ISSUES & ANSWERS IN CARDIOVASCULAR DISEASE. NHS Health Check Update. Jamie Waterall National Lead Public Health England

ISSUES & ANSWERS IN CARDIOVASCULAR DISEASE NHS Health Check Update Jamie Waterall National Lead Public Health England

What % of cardiovascular disease risk factors are considered modifiable? 85% Newton et al 2015 Changes in health in England, with analysis by English regions and areas of deprivation, 1990 2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet 2 Twitter: @JamieWaterall

Burden of disease attributable to leading risk factors for both sexes in 2013, expressed as a percentage of England disability-adjusted life-years Dietary risks Tobacco smoke High body-mass index High systolic blood pressure Alcohol and drug use High fasting plasma glucose High total cholesterol Low glomerular filtration rate Low physical activity Occupational risks Air pollution Low bone mineral density Child and maternal malnutrition Sexual abuse and violence Other environmental risks Unsafe sex Unsafe water/ sanitation/ handwashing HIV/AIDS and tuberculosis Diarrhea, lower respiratory & other common infectious diseases Neglected tropical diseases & malaria Maternal disorders Neonatal disorders Nutritional deficiencies Other communicable, maternal, neonatal, & nutritional diseases Neoplasms Cardiovascular diseases Chronic respiratory diseases Cirrhosis Digestive diseases Neurological disorders Mental & substance use disorders Diabetes, urogenital, blood, & endocrine diseases Musculoskeletal disorders Other non-communicable diseases Transport injuries Unintentional injuries Self-harm and interpersonal violence Forces of nature, war, & legal intervention 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 11% 12% Percent of total disability-adjusted life-years (DALYs) 3 Twitter: @JamieWaterall

How many people have undiagnosed hypertension in England? 5 Million The National Cardiovascular Intelligence Network. Cardiovascular disease key facts. Fact Sheet No 7. London: Public Health England, 2013. 4 Twitter: @JamieWaterall

Over ten years, an estimated 7,000 quality adjusted life years could be saved, and 120m not spent on related health and social care costs, if England achieved a 15% increase in the proportion of adults who have had their high blood pressure diagnosed 5 Twitter: @JamieWaterall

NHS Health Check aim and objectives: The NHS Health Check programme offers a fantastic opportunity to help people to live longer, healthier lives. It aims to improve health and wellbeing of adults aged 40-74 years through the promotion of earlier awareness, assessment, and management of the major risks factors and conditions driving premature death, disability and health inequalities in England. Twitter: @JamieWaterall

The programme will achieve this by: promoting and improving the early identification and management of the individual behavioural and physiological risk factors for vascular disease and the other conditions associated with these risk factors supporting individuals to effectively manage and reduce behavioural risks and associated conditions through information, behavioural and evidence based clinical interventions helping to reduce inequalities in the distribution and burden of behavioural risks, related conditions and multiple morbidities promoting and supporting appropriate operational research and evaluation to optimise programme delivery and impact, nationally and locally Twitter: @JamieWaterall

Twitter: @JamieWaterall

Number of eligible persons offered / taking up NHS Health Check 3,500,000 Nationally, 3,000,000 15,579,278 are eligible for an NHS Health Number of persons 2011-12 offers 2012-13 offers 2013-14 offers 2014-15 offers 2015-16 offers We are entering the third year (2015-16) with complete coverage across England 2011-12 received 2012-13 received 2013-14 received 2014-15 received 2015-16 received Check between 2013 and 2018 2,500,000 Cumulatively, 2,000,000 since Q1 2013-14, a total of 6,623,550 people (42.5%) persons have been offered a NHS Health 1,500,000 Check and 3,206,208 (20.6%) have received a NHS Health 1,000,000 Check. This means that in the nine quarters between April 2013 and June 2015, 48.4% of people 500,000 offered a NHS Health Check have received one 0 Q1 YtD Q2 YtD Q3 YtD Q4 YtD Quarter 9 Twitter: @JamieWaterall

Offers and uptake by local authority (2013-18, nine quarters) 100% 90% Doncaster Isles of Scilly Leicester 80% 70% Surrey Blackpool Bolton Ealing Uptake 60% 50% 40% 30% 20% 10% Croydon Wakefield East Riding of Yorkshire Wandsworth Kingston upon Thames Kensington and Chelsea Lambeth Westminster Hammersmith and Fulham 0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 110% 120% Offers 10 Twitter: @JamieWaterall

NHS Health Checks offered to the eligible population NHS Health Checks 2013-2018 (cumulative figures: 9 quarters) Offered NHS Health Checks which were taken Compare with England Better Similar Worse http://healthierlives.phe.org.uk 11

NHS Health Check Areas of focus: NHS Health Check implementation review and action plan 2013 set out PHE s commitment to local implementation and drive for improved quality, consistency, governance and outcomes. Ten commitments underpin work in 2014-15, including: Leadership: introduce new governance structure including expert scientific and clinical advisory panel, information governance and data sub-group Improve uptake: support behavioural insight research and develop national marketing and branding toolkit to support local delivery (new website presence) Information governance: overcome barriers to data sharing publish a national guidance and IG toolkit Support delivery: establish national and local learning networks Consistency: develop national quality improvement framework Provider competency: establish national competency framework prove the case: support research and evaluation of NHS Health Check to provide evidence for future investment Twitter: @JamieWaterall

PHE will bring strong scientific rigour to the programme Key actions: Expert Clinical and Scientific Advisory Panel Review emerging evidence and research needs. In addition to the two DH national evaluations, PHE will also promote future research, development and evaluation of this programme PHE will also coordinate a refresh of the economic modelling conducted in 2008, updating the assumptions in the light of new data, experience and programme changes Twitter: @JamieWaterall

14 An absence of 1. Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C et al. General health checks in adults for reducing morbidity and mortality from disease. Cochrane Database Syst Rev 2012;10:CD009009. evidence should not be 2. Jørgensen T, Jacobsen RK, Toft U et al. Effect of screening and lifestyle counselling on incidence of ischaemic heart disease in general population: Inter99 randomised trial. BMJ 2014;348:g3617. confused with evidence 3. Caley M, Chohan P, Hooper J et al. The impact of NHS Health Checks on the prevalence of disease in general practices: a controlled study. Br Gen Pract 2014;64(625):e516 21. of ineffectiveness

15 NIHR Policy Research Programme Queen Mary University: Observational study over four years April 2009 March 2013 655 general practices across England (QResearch database) Comparison between attendees (214,295) and non-attendees (1,464,729) Imperial Collage London : Retrospective electronic medical records obtained from the Clinical Practice Research Datalink (CPRD) Random sample of 95,571 persons eligible for a Health Check between April 2009 and March 2013

Local evaluations Robson et al (2015) The NHS Health Check programme: implementation in east London 2009-2011 In the 6 months following an NHS Health Check, 1349 new cases of hypertension, 638 new cases of diabetes and 89 new cases of chronic kidney disease (CKD) were diagnosed. This represents 1 new case of hypertension per 38 Checks, 1 new case of diabetes per 80 Checks and 1 new case of CKD per 568 Checks. Khunti et al (2015) A retrospective evaluation of the NHS Health Check Programme in a multi-ethnic population Over a 5-year period, 53 799 health checks were performed, 16 388 (30%) people were diagnosed with at least one condition when diagnosis of being at high risk of cardiovascular disease was defined as 20%. This figure increased to 43% when diagnosis of high cardiovascular risk 10% was included. Of the 3063 (5.7%) individuals diagnosed with type 2 diabetes, 54% were prescribed metformin and 26% were referred for structured education. Of the 5797 (10.8%) individuals diagnosed at high risk of cardiovascular disease (20%), 64% were prescribed statins. Twitter: @JamieWaterall

PHE and DH Collaborative Projects Stoke on Trent RCT: 1 invitation letter frame based on risk 2 traditional invite 2 telephone/ verbal invite; Salford: The effectiveness of video messages on screens in GP waiting rooms Northamptonshire: Myth busting letter vs costs to NHS letter Southwark (letters / texts): 12% absolute increase in uptake with best letter and both primer and reminder Bristol: Quasi-experiment of telephone outreach by a community in-reach worker vs the traditional letter invite Southwark (prompts): Quasi-experiment of electronic prompts for staff to offer NHS HC Medway letters: 13% relative increase in uptake 4% net increase in uptake

NHS Health Check If the NHS Check programme is to achieve This priorities its potential for as research one of the largest systematic document prevention encourages programmes in the world, it must be grounded in and led by the commissioners best possible evidence. of research The and evidence base relevant is currently research incomplete. active This can and organisations must be addressed to address by generating those relevant new knowledge, and then research questions and other translating that knowledge into practice. This priorities will allow that us PHE to better and understand its the impact stakeholders of the programme, have identified maximise as its benefits most relevant to population to the health, programme. and contribute to the international evidence base.

NHS Health Check (data) Through the work of the NHS Health Check data, intelligence and information governance sub group, it is apparent that there is a consensus for the development of a national centralised collection system for the NHS Health Check programme. We need to ensure that we have consistency in the way that the NHS Health Check information has been recorded locally to facilitate local and national evaluation, and research requires data that are accurate and can be segmented (eg, according to gender, ethnicity).

Cambridge Microsimulation Model Building a microsimulation model based upon available data on the NHS Health Check programme to date Focus on cardiovascular risk and dementia risk Simulating What If scenarios: How would health outcomes change under different assumptions or due to policy changes Improve current methodology around comparable approaches (eg. Simulating individual trajectories for risk factors Produce report, publish results and model (open source)

http://www.nhs.uk/conditions/nhs-health-check/pages/nhs-health-check.aspx Twitter: @JamieWaterall

Thank you Working together for the public s health Jamie Waterall NHS Health Check National Lead e-mail: jamie.waterall@phe.gov.uk website: www.healthcheck.nhs.uk Twitter: @JamieWaterall

CVD Prevention We Need Primary Care Leadership Dr Matt Kearney GP Runcorn National Clinical Advisor NHS England and Public Health England www.england.nhs.uk

Midlife checks for the worried well leave no time to treat the sick, warn GPs RCGP Over-diagnosis Group www.england.nhs.uk 24

CVD prevention in primary care Challenging questions Does CVD risk assessment increase over-diagnosis and over treatment? Are we not just medicalising lifestyle issues? Shouldn t we put our efforts into population measures? www.england.nhs.uk

Premature mortality the Big Killers CVD www.england.nhs.uk

Most premature deaths are avoidable www.england.nhs.uk

CVD Risk: the ageing population 50% England Population Projections (Principal) % Growth to 2012, 2017 & 2022 45% 40% 2010-2012 % Increase 2010-2017 % Increase 2010-2022 % Increase 85 plus to grow By 44% 2010-2022 44% Projected % Increase in Population 35% 30% 25% 20% 15% 65-74 to grow By 20% 2010-2017 20% 21% 31% 22% 10% 10% 10% 10% 7% 7% 6% 6% 6% 5% 5% 4% 3% 2% 2% 2% 1% 1% 0% 0-19 20-44 45-64 65-74 75-84 85 plus All Ages Source: ONS Population Projections. 2010-Based

CVD risk the normalisation of obesity Two thirds of English adults and one third of 11-15 year olds are currently overweight or obese. One in five children is overweight or obese on starting primary school and one in three when they leave. www.england.nhs.uk

DALYs Attributable to top 20 (of 67) Risk Factors (UK) Global Burden of Disease Study. Lancet 2013;381:997-1020

The NHS needs a radical upgrade in prevention if it is to be sustainable 5 year Forward View 2014 www.england.nhs.uk

www.england.nhs.uk Prevention what can the NHS do?

What can the NHS do to reduce premature mortality? Population level interventions are important for prevention But the NHS has a pivotal role in risk identification, support for behaviour change, earlier diagnosis, secondary prevention Much of this is done in primary care www.england.nhs.uk

CVD 1 o and 2 o Prevention Essential Primary Care Behavioural risk factors brief interventions and signposting 2/3 obese or overweight 1/3 physically inactive 20% smoke but over 50% in some communities Physiological risk factors early detection and secondary prevention o Hypertension o Atrial Fibrillation o Diabetes o Chronic Kidney Disease o High CVD risk www.england.nhs.uk

Family of Vascular Diseases One Thing Leads to Another Previous Stroke MI Risk x 2-3 Stroke Risk x9 Previous MI MI Risk x 5-7 Stroke Risk x3-4 CKD MI Risk x2 Stroke risk x1.5 Type 2 Diabetes MI risk x2 Stroke risk x1.5-2 Peripheral Arterial Disease MI Risk x4 Stroke Risk x2-3 Atrial Fibrillation Stroke risk x5 Hypertension 2nd biggest cause of premature death and disability Causes around half of all strokes and heart attacks

www.england.nhs.uk How well are we doing in identifying and managing cardiovascular risk?

Hypertension Hypertension 2nd biggest cause of premature death and disability But 5 million undiagnosed hypertension 40% hypertension treatment suboptimal www.england.nhs.uk

Hypertension Percent diagnosed GP practice CCG Dr Butt & Partners P85612 Medlock Medical Practice P85610 Drs Akram & Datta P85028 Jarvis Medical Practice P85622 Dr Jaishankar & Dr Pattabiraman P85019 Dr Isukapalli & Partner P85001 Ch Medical Practice P85011 Hill Top Surgery Y02753 Saddleworth Medical Practice P85016 The Duru Practice Y01124 Dr B Perkins P85608 Hollinwood Medical Practice Y02933 St Mary'S Medical Practice P85002 Dr A Sharma & Partner P85607 Oldham Family Practice P85007 Glodwick Medical Practice P85021 Failsworth Group Practice P85008 Gtd Primary Care P85614 Dr S Perveen & Partners P85605 Dr D S Mcmaster & Partner P85026 Hopwood House Medical Practice P85014 Dr Whitley & Partners P85005 Dr M Chowdhury P85003 Dr S Sidhu P85025 Dr Akhter & Partners P85004 Dr N T Mistry & Partner P85022 Woodlands Medical Practice P85010 Springfield House Medical Centre P85020 Danson Family Practice P85018 P85018 Saraf Medical Practice P85602 Drs Addy & Nelson P85603 Pennine Medical Practice P89006 The Parks Medical Practice P85006 Dr Hampson And Partners P85015 Moorside Medical Practice P85606 Royton & Crompton Family Practice P85013 Kapur Family Care P85615 Radcliffe Medical Practice P85029 St Chads Medical Practice P85620 Dr A Mohanty P85613 Dr P J Trewinnard P85601 Oldham Medical Services P85012 Dr Woodhouse & Partners P85017 Mach Healthcare Limited P85621 John Street Medical Practice Y02827 Gtd Primary Care Y02875 Practice Comparison Practice variation 38 to 76% 25,082 people with undiagnosed hypertension in CCG 0 0.2 0.4 0.6 0.8 1 ratio of observed to expected www.england.nhs.uk

Hypertension Percentage with BP NOT controlled below 150/90 Graph Not below 150/90 Mach Healthcare Limited P85621 Moorside Medical Practice P85606 The Parks Medical Practice P85006 Dr S Sidhu P85025 Dr N T Mistry & Partner P85022 Dr Akhter & Partners P85004 St Mary'S Medical Practice P85002 Drs Addy & Nelson P85603 Pennine Medical Practice P89006 Radcliffe Medical Practice P85029 Hopwood House Medical Practice P85014 Springfield House Medical Centre P85020 Dr M Chowdhury P85003 Oldham Medical Services P85012 Gtd Primary Care P85614 Dr Butt & Partners P85612 Ch Medical Practice P85011 Dr Whitley & Partners P85005 Hollinwood Medical Practice Y02933 Drs Akram & Datta P85028 Dr Jaishankar & Dr Pattabiraman P85019 Saddleworth Medical Practice P85016 Dr D S Mcmaster & Partner P85026 Dr Hampson And Partners P85015 The Duru Practice Y01124 Dr Woodhouse & Partners P85017 Oldham Family Practice P85007 Dr Isukapalli & Partner P85001 Jarvis Medical Practice P85622 Medlock Medical Practice P85610 John Street Medical Practice Y02827 Woodlands Medical Practice P85010 Saraf Medical Practice P85602 Royton & Crompton Family Practice P85013 Dr A Mohanty P85613 Hill Top Surgery Y02753 Danson Family Practice P85018 P85018 Kapur Family Care P85615 Failsworth Group Practice P85008 Dr S Perveen & Partners P85605 Dr P J Trewinnard P85601 Dr B Perkins P85608 Dr A Sharma & Partner P85607 Gtd Primary Care Y02875 St Chads Medical Practice P85620 Glodwick Medical Practice P85021 Exceptions reported Practice Comparison Practice variation 9.8% to 39.3% 6,856 people in CCG whose blood pressure is not controlled 0% 10% 20% 30% 40% 50% www.england.nhs.uk

Atrial Fibrillation AF increases the risk of stroke by a factor of 5 AF strokes are often more severe with higher mortality and greater disability. Anticoagulation substantially reduces the risk of stroke in people with AF BUT 25-30% of people with AF are undiagnosed and untreated 70% of people with known AF who have a stroke are not anticoagulated Half of all people with AF on anticoagulants are undertreated www.england.nhs.uk

Atrial Fibrillation Percent diagnosed Graph GP practice CCG Hill Top Surgery Y02753 Gtd Primary Care P85614 Hollinwood Medical Practice Y02933 St Chads Medical Practice P85620 Danson Family Practice P85018 P85018 St Mary'S Medical Practice P85002 Moorside Medical Practice P85606 Glodwick Medical Practice P85021 Dr Whitley & Partners P85005 Drs Akram & Datta P85028 Saddleworth Medical Practice P85016 Woodlands Medical Practice P85010 Dr S Perveen & Partners P85605 Royton & Crompton Family Practice P85013 Dr B Perkins P85608 Ch Medical Practice P85011 Hopwood House Medical Practice P85014 The Parks Medical Practice P85006 Saraf Medical Practice P85602 Failsworth Group Practice P85008 Dr A Sharma & Partner P85607 Dr Isukapalli & Partner P85001 Dr Butt & Partners P85612 Dr N T Mistry & Partner P85022 Dr Jaishankar & Dr Pattabiraman P85019 Dr Hampson And Partners P85015 Drs Addy & Nelson P85603 Pennine Medical Practice P89006 Oldham Medical Services P85012 Dr Woodhouse & Partners P85017 The Duru Practice Y01124 Medlock Medical Practice P85610 Springfield House Medical Centre P85020 Kapur Family Care P85615 Dr Akhter & Partners P85004 Dr D S Mcmaster & Partner P85026 Oldham Family Practice P85007 Gtd Primary Care Y02875 Mach Healthcare Limited P85621 Dr P J Trewinnard P85601 Dr M Chowdhury P85003 John Street Medical Practice Y02827 Dr A Mohanty P85613 Jarvis Medical Practice P85622 Dr S Sidhu P85025 Radcliffe Medical Practice P85029 Practice Comparison Practice variation 18% to 89% 2,343 people with undiagnosed AF in CCG 0 0.2 0.4 0.6 0.8 1 ratio of observed to expected www.england.nhs.uk 41

Atrial Fibrillation Percent eligible people NOT treated with anticoagulant Dr S Sidhu P85025 Mach Healthcare Limited P85621 Medlock Medical Practice P85610 Radcliffe Medical Practice P85029 Dr P J Trewinnard P85601 Jarvis Medical Practice P85622 John Street Medical Practice Y02827 The Parks Medical Practice P85006 Ch Medical Practice P85011 Dr A Sharma & Partner P85607 Danson Family Practice P85018 P85018 Dr D S Mcmaster & Partner P85026 Springfield House Medical Centre P85020 Hill Top Surgery Y02753 Dr M Chowdhury P85003 Moorside Medical Practice P85606 Hollinwood Medical Practice Y02933 Hopwood House Medical Practice P85014 Dr B Perkins P85608 Dr Woodhouse & Partners P85017 Pennine Medical Practice P89006 St Mary'S Medical Practice P85002 Dr N T Mistry & Partner P85022 Dr Butt & Partners P85612 Dr Hampson And Partners P85015 Dr Akhter & Partners P85004 St Chads Medical Practice P85620 Failsworth Group Practice P85008 Dr Whitley & Partners P85005 Dr Jaishankar & Dr Pattabiraman P85019 Dr Isukapalli & Partner P85001 Woodlands Medical Practice P85010 Gtd Primary Care P85614 Royton & Crompton Family Practice P85013 The Duru Practice Y01124 Glodwick Medical Practice P85021 Drs Akram & Datta P85028 Saddleworth Medical Practice P85016 Kapur Family Care P85615 Oldham Medical Services P85012 Oldham Family Practice P85007 Saraf Medical Practice P85602 Dr S Perveen & Partners P85605 Drs Addy & Nelson P85603 Dr A Mohanty P85613 Gtd Primary Care Y02875 Graph No treatment Exceptions reported Practice Comparison Practice variation 12% to 67% 497 people in CCG not receiving treatment 0% 10% 20% 30% 40% 50% 60% 70% www.england.nhs.uk 42

Chronic Kidney Disease CKD is common and affects a third of people over 65 CKD substantially increases the risk of heart attack and stroke CKD increases risk of acute kidney injury during intercurrent illness Treatment (CVD risk reduction, BP control and proteinuria management) reduce the risk of cardiovascular events and progression to kidney failure. But Around a third of people with CKD are undiagnosed www.england.nhs.uk

Chronic Kidney Disease recorded prevalence Graph GP practice Dr Hampson And Partners P85015 Danson Family Practice P85018 P85018 Oldham Family Practice P85007 Dr B Perkins P85608 Dr Woodhouse & Partners P85017 Woodlands Medical Practice P85010 Dr Isukapalli & Partner P85001 Kapur Family Care P85615 St Mary'S Medical Practice P85002 Dr S Perveen & Partners P85605 Dr P J Trewinnard P85601 Saddleworth Medical Practice P85016 Mach Healthcare Limited P85621 Drs Akram & Datta P85028 Radcliffe Medical Practice P85029 Dr A Sharma & Partner P85607 Ch Medical Practice P85011 Dr Butt & Partners P85612 Dr D S Mcmaster & Partner P85026 Dr Whitley & Partners P85005 Drs Addy & Nelson P85603 The Parks Medical Practice P85006 Failsworth Group Practice P85008 Glodwick Medical Practice P85021 Saraf Medical Practice P85602 Medlock Medical Practice P85610 Gtd Primary Care P85614 Springfield House Medical Centre P85020 Moorside Medical Practice P85606 Oldham Medical Services P85012 Dr N T Mistry & Partner P85022 Hopwood House Medical Practice P85014 Hollinwood Medical Practice Y02933 Royton & Crompton Family Practice P85013 John Street Medical Practice Y02827 Pennine Medical Practice P89006 The Duru Practice Y01124 Hill Top Surgery Y02753 Dr A Mohanty P85613 Dr Jaishankar & Dr Pattabiraman P85019 St Chads Medical Practice P85620 Dr M Chowdhury P85003 Dr S Sidhu P85025 Dr Akhter & Partners P85004 Jarvis Medical Practice P85622 Gtd Primary Care Y02875 CCG 0.0 1.0 2.0 3.0 4.0 5.0 6.0 prevalence % Practice Comparison Practice variation 1 to 5.7% 4,174 people with undiagnosed CKD in CCG www.england.nhs.uk 44

Chronic Kidney Disease Percentage with BP NOT controlled below 145/90 Not below 140/85 Gtd Primary Care Y02875 Graph Dr M Chowdhury P85003 The Duru Practice Y01124 Dr Whitley & Partners P85005 Medlock Medical Practice P85610 The Parks Medical Practice P85006 Saddleworth Medical Practice P85016 Saraf Medical Practice P85602 Moorside Medical Practice P85606 Hopwood House Medical Practice P85014 Dr N T Mistry & Partner P85022 Dr Woodhouse & Partners P85017 Failsworth Group Practice P85008 Royton & Crompton Family Practice P85013 Oldham Medical Services P85012 St Mary'S Medical Practice P85002 Woodlands Medical Practice P85010 Ch Medical Practice P85011 Pennine Medical Practice P89006 Dr Akhter & Partners P85004 Springfield House Medical Centre P85020 Mach Healthcare Limited P85621 Danson Family Practice P85018 P85018 Radcliffe Medical Practice P85029 Kapur Family Care P85615 Dr D S Mcmaster & Partner P85026 Drs Addy & Nelson P85603 Jarvis Medical Practice P85622 Dr Butt & Partners P85612 Drs Akram & Datta P85028 Hollinwood Medical Practice Y02933 John Street Medical Practice Y02827 Oldham Family Practice P85007 Dr P J Trewinnard P85601 Dr A Mohanty P85613 Glodwick Medical Practice P85021 Dr Isukapalli & Partner P85001 Gtd Primary Care P85614 Dr Hampson And Partners P85015 Dr S Perveen & Partners P85605 Dr Jaishankar & Dr Pattabiraman P85019 Dr S Sidhu P85025 Hill Top Surgery Y02753 Dr A Sharma & Partner P85607 St Chads Medical Practice P85620 Dr B Perkins P85608 Exceptions reported Practice Comparison Practice variation 3 to 46% 1,943 people in CCG with CKD whose blood pressure is not controlled 0% 10% 20% 30% 40% 50% www.england.nhs.uk 45

Type 2 Diabetes Diabetes greatly increases the risk of heart disease and stroke, kidney failure, amputations and blindness. 80% of NHS spending on diabetes goes on managing these complications. The 8 essential care processes substantially reduce complication rates But But around a third of people do not receive all 8 care processes www.england.nhs.uk

Diabetes recorded prevalence GP practice Dr Butt & Partners P85612 Graph Dr S Sidhu P85025 Jarvis Medical Practice P85622 Drs Akram & Datta P85028 Mach Healthcare Limited P85621 Dr S Perveen & Partners P85605 Dr M Chowdhury P85003 John Street Medical Practice Y02827 Kapur Family Care P85615 Dr Hampson And Partners P85015 Radcliffe Medical Practice P85029 Dr Akhter & Partners P85004 Dr A Mohanty P85613 Dr Isukapalli & Partner P85001 Glodwick Medical Practice P85021 Woodlands Medical Practice P85010 Danson Family Practice P85018 P85018 Drs Addy & Nelson P85603 Oldham Family Practice P85007 St Mary'S Medical Practice P85002 Dr B Perkins P85608 Oldham Medical Services P85012 Hopwood House Medical Practice P85014 The Duru Practice Y01124 Medlock Medical Practice P85610 Dr P J Trewinnard P85601 Gtd Primary Care P85614 Dr Woodhouse & Partners P85017 Hollinwood Medical Practice Y02933 Failsworth Group Practice P85008 Dr N T Mistry & Partner P85022 Royton & Crompton Family Practice P85013 The Parks Medical Practice P85006 Dr Jaishankar & Dr Pattabiraman P85019 Hill Top Surgery Y02753 Dr D S Mcmaster & Partner P85026 Springfield House Medical Centre P85020 Dr A Sharma & Partner P85607 Moorside Medical Practice P85606 Ch Medical Practice P85011 Dr Whitley & Partners P85005 Pennine Medical Practice P89006 Saddleworth Medical Practice P85016 St Chads Medical Practice P85620 Gtd Primary Care Y02875 Saraf Medical Practice P85602 CCG 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 prevalence % Practice Comparison Practice variation 4 to 14% 3,681 people with undiagnosed Diabetes in CCG www.england.nhs.uk 47

Diabetes Percent who have the 8 recommended care processes NHS Lancashire North CCG NHS Fylde & Wyre CCG NHS Blackburn with Darwen CCG NHS Wigan Borough CCG NHS Heywood, Middleton and Rochdale CCG NHS East Lancashire CCG NHS Chorley and South Ribble CCG NHS Blackpool CCG NHS Stockport CCG NHS Oldham CCG NHS West Lancashire CCG NHS Salford CCG NHS Tameside and Glossop CCG NHS Greater Preston CCG NHS Bolton CCG NHS South Manchester CCG NHS North Manchester CCG NHS Trafford CCG NHS Bury CCG NHS Central Manchester CCG 72.0 71.5 70.6 68.4 67.4 66.7 66.0 65.9 65.6 65.0 63.9 63.6 63.5 62.6 62.5 60.3 59.0 57.7 49.9 47.3 CCG Comparison 65.0% of people with diabetes in CCG had the 8 care processes At least 3,546 people did not receive the 8 care processes England 59.5 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 percentage www.england.nhs.uk 48

The Size of the Gap in Primary Care Presentation title - edit in Header and Footer www.england.nhs.uk 49

National Support for Prevention in Primary Care 1. NHS Health Check Programme 2. NHS Diabetes Prevention Programme www.england.nhs.uk

NHS Health Check targets the Top 7 causes of premature mortality www.england.nhs.uk

NHS Health Check Pathway Risk assessment Diagnosis Risk Management Age Gender Ethnicity smoking NHS HEALTH CHECK A pathway - not a standalone activity Multi-component intervention Good quality primary care a core component 40-74 65-74 Family history Smoking status Alcohol use Physical activity Body Mass Index (BMI) Cholesterol test BP Measure Diabetes filter BMI BP Measure Dementia awareness and signposting If at risk HbA1c or Fasting Glucose High BP Risk Assessment? Diabetes High CVD Risk Lifestyle interventions High risk of DM DM Alcohol physical activity Weight Impaired Glucose Consider statin RECALL Diabetes register High Risk register? Hypertension? CKD Treat BP CKD Management Hypertension register CKD register www.england.nhs.uk

NHS DIABETES PREVENTION PROGRAMME www.england.nhs.uk

DIABETES the fastest growing health issue 2.8 million people in England with type 2 diabetes By 2025 this will exceed 4 million people 5 million people currently at high risk of diabetes Diabetes already accounts for 10% of the NHS budget www.england.nhs.uk

Diabetes Prevention - the evidence Strong international evidence exists for behaviour change programme to delay onset and reduce incidence amongst those at high risk of diabetes. Trials in China, Finland, the USA, Japan and India show 30-60 per cent reductions in Type 2 diabetes incidence over three years in adults at high risk through intensive behaviour change interventions www.england.nhs.uk

NHS Diabetes Prevention Programme National roll out from 2016 Ambition 100,000 people on programme per year by 2020 Case finding non diabetic hyperglycaemia o HbA1c 42-47 (6-6.4%) or FPG 5.5 6.9 o GP referral and NHS Health Check Evidence based intervention: Group and face-to-face, 8+ sessions, 9-18 months Underpinned by behavioural theory / motivational approach Core lifestyle goals weight loss, dietary change, increased physical activity www.england.nhs.uk

CVD Prevention The Challenge for Primary Care Yes we do need to guard against over-diagnosis and inappropriate medicalisation But we should be equally challenging about the widespread underdiagnosis and under-treatment of major risk factors such as hypertension, atrial fibrillation, CKD, non diabetic hyperglycaemia and high CVD risk. We should champion improvement in these areas with strong primary care leadership Because this will significantly improve outcomes for our patients www.england.nhs.uk

Building Primary Care Leadership for Prevention, Detection and Management of CVD Primary Care CVD Leadership Forum o Nurses, GPs, pharmacists CVD - RCGP Spotlight Clinical Priority Priorities: AF, BP and CVD risk Input to national programmes Input to NICE consultations Resources eg o CVD Intelligence Pack o AF Intelligence Pack o BP Intelligence Pack www.england.nhs.uk

Primary Care CVD Leadership Forum BP Intelligence Packs - Under construction www.england.nhs.uk