high level of lower limb amputations (one of the highest, see figure 26 below) and nearly 50% of known diabetic patients are still not receiving all nine of the key care processes (figure 27 below) for diabetes care as recommended by NICE; the nine crucial tests at an annual review of diabetes management include measurements of weight, blood pressure, smoking status, HbA1c, urinary albumin, serum creatinine, cholesterol, and tests to assess whether the eyes and feet have been damaged by diabetes. These tests are essential to ensure that diabetes is controlled. If left unchecked, diabetes can lead to blindness, kidney failure and increase the risk of developing cardiovascular problems such as heart attacks and stroke. The PCT is an outlier for premature mortality in diabetes with an SMR of indicating 40% more deaths in the under 75s than expected. In respect to Cholesterol levels in diabetic patients, the PCT has achieved 82% but there is room for improvement as the top performing PCT achieved 87.1%. Micro-albuminuria testing is another area where NE Essex (86.6%) has a lower achievement compared to the national average (88.5%). It is important that diabetics are tested for micro-albuminuria to detect the onset of kidney disease. In order to slow down the progression of kidney disease, those who have been diagnosed should be treated with ACE inhibitors in NE Essex, 83% were treated with ACE compared to a national average of 89% (figure 34 below). Figure 26: Lower Limb Amputations by PCT Figure 27: DM & 9 Key Care Processes Figure 28: Diagnosed v.s Expected DM prevalence Figure 29: SMR from DM, u75years, Percentage difference between observed number of diabetic patients on GP registers and expected + 10% 0% 10% 20% 30% 40% 50% Source: IC and APHO Observed vs Expected prevalence for diabetes for all PCTs in England Expected number of diabetic patients Mortality from diabetes, u75 years ( ): Expected Deaths Source: Compendium of Clinical and Health Indicators Crown Copyright - Standardised Mortality Ratio 23

24 Figure 30: DM - Hospital Admissions from Ketoacidosis & Coma Emergency Hospital Admissions for: Diabetic ketoacidosis and coma ( ) Directly age & sex standardised rate per 100, North East Essex PCT Q1 Q2 Q3 Q4 Q5 England East of England 0.00 Source: nww.nchod.nhs.uk PCT ranked In terms of population diabetes ascertainment, it is estimated that NE Essex has 27% fewer cases of diabetes than expected (figure 28). It is important that every opportunity is taken in primary care to improve early identification of diabetics to ensure good care management and better patient outcomes. Figures 31 to 34: QOF Achievements for by PCT Figure 31: Micro-albuminuria testing Micro-albuminuria testing in patients with diabetes mellitus (DM13) Figure 32: Ace Inhibitor therapy ACE inhibitor therapy in patients with diabetes mellitus (DM15) Percent Coverage Percent Coverage Population of Diabetics Source: Quality and Outcomes Framework Population of Diabetics Source: Quality and Outcomes Framework Figure 33: Cholesterol level of 5mmol or less Cholesterol levels in patients with diabetes mellitus - 5mmol or less (DM17) Figure 34: Controlled hyperglycaemia (7mmol/L or less) Controlled blood glucose levels (7 or less) in patients with diabetes mellitus (DM23) 88 Percent Coverage Percent with HbA1c at 7 or less Population of Diabetics Source: Quality and Outcomes Framework Eligible diabetic population Source: Quality and Outcomes Framework

25 Mental Disorders This programme covers the full range of mental and behavioural disorders including neurosis and psychosis. This also covers key areas such as drug and alcohol misuse, child psychiatry and mental health in older age (including Alzheimer s disease and dementia). The prevalence of metal health problems in NE Essex (0.8%) is similar to the national average (0.8%), although there is a lower prevalence of depression in the local population (figure 7). The mental health spend in NE Essex (17.2m/100,000 population) is only marginally lower than our ONS group of PCTs (17.7m/100,000 population) but much lower than the national average (20.4m/100,000 population) Figure 35. Figure 35: Programme Budgeting Spend on Mental Disorders Select year: Select commissioner: Select programme: Select expenditure basis: EXPENDITURE ON OWN POPULATION Q35 North East Essex PCT (5PW) Select cluster level: 3 SUB GROUP (20 groups) 05. Mental health disorders Select population weighting: UNIFIED WEIGHTED POPULATION Select comparison: Cluster average Cluster description: Prospering Smaller Towns - B 45.0 All PCTs expenditure per 100,000 population for the selected programme st quintile Expenditure ( million per 100,000 population) East Riding Of Yorkshire PCT Lincolnshire Teaching PCT Somerset PCT North East Essex PCT Northumberland Care Trust East Sussex Downs and Weald PCT North Somerset PCT Suffolk PCT North Yorkshire and York PCT Shropshire County PCT Norfolk PCT Gloucestershire PCT Herefordshire PCT 2nd quintile 3rd quintile 4th quintile 5th quintile North East Essex PCT PCTs within selected cluster level Cluster average 0.0 National Rank Lowest to Highest However, figure 36 highlights the significantly higher hospital admission rates in in NE Essex, as well as an element of poor patient care management with a significantly lower proportion of patients on the mental health register, having had a comprehensive care plan completed (figure 45- Below). Figure 36: Key Indicators for Mental Disorders Key: Significantly better than England average Not significantly different from England average Significantly worse than England average No significance can be calculated England Key: Indicator Local Number Local Value Eng Eng Avg Worst England Range 1 MENTAL HEALTH MORTALITY 2 Mortality from suicide Mortality from suicide u75 years QOF ATTAINMENT 5 Comprehensive care plan for patients on mental health register (MH6) Care review among patients with dementia (DM2) SECONDARY CARE 8 Mental Health Admissisons ( ) Emergency admissions for neuroses Emergency admissions for schizophrenia Eng Best 25

26 Figure 37: Mental health expenditure per 1,000 Mental Health Expenditure( ) Spend per 1,000 population 400, , , , , ,000 North East Essex PCT Q1 Q2 Q3 Q4 Q5 Engalnd East of England 100,000 50,000 0 Source: NHS National Programme Budgeting & Weighted PCT population estimates PCT ranked In regards to access to IAPT services, NE Essex is currently around average and marginally better than the East of England position (figure 41). Despite projected increases in mental health prevalence across NE Essex, there has been little change in the number of contacts that CMHT has had with local patients. With the low level of comprehensive care planning in NE Essex, it is essential that patients are supported to improve health and social care outcomes. Figure 38: IAPT Q1 (Apr-Jun) 2011 Figure 39: Contacts with CMHT for NEEPCT (2010/11) % receiving treatment as a proportion of those with anxiety or depression 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% IAPT - People who have entered treatment as a proportion of people with anxiety or depression Q1 (Apr-Jun) 2011 Q1 Q2 Q3 Q4 Q5 England East of England Number of contacts with CMHT 2,500 2,000 1,500 1, Contacts with CMHT for NE Essex PCT ( ) Adults Older People Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0.00% Q1 Q2 Q3 Q4 PCTs ranked Emergency hospital admissions are generally low for people with acute mental health conditions but this is not the case with neurotic conditions, for neuroses the PCT has a higher rate of admission (13.3/100k) than the East of England (10.4/100k). Figure 40: Emergency Hospital Admissions Neuroses Figure 41: Emergency Hospital Admissions Schizophrenia Emergency hospital admissions: neuroses ( ) Emergency hospital admissions: schizophrenia ( ) Rate per 100,000 Population per Year Rate per 100,000 Population per Year Population Population Source: Compendium of Clinical and Health Indicators Crown Copyright - Note: Population is adjusted due to Standardisation Calculations 26

27 Figure 42: Mental Health Admissions (for Neurotic Conditions) Figure 43: Claimants of Benefit & SDA with MH Directly age & sex standardised rate per 100, Emergency hospital admissions: Neuroses ( ) North East Essex PCT Q1 Q2 Q3 Q4 Q4 England East of England Claimants of incapacity benefit/severe disablement allowance with mental or behavioural disorders, by local authority, Rate per 1, LAs Colchester LA Tendring LA Source: PCTs ranked Working Age Population More can be done to improve the management of care for people with dementia (below average for NE Essex) and people who should have a comprehensive care plan. The variation in GP registers across Essex may be due to the fact that dementia is difficult to diagnose in the early stages. By 2021, the projected increase in prevalence is expected to reach 38%. Figure 44: Care Review for Dementia Patients Figure 45: % of MH patients with Comprehensive CPs Care review among patients with dementia DM2) Eligible Dementia Population Population Source: Quality & Outcomes Framework, Comprehensive care plan for patients on mental health register (MH6) Eligible Mental Health Population Source: Quality & Outcomes Framework Population Child & Adolescent Mental Health Poor mental health in childhood affects educational attainment, social skills and physical health. It also increases the likelihood of smoking, alcohol and drug use. There are also wider consequences for later in life as it increases the risk of poorer physical health, unemployment, reduced earnings and criminal activity. It is estimated that there are over 19,200 children and young people aged up to 19 years that have behavioural or mental illness at any one time in Essex. Problems are more common with boys aged years. In , overall there were 1,015 referrals into the CAMH service, 45 were looked after children (LAC), however of these 10 were not accepted (22%). There were also 22 referrals of children with a child protection plan but 5 (23%) of these were also not accepted. Table 10: Referrals and Rejections in to CAMHS service for North East Essex PCT Tier 3 Community Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Total LAC Referrals Accepted LDD Referrals Accepted Children with CP Plan Referrals Accepted Routine Accepted Referrals LAC Referrals not Accepted Children with CP Plan Referrals not Accepted Source: Essex CAMHS Commissioning 27

28 Problems of Learning Disability Life expectancy has been increasing in people with learning disabilities (LD) but is still lower than in the general population. Some studies suggest that reduced life expectancy is confined to people with more severe LD, which is also frequently associated with marked physical health problems. Around 4,100 adults with a learning disability are supported by social care, with 845 living in Residential and Nursing care homes. Further over 200 people across ECC present with challenging behaviours which necessitate intensive health and/or social care interventions. The two highest LD rates In Essex is in Tendring and Colchester which explains the significantly high expenditure rate in NE Essex (figure 46). By 2030, the LD population is projected to grow by 19.5%. Figure 46: Programme Budgeting Spend on Learning Disability Select year: Select commissioner: Select programme: Select expenditure basis: EXPENDITURE ON OWN POPULATION Q35 North East Essex PCT (5PW) Select cluster level: 3 SUB GROUP (20 groups) 06. Problems of learning disability Select population weighting: UNIFIED WEIGHTED POPULATION Select comparison: Cluster average Cluster description: Prospering Smaller Towns - B 18.0 All PCTs expenditure per 100,000 population for the selected programme st quintile Expenditure ( million per 100,000 population) East Sussex Downs and Weald PCT East Riding Of Yorkshire PCT Somerset PCT Lincolnshire Teaching PCT Herefordshire PCT Suffolk PCT North Somerset PCT Norfolk PCT Northumberland Care Trust Gloucestershire PCT Shropshire County PCT North Yorkshire and York PCT North East Essex PCT 2nd quintile 3rd quintile 4th quintile 5th quintile North East Essex PCT PCTs within selected cluster level Cluster average 0.0 National Rank Lowest to Highest Neurological Problems NE Essex has a lower spend on neurological spend (this primarily covers Epilepsy, MS, Meningitis-related and Parkinson s) than other PCTs in its cluster group (figure 47). This may be masking a number of issues including poor management of existing patients (figures 48) and the reasons behind the higher than average mortality rates for patients suffering from epilepsy. With an increasingly ageing population, and a larger than average population of people with learning disabilities and acquired brain injuries, the neurological burden is likely to become more serious. Figure 47: Programme Budgeting Spend on Neurological Problems Select year: Select commissioner: Select programme: Select expenditure basis: EXPENDITURE ON OWN POPULATION Q35 North East Essex PCT (5PW) Select cluster level: 3 SUB GROUP (20 groups) 07. Neurological Select population weighting: UNIFIED WEIGHTED POPULATION Select comparison: Cluster average Cluster description: Prospering Smaller Towns - B Expenditure ( million per 100,000 population) All PCTs expenditure per 100,000 population for the selected programme North East Essex PCT Herefordshire PCT Northumberland Care Trust Lincolnshire Teaching PCT Gloucestershire PCT Suffolk PCT East Riding Of Yorkshire PCT Somerset PCT East Sussex Downs and Weald PCT Shropshire County PCT North Yorkshire and York PCT Norfolk PCT North Somerset PCT 1st quintile 2nd quintile 3rd quintile 4th quintile 5th quintile North East Essex PCT PCTs within selected cluster level Cluster average National Rank Lowest to Highest 28

29 Figure 48: Key Indicators for Neurological Disorders Figure 49: Reported Vs Expected Prevalence of Epilepsy Figure 50: Patients with Managed Epilepsy Patients with epilepsy on drug treatment and convulsion free (EPILEPSY8) 80 Percentage of Population Population Source: Quality and Outcomes Framework It is estimated that nearly 10% of registered patients (figure 49) in NE Essex may be suffering from epilepsy who are unknown to local clinicians. Actions are required that can be beneficial directly by decreasing the mortality, morbidity and disability caused by neurological disorders and indirectly by improving the functioning and quality of life of patients and their families. 29

30 Problems of Vision This section covers areas such as low vision and blindness (related to age-related macular degeneration - AMD), cataracts, glaucoma (including conditions such as diabetes), disorders of the retina and squint. NE Essex is an outlier in terms of spend in this programme despite having a comparably low surgical intervention rate for cataracts (figure 52) against a larger and growing ageing population. A lower than expected diabetic prevalence rate (see figure 28 above) could give rise to further increase spending with late diagnosis and complications from diabetes. Figure 51: Programme Budgeting Spend on Problems of Vision Select year: Select commissioner: Select programme: Select expenditure basis: EXPENDITURE ON OWN POPULATION Q35 North East Essex PCT (5PW) Select cluster level: 3 SUB GROUP (20 groups) 08. Problems of vision Select population weighting: UNIFIED WEIGHTED POPULATION Select comparison: Cluster average Cluster description: Prospering Smaller Towns - B 7.0 All PCTs expenditure per 100,000 population for the selected programme Expenditure ( million per 100,000 population) Lincolnshire Teaching PCT Shropshire County PCT East Riding Of Yorkshire PCT North Somerset PCT Herefordshire PCT Northumberland Care Trust Gloucestershire PCT East Sussex Downs and Weald PCT North Yorkshire and York PCT Norfolk PCT North East Essex PCT Somerset PCT Suffolk PCT 1st quintile 2nd quintile 3rd quintile 4th quintile 5th quintile North East Essex PCT PCTs within selected cluster level Cluster average 0.0 National Rank Lowest to Highest NE Essex is an outlier for cataract surgery. It is estimate that one third of people aged 65 years and over will have cataracts. Middle Super Output Areas (MSOAs) in central Colchester and the coastal areas of Tendring have a higher than average rate of service users with a sensory impairment. It is important that the NHS aims to delay the average age of onset of loss of visual acuity in patients with hypertension, diabetes and glaucoma. Figure 52: Hospital Procedures: Cataract Removal ( ) Hospital procedures: cataract removal ( ) Rate per 100,000 Population per Year Population Source: Compendium of Clinical and Health Indicators Crown Copyright - Note: Population is adjusted due to Standardisation Calculations 30

31 Problems of Circulation This area of spend includes all of CVD, including high BP and is closely linked to the programme covering endocrine, nutritional and metabolic diseases in relation to obesity, diabetes and blood lipids as risk factors. Despite CVD being responsible for the largest level of population mortality and morbidity, NE Essex has a below average spend ( 13.2m/100k) figure 53. Age is a key risk factor with increasing spend on the programme. In relation to hospital admissions, the age profile rises sharply at 45 years. These are groups (45-64, 65+,) in the population that are set to rise in the next 15 years, so unless steps are taken to prevent illness or its complications, it will put increased pressure on hospital beds. Figure 53: Programme Budgeting Spend on Problems of Circulation Select year: Select commissioner: Select programme: Select expenditure basis: EXPENDITURE ON OWN POPULATION Q35 North East Essex PCT (5PW) Select cluster level: 3 SUB GROUP (20 groups) 10. Problems of circulation Select population weighting: UNIFIED WEIGHTED POPULATION Select comparison: Cluster average Cluster description: Prospering Smaller Towns - B All PCTs expenditure per 100,000 population for the selected programme Expenditure ( million per 100,000 population) Herefordshire PCT Shropshire County PCT North East Essex PCT North Yorkshire and York PCT Gloucestershire PCT Norfolk PCT Northumberland Care Trust North Somerset PCT Lincolnshire Teaching PCT Suffolk PCT Somerset PCT East Riding Of Yorkshire PCT East Sussex Downs and Weald PCT 1st quintile 2nd quintile 3rd quintile 4th quintile 5th quintile North East Essex PCT PCTs within selected cluster level Cluster average 0.0 National Rank Lowest to Highest Figure 54: Key Indicators for Problems of Circulation 31

32 Figure 55: SMR for Hypertensive Disease (<75 yrs) Figure 56: Patients who spend 90% on Stroke Unit Mortality from hypertensive disease, u75 years, Standardised Mortality Ratio Percent spending 90% of their time on a stroke unti The % of patients following a stroke who spent 90% of their time on a stroke unit - Q Expected deaths Source: Compendium of Clinical and Health Indicators Crown Copyright Number of people admitted to hospital following a stroke Source: Quality and Outcomes Framework In relation to circulatory diseases, NE Essex has a modest level of mortality rates (figure 54 - lines 2-11) for most associated conditions (excluding strokes) and is just below the national average for deaths from hypertensive diseases (figure 55). Services for people who have suffered from stroke are fast improving with over 80% of patients spending 90% of their time on a stroke unit (figure 56). The percentage of TIA cases with a higher risk who are treated within 24 hrs has now consistently been over 90% in NE Essex, since changes were implemented in the stroke care pathway during Revascularisation (CABG & PTCA) is accepted as an effective medical intervention in managing patients with coronary artery disease to improve symptoms and/or prognosis. Recent studies have shown that over one year, CABG was more expensive and offered greater survival than PTCA but little added benefit in terms of quality adjusted life years. Figure 57: CABG Admissions Elective (2008/09) Figure 58: PCTA Admissions Elective (2008/09) Figure 59: QOF for BP for CHD Patients Percentage of patients with CHD in whom the last blood pressure reading is 150/90 or less (CHD6) Figure 60: QOF for Cholesterol for CHD Patients 88 Percentage of patients with coronary heart disease whose last measured cholesterol is 5mmol or less (CHD8) Percent Coverage Percent Coverage CHD List Size Source: Quality and Outcomes Framework Elgiible CHD population Source: Quality and Outcomes Framework

33 In our ONS Cluster group 12 (13 PCTs), 10 PCTs have lower rates of CABGs and 8 have higher rates of PTCAs than NE Essex (figures 57 & 58). As the costs associated with CABG interventions are around 40% more, clinicians need to ensure that the overall benefit for the patients of having a CABG outweighs the use of PTCA. In terms of quality in primary care, NE Essex practices are still performing modestly compared to other PCTs. Areas where there should be more improvement include the management of cholesterol and BP in known CHD and stroke patients (figures 59-62). Figure 61: QOF for BP for TIA/Stroke Patients Percentage of patients with a history of TIA or stroke in whom the last blood pressure reading was 150/90 or less (STROKE6) Figure 62: QOF for Cholesterol for TIA/Stroke Patients Percentage of patients with TIA or stroke whose last measured total cholesterol is 5mmol or less (STROKE8) Percent Coverage Percent Coverage Eligible stroke population Source : Quality and Outcome s Framework Eligible stroke population Source : Quality and Outcomes Framework The NE Essex s (7.6/100) emergency CHD-related hospital admission rate is marginally higher than the national average (7.5/100). Local analysis has shown a significant link between these admission rates and level of deprivation in NE Essex. Figure 63: Emergency CHD Admissions per 100 on Disease Register ( ) Emergency CHD admissions per 100 on disease register ( ) Q1 Q2 Q3 Q4 Q5 England East of England Rate per 100 on disease register North East Essex PCT PCTs ranked Source: NHS Comparators Figure 64: Observed Vs Expected CHD Prevalence Percentage difference between observed number of CHD patients on GP registers and expected + 20% + 10% 0% 10% 20% 30% 40% 50% 60% Source: IC and APHO Observed vs Expected prevalence for CHD for all PCTs in England Expected number of CHD patients Figure 65: Observed Vs Expected HF Prevalence Percentage difference between observed number of heart + 20% + 10% failure patients on GP registers and expected 0% 10% 20% 30% 40% 50% 60% 70% Observed vs Expected prevalence for Heart Failure for all PCTs in England Source: Expecte d number of heart failure patients 12 PCTs with similar characteristics based on demographics, household composition, housing, socio-economic, employment and industry factors are grouped together to form an ONS cluster group NE Essex is clustered in the Prospering Smaller Towns group 33

34 Figure 66: Observed Vs Expected Hypertension Prevalence Percentage difference between observed number of hypertensive patients on GP registers and expected + 20% Observed vs Expected prevalence for hypertension for all PCTs in England + 10% 0% 10% 20% 30% 40% 50% 60% 70% Expected number of hypertensive patients Source: IC and APHO Figure 67: Observed Vs Expected Stroke Prevalence Percentage difference between observed number of stroke patients on GP registers and expected + 20% Observed vs Expected prevalence for stroke for all PCTs in England + 10% 0% 10% 20% 30% 40% 50% Source: IC and APHO Expected number of stroke patients There is marked variation in observed and expected circulatory diseases prevalence rates, and observed rates are much lower than expected rates the difference for CHD is -22%, hypertension is -45%, HF is -52% and stroke is -19%. The earlier identification of at risk patients will further contribute to the rising circulatory diseases prevalence in NE Essex and expected to further increase demand for CHD services locally. Problems of the Respiratory System This programme covers the entire respiratory tract, and includes among others, diseases of the nose and throat, asthma, emphysema, chronic obstructive pulmonary disease and respiratory failure. NE Essex is a low spender on this programme but has some better-than-average health outcomes e.g. in mortality rates (figure 69) and hospital admissions from asthma and COPD (figure 69 lines 14/15). Figure 68: Programme Budgeting Spend on Problems of the Respiratory System Select year: Select commissioner: Select programme: Select expenditure basis: EXPENDITURE ON OWN POPULATION Q35 North East Essex PCT (5PW) Select cluster level: 3 SUB GROUP (20 groups) 11. Problems of the respiratory system Select population weighting: UNIFIED WEIGHTED POPULATION Select comparison: Cluster average Cluster description: Prospering Smaller Towns - B Expenditure ( million per 100,000 population) All PCTs expenditure per 100,000 population for the selected programme North East Essex PCT Shropshire County PCT East Riding Of Yorkshire PCT Herefordshire PCT Somerset PCT North Yorkshire and York PCT North Somerset PCT Norfolk PCT Suffolk PCT Northumberland Care Trust Gloucestershire PCT East Sussex Downs and Weald PCT Lincolnshire Teaching PCT 1st quintile 2nd quintile 3rd quintile 4th quintile 5th quintile North East Essex PCT PCTs within selected cluster level Cluster average 0.0 National Rank Lowest to Highest In relation to mortality for these two respiratory conditions, the rates are below the national average and significantly more positive for COPD (figures 70 & 71). 34

35 Figure 69: Key Indicators for Problems of the Respiratory System Key: England Key: Significantly better than England average Not significantly different from England average Significantly worse than England average No significance can be calculated Indicator Local Number Local Value Eng Eng Avg Worst England Range 1 MORTALITY FROM RESPIRATORY CONDITIONS 2 Asthma Bronchitis & Emphysema Bronchitis & Emphysema, u75 years Bronchitis, Emphysema & Other COPD Bronchitis, Emphysema & Other COPD u75 years Pneumonia Pneumonia u75 years QOF ATTAINMENT 10 Influenza vaccination in those with COPD (COPD8) FeVI checks in COPD patients (COPD10) Diagnosis by spirometry in COPD patients (COPD12) SECONDARY CARE 14 Asthma Emergency admissions per 100 on disease register ( ) COPD Emergency admissions per 100 on disease register ( ) Eng Best Figure 70: SMR for Asthma ( ) Mortality from asthma ( ) Figure 71: SMR COPD & other respiratory conditions Mortality from bronchitis, emphysema and other COPD, u75 years ( ) Standardised Mortality Ratio Standardised Mortality Ratio Expected Deaths Source: Compendium of Clinical and Health Indicators Crown Copyright Expected Deaths Source: Compendium of Clinical and Health Indicators Crown Copyright - Although in , NE Essex was in the bottom quintile for emergency hospital admissions for asthma and COPD, it has seen a high utilisation of beds for COPD cases above the national average (figure 72). Thoracic Medicine as whole was a significant national outlier in 2009/10 (table 11 below), with high rates of emergency admissions & readmissions, and again bed utilisation. This should be seen as an area of concern, if not for the health outcomes, but for the potential of further increases in coming years due to both COPD and asthma expected prevalence rates suggesting a significant difference with the recorded prevalence on GP disease registers (figures 73 & 74). Figure 72: Emergency bed-days per 1,000 for COPD ( ) Emergency Bed Days for COPD ( ) Q1 Q2 Q3 Q4 Q5 England East of England Rate per 1000 COPD prevalence North East Essex PCT PCTs Ranked Source: NHS Atlas of Variation 35

36 If COPD is excluded as this is more likely to affect people over 50 years, the predominance of asthma is amongst pre-school children (0-4 years). Therefore the management of childhood respiratory conditions, and avoidance of admissions, should be a priority for commissioning in this programme in the years ahead. Table 11: Emergency Admissions for Thoracic Medicine NE Essex v. England NE ESSEX Emergency admissions Emergency bed days Emergency admissions - length of stay Thoracic medicine Significantly higher Significantly higher Significantly lower Source: NHS Comparators 2009/10 Figure 73: Observed Vs Expected prevalence of Asthma Percentage difference between observed number of asthma patients on GP registers and expected + 30% + 20% + 10% 0% 10% 20% 30% 40% 50% 60% 70% Observed vs Expected prevalence for Asthma for all PCTs in England, Source: Expecte d numbe r of Asthma patie nts Figure 74: Observed Vs Expected prevalence of COPD Percentage difference between observed number of COPD patients on GP registers and expected + 10% 0% 10% 20% 30% 40% 50% 60% 70% 80% Source: IC and APHO Observed vs Expected prevalence for COPD for all PCTs in England Expected number of COPD patients The use of spirometry testing (FeV1 recording) in NE Essex, to help diagnose some of the respiratory conditions, is one of the best nationally, which is highly commendable and has seen a further push during Dental Problems The spend on this programme is primarily focused on the access to primary and secondary care dental services, in promoting good oral health. NE Essex has an above-average spend and good health outcomes one of the lowest levels of tooth decay in children as well as improved access to NHS dentistry over the past 2-3 years. In recent surveys, NE Essex has been better than the national average in regards to five year olds who only have one decayed, missing or filled tooth (DMFT) and had consistently the lowest rate of DMFT in our ONS cluster group. With this sustained good outcome, it may be necessary to review the spending level on this programme. There is also a need to maintain a watchful eye over the number of wisdom teeth extractions being undertaken locally and ensuring that the relevant service restriction policy is adhered to see table 9. Figure 75: Programme Budgeting Spend on Dental Problems Select year: Select commissioner: Select programme: Select expenditure basis: EXPENDITURE ON OWN POPULATION Q35 North East Essex PCT (5PW) Select cluster level: 3 SUB GROUP (20 groups) 12. Dental problems Select population weighting: UNIFIED WEIGHTED POPULATION Select comparison: Cluster average Cluster description: Prospering Smaller Towns - B 12.0 All PCTs expenditure per 100,000 population for the selected programme Expenditure ( million per 100,000 population) Lincolnshire Teaching PCT East Riding Of Yorkshire PCT North Somerset PCT Gloucestershire PCT Norfolk PCT Suffolk PCT Northumberland Care Trust Shropshire County PCT North Yorkshire and York PCT East Sussex Downs and Weald PCT North East Essex PCT Somerset PCT Herefordshire PCT 1st quintile 2nd quintile 3rd quintile 4th quintile 5th quintile North East Essex PCT PCTs within selected cluster level Cluster average 0.0 National Rank Lowest to Highest 36

37 Problems of the Skin This programme covers conditions such as eczema, dermatitis, psoriasis, cellulitis, leg ulcers, acne, moles and pigment changes among others. NE Essex is just below the average spend for our cluster group. However, NE Essex is one of the highest spender in this area in primary care see table 8.. Figure 76: Programme Budgeting Spend on Problems of the Skin Select year: Select commissioner: Select programme: Select expenditure basis: EXPENDITURE ON OWN POPULATION Q35 North East Essex PCT (5PW) Select cluster level: 3 SUB GROUP (20 groups) 14. Problems of the skin Select population weighting: UNIFIED WEIGHTED POPULATION Select comparison: Cluster average Cluster description: Prospering Smaller Towns - B 7.0 All PCTs expenditure per 100,000 population for the selected programme 1st quintile Expenditure ( million per 100,000 population) Norfolk PCT North Yorkshire and York PCT East Riding Of Yorkshire PCT North Somerset PCT Suffolk PCT North East Essex PCT Northumberland Care Trust East Sussex Downs and Weald PCT Somerset PCT Shropshire County PCT Lincolnshire Teaching PCT Gloucestershire PCT Herefordshire PCT 2nd quintile 3rd quintile 4th quintile 5th quintile North East Essex PCT PCTs within selected cluster level Cluster average 0.0 National Rank Lowest to Highest Problems of the Musculo-Skeletal System & Trauma The spend on this programme covers conditions such as juvenile arthritis, gout, rheumatoid arthritis, auto-immune diseases, wear-and-tear osteoarthritis, osteoporosis, joint deformities, back pain and other chronic pain of bone, muscle or joints but excludes injuries. Some of the local indicators (such as mortality from accidental falls, emergency readmissions within 28 days) are significantly better than the national average (Figure 78). NE Essex has the lowest spend on this programme in our cluster group, although the overall spend has seen a gradual increase (figure 77). This is not unsurprising given the large than average proportion of people aged 55 years and over. Figure 77: Programme Budgeting Spend on Problems of the Musculo-Skeletal System & Trauma Select year: Select commissioner: Select programme: Select expenditure basis: EXPENDITURE ON OWN POPULATION Q35 North East Essex PCT (5PW) Select cluster level: 3 SUB GROUP (20 groups) 15. Problems of the musculoskeletal system Select population weighting: UNIFIED WEIGHTED POPULATION Select comparison: Cluster average Cluster description: Prospering Smaller Towns - B Expenditure ( million per 100,000 population) All PCTs expenditure per 100,000 population for the selected programme North East Essex PCT Suffolk PCT North Somerset PCT East Riding Of Yorkshire PCT Lincolnshire Teaching PCT North Yorkshire and York PCT Gloucestershire PCT Northumberland Care Trust Somerset PCT Norfolk PCT Herefordshire PCT Shropshire County PCT East Sussex Downs and Weald PCT 1st quintile 2nd quintile 3rd quintile 4th quintile 5th quintile North East Essex PCT PCTs within selected cluster level Cluster average 0.0 National Rank Lowest to Highest This programme is dominated by major joint replacement surgery in the pre-retirement and post-retirement age groups, which are projected to increase in number in the next 15 years. In regards to knee and hip replacements, the PCT is undertaking higher rates (figure 78, lines 7-9 & figures 82/83 below). 37

38 Figure 78: Key Indicators for Musculoskeletal System & Trauma Although these interventions are seen as highly effective in improving overall quality of life, it is important to understand whether these are being undertaken when most needed and if the right procedure is being used. Some PCTs (e.g. Hammersmith & Fulham, Richmond and Twickenham, Camden) all had high (>3 rd quintile) Pre-Op Patient Recorded Outcome Measure Scores (PROMS) (figure 81) for hip replacement but lower levels of procedures than NE Essex. These variations suggest that in some populations people are receiving hip replacement much earlier, perhaps when they have less pain or disability. Figure 79: Primary Hip Replacement (2009/10) Figure 80: Revision Hip Replacement (2009/10) Figure 81: PROMS Pre Operative Score for Hip Replacement Score Mean (average) pre-operative EQ-5D Index score for Hip replacement surgery by PCT, 2009/10 North East Essex PCT PCTs Ranked Q1 Q2 Q3 Q4 Q5 East of England England Source: NHS Atlas of Variation 38

39 Figure 82: Hip Replacement Emergency Admissions Figure 83: Mortality from Falls NE Essex had a significantly high rate of emergency admissions for hip replacement (figure 82) but had one of the lowest mortality rates (figure 83) from falls in people aged 65yrs+. This is an indication that post-falls interventions may be good in NE Essex but that more prevention work is needed to reduce falls. However, information in figure 84 also suggests that NE Essex has an average performance in regards to 30-day mortality following a fall-related fracture. The 28-day hospital readmission rate is relatively low in our area (figure 85). Figure: 84: Deaths within 30 days of admission, Figure 85: Emergency readmission to hospital within fractured proximal femur (2008/09) 28 days of discharge (fractured proximal femur) (2008/09) Rate per Deaths within 30 days of emergency admission to hospital: fractured proximal femur 2008/09 Q1 Q2 Q3 Q4 Q5 England EoE North East Essex PCT Indirectly Age & Sex Standardised % Emergency readmissions to hospital within 28 days of discharge: fractured proximal femur 2008/09 North East Essex PCT Q1 Q2 Q3 Q4 Q5 EoE England PCTs Ranked 0.00 PCTs Ranked Problems of the Genito-Urinary System The spend on this programme covers conditions such as nephritis, acute and chronic renal failure, urinary stones, cystitis, prostate disease, diseases of the testes and ovaries, pelvic inflammatory disease, endometriosis, fibroids, uterine prolapse, menstrual disorders and sexually transmitted infections but excluded infertility. Figure 86: Programme Budgeting Spend on Problems of the Genito-Urinary System Select year: Select commissioner: Select programme: Select expenditure basis: EXPENDITURE ON OWN POPULATION Q35 North East Essex PCT (5PW) Select cluster level: 3 SUB GROUP (20 groups) 17. Problems of the genito urinary system Select population weighting: UNIFIED WEIGHTED POPULATION Select comparison: Cluster average Cluster description: Prospering Smaller Towns - B Expenditure ( million per 100,000 population) All PCTs expenditure per 100,000 population for the selected programme Shropshire County PCT North East Essex PCT East Riding Of Yorkshire PCT Gloucestershire PCT North Yorkshire and York PCT Herefordshire PCT Somerset PCT North Somerset PCT Lincolnshire Teaching PCT Northumberland Care Trust Norfolk PCT Suffolk PCT East Sussex Downs and Weald PCT 1st quintile 2nd quintile 3rd quintile 4th quintile 5th quintile North East Essex PCT PCTs within selected cluster level Cluster average National Rank Lowest to Highest 39

40 NE Essex has one of the lowest spend in the country, but with a large undetected population (expected prevalence figure 86), it is likely to become a challenge for primary care to manage by improving health outcomes and minimise renal failure. Figure 87: Key Indicators for Problems of the Genito-Urinary System Key: England Key: Significantly better than England average Not significantly different from England average Significantly worse than England average No significance can be Indicator Local Number Local Value Eng Eng Avg Worst England Range 1 MORTALITY 2 Chronic Renal Failure Chronic Renal Failure u75 years QOF ATTAINMENT 5 BP 145/85 (CKD3) ACE/ARB Therapy (CKD5) Kidney function test (CKD6) Eng Best Figure 88: Observed Vs Expected Prevalence of CKD Figure 89: Use of ACE inhibitor & ARB therapy in CKD + 20% Observed vs Expected prevalence for CKD for all PCTs in England, ACE inhibitor / ARB therapy for CKD with hypertension and proteinuria (CKD5) Percentage difference between observed number of CKD patients on GP registers and expected + 10% 0% 10% 20% 30% 40% 50% 60% 70% 80% Expected number of CKD patients Source: Percentage of Population CKD Population Source: Quality & Outcomes Framework Maternity & Reproductive Health The spend on this programme includes services dealing with infertility (e.g. IVF), family planning and termination of pregnancy and supporting people through pregnancy to childbirth and parenting. NE Essex has the highest spend in the peer group and in the second top quintile. Figure 90: Programme Budgeting Spend on Maternity & Reproductive Health Select year: Select commissioner: Select expenditure basis: EXPENDITURE ON OWN POPULATION Q35 North East Essex PCT (5PW) Select cluster level: 3 SUB GROUP (20 groups) Select programme: 18. Maternity and reproductive health Select population weighting: UNIFIED WEIGHTED POPULATION Select comparison: Cluster average Cluster description: Prospering Smaller Towns - B All PCTs expenditure per 100,000 population for the selected programme st quintile 16.0 Expenditure ( million per 100,000 population) Norfolk PCT East Riding Of Yorkshire PCT Shropshire County PCT North Somerset PCT North Yorkshire and York PCT East Sussex Downs and Weald PCT Lincolnshire Teaching PCT Herefordshire PCT Suffolk PCT Somerset PCT Gloucestershire PCT Northumberland Care Trust North East Essex PCT 2nd quintile 3rd quintile 4th quintile 5th quintile North East Essex PCT PCTs within selected cluster level Cluster average 0.0 National Rank Lowest to Highest 40

41 NE Essex is known to have higher than average teenage pregnancy rates 13, a high termination rate and a hub-and-spoke model of maternity services, that includes two midwifery-led maternity units on the coastal areas. Deliveries in hospital are costly and the current model of service delivery is under scrutiny. Good antenatal and postnatal care will reduce potential complications with childbirth, maternal health (e.g. post-natal depression), improve the initiation and sustenance of breastfeeding and can provide the opportunities to develop good parenting skills. High levels of unwanted pregnancies, including teenage pregnancies are an indication that more prevention work is required to reduce termination rates. Improving access to contraception, terminations and good pre- and post-intervention care is important. Figure 91: Level of Home Births (2009) % Percentage of Home Births (2009) North East Essex PCT Q1 Q2 Q3 Q4 Q5 East of England England 0.00 PCTs Ranked Healthy Individuals Preventing Ill-health & Immunisation This programme includes prevention programmes (e.g. strategies for tackling smoking, obesity and sensible drinking of alcohol, health trainers) and activities with healthy individuals such as immunisations and vaccinations and health promotion campaigns. NE Essex has a higher spend in this area but is considerably lower (bottom of the 4 th quintile) than other areas, including two PCTs in our ONS cluster group. The sections below highlight the areas of main concern (e.g. high prevalence of smoking). Figure 92: Programme Budgeting Spend on Preventing Ill-health & Immunisation 13 Under 18 conception rate by LAD2 ( ), Office of National Statistics 41

42 The key killer diseases are all to a degree preventable and include smoking, unhealthy weight, poor diet, physical inactivity and excessive alcohol consumption. The prevalence of many of these risk factors is estimated to be higher than average in NE Essex. Communicable disease management through the national immunisation programmes, provides both protection for the population as well as reducing morbidity and mortality. Smoking and alcohol are two risks factors which we can tackle in the short to medium term with very good outcomes. NE Essex continues to provide a successful stop-smoking service (figure 93) and needs to persevere in reducing the smoking prevalence. However, much effort is required to tackle the continuing rise in alcohol-related morbidity and hospital admissions (figure 95); poor data collection may skew local rates. Figure 93: Smoking Cessation (quit rate) Comparison by PCTs Rate per 100,000 Pop 2,500 2,000 1,500 1, Quitters per 100,000 Population by PCT 2010/11 North East Essex, 1,154 England Figure 94: Alcohol-related Hospital Admissions by PCT Rate per 100,000 Pop 3,500 3,000 2,500 2,000 1,500 1, Rate of Alcohol Related Admissions by PCT, 2009/10 England NORTH EAST ESSEX, 1,196 Alcohol misuse remains a real concern for NE Essex with the trend for the four quarters of 2010 highlighting a continued increase in contrast to the decrease nationally (figure 95). A number of high impact interventions (such as identification & brief advice (IBA) in primary care, Alcohol Liaison nurse in A&E) during will hopefully slow down this trend in NE Essex. Figure 95: Alcohol-related hospitalisation 3-year Trend ( ) Alcohol Related Hospital Admissons ( ) England East of England NE Essex PCT Rate per 100, Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q Source: NWPHO 42

43 IMMUNISATION Recent investment, with targeted interventions, has seen an increase in uptake for childhood immunisation. In most areas, including pneumococcal coverage (PCV), NE Essex is below 88% (table 12) and not achieving the 95% required for herd immunity. Best performing PCTs are doing significantly better than NE Essex, although the latest figures ( ) show an improvement in uptake. Table 12: Comparison of Selected Childhood Immunisation Programmes Childhood Immunisation by 5th Birthday Best PCT NEEPCT Worst PCT NEEPCT Diptheria, Tetanus, Polio 98.7% 92.4% 81.1% 94.2% Hib 98.0% 92.4% 58.7% 94.2% Diptheria, Tetanus, Polio & Pertussis Booster 96.4% 82.9% 42.7% 85.5% MMR Year % 87.7% 78.4% 87.2% MMR Year % 80.4% 49.3% 83.2% In regards to flu immunisation for people aged 65yrs+, NE Essex is still below the national average (figure 96) and with the target now set at 75%, GP practices will need to encourage an increase in uptake locally. Figure 96: Flu Uptake in 65+ Years (2010/11) Percentage of persons aged 65 and over immunised against influenza (seasonal flu) by Primary Care Trust, North East Essex PCT Q1 Q2 Q3 Q4 Q5 EoE England % Immunised Source: NHS Information Centre PCTs Ranked Social Care Needs & Third Sector Commissioning This area of spend covers a wide range of activities, which aims to enhance quality of life by collaborating with other agencies, especially the third sector. For example, working with our partners to ensure better support for carers, rehabilitation in the community, collaborating to ensure affordable warmth and minimise the effects of fuel poverty, and collaboration in Children s Centres. Figure 97: Programme Budgeting Spend on Social Care Needs & Third Sector Commissioning 43

44 The evidence (see the Public Health Outcomes Evidence Base 4 Error! Bookmark not defined. and NHS Outcomes Evidence Based Practice documents) suggests that joint investment in these activities will promote innovative approaches in prevention work, can improve productivity (through improved effectiveness) and can contribute to significant savings to health and social care spend. There are potentially some discrepancies in the reporting of spending in this programme, so we need to be cautious with the comparative data. Some areas that we can further explore will include patients admitted to hospital that were related to convalescence or respite care. Better coordination between care agencies can minimise these further. GMS/PMS and Pharmaceutical Services This programme includes all other expenditure that cannot be allocated to any of the other categories. The biggest element at present is the GMS & Pharmaceutical Services Contract. In time, better information will allow this area of NHS expenditure to be allocated to the appropriate Programme Budget category. Figure 98: Programme Budgeting Spend on GMS/PMS and Pharmaceutical Services Older People Health & Well-being As people get older, mobility becomes a common problem and many could become isolated and unable to access the services they need. It is estimated that the number of people aged 65+ living on their own, will increase by 44% by 2025 and are the highest user of statutory services, although locally hospital admissions, in people aged 75yrs and over, is amongst the lowest (figure 99) in England. Loneliness can damage both physical and mental health and can be further exacerbated by lack of transport and poor mobility. Figure 99: Emergency admissions in persons over 75 years ( ) Emergency admissions in over 75s, Rate per 1,000 Population per Year Population Source: NHS Atlas of Variation Note: Population is adjusted due to Standardisation Calculations Many of our most vulnerable residents rely on the day-to-day care and support of relative carers to help them maintain their independence. It is estimated that over 6,500 people aged 65 years and older provided unpaid care for others in NE Essex as 44

45 of 2001, which is of particular concern as they are more likely to be suffering from ill health themselves (please note this figure is likely to be an underestimate). Figure 100 shows the concentration of unpaid carers in most of Tendring and in the north and south of Colchester. Overall, Tendring (140/1,000) has the highest rate of unpaid carers in Essex. Figure 100: Percentage of Population in Essex Providing Unpaid care The growth in the ageing population will translate into additional pressure on all services, especially with an increase in neurological, circulatory, endocrinology, respiratory and mental health conditions. It is estimated that two thirds of people with dementia are looked after by unpaid carers. According to research conducted by the Royal Pharmaceutical Society of Great Britain (RPSGB), older people are taking a cocktail of medicines without fully understanding what they are or the side effects they are causing, with 1 in 5 patients not complying with their medication. Primary care practitioners and partner agencies need to encourage older people to have a regular Medicine Use Review (MUR). End-of-Life Care The national strategy 14 is intended to ensure that people with advanced, progressive and incurable illness will live as well as possible. It promotes the identification of palliative care needs of both patient and family and planning of supportive care. Figure 101: Percentage of all Deaths in an Area Occurring in Hospital by Local Authority, Percentage of all deaths occurring in hospital by local authority, Percentage of all deaths occuring in hospital LAs Colchester Tendring Population Source: NHS Atlas of Variation The national drive is also intended to promote people dying at home rather than in hospital, which requires collaborative working and good planning. A key aim of the strategy therefore is to improve provision for support and palliative care in the 14 End of life care strategy, Department of Health, July

46 community to make this possible. One review 15 estimated that 40% of the patients who had died in hospital had not had medical needs, which required them to be there in the first place. Tendring (60%) has a significantly higher level of deaths happening in hospital, with Colchester (56%) just below the national average. Dealing with this area of people s care is complex and decisions are normally informed both by technical, medical considerations, economic factors as well as ethical issues (especially where rationing of care is concerned). It is paramount that end-of-life decisions are subject to considerations of patient autonomy and involves relevant carers. Diagnostic Services Good access to diagnostic service (radiology, pathology & cytology) is critical in modern medicine, as it helps optimise diagnosis and brings about rapid intervention to ensure the best health outcomes for patients as well as aiding decisions around cost-effectiveness of potential interventions. Figure 102: Magnetic Resonance Imaging (MRI) Figure 103: Computed Axial Tomography (CT) rate per1,000 rate per 1,000 by PCT 2009/10 by PCT, 2009/10 Rate of magnetic resonance imaging (MRI) activity by PCT, 2009/ Rate per 1,000 Population per Year Rate of computed axial tomography (CT) activity by PCT, 2009/ Rate per 1,000 Population per Year Population Source: NHS Atlas of Variatiion Note: Population is adjusted due to Standardisation Calculations Population Source: NHS Atlas of Variatiion Note: Population is adjusted due to Standardisation Calculations The main challenge is to ensure a high quality service (e.g. interpretation of imaging) and improve waiting times. There is a plethora of evidence-based service improvements on the NHS Improvement 16 site. The introduction of new screening programmes, such as Abdominal Aortic Aneurysm (AAA) screening, and the planned age-extension for breast and bowel cancer screening will all have an impact on activity level and diagnostic. In the case with Bowel cancer screening, local providers will need to provide additional capacity for endoscopy. 15 End of Life care, UK National Audit Office Comptroller and Auditor General's report, 26 November

47 Prescribing There are a number of indicators that can be used to measure or monitor prescribing in primary care. Indicators are often used within the performance management process or locally in prescribing incentive schemes. These can be to ensure patients are receiving optimal care (e.g. statins for CVD risk factors), for minimising the risk of the spread in medicine-resistant bacteria by over prescribing of antibiotics (e.g. Cephalosporin & Quinolone) and for cost reduction measures (e.g. generic prescribing of statins). Figure 104: Ezetimibe prescribing July-Sept Ezetimibe cost per lipid lowering STAR(09)-PUs by PCT, July Sept 2009 Q1 Q2 Q3 Q4 Q5 Cost per 1000 lipid lowering STAR(09)-PUs ( ) North East Essex PCT PCTs ranked NB: Ezetimibe is used as a an alternative cholesterol lowering drug in those that cannot tolerate statins Source: NHS Atlas of Variation Figure 105: Cephalosporin prescribing Cephalosporin items per 1000 Antibacterial STAR(09)-PUs by PCT, Q1 Q2 Q3 Q4 Q5 Items per 1000 Antibacterial STAR(09)-PUs North East Essex PCT 20 0 PCTs ranked Source: NHS Atlas of Variation Figure 106: Quinolone items per 1000 Antibacterial STAR(09)-PUs by PCT /Practice / Quinolone items per 1000 Antibacterial STAR(09)-PUs by PCT, Q1 Q2 Q3 Q4 Q5 Quinolone items per 1000 Antibacterial STAR(09)-PU North East Essex PCT 0.0 PCTs ranked Source: NHS Atlas of Variation 47

48 Therefore, high prescribing cost for some medicines is not necessarily a poor measure if the intended outcome is achieved. The are clear local policies and a number of national policies (NICE) to support better prescribing so as to ensure we have the best health outcomes, reduce over-prescribing of antibiotics, reduce costs and reduce wastage. In regards to antibiotics prescribing, NEE has one of the lowest rate in the East of England and our ONS cluster group (Figure 107). However, we have a number of practices that are prescribing well above the PCTs average (Figure 108). High levels of antibiotic prescribing can have a negative impact on HCAI level as well as on length of stay in hospital. Therefore, NEECCG has a responsibility to encourage prudence in antimicrobial prescribing. Figure 107: Cephalosporins & Quinolones Prescribed as a Proportion of all items prescribed by PCT 2010/11 Figure 108: Cephalosporins & Quinolones Prescribed as a Proportion of all items prescribed by GP practice in NE Essex PCT 2010/11 During (Figure 109), the level of prescribing for low cost statins was as high as the England average (75.8%), with only a handful of practices (figure 110) prescribing below the national average. 48

49 Figure 109: Pravastatin & Simvastatin Prescribing as a Proportion of Statins Prescribed by PCT /11 Figure 110: Pravastatin & Simvastatin Prescribing as a Proportion of Statins Prescribed by GP Practice in NE Essex PCT /11 In regards to the overall generic prescribing level, NEE performs better than the national average and all the PCTs in our ONS Cluster group (Figure 111). There is an almost uniform performance across all practices in NE Essex (Figure 112). Figure 111: Generic Prescribing as a Proportion of all items Prescribed by PCT /11 49

50 Figure 112: Generic Prescribing as a Proportion of all items Prescribed by GP practice in NE Essex PCT /11 CONCLUSION The analysis undertaken in this JSNA toolkit has mainly focused on areas where NHS NEE is an outlier in programme spend, has poor health outcomes, has poor QOF outcomes and where modelling is suggesting that the level of disease prevalence (i.e. people on disease registers) is lower than expected. NHS NEE has made significant progress in some areas but this Needs Assessment is highlighting where we have significant gaps in our healthcare delivery for our local population. We have summarised, in the introduction of this document, the areas that would require the NE Essex s CCG to focus their attention on in setting priorities and announcing their commissioning intentions. The following are topics that CCG will need to consider as key priority areas: Diabetes Circulatory Disease COPD/Asthma Mental Health Procedures of Limited Clinical Value Timeliness of other procedures (e.g. CABG, Hip/Knee replacements) Learning Disability Maternity services Spend on Dentistry & Vision Prescribing Lifestyle & first line interventions Some of these areas will require CCG to review current practices (both in primary and secondary care), adherence to local policies (especially the restricted clinical priorities policy) and the high level of investment in dentistry and opthalmology services consider the opportunity costs of these investments. The Public Health team will soon be completing an Urgent Care Needs Assessment which will identify specific areas where targeted collective interventions will be productive. It is recommended that more in-depth analyses are undertaken in other areas of concern such as the circulatory disease programme, to better support planned intervention by commissioners, in collaboration with partners and/or providers. A suite of evidence-based practice documents is being produced to support commissioners in this process and to date we have completed two such reviews alongside the proposed national outcomes framework for the NHS and Public Health. We would also recommend that GP practice level analyses are undertaken in some areas to equalise the inequalities in service provision, improve patients experience and health and social care outcomes. To aid some of this information synthesis, we would highly recommend that NE Essex CCG agrees to a robust annual Audit programme, with multi-agency, multi-disciplinary engagement, to help better inform the commissioning process as well as quality of care. It is our intention to work collaboratively with NE Essex CCG to update and enhance this toolkit on an annual basis. 50

51 Appendix Figure (I) Demographics & Deprivation Procedures with Limited Clinical Value Figure (II) Emergency Appendectomy Admissions Figure (III) Elective Admissions for Cataracts (2008/09) (2008/09) Figure (IV) Tonsillectomy Elective Admissions Figure (V) Hernia Elective Admissions (2008/09) (2008/09) 51

52 Figure (VI) Hernia Emergency Admissions (2008/09) Cancers & Tumours Figure (VII) SMR From Breast Cancers ( ) Figure (VIII) SMR From Breast Cancers U75 ( ) Mortality from Breast Cancer, Mortality from Breast Cancer, u75 years, Standardised Mortality Ratio Standardised Mortality Ratio Expected Deaths Source: Compendium of Clinical and Health Indicators Crown Copyright Expected Deaths Figure (IX) SMR From Prostate Cancer ( ) Figure (X) SMR From Prostate Cancer U75 ( ) Mortality from Prostate Cancer, Mortality from Prostate Cancer, u75 years, Standardised Mortality Ratio Standardised Mortality Ratio Expected Deaths Expected Deaths 52

53 Figure (XI) SMR From Lung Cancer ( ) Figure (XII) SMR From Lung Cancer U75 ( ) Lung Cancer Mortality, Mortality from Lung Cancer, u75 years, Standardised Mortality Ratio Standardised Mortality Ratio Expected Deaths Expected Deaths Source : Compe ndium of Clinical and Health Indicators Crown Copyright - Figure (XIII) Cancer Bed Days Cancer Bed Days - Q Q3 2009/10 Q1 Q2 Q3 Q4 Q5 England East of England No of Cancer Bed Days per 1,000 Population North East Essex PCT PCT ranked Source: NHS Atlas of Variation 53

54 Figure (XIV) Emergency Cancer Admissions per 100 on Disease Register ( ) Emergency Cancer admissions per 100 on disease register ( ) Q1 Q2 Q3 Q4 Q5 England East of England Rate per 100 on disease register PCTs ranked Source: NHS Comparators Figure (XV) Inpatient Expenditure per 1,000 45,000 40,000 Cancer Inpatient Expenditure Q4 2008/09 - Q3 2009/10 Q1 Q2 Q3 Q4 Q5 England East of England Inpatient Expenditure per 1000 population ( s) 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 PCTs Ranked Source: NHS Atlas of Variation 54

55 Endocrine, Nutritional and Metabolic Problems Figure (XVI) DM Lower Limb Amputations in Diabetic Patients ( ) Hospital procedures: lower limb amputations in diabetic patients ( ) Directly Standardised Rate per 100, Population Source: Compendium of Clinical and Health Indicators Crown Copyright - Note: Population is adjusted due to Standardisation Calculations Figure (XVII) Emergency Diabetes Admissions per 100 on Disease Register ( ) 4.00 Emergency Diabetes Admissions per 100 on disease register ( ) Q1 Q2 Q3 Q4 Q5 England East of England Rate per 100 on disease register PCTs ranked Source: NHS Comparators 55

56 Figure (XVIII) DM - Hospital Admissions (Ketoacidosis &Coma) Emergency hospital admissions: diabetic ketoacidosis and coma, Rate per 100,000 Population per Year Population Source: Compendium of Clinical and Health Indicators Crown Copyright - Note: Population is adjusted due to Standardisation Calculations Figure (XIX): DM Blood Pressure 145/85 or Less (DM12) Percent Coverage Proportion of patients with diabetes in whom the last blood pressure reading is 145/85 or less (DM12) Population of Diabetics Source : Quality and Outcomes Framework Figure (XX): Influenza Vaccination for Diabetics (DM18) Percent Coverage Vaccination: influenza, for patients with diabetes mellitus (DM18) Population of Diabetics Source: Quality and Outcomes Framework Figure (XXI): Retinal Screening in Diabetics (DM21) Retinal screening in patients with diabetes mellitus (DM21) Figure (XXII): Renal Function in Diabetics (DM22) Renal function testing in patients with diabetes mellitus (DM22) Percent Coverage Percent Coverage Population of Diabetics Source : Quality and Outcomes Framework Population of Diabetics Source : Quality and Outcomes Framework

57 Figure (XXIII): DSR of bariatric procedures in hospital 2007/ /10 Hospital Procedures for Bariatric Surgery, 2007/08 to 2009-/ Directly Standardised Rate per 100, Population Source: Compendium of Clinical and Health Indicators Crown Copyright - Note: Population is adjusted due to Standardisation Calculations Mental Disorders Figure (XXIV): Mortality from Suicide ( ) Figure (XXV): Mortality from Suicide U75 ( ) Mortality from suicide ( ) Standardised Mortality Ratio Expected Deaths Source: Compendium of Clinical and Health Indicators Crown Copyright - Figure (XXVI): Total Adults Receiving Secondary MH Services (18-69) Total Number of Adults Receiving Secondary MH Services (aged 18-69) in NE Essex 3,000 Number of adults receiving secondary MH services 2,900 2,800 2,700 2,600 2,500 2,400 2,300 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Q1 Q2 Q3 Q4 Source: NEPFT 57

58 Figure (XXVII): Emergency Hospital Admissions: Schizophrenia ( ) Emergency hospital admissions: Schizophrenia ( ) Directly age & sex standardised rate per 100, North East Essex PCT Q1 Q2 Q3 Q4 Q5 England East of England 0.00 Source: nww.nchod.nhs.uk PCTs ranked Figure (XXVIII): Substance Use Elective Admissions 2008/09 Figure (XXIX): Substance Use Emergency Admissions 2008/09 58

59 Neurological Problems Figure (XXX): Mortality from Epilepsy ( ) Figure (XXXI): Mortality from Epilepsy U75 ( ) Mortality from epilepsy ( ) Mortality from epilepsy, u75 years ( ) Standardised Mortality Ratio Standardised Mortality Ratio Expected Deaths Source: Compendium of Clinical and Health Indicators Crown Copyright Expected Deaths Source: Compendium of Clinical and Health Indicators Crown Copyright - Figure (XXXII): Elective Admissions from Epilepsy (2006/07- Figure (XXXIII): Emergency Admissions from Epilepsy 2008/09) (2006/ /09) Elective Admissions from Epilepsy, 2006/ /09 Rate per 100,000 Population per Year Population Source: NHS Atlas of Variation Note: Population is adjusted due to Standardisation Calculations 59

60 Problems of Vision Figure (XXXIV): Expenditure on Phako-Emulsification Cataract Extraction & Lens Insertion (2008/09) Expenditure on phako-emulsification cataract extraction & insertion of lens ( ) 9,000 8,000 Q1 Q2 Q3 Q4 Q5 England East of England 7,000 Cost per 1,000 population ( s) 6,000 5,000 4,000 3,000 North East Essex PCT 2,000 1,000 0 PCTs ranked Source: NHS Atlas of Variation Problems of Circulation Figure (XXXV): SMR of All Circulatory Diseases by PCT Figure (XXXVI): SMR of All Circulatory Diseases (U75) Mortality from all circulatory diseases, Mortality from all circulatory diseases, u75 years, Standardised Mortality Ratio Standardised Mortality Ratio Expected deaths Source: Compendium of Clinical and Health Indicators Crown Copyright Expected deaths Source: Com pendium of Clinical and Health Indicators Crow n Copyright - w w w.nchod.nhs.uk 60

61 Figure (XXXVII): SMR From MI ( ) Figure (XXXVIII): SMR From MI (U75) ( ) Mortality from Acute Myocardial Infarction, Mortality from acute myocardial infarction, u75 years, ( ) Standardised Mortality Ratio Standardised Mortality Ratio Expected Deaths Source: Compendium of Clinical and Health Indicators Crown Copyright Expected deaths Source: Compendium of Clinical and Health Indicators Crown Copyright - Figure (XXXIX): SMR From CHD (U75) ( ) Figure (XL): SMR From Hypertensive Diseases ( ) Mortality from CHD, u75 years, ( ) Mortality from Hypertensive Diseases, Standardised Mortality Ratio Standardised Mortality Ratio Expected deaths Source: Compendium of Clinical and Health Indicators Crown Copyright Expected deaths Source: Compendium of Clinical and Health Indicators Crown Copyright - Figure (XLI): SMR From Stroke U75 ( ) Mortality from stroke, u75 years, Standardised Mortality Ratio Expected deaths Source: Compendium of Clinical and Health Indicators Crown Copyright - Figure (XLII): Percentage of TIA Cases with a Higher Risk who are Treated within 24 hrs (Q3 2010/11) Number of Transient Ischaemic Attack (TIA) cases with a higher risk of stroke who are then subsequently treated within 24 hours (Q3 Oct - Dec 2010) 100 Proportion treated within 24hrs Population Source: Department of Health: Unify2 data collection - VSMR LAs 61

62 Figure (XLIII): % with a History of MI who are Currently Figure (XLIV): CHD and Influenza Immunisation Treated with ACE Inhibitor or Angiotensin II (CHD 11) (CHD 12) Percent Coverage Percentage of patients with a history of MI who are currently treated with an ACE inhibitor or Angiotensin II antagonist (CHD11) Percent Coverage Percentage of patients with coronary heart disease who have a record of influenza immunisation (CHD12) Eligible CHD population Source: Quality and Outcomes Framework Eligible CHD population Source: Quality and Outcomes Framework Figure (XLV): TIA/Stroke and Influenza Immunisation (Stroke 10) Percent Coverage Percentage of patients with TIA or stroke who have had influenza immunisation (STROKE10) Figure (XLVI): % with Hypertension and BP 150/90 or Less (BP5) Percent Coverage Percetage of patients with hypertension in whom the last blood pressure is 150/90 or less (BP5) Eligible stroke population Source: Quality and Outcomes Framework Eligible hypertensive population Source : Quality and Outcome s Framework Figure (XLVII): Emergency Admissions for Acute Figure (XLVIII): Elective Angiogram Admissions (2008/09) Hypertensive Disease (2008/09) 62

63 Figure (XLIX): Emergency Angiogram Admissions (2008/09) Figure (L): Emergency AF Admissions per 100 on Disease Register ( ) Emergency AF admissions per 100 on disease register ( ) Q1 Q2 Q3 Q4 Q5 England East of England Rate per 100 on disease register North East Essex PCT PCTs ranked Source: NHS Comparators 63

64 Problems of the Respiratory System Figure (LI): Mortality from Bronchitis, Emphysema & Figure (LII): Mortality from Pneumonia ( ) other COPD ( ) Mortality from bronchitis, emphysema and other COPD ( ): Mortality from pneumonia ( ): Standardised Mortality Ratio Standardised Mortality Ratio Expected Deaths Source: Compendium of Clinical and Health Indicators Crown Copyright Expected Deaths Source: Compendium of Clinical and Health Indicators Crown Copyright - Figure (LIII): Mortality from Pneumonia (U75) ( ) Mortality from pneumonia ( ) (Under 75) Standardised Mortality Ratio Expected Deaths Figure (LIV): Emergency Hospital Admissions for Asthma U18 ( ) Emergency hospital admissions for asthma in persons u18 years, Rate per 100,000 Population per Year Population Source: NHS Atlas of Variation Note: Population is adjusted due to Standardisation Calculations 64

65 Problems of the Musculo-Skeletal System & Trauma Figure (LV): Primary Knee Replacement Expenditure per 1,000 of population, ( ) Cost ( ) 14,000 12,000 10,000 8,000 6,000 Primary knee replacement in patient admission expenditure per 1000 population, 2008/09 Q1 Q2 Q3 Q4 Q5 East of England England North East Essex PCT 4,000 2, PCTs Ranked Source: NHS Atlas of Variation Figure (LVI): SMR For Falls ( ) Figure (LVII): SMR For Falls (U75) ( ) Figure (LVII): Mean Pre-Operative EQ-5D Index Score for Knee Replacement Surgery ( ) Mean (average) pre-operative EQ-5D Index score for knee replacement surgery by PCT, 2009/10 North East Essex PCT Q1 Q2 Q3 Q4 Q5 East of England England 0.4 Score PCTs Ranked Source: NHS Atlas of Variation 65

66 Figure (LVIII): Hospital Procedure: Fractured Proximal Figure (LVIX): Hospital Procedure: Primary Knee Femur (2009/10) Replacement (2009/10) NB: It should be noted that fractured proximal femur data includes: Fracture of NOF, Petrochanteric fracture & subtrochanteric fractures. Figure (LX): Hospital Procedure: Primary Hip Replacement Figure (LXI): Hospital Procedure: Revision Hip (2009/10) Replacement (2009/10) Figure (LXII): Elective Hip Replacement Admissions (2008- Figure (LXIII): Elective Knee Replacement Admissions ( ) 09) 66