Commissioning for Value Focus Pack. CCG: Heywood, Middleton & Rochdale Focus Area : Respiratory Programme Budget Category

Commissioning for Value Focus Pack CCG: Heywood, Middleton & Rochdale Focus Area : Respiratory Programme Budget Category 1

What is a Deep Dive pack? CCGs have received a bespoke Commissioning for Value insights pack. These packs, sometimes referred to as Level 1 packs, analyse data on spend and outcomes at a Programme Budget level across a wide range of programmes. Those packs identified candidate programmes which offered the most value in return for improvement work they answered the question of - where to look. Deep Dive packs further examine areas chosen by the CCGs in order to gain a deeper understanding of issues within specific programmes of work or clinical pathways - What to change. The structure and content of Deep Dive packs has evolved through work done by Right Care and Yorkshire and Humber PHO (now PHE Knowledge and Intelligence Team) working with CCGs in Derbyshire and Yorkshire and Humber. The packs are produced by GEM CSU analysts working with consultants in public health medicine from Solutions for Public Health (an NHS enterprise hosted by GEM CSU). 2

Contents 1. Background and context Aims of the packs Packs as part of transformation process 2. Methodology Analysis methods CCG Benchmarking and Opportunities 3. CCG Analysis Respiratory the context for the deep dive analysis Summary messages for pathway stages: Prevalence Management in Primary Care Management in Secondary Care Mortality Opportunity table for indicators in the bottom quintile of benchmark group 4. Where to focus: Understanding practice variation All Practices: Indicators in the bottom quintile Top 3 Practices: Opportunities table 5. Bringing it all together, National Guidance Annexes Annex 1 Spine charts and opportunity tables Annex 2 CCG Cluster Classification Annex 3 Practice Cluster Classification Annex 4 Indicator List Glossary 3

1. Background and context Aims of the Packs The Commissioning for Value phase one packs, produced by NHSE, PHE and NHS Right Care, included an offer to work with CCGs to develop this Focus Pack, or deep dive. The deep dive looks at an agreed programme area to understand variation across the pathway, including GP practice benchmarking. Working with local intelligence teams, the deep dive will look to identify opportunities for improvement and support the CCG's discussion on methods of improving clinical pathways. Further support is available to use and explore the intelligence in this pack 4

1. Background and context How these Packs Support Service Improvement NHSE GEM 5

2. Methodology Analysis Methods Analysed wide range of indicators from across the pathway focussing on risk factors, spend, primary and secondary care usage and quality Analysed wide range of national benchmarked data to identify indicators where CCG is below the average for its CCG cluster group (see Annex 2) Identified indicators where CCG is in worst quintile within its cluster group Analysed practice based variation to identify practices which consistently compare poorly against their national clusters Identified opportunities for value improvement and quantified potential impact Listed all the indicators where CGG is below average for CCG cluster Quantified opportunity for indicators in bottom quintile moving to the CCG Cluster average Quantified additional opportunities for indicators moving to the top 20% for the CCG Cluster Quantification does not mean that the saving or improvement can actually be made, but may however answer the question Is it going to be worth focussing on this area? Reviewed national evidence base to identify potential interventions linked to opportunities Pulled together examples of what works against opportunity areas across the pathway 6

2. Methodology CCG Benchmarking and Opportunities CCGs are compared using a benchmark cluster group of most similar CCGs in terms of age, ethnicity, deprivation and population density The benchmark cluster group is based on YHPHO CCG classification methodology and differs to those used in the phase 1 packs. The definitions and constituent CCGs are in Annex 2 Indicators are ranked out of 100 within the CCG benchmark group. A rank of 1 is taken as comparatively worse e.g. higher spend/higher prevalence/ higher admission rate/lower screening uptake/lower urgent referrals Indicators where the CCG is in the bottom quintile of the benchmark group (ranked 1-20) are highlighted in the summary analysis slides and summary opportunity table 7

2. Methodology CCG Benchmarking and Opportunities An opportunity is calculated based on the CCG reaching the benchmark group average, and also reaching the 80 th percentile value, i.e. the best performing quintile, of the benchmark group Quantification does not mean that the saving or improvement can actually be made, but may however answer the question Is it going to be worth focussing on this area? Spine graphs and the full opportunity tables are in Annex 1 A list of all indicators used is in Annex 4 A Glossary is available 8

Deep Dive Pack Phase 1 9

3. Respiratory Context for Deep Dive Analysis The Right Care Commissioning for Value phase 1 pack highlighted that, compared to their comparator CCGs, Heywood, Middleton & Rochdale CCG had: Significantly higher prevalence of asthma COPD prevalence in the highest quartile in England Significantly higher spend on prescribing Significantly higher respiratory admission rates across all secondary care, and non-elective care Significantly higher emergency admissions relative to patients on the register 14

DDP Phase 1 vs DDP Phase 2 analysis DDP Phase 2 Differs from DDP Phase 1 analysis Different clustering methods nearest 10 CCGs vs colour coded-cluster CCGs Phase 1, but not phase 2 method included population size as a clustering metric Different years of data 2011/12 vs 2012/13 for phase 2 Therefore analysis gives different results 15

DDP1 Analysis based on comparison with 10 most similar CCGs NHS Bolton CCG NHS Oldham CCG NHS Bradford Districts CCG NHS Stoke on Trent CCG NHS South Tees CCG NHS Bury CCG NHS Tameside and Glossop CCG NHS Newcastle West CCG NHS Leeds South and East CCG NHS Walsall CCG 16

DDP 2 Analysis based on comparison with all CCGs in yellow cluster group Heywood, Middleton & Rochdale CCG is in the Yellow Cluster Group: A younger population with a higher than average proportion of the population from Black and Asian ethnic groups and moderate levels of deprivation. Code CCG Name Code CCG Name 00G NHS Newcastle North and East CCG 06P NHS Luton CCG 00H NHS Newcastle West CCG 07L NHS Barking and Dagenham CCG 00Q NHS Blackburn with Darwen CCG 07M NHS Barnet CCG 00Y NHS Oldham CCG 07V NHS Croydon CCG 01D NHS Heywood, Middleton and Rochdale CCG 07W NHS Ealing CCG 01G NHS Salford CCG 07X NHS Enfield CCG 01M NHS North Manchester CCG 07Y NHS Hounslow CCG 01N NHS South Manchester CCG 08A NHS Greenwich CCG 02R NHS Bradford Districts CCG 08E NHS Harrow CCG 03C NHS Leeds West CCG 08G NHS Hillingdon CCG 03F NHS Hull CCG 08J NHS Kingston CCG 03G NHS Leeds South and East CCG 08N NHS Redbridge CCG 03J NHS North Kirklees CCG 08R NHS Merton CCG 03N NHS Sheffield CCG 09H NHS Crawley CCG 04C NHS Leicester City CCG 10R NHS Portsmouth CCG 04F NHS Milton Keynes CCG 10T NHS Slough CCG 04K NHS Nottingham City CCG 10W NHS South Reading CCG 04X NHS Birmingham South and Central CCG 10X NHS Southampton CCG 05A NHS Coventry and Rugby CCG 11H NHS Bristol CCG 05L NHS Sandwell and West Birmingham CCG 13P NHS Birmingham Crosscity CCG 05Y NHS Walsall CCG 99A NHS Liverpool CCG 06A NHS Wolverhampton CCG 17

Annex 2: CCG cluster classification The CCG Cluster groups are taken from YHPHO methodology, which groups together CCGs with similar populations. It is based on statistical cluster analysis (K-means analysis) including variables of age structure of the population, the population from Black and Asian ethnic groups, population density and deprivation. Cluster Classification Group Purple Blue Green Yellow Orange 0-19 years 20-39 years 40-59 years 60-79 years 80+ years Population from Black ethnic groups Population from Asian ethnic groups Population density (persons per hectare) Average IMD 2010 score An older population living in rural areas and low deprivation levels 22.3% 22.0% 27.8% 21.9% 6.0% 0.5% 1.9% 1.9 16.85 A very young population with a high proprtion of the population from Black and Asian ethnic groups and high levels of deprivation. A younger population with a high proportion of the population from Black and Asian ethnic groups and moderate levels of deprivation. A younger population with a higher than average proportion of the population from Black and Asian ethnic groups and moderate levels of deprivation. A population with an average age structure, average deprivation levels and a low population density. 26.4% 41.1% 21.3% 9.0% 2.1% 16.2% 31.6% 80.4 40.78 21.6% 42.0% 23.5% 10.4% 2.5% 16.7% 10.3% 100.1 28.81 26.0% 31.6% 24.5% 14.1% 3.7% 6.7% 17.7% 26.2 29.00 24.2% 25.3% 27.9% 18.2% 4.5% 1.5% 4.6% 5.1 20.38 18

Deep Dive Phase 2 19

3. ANALYSIS CCG Indicators and Opportunities in the bottom quintile of the benchmark cluster group Pathway step Prevalence Primary Care Indicator Gain if CCG had same 'rate' as benchmark cluster of CCGs Benchmark average Percentage of patients registered with a GP aged 15+ recorded as current smoker 24.50% 21.10% 6096 fewer smokers QOF COPD prevalence 2.30% 1.70% 1439 fewer COPD cases QOF Asthma prevalence 6.90% 5.70% 2518 fewer asthma cases Respiratory Cost prescribed per 1000 population 24,590 19,164 1536312 reduction Respiratory Items prescribed per 1000 population 1683.5536 1282.757478 89915 fewer items prescribed Inhaled Corticosteroids ADQ per STAR PU Cost 0.60 0.50 381442 reduction COPD Cost prescribed per 1000 population 7,382 5,097 589652 reduction COPD Items prescribed per 1000 population 353.3 251.1 24952 fewer items prescribed % with COPD who have had a review including assessment of breathlessness in last 15 months (COPD13) 88.80% 90.90% 101 additional patients managed Asthma Cost prescribed per 1000 population 15,619 12,014 855836 reduction Asthma Items prescribed per 1000 population 874.66724 646.1322258 56207 fewer items prescribed Other Respiratory Cost prescribed per 1000 population 2,383 1,938 120193 reduction Other Respiratory Items prescribed per 1000 population 546.31832 393.2738719 39474 fewer items prescribed CCG Value Benchmark Value 20

3. ANALYSIS CCG Indicators and Opportunities in the bottom quintile of the benchmark cluster group Pathway step Secondary Care All Respiratory Secondary Care All Asthma Secondary Care Other Respiratory Indicator Gain if CCG had same 'rate' as benchmark cluster of CCGs Benchmark average Respiratory Inpatient spend per 1000 population 2,891 2,127 170505 reduction Respiratory Secondary care admissions per 1000 population 25.7 19.3 1410 fewer admissions Respiratory Inpatient admissions per 1000 population 2.0 1.5 121 fewer admissions Respiratory Emergency admissions per 1000 population 21.6 15.4 1352 fewer admissions Under 75 years Emergency Respiratory Admissions DSR per 100,000 3217.9 2072.7 2387 fewer admissions Asthma Secondary care spend per 1000 population 2,005 1,299 159105 reduction Asthma Emergency spend per 1000 population 1,775 1,208 127738 reduction Asthma Secondary care admissions per 1000 population 2.3 1.4 206 fewer admissions Asthma Emergency admissions per 1000 population 2.1 1.3 170 fewer admissions Asthma Secondary care admissions per Asthma register 3.5 2.5 145 fewer admissions Other Respiratory Inpatient spend per 1000 population 2,703 2,028 150817 reduction Other Respiratory Secondary care admissions per 1000 population 19.9 15.2 1022 fewer admissions Other Respiratory Inpatient admissions per 1000 population 2.0 1.5 112 fewer admissions Other Respiratory Emergency admissions per 1000 population 16.1 11.5 1002 fewer admissions Emergency admissions for children with lower respiratory disease 684.5 418.6 144 fewer admissions Upper Respiratory Infection All Ages Emergency Admissions DSR per 100,000 931.1 430.8 1115 fewer admissions Upper Respiratory Infection <75 Emergency Admissions DSR per 100,000 966.6 445.4 1086 fewer admissions Lower Respiratory Infection All Ages Emergency Admissions DSR per 100,000 801.2 510.0 649 fewer admissions Lower Respiratory Infection <75 Emergency Admissions DSR per 100,000 741.2 447.6 612 fewer admissions CCG Value Benchmark Value 21

3. ANALYSIS Summary: Prevalence 3 / 6 indicators for prevalence are in the bottom quintile of the benchmark group: 1. Percentage of patients registered with a GP aged 15+ recorded as current smoker 2. QOF COPD prevalence 3. QOF Asthma prevalence 22

3. ANALYSIS Summary: Management in Primary Care 10 / 35 indicators are in the bottom quintile of the benchmark group Prescribing: 1. Respiratory Cost prescribed per 1000 population 2. Respiratory Items prescribed per 1000 population 3. Inhaled Corticosteroids ADQ per STAR PU Cost 4. COPD Cost prescribed per 1000 population 5. COPD Items prescribed per 1000 population 6. Asthma Cost prescribed per 1000 population 7. Asthma Items prescribed per 1000 population 8. Other Respiratory Cost prescribed per 1000 population 9. Other Respiratory Items prescribed per 1000 population 23

3. ANALYSIS Summary: Management in Primary Care 10 / 35 indicators are in the bottom quintile of the benchmark group QOF 10.% with COPD who have had a review including assessment of breathlessness in last 15 months (COPD13) 24

3. ANALYSIS Summary: Management in secondary care 19 / 50 indicators are in the bottom quintile of the benchmark group. Respiratory admissions (elective, non-elective) and inpatient spend 1. Respiratory Inpatient spend per 1000 population 2. Respiratory Secondary care admissions per 1000 population 3. Respiratory Inpatient admissions per 1000 population 4. Respiratory Emergency admissions per 1000 population 5. Under 75 years Emergency Respiratory Admissions DSR per 100,000 25

3. ANALYSIS Summary: Management in secondary care 19 / 50 indicators are in the bottom quintile of the benchmark group. Admissions (elective, non-elective) and spend for asthma 6. Asthma Secondary care spend per 1000 population 7. Asthma Emergency spend per 1000 population 8. Asthma Secondary care admissions per 1000 population 9. Asthma Emergency admissions per 1000 population 10.Asthma Secondary care admissions per Asthma register 26

3. ANALYSIS Summary: Management in secondary care 19 / 50 indicators are in the bottom quintile of the benchmark group. Other Respiratory admissions (elective, non-elective) and spend 11.Other Respiratory Inpatient spend per 1000 population 12.Other Respiratory Secondary care admissions per 1000 population 13.Other Respiratory Inpatient admissions per 1000 population 14.Other Respiratory Emergency admissions per 1000 population 27

3. ANALYSIS Summary: Management in secondary care 19 / 50 indicators are in the bottom quintile of the benchmark group. Emergency admissions for upper and lower RT infections and for children with lower respiratory disease 15.Emergency admissions for children with lower respiratory disease 16.Upper Respiratory Infection All Ages Emergency Admissions DSR per 100,000 17.Upper Respiratory Infection <75 Emergency Admissions DSR per 100,000 18.Lower Respiratory Infection All Ages Emergency Admissions DSR per 100,000 19.Lower Respiratory Infection <75 Emergency Admissions DSR per 100,000 28

3. ANALYSIS Summary: Mortality 0 / 3 indicators are in the bottom quintile of the benchmark group: 29

Respiratory Prevalence 30

Respiratory Prevalence The analysis showed HMR CCG in the bottom quintile of cluster CCGs for estimates of COPD and asthma prevalence in the registered population, as well as adult (>15 years of age) smoking prevalence 31

Respiratory Prevalence Hypothesis: smoking prevalence Recorded smoking status in the registered population provides an estimate of the adult population smoking prevalence Smoking prevalence can be reduced by tobacco control which includes smoking cessation services The effectiveness of tobacco control and smoking cessation services can be evaluated using indicators such as smoking prevalence in the registered population Higher estimates of smoking prevalence suggests comparatively higher unmet need and an opportunity to offer smoking cessation interventions to more smokers Primary and secondary care services offer opportunities to reduce smoking prevalence, maximise the number of people who quit smoking thereby reducing smoking related morbidity and mortality 32

Respiratory Prevalence Smoking prevalence: Explanations to consider The relatively higher smoking prevalence in the HMR CCG registered population may reflect relative under-provision and/or lower uptake of smoking cessation services Alternative explanations include: Better recording of smoking status Subgroup(s) of the population with significantly higher smoking rates than would be expected from the known sociodemographic characteristics of the population High provision and uptake of smoking cessation services but issues concerning the wider programme of tobacco control Higher prevalence rate may be due to chance/random variation/usual cause variation no CIs or statistical tests have been performed 33

Respiratory prevalence Hypothesis: asthma prevalence o o o o o Asthma prevalence in the lower quintile of CCGs reflects higher asthma prevalence in the population To be on the asthma register, patients need a diagnosis of asthma and a prescription for an asthma drug within the year Higher prevalence may reflect CCG population more at risk eg LBW babies, maternal smoking and secondary exposure of tobacco smoke in children, environmental and occupational exposure to allergens Investment in programmes aiming to decrease the at risk population eg high quality tobacco control programmes and high quality smoking cessation services, may reduce population exposure to triggers and thereby reduce the number of asthma episodes managed by respiratory services in both primary and secondary care Higher asthma prevalence may therefore reflect the need to target action to further reduce the at risk population 34

Respiratory prevalence Other explanations to be considered Asthma is not preventable therefore estimates of asthma prevalence cannot be used to evaluate effectiveness of primary prevention interventions. Interventions are aimed at improving control of asthma and prevention of asthma attacks. Asthma is under-diagnosed due to a combination of patients not presenting and clinicians not diagnosing /misdiagnosing?higher prevalence rate may reflect better case ascertainment - desirable?higher prevalence rate may reflect more misdiagnosis and/or poorer quality assessment with spirometry - undesirable?higher prevalence rate may be due to chance/random variation/usual cause variation no CIs or statistical tests have been performed 35

Respiratory prevalence Hypothesis: COPD Prevalence Chronic obstructive pulmonary disease (COPD) is the name for a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease The main cause of COPD is smoking Estimated COPD prevalence in the registered population is a marker of historic smoking patterns, as the development of COPD is related to the level of tobacco exposure over time, usually years Higher prevalence of COPD reflects higher need for Primary prevention (tobacco control) and smoking cessation (to prevent disease progression) High quality health care services (primary and secondary care, pulmonary rehab) as defined by QOF and NICE 36

Respiratory Prevalence COPD Prevalence: Explanations to consider COPD is under-diagnosed due to a combination of patients not presenting and clinicians not diagnosing /misdiagnosing?higher prevalence rate may reflect better case ascertainment - desirable?higher prevalence rate may reflect more misdiagnosis and/or poorer quality assessment with spirometry - undesirable?higher prevalence rate may be due to chance/random variation/usual cause variation no CIs or statistical tests have been performed 37

Respiratory primary care 38

Respiratory primary care Analysis showed HMR CCG to be in the lower quintile of cluster CCGs for: 9 Prescribing indicators 1 QOF indicator - % with COPD who have had a review including assessment of breathlessness in last 15 months (COPD13) 39

Respiratory prescribing Prescribing: Hypothesis o Examination of the variation in prescribing costs and items prescribed can be useful in identifying potentially inappropriate prescribing o High prescribing costs may point to the need for better medicines optimisation and better medicines management both of which support better and more cost-effective prescribing in primary care o Optimisation of prescribing reduces hospital admissions and associated costs helps patients better manage their care with consequent improvement in health outcomes may reduce prescribing costs 40

Respiratory prescribing 9 indicators are in the bottom quintile of the benchmark group: Respiratory Cost prescribed per 1000 population Respiratory Items prescribed per 1000 population Inhaled Corticosteroids ADQ per STAR PU Cost COPD Cost prescribed per 1000 population COPD Items prescribed per 1000 population Asthma Cost prescribed per 1000 population Asthma Items prescribed per 1000 population Other Respiratory Cost prescribed per 1000 population Other Respiratory Items prescribed per 1000 population If the CCG had the same rate of spend on respiratory drugs as the cluster average, potential savings could reach 1.5m reduction in respiratory prescribing spend 41

Respiratory prescribing The bulk of the prescribing data covers the following classes of drugs, most of which are prescribed in primary care rather than secondary care: Bronchodilators Corticosteroids Cromoglicate and related therapy and leukotriene receptor antagonists Antihistamines, hyposensitisation, and allergic emergencies Respiratory stimulants and pulmonary surfactant Oxygen Mucolytics Aromatic inhalations Cough preparations Systemic nasal decongestants 42

Respiratory prescribing Explanations to consider: Prescribing may be appropriate and commensurate with need ie. high prevalence of asthma and COPD Prescribing is suboptimal and requires investigation An audit of drugs used in the management of asthma and COPD could help in the initial investigation of potentially inappropriate prescribing Heads of medicines management could lead medicine optimisation initiatives to improve healthcare utilisation, outcomes and reduce spend 43

Respiratory: Management of Asthma and COPD 44

Respiratory primary care services The analysis shows the CCG to be in the bottom quintile for one of the COPD QOF indicators - suggesting that a lower proportion of patients with COPD are recorded as benefiting from clinical review with assessment of breathlessness (every 15 months) 45

Defining high quality primary care in respiratory disease QOF indicators for smoking, COPD and Asthma NICE guidance and quality standards for COPD and Asthma 46

Smoking QOF standards o o o o Patients with LTCs should have their smoking status assessed and recorded in their notes within the preceding 15 months Patients with LTCs who smoke should be offered smoking cessation advice or referral to a specialist service, where available, within the preceding 15 months Patients aged 15 years and over should have their smoking status assessed and recorded in their notes within the preceding 27 months Patients aged 15 years and over who are recorded as current smokers should be offered support and treatment within the preceding 27 months 47

High quality COPD care QOF o o o o o The practice produces a register of patients with COPD Patients with COPD have a review, undertaken by a healthcare professional, including an assessment of breathlessness using the MRC dyspnoea score in the preceding 15 months Patients with COPD are assessed with spirometry and their FEV1 is recorded within the preceding 15 months. Patients with COPD have their diagnosis confirmed by post bronchodilator spirometry Patients with COPD have influenza immunisation in the preceding 1 September to 31 March 48

High quality asthma care QOF o o o o The practice can produce a register of patients with asthma, excluding patients with asthma who have been prescribed no asthma-related drugs in the preceding 12 months Patients aged 8 years and over diagnosed as having asthma have measures of variability or reversibility recorded Patients with asthma who have an asthma review within the preceding 15 months that includes an assessment of asthma control using the 3 RCP questions Patients with asthma between the ages of 14 and 19 years have their smoking status assessed and recorded within the preceding 15 months 49

Asthma quality standards NICE The elements of good care are specified in NICE guidance and quality standards. High quality asthma care has the following features: 1. People with newly diagnosed asthma are diagnosed in accordance with BTS/SIGN guidance 2. Adults with new onset asthma are assessed for occupational causes. 3. People with asthma receive a written personalised action plan 4. People with asthma are given specific training and assessment in inhaler technique before starting any new inhaler treatment 5. People with asthma receive a structured review at least annually 6. People with asthma who present with respiratory symptoms receive an assessment of their asthma control. 50

Asthma quality standards NICE 7. People with asthma who present with an exacerbation of their symptoms receive an objective measurement of severity at the time of presentation 8. People aged 5 years or older presenting to a healthcare professional with a severe or life-threatening acute exacerbation of asthma receive oral or intravenous steroids within 1 hour of presentation 9. People admitted to hospital with an acute exacerbation of asthma have a structured review by a member of a specialist respiratory team before discharge 10. People who received treatment in hospital or through out-of-hours services for an acute exacerbation of asthma are followed up by their own GP practice within 2 working days of treatment 11. People with difficult asthma are offered an assessment by a multidisciplinary difficult asthma service 51

COPD quality standards NICE The elements of good care are specified in NICE guidance and quality standards. High quality COPD care has the following features: 1.People with COPD have one or more indicative symptoms recorded, and have the diagnosis confirmed by post-bronchodilator spirometry carried out on calibrated equipment by healthcare professionals competent in its performance and interpretation. 2.People with COPD have a current individualised comprehensive management plan, which includes high-quality information and educational material about the condition and its management, relevant to the stage of disease. 3.People with COPD are offered inhaled and oral therapies, in accordance with NICE guidance, as part of an individualised comprehensive management plan. 4.People with COPD have a comprehensive clinical and psychosocial assessment, at least once a year or more frequently if indicated, which includes degree of breathlessness, frequency of exacerbations, validated measures of health status and prognosis, presence of hypoxaemia and comorbidities. 52

COPD quality standards NICE 5.People with COPD who smoke are regularly encouraged to stop and are offered the full range of evidence-based smoking cessation support. 6.People with COPD meeting appropriate criteria are offered an effective, timely and accessible multidisciplinary pulmonary rehabilitation programme. 7.People who have had an exacerbation of COPD are provided with individualised written advice on early recognition of future exacerbations, management strategies (including appropriate provision of antibiotics and corticosteroids for self-treatment at home) and a named contact. 8.People with COPD potentially requiring long-term oxygen therapy are assessed in accordance with NICE guidance by a specialist oxygen service. 53

COPD quality standards NICE 9.People with COPD receiving long-term oxygen therapy are reviewed in accordance with NICE guidance, at least annually, by a specialist oxygen service as part of the integrated clinical management of their COPD. 10.People admitted to hospital with an exacerbation of COPD are cared for by a respiratory team, and have access to a specialist early supported-discharge scheme with appropriate community support. 11.People admitted to hospital with an exacerbation of COPD and with persistent acidotic ventilatory failure are promptly assessed for, and receive, non-invasive ventilation delivered by appropriately trained staff in a dedicated setting. 12.People admitted to hospital with an exacerbation of COPD are reviewed within 2 weeks of discharge. 13.People with advanced COPD, and their carers, are identified and offered palliative care that addresses physical, social and emotional needs. 54

Respiratory primary care Explanations to be considered: Is the annual assessment of COPD patients systematic in the assessment of breathlessness using the MRC dyspnoea score? 55

Respiratory Secondary Care 56

Respiratory secondary care Hypothesis: o o o Asthma and COPD are ambulatory care sensitive conditions Ambulatory care sensitive (ACS) conditions are chronic conditions for which it is possible to prevent acute exacerbations and reduce the need for hospital admission through active management, such as vaccination; better self-management, disease management or case management; or lifestyle interventions Most asthma and COPD is managed in primary care but effective control requires multidisciplinary teams working across both primary and secondary care 57

Respiratory secondary care Hypothesis o o o o Despite hospital admission for asthma and COPD being largely preventable, a significant proportion of all acute hospital activity is related to asthma and COPD. Variation in admission rates is likely to reflect variation in how effectively asthma and COPD are managed particularly in primary care Admissions for respiratory tract infections such as influenza and pneumonia are also preventable through effective vaccination in at risk subgroups of the population and high quality primary care management of RTIs These avoidable admissions are costly and offer the opportunity for significant financial savings 58

Respiratory secondary care Evidence based interventions for reducing spend and improving outcomes in ACS conditions: Purdy S (2010). Avoiding Hospital Admissions. What does the research evidence say? London: The King s Fund. NICE clinical guideline and Quality standards for COPD British Thoracic Society and Scottish Intercollegiate Guidelines Network clinical guideline 101 (2008, updated 2011) and NICE Quality standards for asthma 59

Respiratory secondary care Indicators are in the bottom quintile of the benchmark group include those for: Hospital admissions (all, emergency) for all respiratory conditions including ambulatory care sensitive conditions asthma and respiratory tract infections (including influenza and pneumonia) Respiratory spend (all, emergency) 60

Respiratory secondary care o o The analysis suggests that there is scope for improving the management of ambulatory care sensitive conditions thereby reducing avoidable admissions and spend If HMR CCG reduced its hospital admission rates (all, emergency) and spend for respiratory disease to that of the cluster average, then potential savings 564K reduction in respiratory spend across secondary care 159K reduction in asthma spend across secondary care 314k reduction in other respiratory emergency spend 1115 fewer emergency admissions for upper respiratory infections and 649 fewer emergency admissions for lower respiratory infections 61

3. ANALYSIS Summary: Mortality 0 / 3 indicators are in the bottom quintile of the benchmark group: 62

4. Where to focus: Understanding practice variation Practices are compared using a benchmark cluster group of the most similar practices in terms of age, ethnicity, deprivation and population density. The practice cluster group definitions and constituent practices are in Annex 3. Practices are compared for all the indicators where data is available at practice level This information is presented here to form the basis of a discussion between the CCG, the CSU and Public Health about how further analysis could support practices in reducing unexplained practice variation The number of indicators where the practice is in the bottom quintile for the practice cluster has been compared on the next slide and the opportunities for the practices with the highest number of indicators in the bottom quintile has been quantified on the subsequent slide Practices will have less influence on management in secondary care than they do on management in primary care and this should be taken into account in the way CCGs interpret the information on practice variation 63

4. Where to focus: Understanding practice variation Number of Respiratory indicators in the bottom quintile of the practice cluster The chart on the following slide shows the number of Respiratory indicators in the bottom quintile of the practice cluster. Each coloured bar represents a different set of indicators e.g. dark blue is prevalence. The specific indicators are then shown in the table on slides 20-24 for the 3 practices with the highest total number of indicators in the bottom quintile Note, some of the data are based on small numbers. Statistical significance has not been tested and should not be inferred. The data are presented to identify potential areas of improvements rather than providing a definitive comparison of performance. 64

4. Where Dr HB Syed (P86609) to focus: Understanding 18 practice variation 9 Baillie Street Health Ctr (P86619) York House Surgery (P86605) Littleborough Group Practice Windermere Surgery (P86620) Trinity Medical Centre (P86624) Edenfield Road Surgery (P86003) Hopwood Medical Centre (P86023) Inspire Medical Centre (P86017) Wellfield Health Centre (P86007) Rochdale Road Medical Centre Stonefield Street Surgery (P86022) Vicars Drive Surgery (P86002) Mark Street Surgery (P86008) Family Practice (P86606) The Village Medical Ctr. (P86608) Woodside Medical Centre Durnford Medical Centre (P86019) Tweedale Street Surgery (P86614) Longford Street Medical Centre Ashworth Street Surgery (P86006) Castleton Health Centre (P86009) Argyle Street Medical Ctr (P86016) Pennine Surgery (P86021) Dr IK Babar (P86014) Peterloo Medical Centre (P86004) Healey Surgery (P86013) The Dawes Family Practice Drake Street Surgery (P86622) Yorkshire St Surgery (P86005) The Junction Surgery (P86010) Heady Hill Surgery (P86602) Milnrow Village Practice (P86001) 1 2 2 3 3 2 2 2 2 1 1 1 1 2 1 1 1 1 1 1 1 1 2 3 1 1 4 3 5 5 4 4 5 7 3 1 6 6 7 6 1 9 5 6 11 8 5 3 2 3 11 8 8 7 11 10 14 13 4 5 3 4 5 2 8 2 1 6 4 4 7 18 6 2 5 4 2 3 9 5 21 6 3 2 5 3 6 5 6 6 5 10 6 8 1 4 2 3 3 1 6 1 2 1 9 6 6 5 3 8 3 1 4 5 7 6 5 4 3 8 6 5 4 6 5 12 11 2 12 9 4 7 4 1 5 5 9 8 3 5 2 10 8 11 Each coloured bar represents a different set of indicators e.g. dark blue is prevalence. The specific indicators are then shown in the table on slides 19-23 for the 3 practices with the highest total number of indicators in the bottom quintile 0 5 10 15 20 25 30 35 40 45 7 Prevalence (4 indicators) Management in Primary Care (33 indicators) Respiratory Spend and Admissions (16 indicators) COPD Spend and Admissions (8 indicators) Asthma Spend and Admissions (7 indicators) Other Respiratory Spend and Admissions (19 indicators) 65

4. Where to focus: Understanding practice variation The table shows the 3 GP practices with the highest total number of respiratory indicators in the bottom quintile of the practice cluster group, as depicted on the previous slide. Opportunities for the practice to reach the cluster group average are shown against all of the indicators where applicable, and those highlighted in red are in the bottom quintile. Quantification does not mean that the saving or improvement can actually be made, but may however answer the question Is it going to be worth focussing on this area? Pathway step Indicator Baillie Street Health Ctr (P86619) *40 indicators in bottom quintile of practice cluster Dr HB Syed (P86609) *39 indicators in bottom quintile of practice cluster York House Surgery (P86605) *36 indicators in bottom quintile of practice cluster Prevalence Percentage of patients registered with a GP aged 15+ recorded as current smoker no opportunities no opportunities 352 fewer smokers QOF COPD prevalence no opportunities 4 fewer COPD cases 7 fewer COPD cases Ratio of reported to expected COPD prevalence 6 extra patients to be diagnosed 3 extra patients to be diagnosed no opportunities QOF Asthma prevalence 47 fewer asthma cases no opportunities no opportunities 'Opportunities are shown as Fewer when, to reach the benchmark average, would represent X fewer smokers/admissions/deaths'. Opportunities are shown as Extra/More Managed when, to reach the benchmark average would represent X additional patients managed 66

4. Where to focus: Understanding practice variation Pathway step Indicator Baillie Street Health Ctr (P86619) *40 indicators in bottom quintile of practice cluster Dr HB Syed (P86609) *39 indicators in bottom quintile of practice cluster York House Surgery (P86605) *36 indicators in bottom quintile of practice cluster Management in Primary Care Respiratory Secondary care cost prescribed per 1000 population 12,376 reduction 515 reduction no opportunities Respiratory Secondary care items prescribed per 1000 population 5546 fewer items prescribed 486 fewer items prescribed 703 fewer items prescribed Inhaled Corticosteroids per STAR PU Cost no opportunities no opportunities 2,665 reduction Inhaled Corticosteroids per STAR PU Items Prescribed no opportunities no opportunities 2665 fewer items prescribed Inhaled Corticosteroids Average Cost per ADQ 6,025 reduction 792 reduction no opportunities COPD Secondary care cost prescribed per 1000 population 2,349 reduction no opportunities 270 reduction COPD Secondary care items prescribed per 1000 population no opportunities no opportunities 238 fewer items prescribed Asthma Secondary care cost prescribed per 1000 population no opportunities 842 reduction no opportunities Asthma Secondary care items prescribed per 1000 population 277 fewer items prescribed 9 fewer items prescribed 238 fewer items prescribed Other Respiratory Secondary care cost prescribed per 1000 population 10,814 reduction 1,390 reduction no opportunities Other Respiratory Secondary care items prescribed per 1000 population 5360 fewer items prescribed 486 fewer items prescribed 227 fewer items prescribed % with COPD who have had influenza immunisation in last year (COPD8) no opportunities 2 additional patients managed no opportunities % with COPD who have had influenza immunisation in last year plus exceptions (COPD8) 1 additional patient managed no opportunities no opportunities % with COPD with a record of FeV1 in the last 15 months (COPD10) no opportunities 3 additional patients managed 9 additional patients managed % with COPD with a record of FeV1 in the last 15 months plus exceptions (COPD10) no opportunities 1 additional patient managed 7 additional patients managed % with COPD who have had a review including assessment of breathlessness in last 15 months (COPD13) no opportunities 4 additional patients managed 5 additional patients managed % with COPD who have had a review including assessment of breathlessness in last 15 months plus exceptions (COPD13) no opportunities 2 additional patients managed 6 additional patients managed % with asthma aged 14-19 with record of smoking status in last 15 months (Asthma10) 2 additional patients recorded no opportunities no opportunities % with asthma aged 14-19 with record of smoking status in last 15 months plus exceptions (Asthma10) 2 additional patients recorded no opportunities no opportunities % with asthma with review in last 15 months (Asthma9) no opportunities 2 additional patients managed 9 additional patients managed % with asthma with review in last 15 months plus exceptions (Asthma9) no opportunities no opportunities 8 additional patients managed % aged 8+ with measures of variability or reversibility (Asthma8) no opportunities 12 additional patients managed 3 additional patients managed % aged 8+ with measures of variability or reversibility plus exceptions (Asthma8) 17 additional patients managed 11 additional patients managed 3 additional patients managed Patients with a LTC with record of smoking status (Smoke05) 13 additional patients recorded 19 additional patients recorded no opportunities Patients with a LTC with record of smoking status plus exceptions (Smoke05) 16 additional patients recorded 14 additional patients recorded no opportunities Patients with a LTC who smoke with a record of offer of support and treatment (Smoke06) no opportunities 7 additional patients managed 13 additional patients managed Patients with a LTC who smoke with a record of offer of support and treatment plus exceptions (Smoke06) no opportunities 7 additional patients managed 15 additional patients managed Patients aged 15+ with a record of smoking status in last 27 months (Smoke07) 50 additional patients recorded 564 additional patients recorded no opportunities Patients aged 15+ with a record of smoking status in last 27 months plus exceptions (Smoke07) 27 additional patients recorded 583 additional patients recorded no opportunities Patients aged 15+ recorded as a current smoker with offer of support and treatment in last 27 months (Smoke08) no opportunities 62 additional patients managed no opportunities Patients aged 15+ recorded as a current smoker with offer of support and treatment in last 27 months plus exceptions (Smok no opportunities 62 additional patients managed no opportunities Seasonal flu vaccine uptake, age 6 months to 64 years 201 more vaccinated 21 more vaccinated no opportunities Seasonal flu vaccine uptake, age 65+ years no opportunities 13 more vaccinated no opportunities 'Opportunities are shown as Fewer when, to reach the benchmark average, would represent X fewer cases/admissions/deaths'. Opportunities are shown as Extra/More Managed when, to reach the benchmark average would represent X additional patients managed 67

4. Where to focus: Understanding practice variation Pathway step Indicator Clay Cross Medical Centre (C81056) *54 indicators in bottom quintile of practice cluster Blue Dykes Surgery (C81008) *50 indicators in bottom quintile of practice cluster St Lawrence Road Surgery (C81647) *39 indicators in bottom quintile of practice cluster COPD Spend and Admissions Asthma Spend and Admissions COPD Secondary care spend per 1000 population 12,113 reduction no opportunities 4,920 reduction COPD Emergency spend per 1000 population 3,535 reduction no opportunities 5,575 reduction COPD Secondary care admissions per 1000 population 8 fewer admissions no opportunities 10 fewer admissions COPD Emergency admissions per 1000 population 3 fewer admissions no opportunities 10 fewer admissions COPD Secondary care admissions per COPD register 13 fewer admissions 2 fewer admissions 19 fewer admissions COPD Secondary care admissions Mean LOS no opportunities no opportunities no opportunities COPD Emergency admissions Mean LOS no opportunities no opportunities no opportunities Under 75 years Emergency COPD Admissions DSR per 100,000 19 fewer admissions no opportunities 22 fewer admissions Asthma Secondary care spend per 1000 population 18,916 reduction 2,989 reduction 38,839 reduction Asthma Emergency spend per 1000 population 19,626 reduction 3,295 reduction 14,230 reduction Asthma Secondary care admissions per 1000 population 16 fewer admissions 4 fewer admissions 34 fewer admissions Asthma Emergency admissions per 1000 population 19 fewer admissions 4 fewer admissions 10 fewer admissions Asthma Emergency admissions per Asthma register 32 fewer admissions 10 fewer admissions 38 fewer admissions Asthma Secondary care admissions Mean LOS no opportunities no opportunities 13 fewer bed days Asthma Emergency admissions Mean LOS no opportunities no opportunities 19 fewer bed days 69

4. Where to focus: Understanding practice variation Pathway step Indicator Clay Cross Medical Centre (C81056) *54 indicators in bottom quintile of practice cluster Blue Dykes Surgery (C81008) *50 indicators in bottom quintile of practice cluster St Lawrence Road Surgery (C81647) *39 indicators in bottom quintile of practice cluster Other Respiratory Spend and Admissions Other Respiratory Secondary care spend per 1000 population 76,682 reduction 22,997 reduction 16,666 reduction Other Respiratory Inpatient spend per 1000 population 24,805 reduction 14,194 reduction no opportunities Other Respiratory Daycase spend per 1000 population 2,191 reduction 4,615 reduction no opportunities Other Respiratory Emergency spend per 1000 population 52,170 reduction 5,273 reduction 22,314 reduction Other Respiratory Secondary care admissions per 1000 population 69 fewer admissions 13 fewer admissions 20 fewer admissions Other Respiratory Inpatient admissions per 1000 population 14 fewer admissions 3 fewer admissions 1 fewer admission Other Respiratory Daycase admissions per 1000 population 2 fewer admissions 2 fewer admissions no opportunities Other Respiratory Emergency admissions per 1000 population 36 fewer admissions 2 fewer admissions 10 fewer admissions Other Respiratory Secondary care admissions Mean LOS no opportunities no opportunities no opportunities Other Respiratory Inpatient admissions Mean LOS 10 fewer bed days 9 fewer bed days no opportunities Other Respiratory Emergency admissions Mean LOS no opportunities no opportunities no opportunities Pneumonia All Ages Emergency Admissions DSR per 100,000 no opportunities no opportunities 13 fewer admissions Pneumonia <75 Emergency Admissions DSR per 100,000 2 fewer admissions no opportunities 11 fewer admissions Pneumonia 75+ Emergency Admissions DSR per 100,000 no opportunities no opportunities 2 fewer admissions Flu All Ages Emergency Admissions DSR per 100,000 no opportunities no opportunities no opportunities Upper Respiratory Infection All Ages Emergency Admissions DSR per 100,000 36 fewer admissions 4 fewer admissions 15 fewer admissions Upper Respiratory Infection <75 Emergency Admissions DSR per 100,000 37 fewer admissions 4 fewer admissions 15 fewer admissions Lower Respiratory Infection All Ages Emergency Admissions DSR per 100,000 54 fewer admissions 3 fewer admissions 13 fewer admissions Lower Respiratory Infection <75 Emergency Admissions DSR per 100,000 38 fewer admissions 5 fewer admissions 12 fewer admissions 70

5. Bringing it all together Where to focus, what could work, who should we speak to CCGs should consider what local intelligence is available to further triangulate with the intelligence in this pack. This may include: Practice variation analyses Reviewing referral protocols and guidelines Analysis from Acute Trust quality dashboard or other provider data Contract monitoring data Next step is to move from intelligence to action CCG needs to identify from the summary slides where to focus and what could work and which CCG may be an exemplar to follow There are also many resources available on www.rightcare.nhs.uk to take forwards the improvement agenda. 71

5. National Guidance British Lung Foundation (2007) Invisible lives: chronic obstructive pulmonary disease (COPD) finding the missing millions. Department of Health (2010) Consultation on a strategy for services for chronic obstructive pulmonary disease (COPD) in England impact assessment. London: Department of Health Healthcare Commission (2006) Clearing the air: a national study of chronic obstructive pulmonary disease. London: Healthcare Commission. NICE (2010) Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). NICE clinical guideline 101. London: National Institute for Health and Clinical Excellence. Available from www.nice.org.uk/guidance/cg101 72

5. National Guidance The Kings fund 2010 : Avoiding Hospital Admissions Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. NICE clinical guideline 12 (2004). [Replaced by NICE clinical guideline 101] British Guideline on the Management of Asthma: SIGN101, ISBN 978 1 90581 28 5, May 2008, Revised May 2011, Section 4.3.4 revised Sept 2011, Section 1 revised Jan 2012 73

Annexes Annex 1 Spine charts and opportunity tables Annex 2 CCG Cluster Classification Annex 3 Practice Cluster Classification Annex 4 Indicator List Glossary 74

Annex 1: Spine Charts Prevalence / Diagnosis Percentage of patients registered with a GP aged 15+ recorded as current smoker QOF COPD prevalence Ratio of reported to expected COPD prevalence % COPD diagnosis confirmed by post bronchodilator spirometry % COPD diagnosis confirmed by post bronchodilator spirometry plus exceptions QOF Asthma prevalence Worse Outcome Better Outcome 0 20 40 60 80 100 Opportunities Benchmark average Benchmark Top Quintile 6096 fewer smokers 10437 fewer smokers 1439 fewer COPD cases 2740 fewer COPD cases 249 extra patients to be diagnosed 14 additional patients managed 2518 fewer asthma cases 4230 fewer asthma cases 75

Annex 1: Spine Charts Primary Care Opportunities Worse outcome Better outcome Benchmark average Benchmark Top Quintile Respiratory Cost prescribed per 1000 population Respiratory Items prescribed per 1000 population Inhaled Corticosteroids ADQ per STAR PU Cost Inhaled Corticosteroids ADQ per STAR PU Items Prescribed COPD Cost prescribed per 1000 population COPD Items prescribed per 1000 population % with COPD who have had influenza immunisation % with COPD who have had influenza immunisation plus exceptions % with COPD with a record of FeV1 % with COPD with a record of FeV1 plus exceptions % with COPD who have had a review % with COPD who have had a review plus exceptions Total COPD Exceptions Asthma Cost prescribed per 1000 population Asthma Items prescribed per 1000 population % with asthma aged 14-19 with record of smoking status % with asthma aged 14-19 with record of smoking status plus exceptions % with asthma with review in last 15 months % with asthma with review in last 15 months plus exceptions % aged 8+ with measures of variability or reversibility % aged 8+ with measures of variability or reversibility plus exceptions Total Asthma Exceptions Other Respiratory Cost prescribed per 1000 population Other Respiratory Items prescribed per 1000 population 0 20 40 60 80 100 1536312 reduction 2599692 reduction 89915 fewer items prescribed 145501 fewer items prescribed 381442 reduction 662020 reduction 513573 fewer items prescribed 492592 fewer items prescribed 589652 reduction 947690 reduction 24952 fewer items prescribed 42551 fewer items prescribed 36 additional patients managed 86 additional patients managed 46 additional patients managed 147 additional patients managed 109 additional patients managed 101 additional patients managed 167 additional patients managed 86 additional patients managed 855836 reduction 1456623 reduction 56207 fewer items prescribed 88981 fewer items prescribed 7 additional patients recorded 3 additional patients recorded 26 additional patients recorded 171 additional patients managed 247 additional patients managed 43 additional patients managed 92 additional patients managed 71 additional patients managed 140 additional patients managed 101 fewer exceptions 586 fewer exceptions 120193 reduction 215710 reduction 76 39474 fewer items prescribed 59349 fewer items prescribed

Annex 1: Spine Charts Primary Care Worse outcome Better outcome Benchmark average Opportunities Benchmark Top Quintile Patients with a LTC with record of smoking status Patients with a LTC with record of smoking status plus exceptions Patients with a LTC who smoke with a record of offer of support and treatment Patients with a LTC who smoke with a record of offer of support and treatment plus exceptions Patients aged 15+ with a record of smoking status Patients aged 15+ with a record of smoking status plus exceptions Patients aged 15+ recorded as a current smoker with offer of support and treatment Patients aged 15+ recorded as a current smoker with offer of support and treatment plus Total Smoking Exceptions Seasonal flu vaccine uptake, age 6 months to 64 years Seasonal flu vaccine uptake, age65+ years 0 20 40 60 80 100 193 additional patients recorded 272 additional patients recorded 45 additional patients managed 98 additional patients managed 969 additional patients recorded 1020 additional patients recorded 439 additional patients managed 358 additional patients managed 100 fewer exceptions 77

Annex 1: Spine Charts Secondary Care Worse outcome / Higher spend Better outcome / Lower spend Benchmark average Opportunities Benchmark Top Quintile Respiratory Secondary care spend per 1000 population Respiratory Inpatient spend per 1000 population Respiratory Daycase spend per 1000 population Respiratory Emergency spend per 1000 population Respiratory Secondary care admissions per 1000 population Respiratory Inpatient admissions per 1000 population Respiratory Daycase admissions per 1000 population Respiratory Emergency admissions per 1000 population Respiratory Secondary care spend per admission Respiratory Inpatient spend per admission Respiratory Daycase spend per admission Respiratory Emergency spend per admission Respiratory Secondary admissions Mean LOS Respiratory Inpatient admissions Mean LOS Respiratory Emergency admissions Mean LOS Under 75 years Elective Respiratory Admissions DSR per 100,000 Under 75 years Emergency Respiratory Admissions DSR per 100,000 0 20 40 60 80 100 564394 reduction 1293348 reduction 170505 reduction 293712 reduction 15193 reduction 519771 reduction 1566312 reduction 1410 fewer admissions 1958 fewer admissions 121 fewer admissions 227 fewer admissions 63 fewer admissions 1352 fewer admissions 1993 fewer admissions 111 reduction 130 fewer bed days 258 fewer bed days 140 fewer admissions 351 fewer admissions 2387 fewer admissions 3645 fewer admissions 78

Annex 1: Spine Charts Secondary Care Worse outcome / Higher spend Better outcome / Low er spend Benchmark average Opportunities Benchmark Top Quintile COPD Secondary care spend per 1000 population COPD Emergency spend per 1000 population COPD Secondary care admissions per 1000 population COPD Emergency admissions per 1000 population COPD Secondary care admissions per COPD register COPD Secondary care admissions Mean LOS COPD Emergency admissions Mean LOS Under 75 years Emergency COPD Admissions DSR per 100,000 0 20 40 60 80 100 79524 reduction 444554 reduction 74520 reduction 419264 reduction 172 fewer admissions 335 fewer admissions 174 fewer admissions 333 fewer admissions 49 fewer admissions 149 fewer admissions 226 fewer admissions 430 fewer admissions Worse outcome / Higher spend Better outcome / Low er spend Benchmark average Opportunities Benchmark Top Quintile Asthma Secondary care spend per 1000 population Asthma Emergency spend per 1000 population Asthma Secondary care admissions per 1000 population Asthma Emergency admissions per 1000 population Asthma Secondary care admissions per Asthma register Asthma Secondary care admissions Mean LOS Asthma Emergency admissions Mean LOS 0 20 40 60 80 100 159105 reduction 231008 reduction 127738 reduction 199380 reduction 206 fewer admissions 295 fewer admissions 170 fewer admissions 258 fewer admissions 145 fewer admissions 222 fewer admissions 79

Annex 1: Spine Charts Secondary Care Worse outcome / Higher spend Better outcome / Lower spend Opportunities Benchmark average Benchmark Top Quintile Other Respiratory Secondary care spend per 1000 population Other Respiratory Inpatient spend per 1000 population Other Respiratory Emergency spend per 1000 population Other Respiratory Secondary care admissions per 1000 population Other Respiratory Inpatient admissions per 1000 population Other Respiratory Emergency admissions per 1000 population Other Respiratory Secondary care admissions Mean LOS Other Respiratory Inpatient admissions Mean LOS Other Respiratory Emergency admissions Mean LOS Emergency admissions for children with lower respiratory disease Pneumonia All Ages Emergency Admissions DSR per 100,000 Pneumonia <75 Emergency Admissions DSR per 100,000 Pneumonia 75+ Emergency Admissions DSR per 100,000 Flu All Ages Emergency Admissions DSR per 100,000 Upper Respiratory Infection All Ages Emergency Admissions DSR per 100,000 Upper Respiratory Infection <75 Emergency Admissions DSR per 100,000 Lower Respiratory Infection All Ages Emergency Admissions DSR per 100,000 Lower Respiratory Infection <75 Emergency Admissions DSR per 100,000 321736 reduction 877968 reduction 150817 reduction 270907 reduction 314351 reduction 957589 reduction 1022 fewer admissions 1533 fewer admissions 112 fewer admissions 212 fewer admissions 1002 fewer admissions 1522 fewer admissions 118 fewer bed days 244 fewer bed days 144 fewer admissions 221 fewer admissions 46 fewer admissions 206 fewer admissions 45 fewer admissions 166 fewer admissions 86 fewer admissions 10 fewer admissions 1115 fewer admissions 1564 fewer admissions 1086 fewer admissions 1522 fewer admissions 649 fewer admissions 943 fewer admissions 612 fewer admissions 875 fewer admissions 0 20 40 60 80 100 Mortality Worse outcome Better outcome Benchmark average Opportunities Benchmark Top Quintile Under 75 Respiratory Mortality DSR per 100,000 Mortality from asthma DSR per 100,000 Under 75 Mortality from bronchitis and emphysema and COPD DSR per 100,000 0 20 40 60 80 100 9 fewer deaths 30 fewer deaths 2 fewer deaths 4 fewer deaths 21 fewer deaths 49 fewer deaths 80

Annex 2: CCG cluster classification Heywood, Middleton & Rochdale CCG is in the Yellow Cluster Group. The constituent CCG s are listed below. Code CCG Name Code CCG Name 00G NHS Newcastle North and East CCG 06P NHS Luton CCG 00H NHS Newcastle West CCG 07L NHS Barking and Dagenham CCG 00Q NHS Blackburn with Darwen CCG 07M NHS Barnet CCG 00Y NHS Oldham CCG 07V NHS Croydon CCG 01D NHS Heywood, Middleton and Rochdale CCG 07W NHS Ealing CCG 01G NHS Salford CCG 07X NHS Enfield CCG 01M NHS North Manchester CCG 07Y NHS Hounslow CCG 01N NHS South Manchester CCG 08A NHS Greenwich CCG 02R NHS Bradford Districts CCG 08E NHS Harrow CCG 03C NHS Leeds West CCG 08G NHS Hillingdon CCG 03F NHS Hull CCG 08J NHS Kingston CCG 03G NHS Leeds South and East CCG 08N NHS Redbridge CCG 03J NHS North Kirklees CCG 08R NHS Merton CCG 03N NHS Sheffield CCG 09H NHS Crawley CCG 04C NHS Leicester City CCG 10R NHS Portsmouth CCG 04F NHS Milton Keynes CCG 10T NHS Slough CCG 04K NHS Nottingham City CCG 10W NHS South Reading CCG 04X NHS Birmingham South and Central CCG 10X NHS Southampton CCG 05A NHS Coventry and Rugby CCG 11H NHS Bristol CCG 05L NHS Sandwell and West Birmingham CCG 13P NHS Birmingham Crosscity CCG 05Y NHS Walsall CCG 99A NHS Liverpool CCG 06A NHS Wolverhampton CCG 82

Annex 3: Practice cluster classification The practice cluster groups are taken from YHPHO methodology, which groups together practices with similar populations. It is based on statistical cluster analysis (K-means analysis) including variables of age structure of the population, the population from Black and Asian ethnic groups, rural classification and deprivation. A total of 8074 GP practices were grouped into ten classification groups. A small number of practices (354 covering 1.1% of the population) did not have sufficient data to allocate them to a classification group 83